temporomandibular disorders, examination and tx of, an evidence-based manual pt approach (2010) -...
DESCRIPTION
Temporomandibular Disorders, Examination and TX of, An Evidence-Based Manual PT ApproachTRANSCRIPT
Ken Olson PT, DHSc, OCS, FAAOMPTEric Furto PT, DPT, FAAOMPT
PurposeThis breakout session will include description of the kinematics and functional anatomy of the temporomandibular joint (TMJ) and related structures, and the physical therapy examination, classification, and treatment of Temporomandibulardisorders (TMD).
ObjectivesDescribe the functional anatomy and kinematics of the TMJIdentify the classification of TMD and describe the components of each disorderPerform a comprehensive examination of the TMJ and related structures Perform treatment procedures for the TMJ including soft tissue mobilization, joint mobilization/manipulation, and exercise instructionDescribe the functional interrelationships between the TMJ and cervical spineDescribe the evidence to support a physical therapy approach for treatment of temporomandibular disorders.
Craniomandibular Anatomy and Kinematics
Occlusional plane
AnatomyOsseous StructuresTemporal bone
Postglenoid spineMandibular FossaArticular EminenceArticular CrestArticular Tuberle
MandibleCondyle‐medial and lateral poleNeck of CondyleCoronoid ProcessRamusBody
Teeth ‐Mandibular and Maxillary
Muscles of MasticationTemporalis, Masseter, Buccinator, Medial/Lateral pterygoid
Medial/lateral pterygoids
Hyoid Muscles
Supra – hyoid
DigastricMylohyoidStylohyoid
Infra‐HyoidOmohyoidthyrohyoidSternohyoid
Intercapsular Structures
Articular disc3 bands
Anterior ‐ 2 mmMiddle ‐ 1 mmPosterior ‐ 3 mm
AttachmentsMedial and lateral collateral ligamentsPosterior Attachments / Bilaminar Zone
Superior LaminaeInferior LaminaeRetrodiscal pad
Lateral Pterygoid
Articular Disc
ArthrokinematicsDepressionLateral ExcursionProtrusion
Mandibular Depression
Mandibular Depression Arthrokinematics
Depression Kinematics First 25 mm of opening that occurs primarily as a rotational motion (roll‐gliding) of the condyle in the inferior joint space.Once the collateral ligaments tauten, the opening continues as primarily a translatory gliding motion in the upper joint space until 35 mm is reached and the posterior and collateral ligaments are taut. Opening greater than 35 mm results from further translation with overrotation and further stretching applied to the posterior and collateral ligaments.12The lateral pterygoid, inferior head, provides a protracting force on the condyles and discs; the geniohyoid and digastic muscles produce a depressing and retracting force on the chin; and the mylohyoid muscle pulls downward on the body of the mandible to combine to produce the rotatory and translatory movements of the jaw that occur with mandibular depression
Mandibular depression
Muscular Action with Open/closing
Lateral Excursion
Lateral Excursion KinematicsLateral excursion occurs when the condyle and disc of the contralateral side are pulled forward, downward, and medially along the articular eminence. The condyle on the ipsilateral side performs minimal rotation around a vertical axis and a slight lateral shift.12
These motions take place primarily in the upper joint space. Lateral excursion is created by contraction of the lateral pterygoid muscles on the contralateral side of the direction of the motion combined with the ipsilateral side temporalismuscle contracting to hold the rest position of the condyleto prevent the mandible from deviating anteriorly.12
Protrusion
Protrusion KinematicsProtusion of the mandible is created with symmetrical anterior translation of both condyle/disc complexes on the articulareminenceThe motion occurs at the superior joint space. Protrusion is created by contraction of the inferior head of the lateral pterygoid and holding action of the masseter and medial pterygoid muscles.12 The lateral pterygoid pulls the condyle and disc forward and down along the articular eminence while the elevator and depressor muscles maintain the mandibularposition.12Retrusion is the return to rest position from the protrusion position and is created by the contraction of the middle and posterior fibers of both temporalis muscles while the depressors and elevators maintain a slight opening of the mouth.12
Mandibular Mapping
Cervical Spine and TMJ interrelationships
Relationship Between Posture and The TMJ
The Effect of Occlusion on Resting Posture of TMJ ‐Normal
Kraus
Normal Intermolar relationship (red).
Allows Normal seating of Mandible‐disc‐condyle relationship (blue).
The Effect of Occlusion on Resting Posture of TMJ ‐Pathological
Poor occlusion between molars (red).
