Temporomandibular Disorders and Physical Therapy Interventions

Brittany Annis, Physical Therapy Student Ithaca College, February 2009

Temporomandibular Disorders (TMDs)

Different pathologies affecting the masticatory muscles, the temporomandibular joint (TMJ), and related structures Affects more than 25% of the population 90% of those seeking treatment are women

Signs/Symptoms
Facial pains/Muscle spasms Pain/tenderness in the muscles of mastication and joint Joint sounds (popping, clicking) Limited jaw motion Jaw locking open or closed Headaches Teeth grinding Abnormal swallowing Uncomfortable off bite Inability to comfortably open/close mouth Dizziness/vertigo Ringing in the ears Visual disturbances Insomnia Tingling in hands/fingers Deviation of jaw to one side

Additional Symptoms
People with temporomandibular dysfunctions frequently report symptoms of depression, affected sleep quality, and a decrease in energy. It may also interfere with personal relationships and normal social activities.

Causes
Trauma Excessive stress Arthritis of the TMJ Whiplash injury Postural abnormality Ligamentous laxity Psychosocial distress (stresses) Bruxism (teeth grinding) Unaligned teeth Congenital Jaw abnormalities Prolonged mouth breathing Thumb sucking

TMJ Anatomy
Osseous Anatomy
The articulation between the condyles of the mandible and the temporal bone, which is part of the cranium. The articular surface of the condyle is convex and the articular eminence of the temporal bone is concave.

TMJ Anatomy
Meniscal Anatomy
Oval-shaped fibrocartilaginous articular disk (meniscus) between the osseous components of the joint. The central, intermediate portion of the disk is thin while the anterior and posterior aspects, or bands, are thicker. The bilaminar zone attaches to the posterior disc assists the head of the condyle in moving forward.

Ligaments
Temporomandibular ligament Stylomandibular ligament Sphenomandibular ligament

TMJ Musculature
Four muscles of mastication that move the mandible:
Masseter Temporalis Medial Pterygoid Lateral Pterygoid

TMJ Biomechanics
Two motions:
First 20mm of motion is rotation. The mandible and meniscus move anteriorly together beneath the articular eminence while opening or closing. Second motion is translation, which slides the jaw further forward or from side to side.

Normal TMJ
The TMJ allows the jaw to open, close, protrude, retract, and deviate laterally. Mainly used for chewing and speaking Normal opening 35-40 2 to 3 knuckles

TMD Treatment
Working together:
Dentists Orthodontists Psychologists Physical Therapists Ear, Nose, Throat Doctor Physicians Alternative Medicine

TMD Examination
MRI X-Ray Dental examination for bite alignment

Physical Therapy Treatment

Physical Therapy is an important aspect in the treatment for TMD to:
Relieve musculoskeletal pain Decrease inflammation Restore normal joint/muscular movements for oral motor function Correct poor posture

TMJ Evaluation
History Posture Watch, feel, listen to jaw with AROM Opening between 40-50mm Protrusion/retraction between 8-10mm Lateral deviation while opening (S or C curve) Lateral excursion 8-10mm Ligamentous Laxity testing Transverse Ligament Alar Ligament Cervical ROM testing Palpate joints/muscles for tenderness

Postural Examination
Forward head Thoracic kyphosis Soft tissue dysfunctions ADLs/Occupational activities

Types of Treatment
Therapeutic Exercises Manual Therapy Modalities Electromyographic (EMG) Biofeedback Dental Splint

Therapeutic Exercise
Improve muscular coordination Increase muscular strength Postural exercises Active ROM exercises Muscles of mastication Cervical spine muscles General mobility

Techniques: Tongue Proprioception and Control

Make a clicking sound with the tongue on the roof of the mouth. This slightly opens the jaw with the tongue on the palate behind the front teeth, which is the resting position of the jaw and the first portion of relaxation exercises. Place tip of tongue on palate behind teeth and draw small circles. Place tip of tongue on hard palate and blow air out, rolling the tongue, or making a r r r r sound.

Techniques: Control of Jaw Muscles

Begin with proper resting position of the jaw. Teach the patient control while elevating and depressing the mandible throughout the first half of the ROM. Keeping the tongue on the roof of the mouth, the patient opens the mouth while trying to keep the chin in midline. Use a mirror for visual reinforcement. If the jaw deviates to one side, teach the patient to practice lateral deviation to the opposite side without creating pain or excessive motion.

