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Physical Therapy to Improve Successful
Orthodontic Outcomes in Patients with TMD
Presented by:
Heather Salyers, MPT
1. Recognize the signs and symptoms of TMD
2. Appreciate the relationship between TMD and
poor postural alignment, and how PT can assist in
restoration of an optimal bite with minimal excessive
mandibular muscle tension.
3. Make an appropriate referral to a qualified
Physical Therapist
Learning Objectives
Is TMD in your radar? It should be!
“In everyday clinical practice, orthodontists frequently are
confronted with patients presenting with not only the
various orthodontic malocclusions, but also the clinical
signs and symptoms of TMD.” [Ref 40]
Although the research hasn’t found that orthodontics can
be attributed to causing TMD, there is a lot of interest in
how best to manage orthodontic patients that have or
develop TMD. I came across several articles proposing
that TMD be included in the curriculum of orthodontic
post-graduate programs. [Ref: 39, 48]
2017 Review of Literature Univ of Athens, School of
Dentistry:
Prevalence of TMJ Dysfunction
One in 6 children and adolescents have
clinical signs of TMJ disorders. [Ref:49]
A review of the literature estimates
that 15% to 19% of adults have TMD
requiring treatment.[Ref :6]
Females are 3 to 9 times more likely
to have TMD than males. [Ref: 7]
[1]
TMD can be present at any age, but is
more prevalent during adolescence, and
increases with age into the 20’s. [Ref: 40,41].
Contributing Factors to TMD
Trauma to jaw
Parafunctional behaviors:
• bruxism/clenching
• nail biting
Emotional stress/Psychosocial issues
Malocclusion
Craniofacial Deformities
Obligate mouth breather
Playing wind instrument or violin
Pain with chewing, yawning, talking
Jaw catching, locking, subluxing
Restricted mouth opening
Signs and Symptoms of TMJ dysfunction:
Change in bite (occlusion)
Fatigue/soreness of jaw/face muscles
Ringing in ears
Ear feels clogged
Clicking/noises of TMJ
Headaches
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Screening Tool for TMD
1. Do you have pain in your temples, face, TMJ or jaw once a
week or more?
2. Do you have pain when you open your mouth wide or chew,
once a week or more?
From: Nilsson 2007 “Reliability, validity, incidence
and impact of TMD in adolescents” [Ref:41]
Test-retest reliability of 0.83 (kappa) was found for the
two questions. Sensitivity was 0.98 and specificity 0.90
Clinical Exam to Assess for TMD
1. Palpate joint and mandibular muscles
2. Observe mouth opening kinematics.
3. Is mouth opening restricted?
4. Look for damage to teeth from bruxism.
5. Utilize Diagnostic Imaging (CBCT, MRI)
to assess status of condyles and discs.
1. Palpate joint and mandibular muscles
Palpate TMJ as mouth opens.
As condyle glides anteriorly,
palpate retrodiscal space.
Is it painful?
Palpate along mandibular muscles for any
tenderness, excessive tension or trigger points.
2. Observe mouth opening kinematics
Normal - rotation and anterior gliding without mandibular
deviation or deflection
• Premature thrusting forward of mandible
• Deviation (c or s-curve) with opening and/or closing
• Deflection to one side with opening and closing
Abnormal Kinematics:
3. Is mouth opening restricted?
There is a wide variation amongst individuals as to their
“normal” amount of mouth opening. It can range from 39
to 65 mm. [Ref: 9]
In my experience, the minimal amount of mouth opening
required to be functional is typically 35 mm.
Hypermobility = Lax Ligaments
Score of >4/9 is indicative of hypermobility
Beighton scoring system for joint hypermobility
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4. Look for damage to teeth from bruxism
Fit with a night time appliance to protect teeth
Bruxism is believed to be present in up to 20%
of the general adult population, and is present in
66% of people with TMD. [Ref: 10]
5. Utilize Diagnostic Imaging
(CBCT, MRI)
CBCT visualizes: MRI visualizes:
bone soft tissue
Condyle’s position in fossa Discal displacement
Active breakdown of condyle Effusion
Integrity of TMJ Bone Marrow Disorders
Differential Diagnosis
Submandibular or parotid gland stone or tumor
Sx can mimic TMD, but pain occurs with salivary gland
stimulation, without any jaw movement. (test w/ sour candy)
If infected, sx include swelling and bad taste in mouth. Also
may see pus as sweep along parotid gland.
