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Cranial Made Clinical
Headache Symposium:Part 4:
Temporal Mandibular Joint (TMJ)
Kate Worden, DO, MS
Clinical Professor OMM
MWU AZCOM
AOMA Spring Convention
13 April 2019
1
Disclosure
I have no financial or other disclosures
to make regarding this presentation
2
Learning Objectives: Appreciate TMJ as a frequent cause of
Headache
Recognize TMJ key anatomical landmarks
ID the action of the TMJ on opening and closing
and its affect on the articular disc
Correlate the position of the Temporal bone with
that of the Mandible during the 2 phases of the
cranial mechanism (Fl/Ext)
3
Learning Objectives:
ID TMJ Dysf as primarily a joint problem
that reciprocally influences the cranial
mechanism with secondary head, neck &
shoulder muscular dysfunction
ID the muscles of mastication as they
relate to TMJ dysf
Relate the constellation of clinical
symptoms that can occur with TMJ dysf
4
Learning Objectives (LAB):
Be able to perform the following procedures:
Physical Exam to Evaluate TMJ
Muscle Energy for TMJ dysfunction
Strain Counterstrain (SCS) to
tenderpoints:
Medial Pterygoid muscle
Lateral Pterygoid muscle
5
6
Trephination
Hot stone for TMJ
7
Chinese herbs for TMJ
8
Low level laser for TMJ
9
Acupuncture for TMJ
10
Biofeedback for TMJ
11
Bite Splints for TMJ
12
Osteopathic Manipulation for TMJ
13
Cranial Osteopathy for TMJ
14
Why so many different Txs for TMJ?
The higher the number of treatments,
the less likely that any one is fully
effective alone!
15
Dental Hx:
1950-called TMD (TemporoMandibular
Dysfunction)- They thought that a
dental/teeth problem (Malocclusion)
caused a muscle imbalance problem-
became accepted norm within 12 mos
But inadequate to explain all findings-had
3 theories but no studies.
1979-introduced the concept of TMJ being
an Orthopedic (ie, Joint) Condition.
16
Dental Hx:
2002-today most all agree it is primarily
an orthopedic problem, but they just
tx the secondary muscle problem
the same way they did before- but
now they call it “Orthopedics.”
Many DDS do Sx dept Dx & Tx, ie they
treat a syndrome not the pathology.
17
*Signs & Symptoms of TMJ:
Pain with jaw
movement
Intermittent “locking”
Limited ROM
opening mouth
Facial pain & muscle
fatigue
Noises in Jt. with
movement
Ear pain w/o infection
Bruxism-
clenching/grinding
Ears feel “blocked”
Headache
Neck & Shoulder Pain
Dizziness
Sensitive Teeth
Tinnitus
Insomnia
2ary Depression18
Summary: Classic Triad-
Pain
Altered Function
Bruxism
19
Cranial Motion and TMJ:
The Cranial Rhythmic Impulse (CRI) is
palpable in 2 phases:
Flexion-all bones move away from midline
single bonesFlexion
paired bonesExternal Rotation (ER)
Extension- bones move toward midline-
single bonesExtension
paired bonesInternal Rotation (IR)
20
*Cranial Motion and TMJ:* Movement of Key bones drives motion of
others:
Occiput drives the Post Cranium
Temporals & Parietals
Sphenoid drives the Face esp Maxilla
Temporals drive the MandibleER and IR(Embryology: Mandible 2 parts-functions as paired bones)
Thus, the Maxilla may be in one phase
(Flexion with ER) while the Mandible may be
in the other phase (Extension with IR) leading
to Malocclusion (abnormal bite).
21
*Cr Motion:Temporals & MandibleFlexion: Extension:
Jaw Retrudes-post
Crowds the airway
predisposing to
Obstructive Sleep
Apnea
Jaw Protrudes-ant
22
TMJ & TEMPORAL ROTATION
23
Class II: “Great American Bite”
I=Ideal II=overbite, III=underbite
overjet, retrude protrude
Cr Flexion Cr Extension
24
So where do we start?
Anatomy, Anatomy, Anatomy!
25
Key Landmarks:
Temporal Bone
External Acoustic Meatus (EAM)
Mastoid Process
Occipital Mastoid Suture (OM)
Parietal Notch (PN)
Spheno Squamous Pivot (SSP)
Zygomatic Process
Mandib (Glenoid) Fossa & Artic. Eminence
Petrous Pyramid/ Eustachian Tube
26
27
28
Key Landmarks:
Mandible:
Ramus
Angle
Body
Mental Protruberance
Condylar Process
Articular Cartilage (Disc)
Coranoid Process
Medial & Lateral
Collateral Ligaments
Stylomandib Lig.
Sphenomand Lig.
BiLaminar Zone-
Post: Fascia w.