Places anterior stress on the disc of the TMJ.
Pulls mandible forward (green).
Jaw and facial pain.
Kraus
Effect of FHP on mandible
Neumann
Pseudomalocclusion Change rest position of mandible can change head / neck posture – (Daly)Increase FHP places mandible in more retruded position ‐ (Darling) Increase FHP changes the trajectory of the mandible –(Goldstein)
Daly P. 1982 Postural response of the head to bite opening in adult males. American Journal of Orthodontics. 82:157‐160.Darling DW, et al. 1984 Relationship of head posture and the rest position of the mandible. Journal of Prosthetic Dentistry. 52(1):111‐115.Goldstein DF, Krauss S, Williams WB, Glasheen‐Wray MB. 1984 Influence of cervical posture on mandibular movement. Journal Prosthetic Dentistry. 52(3):421‐426.
How the Muscles and Joints Work Together• Increase forward head
posture.
• Tight posterior neck musculature will rotate the cranium backward leaving the mouth open at rest.
• Muscles of mastication overwork to maintain jaw closure.
Cailliet
Referral patterns from Cervical spine to Mandibular region
S/O muscles and mastoid muscles
Greater and lesser occipital nerves
Cervical plexusC2C3 facet
SummaryFunctional and Anatomical interrelationships between TMJ complex and Cervical spine dictate that a thorough examination and treatment of both regions is necessary to obtain positive clinical outcomes
This an opportunity for physical therapists to play an active role in management of cervical spine and TMD conditions
EvaluationHistoryStructureActive Range of Motion ‐ CervicalActive Range of Motion ‐MandiblePassive Accessory Motion ‐ CervicalPassive Accessory Motion ‐ TMJProvocation / Palpation
Mandibular Dynamics
TMJ Passive Accessory Mobility Testing
Provocation testing
TMD ClassificationCapsulitis / SynovitisCapsular FibrosisHypermobilityArticular Disc Displacement
With reductionWithout reduction
Post ‐ Surgical TMJ
Capsulitis / Synovitis
Tender to palpation at TMJ lateral condyle or posterior compartment Pain with biting on opposite sidePain with retrusive overpressurePain with accessory motion testing
Masticatory Muscle DisordersNo joint soundsPain with palpation muscles of masticationInconsistent alterations in mandibular controlParafunctional oral behaviorsPain with biting on same side
Capsular Fibrosis
Capsular patternDeviation toward limited side with opening and protrusionLimited contralateral lateral excursion
Limited AROM mandibular dynamicsLimited mobility with TMJ accessory motion testsNo joint soundsHistory of trauma or surgery
TMJ Capsular pattern
Hypermobility
End range click with deviation away from hypermobile side? SymptomaticMay lead to disc displacement conditionExcessive AROM with opening >40 mmJoint sound at end range of openingHypermobility with accessory motion testing
Hypermobility
Articular Disc DisplacementWith reduction
Articular Disc Displacement with reduction
Reciprocal joint sound with opening and closing“S” curve with openingFull AROM (unless combined with acute capsulitis or muscle dysfunction)
Disc Displacement w Reduction
Articular Disc DisplacementWithout reduction
Articular Disc Displacement without reduction
History of joint soundsLimited opening <25 mm if acuteDeviation of mandible with opening toward limited side
TMJ Capsular pattern
Post ‐ Surgical TMJ
capsulitis/synovitis Assess for underlying TMJ dysfunction
OsteoarthritisTMJ crepitus as noted with stethoscopePain with TMJ palpationRadiographic evidence of osteoarthritis
Physical Therapy Treatment of TMJ Dysfunction
Physical Therapy GoalsRestore Natural Motion of TMJ and Cervical SpineImprove Postural AwarenessImprove Function (eating, talking, etc.)Decrease Pain and HeadachesTeach Patients How to Prevent Future Occurrences of Head and Facial Pain
Treatments for TMDModalitiesManipulation
Cervical/thoracic spineTMJ
Postural EducationTherapeutic exercise
Neuromuscular re‐education
Modalities
UltrasoundIontophoresisMoist Heat
IontophoresisIn a study by Majwer and Swider,22 27 of 32 cases of posttraumatic TMD benefited with decreased pain from the application of dexamethasone (n = 8) or xylocane (n = 24) through iontophoresis
Cervical ManipulationEnhance cervical mobility and functionImprove postureIndirectly encourage a proper rest position of the condyle
TMJ Manipulations
TechniquesLong Axis DistractionMedial GlideLateral Glide
Indications– Loss of jaw motion– Limited accessory motion– Pain
Case SeriesNicolakis et al9 had successful outcomes in a series of 20 patients with OA of the TMJ with improved measures of pain at rest, incisional opening, and function. The interventions included joint mobilization of the TMJ, soft tissue techniques, active and passive TMJ exercises, and postural exercises.9
Data collected on these patients at a 12‐month follow‐up examination continued to suggest favorable results for the use of exercise and manual physical therapy in the management of TMD.10
Nicolakis et al1030 patients with TMJ anterior disc displacement with reduction treatment with temporomandibular joint and soft tissue mobilization, range of motion and isometric exercises, and postural education for an average of nine visits with a physical therapist. Seventy‐five percent of the patients had successful outcomes
pain level and mouth opening measurements at the 6‐month follow‐up examination; 13% had reduction in TMJ sounds.10
This study supports the use of exercise combined with gentle manual therapy techniques for treatment of anterior disc displacement with reduction.
