Copyright 2005 Lippincott Williams & Wilkins Chapter 23 The Temporomandibular Joint
Copyright 2005 Lippincott Williams & Wilkins 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
Copyright 2005 Lippincott Williams & Wilkins Stomatognathic System Teeth JointsMuscles
Copyright 2005 Lippincott Williams & Wilkins Bones Mandible – Ramus and two condyles. Temporal bone – Articular tubercle, eminence, mandibular fossa, posterior glenoid spine Hyoid bone. Movements of Mandible Elevation Depression Protraction Retraction Lateral gliding Combinations of above
Copyright 2005 Lippincott Williams & Wilkins TMJ – 2 Joints
Copyright 2005 Lippincott Williams & Wilkins Muscles Temporalis Masseter Medial pterygoid Lateral pterygoid Digastric Mylohyoid Genohyoid Omohyoid
Copyright 2005 Lippincott Williams & Wilkins Muscles
Copyright 2005 Lippincott Williams & Wilkins 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.
Copyright 2005 Lippincott Williams & Wilkins 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
Copyright 2005 Lippincott Williams & Wilkins FHP – With PCR and Without PCR
Copyright 2005 Lippincott Williams & Wilkins Examination and Evaluation Subjective Onset of symptoms Incidence of joint locking Presence of joint noise History of surgery Pain (intensity, frequency, location)
Copyright 2005 Lippincott Williams & Wilkins 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
Copyright 2005 Lippincott Williams & Wilkins 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)
Copyright 2005 Lippincott Williams & Wilkins ROM Exercises
Copyright 2005 Lippincott Williams & Wilkins 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.
Copyright 2005 Lippincott Williams & Wilkins 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.
Copyright 2005 Lippincott Williams & Wilkins Isometric Stabilization
Copyright 2005 Lippincott Williams & Wilkins 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.
Copyright 2005 Lippincott Williams & Wilkins 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.
Copyright 2005 Lippincott Williams & Wilkins DJD/Osteoarthritis Treatment AROM exercises Mobilization techniques Stretching techniques
Copyright 2005 Lippincott Williams & Wilkins 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)
Copyright 2005 Lippincott Williams & Wilkins TMJ Clicking Lower jaw thrust exercises Noninvasive isometric exercises Mandibular stabilization exercises
Copyright 2005 Lippincott Williams & Wilkins Anterior Dislocated Disk Without Reduction Joint mobilization techniques (distraction and translation) Soft tissue mobilization (myofascial release and massage) Therapeutic modalities
Copyright 2005 Lippincott Williams & Wilkins 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
Copyright 2005 Lippincott Williams & Wilkins Adjunctive Therapy Surface Electromyography Tension recognition/discrimination training Threshold-based relaxation training Nocturnal SEMG feedback
Copyright 2005 Lippincott Williams & Wilkins 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.
Copyright 2005 Lippincott Williams & Wilkins 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.