Physical therapy ofthe temporomandibular

joint disorder

Tony PT

大纲• 解剖

• 运动学

• 检查评定

• 治疗操作

解剖

TMJ的运动学

Depression-张开下颌骨

Elevation-闭合下颌骨

Lateral deviation-侧方滑移

Protraction-下颌骨前伸

Retraction-下颌骨后缩

Temporomandibular Disorders

• 13 to 35 • women > men

• ■ pain in the area of the jaw• ■ increased or decreased active or passive range of motion• ■ popping or clicking noises• ■ difficulty with functional activities • ■ catching or locking of the jaw• ■ forward head posture

Characteristics ofTMD Classifications

Inflammatory Conditions

• inflammation of the joint capsule, and synovitis is characterized by a fluctuating swelling caused by effusion within the synovial membrane of the joint

• Rheumatoid arthritis is the most common cause of such inflammatory conditions

• pain, stiffness, edema, and warmth

Capsular Fibrosis

• restrict the movement of the disk and limit the function of the TM joint

• Caused by immobilization, trauma, or arthritis

• decrease in translatory motion

• The resultant fibrosis causes progressive damage and loss of tissue function

Osseous Mobility Conditions

• joint hypermobility and dislocation

• pathological changes (hypertrophy,atrophy, or contracture) in 77% of the lateral pterygoid muscles Yang et al

Articular Disk Displacement

• joint hypermobility and dislocation

• known as a reciprocal click

Degenerative Conditions

• 80-90% population older than 60 have osteoarthritis symptoms in the TMJ Kessler and Hertling

• repeated minor trauma to the joint

• Loss of posterior teeth may also contribute to degenerative changes

Cervical Spine---TMD

• Funakoshi et al The increased EMG activity was believed to occur in an att empt to maintain the rest position of the mandible in various head and neck postural positions.

• Goldstein et al These postural infl uences on mandibular function have been postulated as causing a “pseudomalocclusion” that could contribute to increased strain on the joint capsule and myofascial structures associated with TMJ function

• high prevalence rate of headache and facial pain symptoms referred from the upper cervical spine

Assesment

• 病史• 观察• 体检• 主动运动• 被动附属运动• 等长抗阻运动• 触诊• 特殊检查• 影像学检查

病史• 引起疼痛的动作• 张口痛还是闭口痛 -关节内外• 晨痛后缓解 -骨关节炎• 呼吸 -舌头位置影响休息位• 弹性的时间和次数

弹响• 张口弹响 -髁突复位到关节盘• 闭口弹响 -翼外肌上部过分牵拉关节盘前移• 咬牙 /磨牙后弹响 -关节上下部有粘附• 张口最大时弹响 -关节发育不良• 轻柔的弹响 -肌肉运动不协调• 爆破似的弹响 -关节病变或分离• 强烈的捻发音 -关节炎性病变

病史• 引起疼痛的动作• 张口痛还是闭口痛 -关节内外• 晨痛后缓解 -骨关节炎• 呼吸 -舌头位置影响休息位• 弹性的时间和次数• 活动受限

活动受限

活动受限

病史• 引起疼痛的动作• 张口痛还是闭口痛 -关节内外• 晨痛后缓解 -骨关节炎• 呼吸 -舌头位置影响休息位• 弹性的时间和次数• 活动受限• 不良习惯• 牙病• 等等

视诊

主动张合下颌关节• B：提示偏斜侧活动性下降• S形：肌肉失衡，髁突在关节盘游走

• 较早张口偏斜：翼状肌，咀嚼肌的痉挛或关节功能障碍

• 较晚张口偏斜：关节囊炎症或过紧

Examination of the TMJ

治疗策略

• Antiinflammatory treatment

• soft tissue mobilization and joint mobilization to the cervical spine, TMJ, and thoracic spine

• TMJ proprioception and postural exercises

• dynamic neuromuscular control

治疗策略

• Joint mobilization, active and passive mandibular rom exercises, and sustained TMJ stretching

• stretching with moist heat or therapeutic ultrasound

• 20 mins 3times/day

治疗策略

• heat modalities, such as moist heat, therapeutic ultrasound, or warm water rinses

• soft tissue mobilization• educated to inhibit parafun

ctional activities• Muscle reeducation and T

MJ proprioception exercises

治疗策略

• TMJ stabilization treatment program

• multidirectional mandibular isometric exercises,proprioception exercise, and education to avoid full wide opening

治疗策略

• stabilize the joint and improve the neuromuscular control

• lateral excursion progression of ROM,

• ROM with the end range bite, and ROM with the sustained bite

• TMJ distraction mobilization

治疗策略

• TMJ mobilization techniques,cervical spine

• postural and neck exercises, and patient education regarding parafunctional habits, soft diet, relaxation techniques, activity modification, and tongue resting position

治疗策略

• joint mobilization of the TMJ, soft tissue techniques

• active and passive TMJ exercises, and postural exercises

Postsurgical Temporomandibular Joint

• reduce inflammation and restore joint function

• TMJ range of motion exercises

• Joint mobilization techniques and sustained stretching depent on the surgeon’s decision

治疗技术Temporomandibular Joint Proprioception Ex

ercises with a Rubber Tube

治疗技术Passive Mandibular Range of Motion and

Sustained Mandibular Stretching

治疗技术• Temporomandibular Joint Stabilization Ex

ercises

治疗技术• Temporomandibular Joint Distraction A

ccessory Motion Test and Mobilization

治疗技术• Temporomandibular Joint Lateral Glide

Accessory Motion Test and Mobilization

治疗技术• Temporomandibular Joint Medial Glide A

ccessory Motion and Joint Mobilization

治疗技术• Soft tissue mobilization

• lateral pterygoid

治疗技术• Soft tissue mobilization

• Medial pterygoid

治疗技术• TMJ Education

治疗病例• 患者 22岁，半年前主诉颈椎不适，门诊颈肩肌肉放松及姿势训练 2周。

• 一个月前回到门诊主诉张嘴受限 2个月，追问病史得知右侧颞颌关节在近一年半偶有弹响和短时间的疼痛和受限，但都自愈，此次疼痛和活动受限时间较长，已有一个月的口服氨基酸葡萄糖，效果不明显，主被动张嘴上下牙尖一指半，前伸受限，向左侧移受限，右侧颞颌关节最大张嘴和按压疼痛，翼内外肌压痛明显， VAS： 7/10，被动分离牵引和向前滑动微弱，右侧髁突在张嘴时活动减少，关节活动时无弹响

• 门诊超声配合关节松动，翼内外肌放松，分离牵引和向前滑动牵伸后方韧带和关节囊，牵拉右侧翼内肌配合肌肉本体感觉训练，一周 3次治疗，指导治疗后回家自我牵伸和肌力训练巩固。

• 四周后压痛 VAS： 2/10，主动张嘴 3指半，附属运动改善，不影响日常生活

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