1. Temporomandibular Disorders (TMD) & Facial Pain
A Clinical View
 Module 1 
By Todd Henkelmann, PT, MS, CCTT
UPMC Centers for Rehab Services

2. Introductory Remarks
Today’s lecture and demonstrations will be primarily about the basics. Plan to pair up at times!
[Suggest to bring with you: vinyl/non-latex disposable gloves, small tape measure]
What questions would you like answered?
If you delve deeper into the problem of TMD, you’ll discover a very complex and controversial disorder and perhaps the best way to approach it is K.I.S.S.
A good place to start is the AAOP – aaop.org
3/8/14
T. Henkelmann, PT, MS, CCTT

3. What’s in a Name?
“I’ve got TMJ” – Yes, you have two, one on each side…
TMJ Disorder = TMD
Orofacial Pain = OFP
American Academy of Orofacial Pain
Craniofacial Pain = CFP
American Academy of Craniofacial Pain
Craniomandibular Disorder = CMD
European Academy of Craniomandibular Disorders
3/8/14
T. Henkelmann, PT, MS, CCTT

4. Conservative treatment of TMD
This is our role as physical therapists; why you can successfully work in conjunction with dentists and oral surgeons, have a successful niche practice
We need to not let 3rd party private payers prevent treatment of this devastating condition
Medicare & Medicaid cover it’s treatment
The TMJ Association – Terrie Cowley, President
3/8/14
T. Henkelmann, PT, MS, CCTT

5. Functional Anatomy Stomatognathic system
Bony structures
Temporal bone: mandibular fossa, external auditory meatus, articular eminence (a.k.a. tubercle), mastoid & styloid processes
Mandible: condyle (head of the mandible), neck, coronoid process, ramus, angle, and body
Zygoma, teeth
Hyoid bone
Upper cervical spine
3/8/14
T. Henkelmann, PT, MS, CCTT

6. 3/8/14
T. Henkelmann, PT, MS, CCTT

7. Joint Classification: TMJ
A synovial, condylar joint of 2 types:
Ginglymus (hinge) – 0 to 25mm (+/- 2-3) for rotation
Arthrodial (gliding) mm for translation
As a synovial joint, it has a joint capsule and synovial fluid. The bony surfaces are covered by fibrocartilage (not hyaline cartilage…too soft). Fibrocartilage remodels – why it can heal.
3/8/14
T. Henkelmann, PT, MS, CCTT

8. Joint Capsule and Ligaments
Thin, synovial joint capsule, stabilized by the following ligaments:
Medial: sphenomandibular lig. – suspends mandible during wide opening, stylomandibular lig. – acts as a stop to extreme opening
Lateral: Lateral (temporomandibular) lig. – prevents excessive A-P and lateral movements
TMJ is stabilized primarily by ligaments and convex on concave relationships above & below by the bi-concave articular disc
3/8/14
T. Henkelmann, PT, MS, CCTT

9. The Disc (Meniscus)
Fibrocartilagenous structure – areas of collagen fibers, loose connective tissue, blood vessels, and nerve fibers
Function of disc is to act as shock absorber, improve congruency, and enhance joint stability during movement
3/8/14
T. Henkelmann, PT, MS, CCTT

10. Attached to capsule, poles of the condyle via collateral ligs
Attached to capsule, poles of the condyle via collateral ligs., and superior belly of lateral pterygoid muscle. It divides the joint into 2 distinct cavities
Posterior attachment (also called ‘retrodiscal tissue’) has a superior (elastic) and inferior (vascular & neural) stratum that serve to keep disc from moving too far anteriorly
3/8/14
T. Henkelmann, PT, MS, CCTT

11. 3/8/14
T. Henkelmann, PT, MS, CCTT

12. Cervical spine Forward head posture: Loss of cervical lordosis
Backward bent OA
Effects orientation of TMJ
Leads to early DDD and DJD
Can cause neural impingement!
3/8/14
T. Henkelmann, PT, MS, CCTT

13. 3/8/14
T. Henkelmann, PT, MS, CCTT

14. Neurology
Trigeminal nerve (CN V) is the principle nerve supplying the structures of the TMJ
Ophthalmic branch (V1) – sensory to upper face, eye, nose, frontal sinuses, dura
Maxillary branch (V2) – sensory to cheek, upper lip, lower sinuses, maxillary teeth, dura
Mandibular branch (V3) – sensory to lower face, mandibular teeth, chin & jaw (but not angle of jaw =C2 & C3); motor to muscles of mastication
3/8/14
T. Henkelmann, PT, MS, CCTT

15. Location of C2-C3 dermatomes
3/8/14
T. Henkelmann, PT, MS, CCTT

16. Trigeminocervical nucleus
3/8/14
T. Henkelmann, PT, MS, CCTT

17. Time for everyone to stand up and stretch back!
3/8/14
T. Henkelmann, PT, MS, CCTT

18. Overview of TMD Evaluation
History
Cervical screen
Posture
Active TMJ ROM
Strength – cervical, mandible
Specific TMJ tests – palpation & loading
Special tests: sensory exam, jaw jerk, facial nerve
Muscle palpation
Outcome measure
3/8/14
T. Henkelmann, PT, MS, CCTT