Image: Wilson et al 2014
The often complex contributing factors to TMD necessitate
a collaborative approach for successful treatment of these
patients..
A patient with TMD may require the services of a physician,
dentist, orthodontist, physical therapist, maxillofacial surgeon,
psychologist and pain management specialist. [Ref:13,14.,23-26,29.]
Why refer to Physical Therapy?
Since TMD is a musculoskeletal dysfunction, it falls within
the scope of practice of Physical Therapy. A review of the
literature supports Physical Therapy as a successful adjunct in
the management of TMD. [Ref: 13,14,18, 23, 25, 29,30,37,45,51,52]
When to refer to Physical Therapy?
Limited mouth opening due to close-locked or
muscle spasm.
Complaint of Headaches
Forward head and rounded shoulder posture
Tenderness to palpation of muscles of mastication
Neck pain and muscle tension
Pain with jaw functional activities
As Physical Therapists, we are musculoskeletal specialists.
We are trained to recognize abnormal postures and body mechanics.
Basic level of TMD training received in PT school.
Advanced training comes after you graduate if decide
to specialize in treating TMD.
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For my associates and I, our TMD training is based primarily on
the works of Mariano Rocabado, PT. We received this training
as part of our post-graduate studies to enhance our skills as
manual orthopedic therapists.
Ongoing continuing education in various manual therapy
techniques, as well as our collaboration with dentists,
orthodontists and oral surgeons, allow us to grow and evolve as
TMD rehab specialists.
Training as a TMD Rehab Specialist
Pic of staff from website
Our View of TMD – The Big Picture
As PT’s, we are trained to look at the body as an
integrated system. No joint operates in isolation from
the rest of the body, and this is especially true when
looking at the TMJ.
What other 2 regions of the body have muscular
connections to the head and jaw?
Answer: the Neck and Shoulder Girdle
What bone links them?
Answer: the Hyoid bone!
Image: Hislop, H et al 1995
The posture of the head, neck
and shoulders will alter the
muscle length and tension
acting on the hyoid bone,
which alters the muscle forces
around the jaw. [Ref: 14]
Hyoid
How prevalent is forward head posture?
It’s estimated that 90% of the
United States population exhibits
forward head posture of 5 cm or
more!
we just give in to
So, why do we let our heads drift forward? Center of Gravity (C.O.G.) in Ideal Posture
The C.O.G. in ideal posture falls
slightly anterior to the atlanto-
occipital joints. [Ref: 11]
Due to this, the head will fall
anteriorly if the neck muscles
totally relax.
To maintain good head position,
strong posterior neck muscles are
needed to support the weight of the
head against gravity. [Ref:17,18]
Image: Norkin 1992
5
30 lb 20 lb 10 lb The effective weight of your head
increases by 10 lbs for every inch
your head drifts forward!
How heavy can your head feel?
Neck muscle strain
Where the head leads, the shoulders will follow!
This abnormal posture is BAD NEWS, not just for our
shoulders, neck and back, but also for our jaw!
Abnormal postural alignment
directly alters the muscle balance
around the head, jaw, neck and
shoulder girdles.
Abnormal Posture creates Muscle Imbalances
It becomes evident that there is a direct
relationship between craniovertebral
abnormalities and TMD.
[Ref:15,16,31,32,44]
It should now be apparent why the treatment of TMD requires a
broader view and the expertise of other professionals who can
address the muscle imbalances contributing to the pt’s symptoms.
Relationship between Craniovertebral
Abnormalities and TMD
Overview of our TMJ Assessment
Posture Analysis
Assess upper and lower c-spine mobility
Palpate head, neck and jaw musculature
Strength test lips, cheeks, tongue and jaw muscles
Measure jaw AROM and
Assess TMJ mobility (restricted arthrokinematics)
Observe jaw kinematics
Observe and Measure Postural Alignment
Forward head position
Scapular position
Spinal curves
Depressed sternum
Pelvic Alignment
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Facet joints
C1
C2
C3
C4
C5
C6
C7
Facet joint mobility of lower cervical spine
Alignment of First Vertebra
Assess upper and lower c-spine mobility
Lateral and saggital glides of atlanto-occipital joints
Palpate head, neck and jaw musculature
Our highly developed sense of touch enables us to detect
myofascial restrictions, muscle spasms and trigger points.