Single Case designCleland and Palmer27 showed a good clinical outcome in a single case design study of a patient with bilateral articulardisc displacement without reduction that was confirmed with MRI. The treatment approach included TMJ mobilization techniques, cervical spine mobilization/manipulation techniques, postural and neck exercises, and patient education regarding parafunctional habits, soft diet, relaxation techniques, activity modification, and tongue resting position. The patient had a return of normal mouth opening and a reduction in pain and disability measures as a result of the physical therapy approach.27
Neuromuscular Re‐educationTongue/teeth positionControlled openingGentle isometrics
The utilization of a co‐contraction of the musculature surrounding a joint to facilitate stability
Posterior Temporalis (Anteriorly) Deep Masseter (Laterally)Superior Lateral Pterygoid (Medially)
Home Exercise ProgramEvery patient receives a home exercise programExercises take < 1 minute to performExercises are to be performed every 2 hours for 6 repetitions
Encourages postural compliance – “Good Posture Never Rests” Trains endurance and function of postural muscles
All exercises are reviewed at each session
Randomized clinical trial, Yoda et al26
Compared an exercise program with educationForty‐two patients with anterior disc displacement with reductionThe results showed that the exercise group had better outcomes for decreased pain and increased ROM (P = .0001).26
61.9% of the exercise group had favorable outcomes (13/21 patients), and 0% of the control group had favorable results.26
Success was measured on the severity of joint sounds or pain with maximal mouth opening. Of the 13 patients with a successful outcome, only three of the patient’s TMJ articular discs (23.1%) were recaptured with reexamination with magnetic resonance imaging (MRI).26
Condylar Remodeling ‐ TheoryHyperboloid encourages proper jaw to disc alignment.Utilization of muscle contraction – biting –increases the natural stability and convexity of the joint structure.Through multiple repetitions (6 times every 2 hours), the joint will be “retrained” to maintain normal condylar alignment with movement.
Condylar Remodeling
Rest PositionGently rest device between teeth between incisors. Maintain normal airway for breathing.
Condylar Remodeling ‐ TheoryContralateral lateral deviation will gap and glide the condyle anteriorly on the eminence while the disc remains positioned correctly. Biting in this position creates a co‐contraction of the musculature acting on the disc and facilitates stabilization
Posterior TemporalisDeep MasseterSuperior Lateral Pterygoid
Condylar Remodeling
Condylar Remodeling ‐ TheoryThe return to midline while maintaining the contraction creates a coupling force.
Approximates the natural condylar‐disc‐eminence relationships with motion. Theory suggests the biconcave disc can reform to the approximated condyle and eminence.
Exercise Phases for RehabRest device gently between front teeth
Phase I ‐ Roll device away from affected side.Phase II ‐ After roll, gently bite down as if to make an impression on the device. Phase III ‐ After bite, maintain force onto device and return to midline
Do all exercises six times three times per day.
Condylar Remodeling ‐Modifications
ProtrusionWhile maintaining bite, protrude jaw
With ResistanceProvide gentle distraction on device while maintaining gentle bite
Furto ES, Olson KA, Whitman JM, Cleland JA.
