evaluation and diagnosis through a manual therapy approach

1

Evaluation and Diagnosis

Through a Manual Therapy

Approach to

Temporomandibular Joint Dysfunction

Dr. David J. Denton, PT, DPT, CIDN, CVT

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Anatomy and Biomechanics of the Temporomandibular Joint

Background

50-75% of individuals have experienced or will

experience a TMD problem

33% have >1 persistent problem

F>M 2:1 Cook, 2007

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Disc Anatomy

Displacement is Anterior and Lateral

Bioconcave, A&P Innervated

Retrodiscal Area

Highly innervated, has synovial fluid

Prone to inflammation

Does not tolerate tensile forces or constant

load (Cook, 2007)


Ligaments

Lateral guide opening

Medial disc has lateral pterygoid attachments

Sphenomandibular and Stylomandibular

Suspend mandible

Muscles – see next slide

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Anatomy and Biomechanics of the

Temporomandibular Joint

Anatomy and Biomechanics of the

Temporomandibular Joint


Biomechanics

Movements: open, close, protrusion, retraction, lateral deviation

If rotating – condyle rolls with inferior portion of disc

If translating – condyle and disc move together

Resting position is teeth slightly apart, lips together, and tongue

touching hard palate.

Jaw Opening

First phase posterior roll – mandible moves inf/post

Late Phase transitions from rotation to ant/inf translation

Muscles involved: Lateral Pterygoid and Suprahyoid

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Jaw Opening and Curves

C-Curve

-This occurs secondary to hypomobility due to an internal derangement.-The mandible deviates to the involved side during the mid-range of motion before the jaw returns back to the center.-In the example below, a C-curve is noted to the Right with the dysfunctional TMJ being on the Right.

S-Curve

-Occurs secondary to hypermobility due to poor neuromuscular control of the muscles of mastication.-Structures causing the dysfunction can include the masseter, temporalis, disc, and lateral ligaments.


Biomechanics

Jaw Closing (elevation)

Posterior/Sup translation then Anterior rotation

Muscles Masseter (primary muscle of elevation)

Medial Pterygoid

Temporalis


Biomechanics

Retraction – posterior translation, aides in closing

Muscles: temporalis and suprahyoid

Protrusion – Anterior translation, aides in max opening

Muscles: Lateral Pterygoid (Primary), Medial Pterygoid, Masseter

Lateral deviation – side to side translation

Ipsilateral side of deviation serves as pivot

Contralateral rotates anterior and medial

Muscles: Med Pterygoid (CL), Lat Pterygoid (CL), Masseter (IL),

Temporalis (IL)

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TMJ ROM Values

Opening – 50mm

Protrusion – 3-6mm

Retraction – 3-4 mm

Lateral Deviation – 11mm

(Magee, 2006)

Palpation: Physiopedia Reference: https://youtu.be/wtOTI5Yt28w

Definitions and Pathology in Temporomandibular Dysfunction

Disc Displacement with Reduction

Clicking – first sign of TM dysfunction, the farther into opening that the click occurs = the worse the problem

Reciprocal Clicking

Opening - condyle moves beneath the disc, snaps and falls back into normal

concave seat

Closing – occurs at end of closing. Condyle slides posterior and disc is

displaced anterior

Disc Displacement without Reduction

Disc remains displaced during all motion

Initially a “closed lock”

Reference: https://youtu.be/mB468Jh9aAY (Physiopedia)

Evaluation of TMD

Locked Jaw and Clicking Patterns

Causes of clicking include normal sounds, hypo-mobility, and internal derangement of disc

Closed Lock

Caused by disc

Disc Dislocation with Reduction and opening limited

Open Lock

2 clicks with opening (dislocation posterior then slides off anterior disc)

2 clicks with closing

https://youtu.be/mB468Jh9aAY

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Evaluation of TMD

Special Tests

OA = AM stiffness

Deep neck flexor imbalance = Mouth breather

Bruxism = adhesions and clenching click

Vertebral Artery test

Trismus – tonic contraction of masticatory muscles

Tongue Thrust

Tongue pushed forward against teeth

Ask patient to swallow with neutral posture

Normal – hyoid bone moves up/down

Abnormal – Hyoid ONLY moves upward as well as suboccipitalcontraction

Manual Treatment Techniques and Relaxation Activities

From: (Cleland, 2006)

Intra-oral Manual Therapy -

Cervical Spine mobilizations

Cervical Soft tissue work

TMJ mobilizations – Grab a skeleton

Inferior glide – distraction

Distraction with anterior glide

Lateral glide

Rocobado exercises sets and reps of 6x6

Ionto with Dex

Videos:

Reference: https://youtu.be/9og0M0hCMbY (www.sleepandtmjtherapy.com)

Reference: https://youtu.be/RhO1fEXKAjQ (Freedom Physical Therapy)

Joint Mobilizations


Inferior glide – distraction

https://youtu.be/9og0M0hCMbY

http://www.sleepandtmjtherapy.com/

https://youtu.be/RhO1fEXKAjQ

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Joint Mobilizations


Distraction with anterior glide

Joint Mobilizations


Lateral glide

Manual Treatment Techniques and Relaxation Activities

Isometric Jaw Exercises

Functional Jaw Opening

Controlled ROM Lateral deviation

Self distraction mobilizations

Dynamic cervical stabilization

Scapular Stabilization

6x6 Exercises (Rocobado)

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Dry Needling to Cervical Spine, Jaw, and Lateral

Pterygoid


Pterygoid


Pterygoid

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Pterygoid

IASTM and Cupping to

Upper Cervical and TMJ Tissue

IASTM and Cupping to

Upper Cervical and TMJ Tissue

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TMJ Mobilization and Exercises

Reference: https://www.youtube.com/watch?v=nbJzbsI-mvM

Inner TMJ mobilization inside mouth behind upper molar

Upper Cervical Flexion – supine or prone into ball

Lower trapezius and retraction strengthening

Self resisted controlled rotation

HEP ADL’s advise the pt to keep the tongue in resting position touching roof of mouth, avoid foods that cause pain, and as part of HEP – perform partial AROM, in opening and lateral deviation to facilitate relaxation of overactive jaw mm.

Disc stabilization protocol – (Cleland, 2006)

With tubing, resting between incisors, patient gently rolls tube away from affected side

through pain free motion.

At end of ROM, patient applies submaximal bite onto tube. Hold 5 seconds and return

to midline. Repeat 6x6

Also same tubing procedure for protrusion and isometric biting

TMJ Mobilization

and Exercises


Realigning the Head, Neck and Jaw through RTTPB:

Objectives:

To promote total body relaxation.

To decrease pressure with in the TMJs.

To provide for good head, neck, and back posture.

To decrease muscular tension in the jaw, neck, and shoulders.

To use as the starting position for all other TMJ exercises

https://www.youtube.com/watch?v=nbJzbsI-mvM

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RTTPB:

Directions:

R-Relax: Stop what you are doing. Allow the tension in your body to be released.

T-Teeth apart: Say the word "Emma." Maintain your jaw in this slightly opened position.

T-Tongue on the roof of your mouth, just behind your upper two front teeth. Hold your tongue in this “clucking" position.

P-Posture: Imagine two strings. One string pulls straight up from the crown of your head to the ceiling; the second string pulls up and out from your breastbone.

B-Breathing: Diaphragmatic (from your stomach). Place one hand on upper chest and the other hand on your stomach. When you breathe in (inhale), the hand on your stomach should rise more than the hand on your chest. (Imagine inflating a balloon in your abdomen as you inhale.)


TMJ Rotation and Translation Control:

Phase I Objectives:

To restore proper "tracking" to the TMJ.

To decrease or eliminate clicking, cracking, popping, or excessive movement occurring in the

TMJ.

To limit TMJ mechanics to rotation through an active-assisted technique. (Active-assisted means

using an external aid. In this case the index finger is used to assist the movement.)

Directions:

1. Keep the tip of your tongue on the roof of your mouth ("clucking" position) throughout the

exercise.

2. Place one index finger on a TMJ (the one with the greatest amount of dysfunction or pain).

3. Place your other index finger on your chin.

4. Allow your jaw to drop down and back, towards your throat, with guidance from your index

finger.

5. Monitor this partial jaw opening in a mirror to ensure a straight opening and closing.

6. Repeat this exercise five times, five times per day. When proficient advance to Phase II.


TMJ Rotation and Translation Control: Phase II Objectives:


To decrease or eliminate clicking, cracking, popping, or excessive movement occurring in the TMJ.

To limit TMJ mechanics to rotation through active exercise by the patient. (Active exercise means that the patient's own jaw muscles perform the movement.)

Directions:

1. Keep the tip of your tongue on the roof of your mouth ("clucking" position).

2. Place both index fingers on your TMJs.

3. Allow your jaw to drop down and back (chin to the throat).

4. Monitor this partial jaw opening in a mirror to ensure a straight opening and closing.

5. Repeat this exercise five times, five times per day. When proficient, advance to Phase III.

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TMJ Rotation and Translation Control: Phase III Directions:

1. Begin with tongue on the roof of your mouth ("clucking" position).

2. Place one index finger on the TMJ with the greatest amount of dysfunction

or pain.