Cervicogenic Headaches[Ref:21,22]
Pain originates from the cervical spine and is
referred to the head.
Often associated with restricted mobility of the
upper c-spine.
Brought on by sustained neck posture.
Changes in the muscle occur causing them to
become abnormally painful.
Headache is often unilateral and can be reproduced
by palpation of the trigger point on the side of pain.
Trigger Points
Small, ischemic, tender points in a muscle that when
palpated refer pain to a remote location.
Trigger points in muscles receiving sensory innervation
from C1 through C3 may refer pain to various regions
of the head.[Ref :20]
Image:www.triggerpoints.net
Referred Pain Pattern for Splenius Capitis
Trigger Point
Spasm of the splenius capitis may cause top of
the head headache. [Ref:20]
Image:www.triggerpoints.net
Referred Pain Pattern for SCM
Trigger Point
Image:www.triggerpoints.net
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Referred Pain Pattern for Sub-Occipital
Trigger Point
Trigger points in the sub-occipitals can cause
headache symptoms around the ear. [Ref:20]
Image:www.triggerpoints.net
Referred Pain Pattern for Temporalis
Trigger Point
Image:www.triggerpoints.net
Referred Pain Zones for Masseter Trigger Points
A. Upper portion
superficial layer
B. Mid-belly
superficial layer
C. Lower portion
superficial layer
D. Upper portion
deep layer
Image:www.triggerpoints.net
Referred Pain Pattern for Medial
Pterygoid Trigger Point
A. External facial
pain area
B. medial pterygoid
trigger point
C. Internal areas
of referred pain
Image:www.triggerpoints.net
Referred Pain Pattern for Lateral
Pterygoid Trigger Point
Image:www.triggerpoints.net
Referred Pain Pattern of Digastric Muscles
Image:www.triggerpoints.net
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Assess TMJ Mobility
Image: Hertling et al 1996
Measure Jaw AROM
Mouth opening
Measure Jaw AROM
Laterotrusion
Observe Jaw Kinematics
Strength Test lips, cheeks, tongue
and jaw muscles
Image: Hislop 1985
TMJ Dysfunction: Classification
Self-reducing Closed-locked Muscular
Joint noise click None or crepitus None or
crepitus
AROM of
Jaw
Normal or
slightly
decreased
Min of 20-25 mm;
lateral exc to the
opposite side is
decreased
Can be severely
decreased
(<10 mm)
to normal
Kinematics C-curve with
opening &
protrusion
Deviation toward
involved side w/
m/o & protrusion
random
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Overview of our Treatment Approach
Decrease TMJ Inflammation
Decrease Muscle imbalances by :
soft tissue release
stretching exercises
strengthening exercises
Improve postural alignment
Improve TMJ kinematics
Restore normal TMJ mobility (via JM or stabilization)
Restore normal resting tongue position
Recommend splinting when appropriate
Improve tongue coordination and strength
Posture Improvement in response to
Physical Therapy
I hope you found my presentation helpful and informative.
Thank you
Touch Personal
h
y
s
i
c
a
l
h e r a p y
& Wellness Center
West Chester Office Plaza 790 East Market Street
Suite 290 West Chester, PA 19382
(610) 696-3305
Fax (610)-696-3306
Screening Tool for TMD
1. Do you experience pain of your ear, temple or jaw when biting, chewing, yawning or talking? 2. Do you awaken with jaw stiffness, fatigue or pain? 3. Does your jaw make noise when you open your mouth or with chewing/talking? 4. Do you have difficulty opening your mouth wide enough to eat or for dental cleanings? 5. Does your jaw ever lock or catch? 6. Has your bite changed recently? 7. Do your jaw/face muscles feel tired with chewing, talking, or singing? 8. Do you get headaches along your temples, around the eyes, or below your cheekbones? 9. Do you get ringing in your ear(s), or feel pressure/fullness in your ear?
Physical Therapy to Improve Successful Orthodontic Outcomes in Patients with TMD AAO 2018
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