Furto ES, Cleland JA, Whitman JM, Olson KA. Manual Physical Therapy interventions and exercise for patients with temporomandibulardisorders. J of Craniomandibular practice. 2006; 24 (4):283‐291
Background & PurposeTemporomandibular disorder (TMD) is a relatively common and often disabling condition, yet little evidence exists to support the effectiveness of rehabilitation programs for this patient population. The purpose of this study was to investigate the outcomes of a consecutive series of patients with TMD who were treated with manual physical therapy interventions and exercise.
MethodsAll patients (14/15 female) received a comprehensive upper quarter examination, including a manual physical therapy assessment of the bilateral temporomandibular joints (TMJ), the cervical spine, and the upper thoracic spine and rib cage.Manual physical therapy techniques were used to address identified impairments in the TMJ and upper quarter. Home exercises were prescribed to reinforce the manual therapy interventions.Patients completed a self‐report questionnaires at baseline and 2‐week follow‐up. Outcomes included the Temporomandibular Index, body diagram, the Patient Specific Functional Scale, and the Global Rating of Change scale (GROC).
Data AnalysisDescriptive information, including patient gender, age and duration of symptoms, was recorded for all patients.The mean change score and associated 95% confidence intervals were calculated for all outcome measures assessed at baseline and at the 2‐week follow‐up. Paired t‐tests were performed between the baseline and 2‐week follow‐up scores (a=0.05) to evaluate if the experienced change was significant.
ResultsPatients had experienced symptoms in the TMJ region for a median duration of 6 months (range 0.07–120 months). Thirteen had associated headache symptoms for a median duration of 6 months (range 0.07–60 months).At the time of the two‐week follow‐up session, the group had received a mean of 4.3 (0.98) physical therapy intervention sessions.The mean TMD Disability Index scores were 32.1% (15.4%) at baseline and 18.3% (12.5%) at the 2‐week follow up, representing an improvement of 13.9% (CI: 8.2%, 19.5%) (p<0.05).Seventy‐three percent (11/15) of patients reported they were “somewhat better” to “a very great deal better” on the GROC, and Patient Specific Functional Scale (PSFS) scores improved 3.1 points (CI: 2.3, 3.9) (p<0.05).
0
2
4
6
8
10
12
Basline 2-Week
PSFS
Sco
re (0
-10)
Patient Specific Functional Scale
PSFS: 0 = unable to do activity due to the problem, 10=able to do activity as before the problem; Score is average of 3 activity scores
05
101520253035404550
Basline 2-Week
TMD
Sco
reTMD Disability Questionnaire
Higher scores mean higher levels of disability
0
1
2
3
4
5
6
7
TMD TMD & Associated Symptoms
GR
C S
core
(ran
ge -7
to +
7)Global Rating of Change Scale (GRC)
Score of -7= “a very great deal worse”, 0=“no change”, +3=“somewhat better”,
+7=“a very great deal better”.
DiscussionPatients with temporomandibular disorder who are treated with a rehabilitation program including manual physical therapy interventions plus exercise can demonstrate clinically meaningful improvements in disability and overall perceived change in a relatively short period of time.
Continued research is needed to identify the long term effects and to determine if a specific subgroup of patients most likely to benefit from a manual physical therapy approach exists as well at to determine whether this mode of treatment is more beneficial than other management strategies for patients with TMD.
TMD Classification Interventions
Exercise-
Iontophoresis
Stabilization exercises
Hypermobility Capsular Fibrosis
Classification Criteria
Classification Criteria
Classification Criteria
TMJ mobilization Mobility exercises
Sustained stretch
Ultrasound?
Capsulitis
TMD Classification Interventions
Mobility, stability and proproprioception exercises
STM techniquesJt mob
Exercise—Mobility, stability and
proprioception
Post surgical
Classification Criteria
Classification Criteria
Muscles of Mastication Disorders
TMD Classification Interventions
Exercise-mobility, stability, and proprioception
TMJ mobilizationExercise-mobility,
stability, and proprioception
TMJ mobilization
Disc dislocation without reduction
Classification Criteria
Classification Criteria
Disc dislocation with reduction
EducationLimit parafunctional activities: nail biting, gum chewing, clenching and grinding teethTongue position: at rest, the tip of the tongue should be at the ridge of the roof of the mouth with the front one third of the tongue on the roof of the mouthTeeth position: the teeth should be 2 to 3 mm apart at restLips should be lightly together with breathing through the noseKeep the tip of the tongue up on the roof of the mouth when yawningAvoid sleeping in the prone position Do not rest chin in handsSoft diet: avoid hard crunchy foodsCut food up into small bites Warm water rinsesPostural and TMJ exercises 5‐6 times per day