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Temporomandibular Disorders, Examination and TX of, An Evidence-Based Manual PT Approach

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  • KenOlsonPT,DHSc,OCS,FAAOMPTEricFurto PT,DPT,FAAOMPT

  • Purposey Thisbreakoutsessionwillincludedescriptionofthekinematicsandfunctionalanatomyofthetemporomandibular joint(TMJ)andrelatedstructures,andthephysicaltherapyexamination,classification,andtreatmentofTemporomandibulardisorders(TMD).

  • Objectivesy DescribethefunctionalanatomyandkinematicsoftheTMJy IdentifytheclassificationofTMDanddescribethecomponentsof

    eachdisordery PerformacomprehensiveexaminationoftheTMJandrelated

    structuresy PerformtreatmentproceduresfortheTMJincludingsofttissue

    mobilization,jointmobilization/manipulation,andexerciseinstruction

    y DescribethefunctionalinterrelationshipsbetweentheTMJandcervicalspine

    y Describetheevidencetosupportaphysicaltherapyapproachfortreatmentoftemporomandibular disorders.

  • Craniomandibular AnatomyandKinematics

  • Occlusionalplane

  • AnatomyOsseousStructuresTemporalbone

    Postglenoid spineMandibular FossaArticular EminenceArticular CrestArticular Tuberle

    MandibleCondyle medialandlateralpoleNeckofCondyleCoronoid ProcessRamusBody

    Teeth Mandibular andMaxillary

  • MusclesofMasticationTemporalis,Masseter,Buccinator,Medial/Lateralpterygoid

  • Medial/lateralpterygoids

  • HyoidMuscles

    Supra hyoid

    DigastricMylohyoidStylohyoid

    InfraHyoidOmohyoidthyrohyoidSternohyoid

  • IntercapsularStructures

    y Articulardiscy 3bandsy Anterior 2mm

    Middle 1mmy Posterior 3mmy Attachmentsy Medialandlateralcollateralligamentsy PosteriorAttachments/BilaminarZoney SuperiorLaminaey InferiorLaminaey Retrodiscalpady LateralPterygoid

  • ArticularDisc

  • Arthrokinematicsy Depressiony LateralExcursiony Protrusion

  • MandibularDepression

  • Mandibular DepressionArthrokinematics

  • DepressionKinematicsy First25mmofopeningthatoccursprimarilyasarotational

    motion(rollgliding)ofthecondyle intheinferiorjointspace.y Oncethecollateralligamentstauten,theopeningcontinuesas

    primarilyatranslatory glidingmotionintheupperjointspaceuntil35mmisreachedandtheposteriorandcollateralligamentsaretaut.

    y Openinggreaterthan35mmresultsfromfurthertranslationwithoverrotation andfurtherstretchingappliedtotheposteriorandcollateralligaments.12

    y Thelateralpterygoid,inferiorhead,providesaprotractingforceonthecondyles anddiscs;thegeniohyoid anddigastic musclesproduceadepressingandretractingforceonthechin;andthemylohyoid musclepullsdownwardonthebodyofthemandibletocombinetoproducetherotatory andtranslatory movementsofthejawthatoccurwithmandibular depression

  • Mandibulardepression

  • MuscularActionwithOpen/closing

  • LateralExcursion

  • LateralExcursionKinematicsy Lateralexcursionoccurswhenthecondyle anddiscofthecontralateral sidearepulledforward,downward,andmediallyalongthearticular eminence.y Thecondyle ontheipsilateral sideperformsminimalrotationaroundaverticalaxisandaslightlateralshift.12

    y Thesemotionstakeplaceprimarilyintheupperjointspace.y Lateralexcursioniscreatedbycontractionofthelateralpterygoid musclesonthecontralateral sideofthedirectionofthemotioncombinedwiththeipsilateral sidetemporalismusclecontractingtoholdtherestpositionofthecondyletopreventthemandiblefromdeviatinganteriorly.12

  • Protrusion

  • ProtrusionKinematicsy Protusion ofthemandibleiscreatedwithsymmetricalanterior

    translationofbothcondyle/disccomplexesonthearticulareminence

    y Themotionoccursatthesuperiorjointspace.y Protrusioniscreatedbycontractionoftheinferiorheadofthe

    lateralpterygoid andholdingactionofthemasseter andmedialpterygoid muscles.12 Thelateralpterygoid pullsthecondyle anddiscforwardanddownalongthearticular eminencewhiletheelevatoranddepressormusclesmaintainthemandibularposition.12

    y Retrusion isthereturntorestpositionfromtheprotrusionpositionandiscreatedbythecontractionofthemiddleandposteriorfibersofbothtemporalis muscleswhilethedepressorsandelevatorsmaintainaslightopeningofthemouth.12

  • Mandibular Mapping

  • CervicalSpineandTMJinterrelationships

  • RelationshipBetweenPostureandTheTMJ

  • TheEffectofOcclusiononRestingPostureofTMJNormal

    Kraus

    zNormalIntermolarrelationship(red).

    zAllowsNormalseatingofMandibledisccondylerelationship(blue).

  • TheEffectofOcclusiononRestingPostureofTMJPathological

    zPoorocclusionbetweenmolars(red).

    zPlacesanteriorstressonthediscoftheTMJ.

    zPullsmandibleforward(green).

    zJawandfacialpain.

    Kraus

  • EffectofFHPonmandible

    Neumann

  • Pseudomalocclusiony Changerestpositionofmandiblecanchangehead/neckposture (Daly)y IncreaseFHPplacesmandibleinmoreretrudedposition (Darling)y IncreaseFHPchangesthetrajectoryofthemandible(Goldstein)

    DalyP.1982Posturalresponseoftheheadtobiteopeninginadultmales.AmericanJournalofOrthodontics.82:157160.DarlingDW,etal.1984Relationshipofheadpostureandtherestpositionofthemandible.JournalofProstheticDentistry.52(1):111115.GoldsteinDF,KraussS,WilliamsWB,GlasheenWrayMB.1984Influenceofcervicalpostureonmandibular movement.JournalProstheticDentistry.52(3):421426.

