Temporomandibular disorders Mgr. Veronika Mrkvicová, Ph.D. (physioterapist) Physiotherapy Department, Medical Faculty, Masaryk University Physiotherapy, Stomatology (2024) Contents nTemporomandibular joint (TMJ) • nTemporomandibular joint dysfunction (TMD) • nExamination of TMD • nTreatment of TMD • nPhysiotherapy of TMD Introduction •The temporomandibular joint (TMJ) •- the most active joint in the body (located on each side of the cranium) •- needs to open and close up to 2000 times a day (chewing, talking, breathing, swallowing, yawning, and snoring...) • •Relations -the jaw, cervical spine, alignment of the teeth are integrally related -dysfunction in one of these regions may lead to a temporomandibular joint disorder (TMD) • •TMD = a term used to describe a variety of clinical disorders resulting in jaw pain or dysfunction, which is very frequent in population, needs to be diagnosed early on and tread complexly (typically by the team of medical professionals: stomatologist, physiotherapist, physiatrist, orthodontist, neurologist,…), most often using conservative therapy Masticatory system Anatomy TMJ and most of the muscles of mastication are innervated by the mandibular branch of the trigeminal nerve (cranial nerve V) Therefore, pain may be referred to neighbouring areas on the face in the distribution of CN V Temporomandibular joint (TMJ) nThe two bones that form the TMJ are the mandible (jaw) located inferiorly, and the temporal bone of the skull (located superiorly) • nA disc that is connected to the capsule divides the joint cavity into inferior and superior spaces Temporomandibular joint (TMJ) The muscles of the TMJ (masticatory muscles) Muscle function Elevation: Temporalis, masseter, medial pterygoid of both sides Depression: Lateral pterygoids (hyoid muscles) Protrusion: Lateral and medial pterygoids. Retraction: Temporalis (posterior fibres) Lateral movements: Medial and lateral pterygoids of each side working alternatively Unique characteristics of masticatory muscles Have shorter contraction times than most other body muscles Incorporate more of muscle spindles to monitor their activity Do not have golgi tendon organs to monitor tension Elevators predominantly white fibrous which perform fast twitching Do not get fatigued easily Psychological stress increases the activity of jaw closing muscles Occlusal interferences cause a hypertonic synchronous muscle activity Closing movement also determined by the height of the teeth Movements of the TMJ Movements of the TMJ •Three motions occur at the mandible: •- depression (during mouth opening) •- protrusion/retrusion (or protraction/retraction) •- lateral excursion (right and left) • •Accessory motions of rotation, which occurs in the inferior portion of the TMJ, and translation (gliding), which occurs in the superior portion of the TMJ, allow for proper function of the joint. • •Both TMJ must work in coordination in order to allow normal movement to occur •for the purpose of chewing and speaking • •TMJ movement video: •https://www.youtube.com/watch?v=lP_VPiYnyNs • Temporomandibular Joint Dysfunction (TMD) Temporomandibular Joint Dysfunction (TMD) • nTMD describes a variety of conditions that affect jaw muscles, temporomandibular joints, and nerves • nTMD can be associated with chronic facial pain • nSymptoms may occur on one or both sides of the face, head or jaw, or develop after an injury • nTMD affects more than twice as many women than men and is the most common non-dental related chronic orofacial pain. TMD • nThe most common dysfunctions associated with the TMJ are: muscle imbalances, hypomobility or hypermobility n nThe synovium, retrodiscal tissue and the capsule are some of the tissues that can become affected in the TMJ TMD nTMD can be often overlooked • nSome of the more common symptoms include clicking or popping with opening or closing of the mouth, pain around the jaw joints, locking of the jaw, headaches and an improper bite (teeth do not fit together properly) n nTMD video: https://www.youtube.com/watch?v=Dd3aT9c_08M n • Types of TMD patology •a) muscle disorders • •b) internal disk derangement (with or without dislocation of the disk) • •c) subluxation of the TMJ • •d) arthralgias or arthritic conditions A. Muscle disorders •- myofascial pain syndrome (TPs, reffered pain) • •- emotional stress/tension which may lead to bruxism • •- postural dysfunction (forward head posture, resting the head in the hand), may also lead to muscle pain in the jaw from repetitive stress • •- spasm of the masticatory muscles (most