Neurovascular Bundle
incl. Temporal a.
29
FIGURE #2
30
31
TMJ
1. Mandibular condyle
2. Articular disk
3. Superior joint cavity
4. Articular eminence
5. External ear
TMJ Sagittal View (like MRI view)
32
TMJ- Gross Sagittal Section
33
“Bow tie” Disc
EAM
Condyle
Bilaminar
Zone
Glenoid
Fossa
TMJ Features:
Synovial Jt.-Med. & Lat Disc attached to Condyle by Med. & Lat. Collateral Ligaments
Ant. Disc attached to Jt. Capsule & fascia of Sup. Head of Lat. Pterygoid M.
Post Disc attached to Bilaminar Zone (Neurovascular Bundle btwn loose areolar fascia)-subject to compression with TMJ Dysfunction.
34
Jaw Full Open- disc forms “bowtie”
35Jaw Full Closed-HyperExtension leads to grinding
Key Ligaments of the TMJ:
36
Stylomandibular-styloid process Temporal to medial angle of Mandible
Sphenomandibular –spine of Sphenoid to medial ramus of Mandible
Joint capsule w Medial & Lateral Collateral Ligaments
37
38
TMJ Troublemakers
Muscles of Mastication (CN V-Trigeminal):
Temporalis m
Masseter m
Lateral Pterygoid m
Medial Pterygoid m
Also:
Sternocleidomastoid (SCM) m (CN XI-Spinal
Accessory)
Omohyoid & Digastric mm
Suboccipital mm
Occipital-Mastoid Suture Compression 39
TEMPORALIS MUSCLE:
O: Temporal Fossa (formed by Frontal & Parietal bones)
I: medial aspect of the Ramus & the Coronoid Process of the Mandible
40
MASSETER MUSCLE:
O: Zygomatic Arch & Maxilla
I: post-lateral aspect of Angle of Mandible
41
LATERAL PTERYGOID MUSCLE:
Superior Head: O: inf-lat Greater Wing of Sphenoid
I: investing fascia which then attaches to the Disc & Joint Capsule
Inferior Head: O: lat. aspect Lat. Pterygoid Plate of Sphenoid
I: ant-lat Condylar Process of Mandible42
MEDIAL PTERYGOID MUSCLE:
O: med. aspect of Lateral Pterygoid Plate of Sphenoid
I: med. aspect of Angle of the Mandible43
Motions of the TMJ:
Opening (depression) ( Dental Flexion)– Hinge Motion: sl open (jaw drop) ~20mm
Glide Motion: full open ~30mm
Total ~50mm in the adult-3 knuckles of dom. hand
Closing (elevation) (Dental Extension)
Protrusion (forward)- esp w/ Cranial Extension
Retrusion (backward) – esp w/ Cranial Flexion
Lateral Motion – Usu 12-16mm from the midline –reflects tightness of Lat Pterygoid m/Stab: M&L Col L
Chewing –combo of all 4 M. of Mastication
Dental Terms:
Extension = Mouth Closed
Flexion = Mouth Fully Open
44
NORMAL TMJ FUNCTION
45
So. . .what can go wrong?
Internal Joint Derangement- via prolonged microtrauma from shearing forces with Hyperextension on closing
Anterior displacement of the Disc
Reversible
Irreversible
Muscle Imbalance- esp with head forward posture so common today, whiplash
Acute Lock- Open or Closed
Arthritis: Rheumatoid or Osteoarthritis
46
O’Donahue’s Terrible Triad –
Knee
Medial Collateral
Ligament
Medial Meniscus
Ant. Cruciate Ligament
TMJ
Medial Collateral Ligament
Articular Disc
Lateral Collateral Ligament
NO Cruciate Ligaments
47
TMJ Jt. analogous to Knee Jt.:
O’Donahue’s Terrible Triad –
Lateral Collateral Ligament fails first->Disc begins
to deviate medially->Med.Col. Lig fails
Cartilage Disc is displaced Anterior by the
forward motion of the Condyle (but NOT actively
pulled by any muscle contraction)
Disc can get caught ant. & won’t reduce back up
on the Condyle
Spheno/Stylomandib Ligs-check ligs. to prevent
HyperFlex (opening)
*No Cruciate Lig. to prevent HyperExt* (closing)
48
TMJ Model:
On Full Opening (Flexion) “classic
bowtie appearance” on MRI- ie, Disc
should be seated mid-Condyle
On Closing (Extension)
By convention, as a frame of reference,
the midpoint of the Condyle acts as mid pt.
of a clock
Post aspect of Disc should line up at
EXACTLY 12 o’clock to prevent Hyper Ext
Bite splint acts to prevent/correct Hyper Ext
49
Perfect closure (TMJ Ext) @ 12:00
50
12
Perfect Open (TMJ Flex) “Bow-Tie”
51
ABN Closure (HyperExt) @ 10:00
52
1210
Closure corrected w/ Bite splint to 12:00
53
12
Summary:
54
Jaw Click
55
Internal Jt. Derangement can produce “click” Displacement/distortion of the disc
Catching of torn ligaments/disc in Jt.