19. 1. History When did it start, what were you doing?
Gradual or sudden onset
What tests have been done?
Panorex x-ray, CT scan, MRI – provide “clues”
Have you suffered a blow to the jaw?
Volleyball, soccer ball, fist, MVA
Do you have a click/pop now or in past?
Was there period of prolonged immobilization?
Mouth wired shut? Could cause capsular restriction
3/8/14
T. Henkelmann, PT, MS, CCTT

20. What makes the pain worse? What makes the pain better?
“What do you do to get any relief?”
“What can’t you do because of this problem?”
Have you worn braces and for how long?
Ask about parafunctional habits
Start the education process here
3/8/14
T. Henkelmann, PT, MS, CCTT

21. Parafunctional Habits
Clenching teeth (daytime) – teeth touching at rest?
Bruxing at night
Chewing gum, fingernails, ice
Habitually chewing hard-to-chew items
Hand rest on jaw
Holding phone with shoulder against head
Tongue thrusting
High stress level – we all have stress, ask if worse in the past 6 months
Prone sleep position
3/8/14
T. Henkelmann, PT, MS, CCTT

22. 2. Cervical Screen Take AROM – Rot, SB, Flex, Ext
Alar & transverse ligament tests – See next slide
Spurling’s test
Cervical compression & distraction tests
I do not do anything else, unless there is a reason to
If the patient has radicular symptoms, then you need to recognize that you’re dealing with 2 different problems – not part of TMD per se
3/8/14
T. Henkelmann, PT, MS, CCTT

23. 3/8/14
T. Henkelmann, PT, MS, CCTT

24. 3. Posture First thing: just observe head, neck & face at rest
Look for overt asymmetry or swollen area
Before you say anything about posture, look at head/neck posture from the side
Minimal, moderate, severe forward head?
Are they missing teeth? Does bite come together evenly?
Malocclusion vs. unilateral joint effusion vs. unilateral muscle spasm
3/8/14
T. Henkelmann, PT, MS, CCTT

25. 4. AROM of TMJ Mandible depression: 0mm to 40-60mm (adult)
Measure R incisors, unless unavailable
Side glide (aka, lateral excursion): 0mm to 8mm (I don’t usually measure)
Protrusion: 0mm to 6-9mm (I don’t usually measure)
Retrusion (aka, retraction): Not measured
Watch for deviation or deflection with depression & protrusion – can confirm or deny disc displacement
3/8/14
T. Henkelmann, PT, MS, CCTT

26. TMJ Muscle Actions
Depression (opening): Lateral Pterygoid – inferior belly, Anterior Digastric, and gravity
Elevation (closing): Temporalis, Masseter, Medial Pterygoid
Lateral Excursion: To Right : R Lat. Pterygoid, L med. Pterygoid, to Left: L Lat. Pterygoid, R med. Pterygoid
Protrusion: Lat. Pterygoids – inferior belly, acting bilaterally, Med. Pterygoids – indirect
3/8/14
T. Henkelmann, PT, MS, CCTT

27. 5. Strength Testing Manual muscle tests of:
Cervical SB, Rot, Flex, Ext
Mandible SB, Depression, & elevation
Note: It is not common to see weakness, in my experience. Roughly 90% of all orofacial pain patients I see don’t test (+) for weakness. Don’t know that MMT is the best way to test strength in this population
3/8/14
T. Henkelmann, PT, MS, CCTT

28. 6. Specific TMJ tests Force biting test Lateral condyle palpation test
Teeth together, mouth opened
Retrussive overpressure test
External auditory meatus test
3/8/14
T. Henkelmann, PT, MS, CCTT

29. 7. Special Tests
Sensory testing - I consider this crucial, yet doctors and many therapists don’t take the time…
Test V1, V2, V3, & C2
Pain sensation, light touch sensation
Slightly diminished can be caused by mm. spasm, greater involvement in V2, V3 may mean a tumor
Jaw Jerk reflex
Indicative of upper motor neuron condition, but is not diagnostic
Facial nerve screen – go through all facial mov’ts.
3/8/14
T. Henkelmann, PT, MS, CCTT

30. 8. Muscle Palpation Internally: masseter, medial & lateral pterygoids
Externally: temporalis, digastric, sternocleidomastoid (SCM), suboccipitals, upper trapezius
Others for consideration: zygomaticus, buccinator, tensor veli palatini, frontalis
3/8/14
T. Henkelmann, PT, MS, CCTT

31. 3/8/14
T. Henkelmann, PT, MS, CCTT

32. 3/8/14
T. Henkelmann, PT, MS, CCTT

33. 3/8/14
T. Henkelmann, PT, MS, CCTT

34. 3/8/14
T. Henkelmann, PT, MS, CCTT

35. Outcome Measures TMD Disability Index Questionnaire (TDI)
Similar to Oswestry or Neck Disability Index
Used by Joshua Cleland, et al in research studies (see bibliography)
Published by a chiropractor and has not undergone validation studies
Scoring method is on last page of handout
It’s not perfect, but it’s all I have to recommend at this time
For Medicare: I am also using AMPAC 4
3/8/14
T. Henkelmann, PT, MS, CCTT

36. Take a Break Stand up and stretch backward
Relax your jaw – were your teeth touching?
How’s your posture? Are you setting a good example for your patients? 
3/8/14
T. Henkelmann, PT, MS, CCTT

37. 3/8/14
T. Henkelmann, PT, MS, CCTT