  • HowtheMusclesandJointsWorkTogether Increaseforwardhead

    posture.

    Tightposteriorneckmusculaturewillrotatethecraniumbackwardleavingthemouthopenatrest.

    Musclesofmasticationoverworktomaintainjawclosure.

    Cailliet

  • ReferralpatternsfromCervicalspinetoMandibular region

    S/Omusclesandmastoidmuscles

    Greaterandlesseroccipitalnerves

    CervicalplexusC2C3facet

  • Summaryy FunctionalandAnatomicalinterrelationshipsbetweenTMJcomplexandCervicalspinedictatethatathoroughexaminationandtreatmentofbothregionsisnecessarytoobtainpositiveclinicaloutcomesy ThisanopportunityforphysicaltherapiststoplayanactiveroleinmanagementofcervicalspineandTMDconditions

  • Evaluationy Historyy Structurey ActiveRangeofMotion Cervicaly ActiveRangeofMotion Mandibley PassiveAccessoryMotion Cervicaly PassiveAccessoryMotion TMJy Provocation/Palpation

  • MandibularDynamics

  • TMJPassiveAccessoryMobilityTesting

  • Provocationtesting

  • TMDClassificationy Capsulitis/Synovitisy CapsularFibrosisy Hypermobilityy ArticularDiscDisplacementy Withreductiony Withoutreduction

    y Post SurgicalTMJ

  • Capsulitis/Synovitis

    y TendertopalpationatTMJlateralcondyleorposteriorcompartmenty Painwithbitingonoppositesidey Painwithretrusiveoverpressurey Painwithaccessorymotiontesting

  • MasticatoryMuscleDisordersy Nojointsoundsy Painwithpalpationmusclesofmasticationy Inconsistentalterationsinmandibularcontroly Parafunctionaloralbehaviorsy Painwithbitingonsameside

  • CapsularFibrosis

    y Capsularpatterny Deviationtowardlimitedsidewithopeningandprotrusiony Limitedcontralaterallateralexcursion

    y LimitedAROMmandibulardynamicsy LimitedmobilitywithTMJaccessorymotiontestsy Nojointsoundsy Historyoftraumaorsurgery

  • TMJCapsularpattern

  • Hypermobility

    y Endrangeclickwithdeviationawayfromhypermobilesidey ?Symptomaticy Mayleadtodiscdisplacementconditiony ExcessiveAROMwithopening>40mmy Jointsoundatendrangeofopeningy Hypermobilitywithaccessorymotiontesting

  • Hypermobility

  • ArticularDiscDisplacementyWithreduction

  • Articular DiscDisplacementwithreduction

    y Reciprocaljointsoundwithopeningandclosingy Scurvewithopeningy FullAROM(unlesscombinedwithacutecapsulitisormuscledysfunction)

  • DiscDisplacementwReduction

  • ArticularDiscDisplacementyWithoutreduction

  • Articular DiscDisplacementwithoutreductiony Historyofjointsoundsy Limitedopening
  • TMJCapsularpattern

  • Post SurgicalTMJ

    y capsulitis/synovitisy AssessforunderlyingTMJdysfunction

  • Osteoarthritisy TMJcrepitusasnotedwithstethoscopey PainwithTMJpalpationy Radiographicevidenceofosteoarthritis

  • PhysicalTherapyTreatmentofTMJDysfunction

  • PhysicalTherapyGoalsy RestoreNaturalMotionofTMJandCervicalSpiney ImprovePosturalAwarenessy ImproveFunction(eating,talking,etc.)y DecreasePainandHeadachesy TeachPatientsHowtoPreventFutureOccurrencesofHeadandFacialPain

  • TreatmentsforTMDy Modalitiesy Manipulationy Cervical/thoracicspiney TMJ

    y PosturalEducationy Therapeuticexercisey Neuromuscularreeducation

  • Modalities

    y Ultrasoundy IontophoresisyMoistHeat

  • Iontophoresisy InastudybyMajwerandSwider,22 27of32casesofposttraumaticTMDbenefitedwithdecreasedpainfromtheapplicationofdexamethasone(n=8)orxylocane(n=24)throughiontophoresis

  • CervicalManipulationy Enhancecervicalmobilityandfunctiony Improveposturey Indirectlyencourageaproperrestpositionofthecondyle

  • TMJManipulations

    y Techniquesy LongAxisDistractiony MedialGlidey LateralGlide

    z Indications Lossofjawmotion Limitedaccessorymotion Pain

  • CaseSeriesy Nicolakis etal9 hadsuccessfuloutcomesinaseriesof20patientswithOAoftheTMJwithimprovedmeasuresofpainatrest,incisional opening,andfunction.y TheinterventionsincludedjointmobilizationoftheTMJ,softtissuetechniques,activeandpassiveTMJexercises,andposturalexercises.9

    y Datacollectedonthesepatientsata12monthfollowupexaminationcontinuedtosuggestfavorableresultsfortheuseofexerciseandmanualphysicaltherapyinthemanagementofTMD.10

  • Nicolakisetal10y 30patientswithTMJanteriordiscdisplacementwithreductiony treatmentwithtemporomandibular jointandsofttissuemobilization,rangeofmotionandisometricexercises,andposturaleducationforanaverageofninevisitswithaphysicaltherapist.y Seventyfivepercentofthepatientshadsuccessfuloutcomesy painlevelandmouthopeningmeasurementsatthe6monthfollowu

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