3. Place your other index finger on your chin.

4. Allow your jaw to drop down and back with guidance from your index

finger (chin to throat).

5. Drop tongue from roof of mouth and complete opening (continue to

direct chin toward throat). *

6. Monitor this complete jaw opening in a mirror to ensure a straight opening and closing.

7. Repeat this exercise five times, five times per day. When proficient, advance to Phase IV. *Optional technique: Drop lower jaw to maximum

opening, maintaining tongue in light contact with roof of mouth.


TMJ Rotation and Translation Control: Phase IV Objectives:

To restore proper sequencing and timing of movement to the TMJ

(rotation followed by forward glide) through active exercise.


To decrease or eliminate clicking, popping, cracking, or excessive

movement occurring in the TMJ. Directions:

1. Begin with your tongue on roof of your mouth (“clucking” position). 2. Place both index fingers on your TMJs.

3. Allow your jaw to drop down and back (toward your throat).

4. Drop your tongue from the roof of your mouth and complete opening (chin to throat).

5. Monitor this complete jaw opening in a mirror to ensure a straight opening.

6. Repeat this exercise five times, five times per day.


Mandibular Stabilization: Stage I Directions:

1. Maintain the RTTPB position throughout this

exercise.

2. Use your index finger to apply the gentle pressures

3. Hold each directional pressure for two seconds.

4. Repeat each direction five times, five times per

day. 5. When proficient, add Stage II.

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Mandibular Stabilization: Stage II Directions:

1. Perform RTTPB.

2. Place the knuckle of your index finger between your top and bottom teeth.

3. Remove your knuckle, keeping teeth separated one

knuckle-width apart.

4. Replace tongue on the roof of your mouth ("clucking"

position).

5. Apply gentle pressure to the lower jaw 6. Maintain each

pressure for two seconds.

7. When proficient, add stage III.


Mandibular Stabilization: Stage III Directions:

1. Perform RTTPB.

2. Place the knuckles of your index and middle fingers between your top and

bottom teeth.

3. Remove them, keeping teeth separated two knuckles-width apart.

4. Replace tongue on the roof of your mouth ("clucking" position) if possible.

5. Apply gentle pressure to your jaw.

6. Hold each pressure for two seconds.

7. Repeat five times, five times per day. Jaw position: Two knucklewidthsapart. * Alternative: If two knuckles cannot be inserted, open as wide as

possible and perform in this jaw position

Roles of Cervical Spine, Radicular Symptoms, and Posture on TMD

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Roles of Cervical Spine, Radicular Symptoms, and Posture on TMD (Travell)

[email protected]

References Bae, Y., & Park, Y. (2013). The Effect of Relaxation Exercises for the Masticator Muscles on

Temporomandibular Joint Dysfunction (TMD). Journal of Physical Therapy Science,25(5), 583-586. doi:10.1589/jpts.25.583

Cleland, J. A., & Koppenhaver, S. (2011). Temporomandibular Joint. Netters Orthopaedic Clinical Examinat ion,15-64. doi:10.1016/b978-1-4377-1384-8.00011-0

Cook, C. (2019). Orthopedic manual therapy: An evidence-based approach. Upper Saddle River: Pearson.

Glas, H. V. (2016). Myogenous temporomandibular joint dysfunction (TMD), physiotherapy compared with occlusal splint therapy using therapy-and-patient-specific treatment durations. Ht tp://isrctn.com/. doi:10.1186/isrctn17469828

Ho, S. (2017). Temporomandibular Joint. Orthopaedic Physical Therapy Secret s,490-494. doi:10.1016/b978-0-323-28683-1.00061-8

Akar, G. C., Govsa, F., & Ozgur, Z. (2009). Examination of the Heads of the Lateral Pterygoid Muscle on the Temporomandibular Joint. Journal of Craniofacial Surgery,20(1), 219-223. doi:10.1097/scs.0b013e318191d04d

Bae, Y., & Park, Y. (2013). The Effect of Relaxation Exercises for the Masticator Muscles on Temporomandibular Joint Dysfunction (TMD). Journal of Physical Therapy Science,25(5), 583-586. doi:10.1589/jpts.25.583

Pathology of the temporomandibular joint. (2015). At las of Temporomandibular Joint Surgery,203-230. doi:10.1002/9781118963319.ch10

Neck pain connected to TMJ pain. (2008). Dental Abst racts,53(3), 122. doi:10.1016/j.denabs.2008.02.052

Madani, A. S., & Mirmortazavi, A. (2011). Comparison of three treatment options for painful temporomandibular joint clicking. Journal of Oral Science,53(3), 349-354. doi:10.2334/josnusd.53.349

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