Temporomandibular Disorders (TMD) & Facial Pain
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Transcript Temporomandibular Disorders (TMD) & Facial Pain
A Clinical View
Module 1
By Todd Henkelmann, PT, MS, CCTT
UPMC Centers for Rehab Services
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
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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
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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 – www.tmj.org, Terrie Cowley,
President
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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
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Joint Classification:
TMJ
A synovial, condylar joint of 2 types:
Ginglymus (hinge) – 0 to 25mm (+/- 2-3) for rotation
Arthrodial (gliding) - 25-50mm 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.
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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 biconcave articular disc
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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
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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
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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!
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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
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Location of C2-C3
dermatomes
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Trigeminocervical nucleus
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Time for everyone to stand
up and stretch back!
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Overview of TMD
Evaluation
1.
2.
3.
4.
5.
6.
7.
8.
9.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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6. Specific TMJ tests
Force biting test
Lateral condyle palpation test
Teeth together, mouth opened
Retrussive overpressure test
External auditory meatus test
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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.
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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
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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
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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?
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