Strengthening Exercises
Periscapular mm Trunk Extensors Shoulder External Rotators

Rocabados 6x6 Program

Six components Repeat six times each Perform six times/day Targets the craniocervical and craniomandibular systems Educate/instruct patient during treatment, then issue for HEP

Rocabados Program
1) Tongue Rest Position Lips together, teeth slightly apart. Anterior 1/3 of tongue against roof of mouth with slight pressure. Breathe through nostrils, and use diaphragm for deep breathing. 2) Control TMJ Rotation While opening jaw, keep anterior 1/3 of tongue on roof of mouth to limit movement to rotation only, no protrusion. Instruct patient to chew in this manner- without translation/protrusion. 3) Rhythmic Stabilization Technique Lightly resisted motions: opening, closing, lateral deviations

Rocabados Program
4)

Cervical Joint Liberation Distract the upper cervical vertebrae by clasping hands behind neck to stablize C2-C7, and flex head 15 degrees for distraction. Not neck flexion exercise, but flexion of the head on the cervical spine. 5) Axial Extension of Cervical Spine Push posteriorly on the upper jaw into lower cervical spine extension and slight flexion of the occiput. This reduces unnecessary cervical mm. activity and improves the functional relationship between the head and cervical spine. 6) Shoulder Girdle Retraction Draw shoulders back and down.
Restores shoulders to normal postural position to reduce tension and increase stability.

Manual Therapy
Massage Joint Mobilizations Muscle stretching (passive and active) Myofascial Release Manual Traction Trigger Points Relaxation techniques
Reduce pain Increase mobility Restore oral range of motion

Massage
Masseter mm Thumb inside mouth, fingers on cheek- sweeping motion to angle of jaw Cross-friction massage parallel to inner and outer fibers of mm. If trigger point, focus there

Temporalis
Circular motions Sternocleidomastoid
Corn Cob technique

Postural mm. Face, shoulders, back of neck Pressure on sensitive points, massage with hard, slow, short strokes

Stretching Tissues
If the jaw is restricted from opening, determine if the cause is:
A dislocated meniscus, which can be repositioned by joint mobilizations, or Hypomobile tissues, which can be passively lengthened with stretching as well as joint mobilizations.

Stretching
Passively increase jaw opening by placing thumbs on last molars of lower jaw and adding slight caudal pressure until the patient can insert the knuckles of the index and middle fingers.
Also focus on:
Upper and Lower Trapezius Sternocleidomastoid Masseter Temporalis Suboccipital/Posterior Cervical mm Scalenes Rotator Cuff mm. Pectorals

Resisted Stretching
Mandibular Opening
Open to widest point Place both thumbs inside mouth on molar surface Resist light closure for 6 seconds Relax 6 seconds Open further, repeat 35x Lateral Mandibular Movement Mouth slightly open Move mandible laterally Resist medial movement for 6 seconds Relax 6 seconds Laterally deviate further, repeat 3-5x

Joint Mobilizations
Long Axis Distraction:
Sitting/Supine PT positioned opposite of affected side Use hand opposite of affected jt. side Thumb in mouth on last molar Apply gentle downward pressure with thumb Hold for ~30 seconds 23x/session Bilaterally

Anterior Glide
Same hand placement Slightly distract using DIP of thumb while gliding anteriorly Oscillate for 30 seconds

Joint Mobilizations
Lateral Glide
Thumb on tongue side of last molar Use whole hand to oscillate laterally

Medial Glide
Stand on affected side Thumb on lateral side of last molar Glide medially

Electrophysical Modalities
Increase blood flow to the area Relax tense muscles Reduce inflammation Reduce pain Increase range of motion for joint opening and lateral deviation
Moist Hot Pack Cold Pack Ultrasound Transcutaneous Electrical Nerve Stimulation (TENS) Laser Shortwave Diathermy

Preventing TMD
Avoid:
Large bites Excessive chewing Removing food from teeth with tongue Gum chewing Chewy foods: bagels, sandwiches, steak, ice, crunchy fruits/vegetables, caramel, nuts etc.

Relaxation techniques to reduce stress/muscle tension Maintain good posture

Bibliography
McNeely, Margeret L., Susan Armijo Olivo, and David J. Magee. "A Systematic Review of the Effectiveness of Physical Therapy Interventions for Temporomandibular Disorders." PT Journal 86 (May 2006): 710-25. Physical Therapy. 27 Jan. 2009 <http://www.ptjournal.org/cgi/content/full/86/5/710?maxtoshow=&HITS=10&hits=10&RESULTFO RMAT=1&title=temporomandibular&andorexacttitle=and&andorexacttitleabs=and&andorexactfullt ext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT>. Medlicott, Marega S., and Susan R. Harris. "A Systematic Review of the Effectiveness of Exercise, Manual Therapy, Electrotherapy, Relaxation, and Biofeedback in the Management of Temporomandibular Disorder." PT Journal 86 (July 2006): 955-73. Physical Therapy. 27 Jan. 2009 <http://www.ptjournal.org/cgi/content/full/86/7/955#T3>. Kisner, Carolyn; Lynn Allen Colby. Therapeutic Exercise, Foundations and Techniques. 2002 http://www.nismat.org/ptcor/tmj http://uwmsk.org/tmj/anatomy.html http://www.nlm.nih.gov/medlineplus/ency/article/001227.htm http://udel.edu/~spetter/TMJWebsite/anatomy.htm