frequently involving the lateral pterygoid) • •- fibromyalgia B. Internal derangement of the disk •It refers to an abnormal relationship between the function and position of the intraarticular disk and its two articulating surfaces • •The classic sign of internal disk derangement is joint clicking • •The most common derangement is an anterior disk dislocation, which can occur with or without reduction of the disk C. Subluxation of the TMJ •Most often cause: poor muscular control or laxity of the articular ligaments •It can have long term consequences leading to TMD and internal disk derangement if left uncorrected •Predisposition for subluxation may occur as a result of a structural deformity, usually congenital, or alterations in the ligamentous structures •Signs of TMJ subluxation include excessive mandibular opening, excessive mandibular translation and joint noise at the beginning of mouth closing •Unilateral subluxation will result in a lateral deviation from midline to the contralateral side at the end of mouth opening http://2.bp.blogspot.com/-VjA7K93R2x8/T8Y_EblK4yI/AAAAAAAAA1w/yyZRUlcU-JY/s1600/image20.jpg D. Arthralgias or arthritis conditions •Structural disorders that affect the TMJ include: •- osteoarthritis (OA) •- rheumatoid arthritis (RA) •- juvenile rheumatoid arthritis (JRA) •- ankylosis • Other possible causes for TMDs • nTrauma to the joint–blow to the jaw or head • nBirth/Congenital trauma • nWhiplash injury • nExcessive stress to the joint from: gum chewing, fingernail biting, yawning, chewing on a pen, chewing on ice, and grinding teeth • nProlonged mouth and upper respiratory breathing • nJaw abnormalities, missing teeth, poor bite (malocclusion) • nLigamentous laxity Malocclusion nProper bite nPoor bite Forward Head Posture Common signs and symptoms of TMDs nClicking or popping with opening or closing nPain at rest or with opening/closing of jaw nDecreased ability to open the jaw (hypomobility) nNeck pain nTooth sensitivity nDry or burning sensation in mouth nUncomfortable bite nForehead or temple headache nBuzzing or ringing in ears nHearing loss Examination Examination of the articulatory system nCase history nObservation nPain and other complaints nRange of movement nJoint sounds nFunctional activities nOcclusion, signs of bruxism nDiagnostic imagine nCervical spine and upper quadrant examination 1. Case history •Medical History: Review longitudinal medical record, review of systems and intake health screening tool •History of Present Illness: Determine course of symptoms and presence of trauma, previous surgery (e.g. dental implants), and/or repetitive trauma. Signs and symptoms of TMD – unilateral x bilateral. Note any history of clicking and locking, current or past use of mouth orthotics or splints (the results and the reason the patient stopped using the appliance, if applicable) •Social History: Daily habitual activities such as smoking, bruxism, chewing gum, snoring, leaning on chin, biting nails, lip biting, clenching teeth, etc. Work, household responsibilities, hobbies and/or recreational activities may involve repetitive stress and sustained postures, e.g. computer work. Emotional stress can trigger nervous habits or poor postural responses •Medications: Note relevant medications including NSAIDS, muscle relaxants, and other analgesics 2. Observation • •• Opening and closing of mouth: • teeth normally close symmetrically, the jaw is normally centered • •• Alignment of teeth: note cross bite, under or over bite • •• Symmetry of facial structures (eyes, nose, mouth) • •• Posture: forward head posture, rounded shoulders and scapular protraction is common • •• Breathing pattern: diaphragmatic breathing or accessory pattern http://3.bp.blogspot.com/--6HTus7uG3A/U2UPb1a-qrI/AAAAAAAAOvc/sFmHpaOerBY/s1600/eva_promena_3.jpg 3. Pain and other complaints •- movements that cause pain, including opening or closing of mouth, eating, yawning, biting, chewing, swallowing, speaking, or shouting. •- headaches and/or cervical pain •- pain may also be present in the distribution of one of the three branches of the trigeminal nerve • • Other complaints may include: - the feeling of fullness of the ear - tinnitus and/or vague dizziness http://www.cedars-sinai.edu/Patients/Programs-and-Services/Pediatric-Surgery/Patient-Guide/Pain-Fun ction-Assessment.jpg 4. Palpation Palpation of posterior aspect Palpation of lateral aspect (the little finger placed in the external auditory meatus, and pressure gently applied forwards) (a finger placed in the pre-auricular area, gently