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Temporomandibular Joint Dysfunction Diane L. Viola Union County College June 14, 2011
. Physical therapy approaches to TMD have been detailed according to research studies documenting therapeutic interventions that provide the most significant relief from the myofascial pain of TMD. This paper gives a basic understanding of how the Temporomandibular joint functions. dysfunctions of the joint.Temporomandibular Joint Dysfunction 2 Abstract Effective treatment of Temporomandibular Joint Dysfunction (TMD) has changed over the past ten years. However. Malocclusion or a faulty joint was the common diagnosis and surgeries on the jaw and/or dental work were the preferred treatments. and therapeutic options available. research on the sources of TMD pain are allowing patients more treatment options without surgery or permanent structural changes to the jaw or teeth.
Temporomandibular Joint Dysfunction 3 Temporomandibular Joint Disorder Temporomandibular Joint Disorder (TMD) refers to an altered functioning of the Temporomandibular Joint.). The following charts details the muscles and structures involved. however this term is somewhat generalized as it does not identify the pathology that is causing the dysfunction. 2. There is an intra. the disk articulates with the mandibular fossa of the temporal bone and inferiorly it articulates with the condyle of the mandible. Masseter. This multifaceted musculoskeletal disorder can consist of many factors and conditions that can either be a cause or an effect of this disorder. The Temporomandibular Joint is connected to several different muscle groups which aides in the difficulty of isolating the symptoms from the problem. Medial Pterygoid and Lateral Pterygoid (“Standard of Care: Temporomandibular Joint Disorder” 2007 p. Temporomandibular Joint The TMJ is a synovial joint that connects the temporal bone and the mandible. Main muscles of TMJ Temporalis Masseter Action Bilaterally: elevation. Determining which structures can be categorized as causation factors and which ones are effects of the disorder will help establish the most effective form of therapy the patient.articular disc that articulates with two surfaces. retrusion Unilaterally: ipsilateral lateral deviation Bilaterally: elevation Unilaterally: ipsilateral lateral deviation . Superiorly. The Temporomandibular ligaments limit motions of the joint in all directions and the main muscles of the joint are the Temporalis. Superiorly it is a plane joint and inferiorly it is a hinge joint The temporal bone has a notch just in front of each ear. The mandible has condyles at each end that fit into the temporal notches to form the joint.
the mandible rotates in the mandibular fossa and as the mouth opens wider the condlyes of the mandible glides downward and forward under the articular eminence of the temporal bone. Inferiorly: attaches to the neck of the mandibular condlye Connected to capsule and tendon of lateral pterygoid.2011 p. The motions that occur at the mandible are depression. breathing. protusion/retrusion. 1). Biomechanics of the TMJ Action limits downward. and lateral excursion with accessory motions of rotation in the inferior TMJ and translation that occurs in the superior TMJ (“Standard of Care: Temporomandibular Joint Disorder” 2007 p. 201-203) The Temporomandibular joint is a highly active joint. swallowing and yawning.Temporomandibular Joint Dysfunction 4 Medial Pterygoid Lateral Pterygoid Suprahyoids Bilaterally: depression. opening and closing up to 2000 time per day accommodating the bodies need for chewing.. Ipsilateral rotation and contralateral translation of the condyles . During the initial opening of the mouth. talking. posterior and lateral motions of mandible Suspends mandible and limits excessive anterior motion Helps limit excessive anterior motion Rotates anterior/posterior Glides anterior/posterior (Lippert. protrusion Unilaterally: contralateral lateral deviation Bilaterally: elevation Unilaterally: contralateral lateral deviation Mandibular depression Structures Temporomandibular Ligament Sphenomandibular Ligament Stylohyoid Ligament Joint Capsule Articular Disk Attachments neck of mandibular condyle and disk to temporal tubercle Sphenoid styloid process to middle ramus of mandible Temporal styloid process to the hyoid bone Superiorly: articular tubercle and borders of the fossa of temporal bone.