Remodeling of the articular surfaces
Joint ligamentous hypermobility
The Disc is displaced anterior to the Condyle.
“Click” occurs as the Disc attempts to locate itself on the Condyle.
56
Acute Closed Lock-Emergent
Must be reduced within short window (~4-6 wks)
Once reduced DON’T CLOSE MOUTH till sees dentist-place bite block/ bite guard to prevent another ant. displacement
If Dx missed, will have Hinge motion only- lose Glide Motion- so can only open mouth 20mm
Forces the neurovascular rich bilaminar zone to now act as disc—Exquisitely Painful!
Leads to DJD-thereafter followed by CT scan until pt. is a candidate for TMJ joint remodeling surgery
NO longer do TMJ joint replacement-off market
57
58
59
Inflam cyst
Irregular condyle
Ant displaced disc
The Condyle is prevented from translating
at all due to the Disc being unable to
locate itself on the Condyle.
60
Causes of TMJ
Joint Pathology- analogous to the Knee
Trauma
Macro- a blow, accel/decel or inertial injuries
Repetitive Micro- clenching, grinding with
malocclusion and/or emotional stress.
Frequently with chronic severe headache
Prior Dental extractions
Posture-can lead to Myofascial Imbalances
Functional or Anatomic Short leg, Scoliosis61
Nociception via Trigeminal from the Teeth leads to Tension in Muscles of Mastication
A Viscero-Somatic Reflex
NMM/OMM Specialist: if you recognize
problems but it is beyond your OMT skills
TMJ Specialist (DDS):
When you suspect internal derangement
or degenerative joint disease which does
not respond to OMT. May be a painful or
painless click or limited opening.
Urgent : Acute Closed Lock: Jaw fails to
open due to the Condyle being unable to
capture the Disc with opening. Must be
treated promptly to avoid sequela
When to Refer?
63
Osteopathic treatment can be considered
when the problems appear to be
A. Muscular in origin: This includes the
major muscles for chewing, cervical,
sternocleidomastoid, trapezius, and
levator scapulae muscles.
B. Articular (Jt) in origin: the cranium, upper
cervicals, ribs, upper thoracics & sacrum
are also important to examine.
Where do you focus the OMT?
64
65
66
TMJ Tomogram X-rays
67
MRI
68
CT scan with sagittal views:
69
Ant disc
TMJ & Sleep Apnea
If you have mild to moderate obstructive sleep apnea
and can't tolerate or haven't been helped by CPAP,
oral appliances may be an effective treatment option.
These devices, which must be fitted by a dentist or
orthodontist, and worn in the mouth at night include:
Mandibular advancement device (MAD). The most widely
used mouth device for sleep apnea, MADs look much like a
mouth guard used in sports. The devices snap over the
upper and lower dental arches and have metal hinges that
make it possible for the lower jaw to be eased forward.
Some, such as the Thornton Adjustable Positioner (TAP),
allow you to control the degree of advancement.
Tongue retaining device. Used less commonly than MAD,
this device is a splint that holds the tongue in place to keep
the airway open. 70
LAB
Evaluate the Bite for TMJ
Muscle Energy TMJ
SCS Medial & Lateral Pterygoid muscles
71
Headache: TMJ
PERFORM A PHYSICAL EXAM
Sit or stand facing your patient1) Observe for:
• facial asymmetries• head tilt (tight SCM on side of tilt)
2) Observe for restriction in the 2 actions on opening of the joint:• hinge• glide
3) Observe for restriction of:• Protrusion (jaw forward)• Retrusion (jaw backward)• Lateral Deviation (L & R)
• less motion available to side that jaw is dysfunctionallydeviated toward
72
PERFORM A PHYSICAL EXAM
4) Have them smile or otherwise show their teeth• Observe the mid-incisor line: Do the top & bottom line up:
• Open (flexed) position• Closed (extended) position
• Observe the other teeth in a closed position:• Do the front teeth meet in front?
• Closed Bite: the front teeth meet but the back teeth do not• Do the back teeth meet when the front teeth meet?
• Open Bite: the back teeth meet but the front teeth do not• Are the upper teeth just anterior to the bottom teeth all the way
around? • Cross bite--on one side the bottom teeth will be anterior to the top
teeth.• Class II (“Great American”) bite (overbite, overjet=buck teeth) is
when the lower teeth slide further superior and posterior to the upper teeth
Headache: TMJ
73
PERFORM A PHYSICAL EXAM
5) Place 5th finger pads on anterior aspect of patients EAC.• Palpate for asymmetry and tenderness. • Motion Test: With opening and closing of the jaw:
palpate again for tenderness and for an opening clickor closing click or other crepitus such as clunking.