applying pressure on the lateral pole/head of the condial while the jaw is closed) Palpation •TMJ: • compare bilaterally • assess joint integrity • and structural deviations • •Muscles of mastication: • compare bilaterally • assess for pain and/or • muscle spasm • Three tests to reproduce pain •The pain associated with TMD can be reproduced in three ways: nthe preauricular exam, palpating the left and right preauricular areas over the TMJs nintraotic manipulation, inserting a fingertip in each ear and pulling as the patient opens and closes his mouth nintraoral examination, inserting the index finger and moving it along the cheek to palpate the pterygoid muscles at the rear of the mouth, where the maxilla connects to the mandible • The typical reflex manifestation of TPs in masticatory muscles •m. temporalis – local pain or its radiation into temple area or upper teeth •m. masseter – pain in the area of facial bone, hypersensitivity or pain of upper and lower teeth, unilateral tinnitus, pain in the ear and around TMJ •m. pterygoideus medialis – nonspecific pain inside the mouth, in the neck, the pain around the TMJ and inside the ear •m. pterygoideus lateralis – pain in the TMJ region, upper jawbone or around the ear •m. digastricus – dysfagia, the pain radiating into occiput, lower teeth or tip of the tongue 5. Joint sounds nThere are 2 types of joint sound to look out for: Clicks and Crepitus • •Clicks (single explosive noise) nrepresents the sudden distraction of 2 wet surfaces, symptomatic of some kind of disc displacement (left, right or bilateral, painful or painless, consistent or intermittent) • •Crepitus (continuos 'grating' noise) nthe continuous noise during movement of the joint, caused by the articulatory surfaces of the joint being worn (degenerative joint disease) • • nThe joint sounds should be listened to with a stethoscope 6. Range of motion nThis is the only truly measurable parameter, as the others are more subjective • •Movements to be measured are: nIncisal opening - pain free limit nIncisal opening - maximum (forced) nLateral mandibular excursions nMandible deviations on pathway of opening Range of motion •AROM: measure from top tooth edge to bottom tooth edge •• Opening and closing of mouth • Normal opening = 35-50 mm (3 knuckles between teeth) • Functional opening = 25-35 mm (at least 2 knuckles between teeth) •• Protrusion of mandible • Normal = 5 mm •• Lateral deviation of mandible • Normal = 8-10 mm •• Assymetrical movements, snapping, clicking, popping or jumps •• Deviations: lateral movements with/without return to midline • •PROM: apply overpressure at the end range of AROM to assess end feel A. Incisal opening nThe incisal opening is measured from the upper incisal tip to the lower, with the patient first of all opening to the limit of their comfortable, pain free range. n nThis is then compared to the normal range of motion • nTheir maximum (forced) limit is also recorded. • nto determine whether a limitation of vertical movement is due to pain (muscular problem) or a physical obstruction (disc displacement) B. Lateral Excursions • nThe lateral movement should be measured from mid-line to mid-line, the patient moving the mandible to their maximum extent, from one side to the other Measurement of maximum active opening and maximum lateral movement C. Mandibular deviation nWhen the jaw is opened, the path it follows should be straight and consistent • nDeviations from the norm are either lasting or transient, and are all suggestive of internal derangements of different sorts Functional activities Assess: chewing, swallowing, coughing, and talking Either have patient demonstrate task or ask for patient’s subjective report Include changes the patient has made to their own diet to accommodate for their pain and dysfunction Diagnostic imaging •Plain film radiography (X-ray): A/P and lateral views • •Ultrasound • •Arthrography • •CT scan • •Magnetic resonance imaging (MRI) • •Electromyography • •Arthroscopy Differential diagnosis •Non-musculoskeletal disorders may also cause facial and/or jaw pain including: • - infection • - dental problems (including malocclusion) • - trigeminal neuralgia • - parotid gland disorder • - other lesions of the face, mouth or jaw • •CAVE: examine the cervical spine and upper quadrant as a part of the TMJ evaluation http://improveyoursmile.co.uk/new/wp-content/uploads/2012/12/jaw-and-bite-problems.jpg Cervical spine and upper quadrant examination -Head and neck alignment -Cervical AROM/PROM -Muscles examination -Neurological