Forward head posture can also cause repetitive stresses on these muscles. joint ligament laxity and structural deformities whether trauma related or congenital. returning to normal position. 2. Internal derangement of the disk involves displacement of the intra-articular disk as it moves anterior or posteriorly between the temporal bone and mandibular condlye.Temporomandibular Joint Dysfunction 5 allow for lateral deviation. (Beale. headaches and dizziness. Symptoms can range from jaw.2) Muscle disorders often involve spasms of the masticatory muscles. both OA and RA can affect the TMJ and increase the risk of TMJ disorders. 2011 p. These imbalances can cause disturbances or impairments in mandibular pattern or functional movements. joint. subluxation of TMJ. Signs of anterior displacement are clicking and popping upon mouth opening and closing. Repetitive stresses such as emotional tension may lead to bruxism or jaw clenching. Posterior displacement can cause jaw locking or catching in the open mouth position. Subluxation of the TMJ can occur from poor muscle control. internal disc derangement.). Classification can overlap when problems with one system alter the balance of another. 202-203) Pathologies Most TMD can be classified into four groups: muscle disorders. Those with RA and juvenile RA have a higher risk of developing TMD due to cervical . Re-establishment of normal joint mechanics is an integral part of rehabilitation and restoration of functional jaw movements (Lippert. and arthritic conditions (“Standard of Care: Temporomandibular Joint Disorder” 2007 p. cervical and facial muscle pain to earaches. Displacement can be permanent or with reduction. Subluxation can occurs as bilateral or unilateral and can affect both the translation and lateral deviation of the mandible. 2008 p. Conditions of arthritis.
The effects of postural training as single intervention have not been documented. decreased pain and impairment. biofeedback.Temporomandibular Joint Dysfunction 6 spine complications. While there seems to be a lack of quality controlled studies comparing specific modalities and treatments of TMJ. A system review. may have decrease pain.(Medlicott and Harris.laser therapy • In acute or chronic TMD use of relaxation training. • Patients with TMD secondary to disk displacement. Women are more prone to TMD than men are (“Standard of Care: Temporomandibular Joint Disorder” 2007 p.) Interventions Noninvasive intervention is usually the first step in treating TMD. It is impossible to determine if combination programs are more effective than individual treatments. manual therapy. literature does support physical therapy as a component of noninvasive care for TMD (Beale. and mylofascial TMD. 2008 p. 2. postural correction and relaxation techniques may provide increased TVO. arthritis. of physical therapy interventions of TMD management offered the following clinical recommendation: • Active exercises and manual mobilizations may be effective for increasing Total Vertical Opening (TVO) for acute cases of disk displacement. EMG training. 4). improved lateral deviation and increased TVO with use of MID. and proprioceptive training may produce more positive effects than occlusal splints or placebo by reducing pain and increasing TVO. in 2006. • Postural training may reduce pain and improve TVO when combined with home exercise programs or other treatment techniques. 2006 p961) . • Combination programs of active exercise.
Problems Interventions Research of Therapeutic Interventions . clear out any adhesions. 2010 p 6). Transection of madibular ramus to change condylar/disc/glenoid fossa relationship Open incision of joint to allow for multiple procedures. irrigate the joint and inject corticosteroids. however there have been studies on combinations of exercise and modalities that have showed significant pain relief for patients with TMD. Raoul. The following chart detail some types of TMJ surgery. The following chart outlines research data on the most effective therapeutic interventions for treatment of TMD pain and functional mandibular rhythms. however.Temporomandibular Joint Dysfunction 7 In cases when non-invasive surgery does not provide significant pain relief or pathology modification surgery is another option. Repositioning or repairing disc. Removal of condyle Total joint replacement Removal of disc with or without replacement (Beale. Steroids or lubricants may be injected into the joint. Surgery Arthrocentesis Arthroscopy Condylotomy Arthrotomy Plication Condylectomy TMJ replacement Discectomy Description Creates hydraulic pressure within the joint space to clear out any extra scar tissue and increase mobility in the joint. 2009 p 2-4) Surgery does provide beneficial effects on TMJ dysfunction. Kleinheinz. Arthroscopic surgery to visual damage. Ferri. Physical Therapy Interventions Research on individual methods of physical therapy have not been documented. research data supports evidence that patients with TMD of a muscular origin get more relief from surgery than those with mainly articular origins (Dujoncquoy.
