1. Copyright 2005 Lippincott Williams & Wilkins Chapter 23 The Temporomandibular Joint

2. 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

3. Copyright 2005 Lippincott Williams & Wilkins Stomatognathic System Teeth JointsMuscles

4. 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

5. Copyright 2005 Lippincott Williams & Wilkins TMJ – 2 Joints

6. Copyright 2005 Lippincott Williams & Wilkins Muscles  Temporalis  Masseter  Medial pterygoid  Lateral pterygoid  Digastric  Mylohyoid  Genohyoid  Omohyoid

7. Copyright 2005 Lippincott Williams & Wilkins Muscles

8. 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.

9. 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

10. Copyright 2005 Lippincott Williams & Wilkins FHP – With PCR and Without PCR

11. 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)

12. 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

13. 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)

14. Copyright 2005 Lippincott Williams & Wilkins ROM Exercises

15. 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.

16. 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.

17. Copyright 2005 Lippincott Williams & Wilkins Isometric Stabilization

18. 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.

19. 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.

20. Copyright 2005 Lippincott Williams & Wilkins DJD/Osteoarthritis  Treatment  AROM exercises  Mobilization techniques  Stretching techniques

21. 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)

22. Copyright 2005 Lippincott Williams & Wilkins TMJ Clicking  Lower jaw thrust exercises  Noninvasive isometric exercises  Mandibular stabilization exercises

23. 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

24. 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

25. Copyright 2005 Lippincott Williams & Wilkins Adjunctive Therapy Surface Electromyography  Tension recognition/discrimination training  Threshold-based relaxation training  Nocturnal SEMG feedback

26. 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.

27. 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.