Chapter 23

The Temporomandibular Joint

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 Anatomy and Kinesiology
 Bones of skull, mandible, maxilla, hyoid, clavicle,
sternum, shoulder girdle, and cervical vertebrae
 TMJ and dentoalveolar joints (e.g., joints of teeth)
 Cervical spine
 Muscles and soft tissues of head and neck and muscles
of cheeks, lips, and tongue

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 Stomatognathic System
Teeth

Muscles Joints

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 Bones Movements of Mandible
 Mandible – Ramus and  Elevation
two condyles.  Depression
 Temporal bone – Articular  Protraction
tubercle, eminence,  Retraction
mandibular fossa,
 Lateral gliding
posterior glenoid spine
 Hyoid bone.  Combinations of above

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TMJ – 2 Joints

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 Muscles

 Temporalis  Mylohyoid
 Masseter  Genohyoid
 Medial pterygoid  Omohyoid
 Lateral pterygoid
 Digastric

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Muscles

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 Tongue

 Genioglossus is main muscle responsible for

positioning of tongue.
 Active in protracting and elevating tongue.
 Anterior open bite, airway compromise, etc. are
indicative of parafunctional habits (tongue thrust,
etc.).
 Tongue position/habits will also influence
cervical spine.

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 Kinetics
 TMJ, teeth, and cervical spine are intimately related.
 Cervical posture affects mandibular path of closure.

 Forward Head Posture (FHP) – 2 types

1. With posterior cranial rotation (PCR)

2. Without posterior cranial rotation

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FHP – With PCR and Without PCR

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Examination and Evaluation
Subjective

 Onset of symptoms
 Incidence of joint
locking
 Presence of joint
noise
 History of surgery
 Pain (intensity,
frequency, location)
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 Pain Examination (Palpation)

Tenderness, Warmth, and Inflammation

 Mandible, hyoid, TMJ

 Relevant joints of upper quadrant, cervical, and
upper thoracic spine
 Muscles
 Relevant trigger points and tender points of
fibromyalgia

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Mobility Impairment Examination

 Active and passive physiologic ROM of

cervical and thoracic spine
 TMJ: A/PROM – Vertical opening, lateral
excursion, protrusion
 Joint function (TMJ translation and rotation)
 Muscle tests (length, test, control)
 Mobility of nervous system (if indicated)

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ROM Exercises

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 Therapeutic Exercise for Common
Physiologic Impairments
Hypomobility
 Limitation of functional movements.
 May result from disorders of mandible or cranial bone (dysplasia,
hypoplasia, etc.).

Treatment
 US + stretching or AROM to increase extensibility of tissues.
 Self-stretch exercises.
 Post isometric relaxation (PIR) techniques.

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 Hypermobility

 Heat and ice if condition is painful.

Muscle Performance

 TMJ rotation and translation control.

 Strengthening and stabilization exercises.
 Isometric or static exercises.
 Dynamic exercises.

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Isometric Stabilization

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Posture and Movement Impairments
 FHP with rounding of shoulders and TMJ
signs/symptoms.

Treatment

 Neuromuscular relaxation training.

 Head, neck, and shoulder postural training.
 Mandible and tongue postural exercises.
 Swallow sequence and breathing exercises.

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 Therapeutic Exercise Interventions for
Common Diagnoses

Capsulitis and Retrodiskitis

 Inflammation response in fibrous capsule, synovial
membrane, retrodiskal tissues.

Treatment
 Ice, moist heat, massage, US, etc. to reduce pain.
 Joint stabilization splint, anterior repositioning appliance.
 Stretching and PIR techniques.

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 DJD/Osteoarthritis

 Treatment

 AROM exercises
 Mobilization techniques
 Stretching techniques

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 Derangement of the Disk
Anterior Dislocated Disk with Reduction

 Anterior repositioning appliance

 Non-repositioning appliance (flat plane splint)
 Heat, ice
 Education to relax muscles (SEMG feedback to
reduce muscle activity)

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 TMJ Clicking

 Lower jaw thrust exercises

 Noninvasive isometric
exercises
 Mandibular stabilization
exercises

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Anterior Dislocated Disk Without
Reduction

 Joint mobilization techniques

(distraction and translation)
 Soft tissue mobilization
(myofascial release and
massage)
 Therapeutic modalities

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 Surgical Procedures

Postoperative Arthroscopic Surgery

 Intraoral joint mobilization techniques
 Active isometric and dynamic exercises
Postarthrotomy Surgery
 Massage of temporalis and inferior to masseter
 Soft tissue mobilization techniques
 Friction massage
 Acupressure
 Myofascial release or manipulations

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 Adjunctive Therapy

Surface Electromyography

 Tension recognition/discrimination training

 Threshold-based relaxation training
 Nocturnal SEMG feedback

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 Summary
 Relationships of stomatognathic system requires
a thorough evaluation and integrated treatment
approach.
 FHP affects the position of mandible, tongue,
hyoid, altering rest position, swallowing function,
airway, and muscle balance.
 Proper positioning of the tongue is essential to
maintain ideal resting position of mandible and
promotes normal swallowing function.

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 Summary (cont.)

 Hypomobility of TMJ may result from various

conditions. Treatment seeks to reduce
inflammation and pain and to increase function.
 Hypermobility is usually bilateral; however, it
occurs unilaterally when there is a unilateral
restriction.
 Postoperative rehab can be 6–12 months.
Intervention includes reducing inflammation and
begin A/PROM.

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