examination (muscle strength, reflexes, senzation) Treatment Potential impairments and functional limitations •Potential impairments: •- Increased pain •- Limited AROM/PROM •- Impaired posture (forward head posture, protracted shoulders, mouth and accessory muscle breathing patterns, abnormal resting position of the tongue and mandible, and abnormal swallowing mechanism) •- Impaired motor control/strength •- Decreased knowledge of habit modification, relaxation techniques • •Potential functional limitations: •Inability to chew, cough, sneeze, swallow or talk without pain Treatment of TMDs • nMost often TMD can be treated conservatively • nA qualified clinician (e.g. a physical therapist, dentist, or orthopedist) can be consulted for an accurate diagnosis since many conditions can mimic the signs and symptoms common to TMD • nA combination of treatments is often need, depending on the severity of the case • Goals of the treatment •1. Reduce (or independently self manage) pain symptoms •2. Normalize ROM and sequence of jaw movements •3. Maximize strength and normalize motor control of muscles of mastication, cervical spine and periscapular region •4. Maximize flexibility in related muscles as indicated •5. Maximize postural correction in sitting and/or standing •6. Correct ergonomic set-up of workstations at home and/or at work •7. Independence with home exercise program •8. Independence with relaxation techniques Most commonly used physiotherapy interventions: an overview •• Modalities for pain control: heat, ice, electrical stimulation, TENS, ultrasound, laserotherapy •• AROM/AAROM/PROM •• Stretching (active, assisted and passive stretching) •• Joint mobilization or manipulation (restore normal joint mechanics of the TMJ, C/Th spine) •• Soft tissue mobilization, myofascial release and deep friction massage •• Muscle energy techniques •• Neuromuscular facilitation (hold-relax, contract-relax, alternating isometrics) •• Relaxation techniques •• Biofeedback and EMG training (to promote muscle control and relaxation) •• Therapeutic exercises •• Changing or stopping poor habits (including grinding or clenching teeth) •• Postural re-education and maintenance correct resting position of the tongue and mandible •• Diaphragmatic breathing •• Home exercise program instruction Self-care for Management of Symptoms nHabit Modification nDiet Modification nPharmacological nHot compresses nDental Appliances nCold packs nPositioning nStress Management nPosture nMassage • • 1. Habit Modification • nTry to avoid the activity that is causing the increased stress to the joint such as nail biting, gum chewing, and ice biting • nYou may see a dramatic change in your symptoms by simply modifying these habits 2. Diet Modification • nEat a diet of soft foods in addition to chewing evenly • nYou may want to cut your food into small pieces which will help decrease overuse of the TMJ 3. Pharmacological • nAnalgesics and non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen can help to decrease pain and inflammation • nAntidepressants (tricyclic antidepressants, SSRI) • nBenzodiazepines • nHowever, you should consult with your physician before taking any of these medications 4. Hot or cold compresses nUse a washcloth soaked in warm/cold water or a commercial moist hot or cold pack over the area of pain or tenderness • •It is used to help reduce: nWarm: any muscle spasm you may be experiencing nCold: any swelling, pain and muscle spasm • nKeep the compress on for about 10-15 minutes • nIf the spasms are severe, try to use these compresses hourly 5. Dental Appliances • nYou may need some type of intra-oral splint, nightguard or other appliance which can be given by your dentist or physical therapist upon diagnosis • nThis may help to stabilize the TMJ so the muscles, teeth, and joints work together without adding additional strain to the TMJ • 6. Positioning • nThe best position to keep your TMJ in is with your teeth slightly apart and lips together • nPlacing the tongue on the roof of the palate (top of the mouth) to ensure the position is kept • ntry to breathe through your nose as much as possible 7. Stress Management • nstress is a common • contributing factor to TMD • ndeep relaxation training, breathing, meditation or biofeedback 8. Posture • nA forward head posture is a big contributor to TMD • nTry to practice good posture, especially when sitting or standing for long periods of time • 9. Massage • ngentle massage over and around the area of discomfort • nhelp to relieve muscle spasm • ncan be done with your