shortwave diathermy. isometric exercises. Physical Agents: Superficial heat and ice packs Manual Therapy: Manual mobilizations of the TMJ Massage 74% improvement of pain compared to placebo.B R= relax T= teeth apart say the wore “Emma” T=“cluck” tongue and leave on roof of mouth P= posture. Mnemonic R.T.Temporomandibular Joint Dysfunction 8 Pain on palpation Pain with function of jaw unilaterally and bilaterally Electrotherapeutic: US. Referral to other disciplines (Beale 2008.condylar remodeling exercises provided significant improvement in limitation when used in combination with Postural correction. magapulse and laser. Stretching exercises. Some studies indicate significant pain reduction and mouth opening with laser therapy (red and infrared light used to reduce pain and swelling and accelerate healing).P. relaxation techniques. stretching. breathing and postural exercises. May have palliative effect Limited jaw opening Impaired posture Therapeutic exercise Decreased knowledge of habit modification. imagine strings from back of head and front of sternum pulling to ceiling B= breathing. The study include mobilization in combination with massage of the temporalis and masseter muscles. Patient education about the nature of the problem and prognosis. manual therapy. relaxation techniques Home exercise program Found to reduce pain and improve oral opening in a study of patients with anterior disk displacement. naso-diaphragmatic Dentist and clinical psychologist along with physical therapist may work as a team to benefit the patient. manual joint distraction.T. stabilization exercises mobilization exercises . Occluant splints may help with nocturnal bruxism and a study published in 2006 found cognitive behavior therapy helped reduce pain and mandibular impairment. p 5-9) . relaxation. breathing training and massage. Educate to reduce over use of masticatory system.
disciplinary approach which includes massage.Temporomandibular Joint Dysfunction 9 Conclusion While more detailed research needs to be compiled in order to provide the best care for those patients with TMD. isometric exercises. occluent splints and cognitive behavior therapy. current research supports a multi. Surgery can offer relief to those patients whose TMD is a result of trauma or congenital deformity of the jaw or teeth. . however physical therapy still plays and integral role in the healing and functional recovery from those surgeries. stretching.
& Harris. Dujoncquoy. M. Standard of Care: Temporomandibular Joint Disorder. (2006). Retrieved June 4. relaxation training.d. Retrieved June 4. and biofeedback in the management of temporomandibular disorder. 2011.org Beale. Retrieved June 2. Beale. Philadelphia: F. Davis. Ferri. 2011.). (2008).brighamandwomens. (2011). K. A systematic review of the effectiveness of exercise. J. Retrieved June 2.. S. from the Head & Face Medicine database.apta.A. (2010). Raoul. & Kleinheinz.org . Oct. 955-973. from http://www.. from the EBSCO database.. J. (n.Temporomandibular Joint Dysfunction 10 References Brigham and Women's Hospital . G. pp. manual therapy. 86. Temporomandibular joint dysfunction and orthognathic surgery:a retrospective study. 6(27). J. Lippert. Retrieved June 4.. from www. 2011. 201-204). Head and Face Medicine.ptjournal.. Nov 6(24). 2011.A Teaching Affiliate of Harvard Medical School. from the EBSCO database. CINAHL Rehabilitation Guide. 2011. K. Temporomandibular joint disorder. L. Physical Therapy. Shoulder Girdle. Clinical kinesiology and anatomy (5th ed. (2009). Temporomandibular joint disorder:postsurgical managmement. electrotherapy. CINAHL Rehabilitation Guide. Medlicott.