mouth open and closed • nmassage the area for about 10- 15 minutes Bite Correction • nIf your TMJ disorder has caused problems with how your teeth fit together, you may need treatment to correct your bite, although this is seldom necessary • nBite problems may be corrected either by orthodontic wiring, or by placing a crown or filling onto your teeth Surgery • nCan help restore jaw joint and its movement, eliminate the pain and other symptoms of TMJ disorders • nIt is rarely needed, except in very severe cases, if the joint has become so badly damaged that it cannot be corrected by other means • Invasive treatment – –- Intra-articular injection, – using steroid or hyaluronic acid –- Surgery options: »Therapeutic arthroscopy »Arthrocentesis »Removal of loose bone fragments »Reshaping the condyle –- More complex procedures, including joint replacement – –- Botulinum toxin A injections Recommendations and referrals to other providers: •• Speech and Language Pathologist • for assessment and treatment of speech or swallowing dysfunction associated with the TMD •• Rheumatologist •• Psychologist/Psychiatrist •• Surgeon • if conservative measures do not alleviate the patient’s symptoms, surgical management may be considered. Surgical interventions may include dental implants, condylectomy, condylotomy, ORIF or surgical manipulation. • 1. Otolaryngologist • 2. Dentist or oral surgeon • 3. Orthopedic surgeon http://improveyoursmile.co.uk/new/wp-content/uploads/2012/12/jaw-and-bite-problems.jpg Physical Therapy Physical Therapy nPhysiotherapy plays an important part in the treatment of any musculoskeletal disorders, and it is beneficial to any patient with TMD where there is muscle involvement • •Methods that are applied in the management of TMDs: nExercise therapy nThermal treatment (hot and cold) nMobilisation, Massage, Stretching nUltrasound, Laserotherapy, TENS, Short wave diathermy • •Other methods: nAcupuncture nBiofeedback nRelaxation Physical Therapy ·A variety of physiotherapy techniques help regain the harmony of jaw joints and muscles • ·is often used when disk, ligaments or other joint tissues are injured • ·promotes healing and reduces pain and swelling • ·aids muscle relaxation and increases jaw's range of motion Therapeutic exercises 1) Tongue Rest Position Tongue Proprioception and Control Control of Jaw Muscles 2) Control TMJ Rotation 3) Isometrics 4) Rhythmic Stabilization Technique Lightly resisted motions: opening, closing, lateral deviations 5) TMJ mobilization Midline exercise • nLook in mirror, bite teeth together, look at position of two center teeth on lower jaw (central incisors) • nOpen slowly while watching these two teeth and attempt to keep lower jaw "centered" as you open • • TMJ/muscle relaxation • nPlace tongue on roof of mouth as far back as possible. Slowly open mouth as far as possible, tongue on the roof Lateral Glide (isometric) nPlace two fingers on right side of jaw. Resist movement of jaw to same side. Relax. Repeat on opposite side Protrusion (isometric) • nPlace two fingers on chin. Resist forward movement of chin. Relax. Repeat Opening (isometric) nPlace fist below jaw. Resist downward movement of chin. Hold. Relax Assisted opening Place two fingers on lower front teeth, slowly open as wide as is comfortable while pushing down with your fingers. Resisted opening • • nCup palm under chin, open jaw slowly, and gently resist opening with hand under chin Lateral movement exercise • nOpen jaw about one inch from clenched bite • nMove lower jaw as far to the right (straight to the right without opening more) as is comfortable • Stabilization exercises • TMJ mobilisation • Ischemic compression (m. masseter) • Stretching nPIR (postisometric • muscle relaxation) • of masticatory • muscles • • • • • • Soft tissue techniques, mobilization (C, Th) •Hyoid bone mobilization Therapy of the neck spine Modalities •Ultrasound Transcutaneous electrical stimulation (TENS) Other methods • https://encrypted-tbn3.gstatic.com/images?q=tbn:ANd9GcRy7l18XmOM5OBV-QEPnJxmJIdWhgrIkMD58GNSuCfAg2Z S_RoYNA https://lgvblogs.files.wordpress.com/2013/09/tmj-laks.jpg http://www.hands-onhealthcare.com/images/site/biofeedback.jpg http://seeadentisttoday.com/wp-content/uploads/2014/08/8829275.jpg Posture correction • http://4.bp.blogspot.com/-Y9utFq1IYhs/Uonm68bR7QI/AAAAAAAAAtg/JSwHPpW1B8M/s1600/Forwardhead.jpg Ergonomic principles •Sitting position correction • •Ergonomic pillow/mattress • •Ergonomy of the workplace C:\Users\datart\Desktop\Lucka\untitled(3).jpg • Thank you for your attention •