6) Palpate for muscle tension• Make note of any SCS points, see table below.
Headache: TMJ
74
Muscles of mastication Occipital Mastoid Suture
Suboccipital muscles Neck Muscles related to forward head posture.
Temporalis Rectus capitis posterior major SCM
Masseter Rectus capitis posterior minor Scalenes
Lateral pterygoid Obliquus capitis Trapezius
Medial pterygoid Levator scapulae
PERFORM A PHYSICAL EXAM
7) Determine the TMJ Deviation pattern of the patient:• C-shaped deviation: jaw deviates to one side
• Always deviates to the side of the dysfunctional joint• Dysfunctional side will stop first upon opening –the other
side opens further & deviates to the dysfunctional side
• S-shaped deviation: jaw deviates from midline in one direction until half-way through the range then deviates the other direction. • Indicates dysfunctional movement of the Disc from
ligamentous instability involving BOTH the Left & Right Condyles.
Headache: TMJ
75
Principle of Muscle Energy
Direct technique (take toward the restrictive
barrier)
Activating force: Pt.’s own muscle force
pushing away from the barrier.
Doc give equal counterforce x 3-5 sec.
Relax.
Wait 1-2 sec for the Post Isometric
Contraction Relaxation Phase.
Take up slack to the next barrier.
Repeat 2-5 x. Retest.76
Headache: TMJ
Treatment of TMJ Dysfunction
Muscle Energy TMJ:
Diagnose:• Using the pads of your 5th fingers, palpate the anterior
external auditory meatus. • Determine which side the mandible deviates while the
mouth opens. This is the “dysfunctional” side!• Is there associated crepitus, muscle tightness, and/or
tenderness of the anterior EAM?• Is it a C or S deviation?
Finger alignment for DX of TMJ Dysfunction
77
Headache: TMJ
Treatment of TMJ Dysfunction
Muscle Energy TMJ:
Technique:Patient: SupinePhysician: Seated at head of patient1. Hold the temporal bone on the “dysfunctional” side to stabilize the head.
With your other hand cup the chin as shown on the “good” side. 2. Have the patient relax their jaw (use instructions like drop or sag the jaw). 3. Have the patient contract their jaw isometrically against your hand for 3-5
seconds (they will be firing the muscles of the “good side” to push their jaw away from the “dysfunctional side).
4. Patient relaxes for 2 seconds. 5. You take up the slack by medial translation of the jaw into the new barrier. 6. Repeat the muscle energy cycle 3 times. 7. At the end of each muscle energy cycle, have the patient slightly open their
jaw further while you hold it at the barrier (the last time they open the jaw fully).
8. Have the patient fully close jaw while you hold the jaw at the barrier. 9. Switch hands and repeat steps 1-8 for the “dysfunctional” side. 10. Reassess by reinserting your 5th digits in the ear canals & have the patient
slowly fully open & close
**At the final open & close by the patient, there is often a palpable clunk in the TMJ as the disc reseats on the mandible.
78
Headache: TMJ
Treatment of TMJ Dysfunction
Muscle Energy: TMJ:
79
Cup the Jaw Patient Sags the jaw, counterforce is applied Patient relaxes, Slack is taken up
Cup the Jaw Patient Sags the jaw, counterforce is applied Patient relaxes, Slack is taken up
Principles of Strain Counterstrain (SCS):
Find a tenderpoint with testing pressure
Put the associated muscle, fascia, etc. in its most
relaxed position, wrapping around the opp. side and
hold for 90 sec
3 phases of release:
Nerve phase: pain diminishes- then use monitoring
pressure (less)
Circulatory phase: as fascia relaxes, the relatively ischemic
area allows fresh blood to enter-feel a pulse
Lymphatic phase: as fluid passes through the capillary, the
lymphatics drain-feel a softening
Slowly, passively return body to a neutral position
Retest. Goal is 70+% improvement
80
PTERYGOID MUSCLES
81
Medial Pterygoid (MPT)
Location of
Tender Point
Posterior surface
of ascending
ramus of
mandible
Approx 2 cm
above
mandibular angle
Press anteriorly
Medial Pterygoid (MPT)
Treatment Position–
Pt. supine
Push slightly open
jaw laterally away
from TP side
Apply stabilizing
force on opposite
side of forehead
w/ forearm
PTERYGOID MUSCLES
84
Lateral Pterygoid (LPT)
Location of
Tender Point(s)
1) Below the
zygomatic arch
(cheek bone),
1 cm anterior to
neck of the
condyle
Press medial
and posterior
Treatment Position
Pt. supine
Pt protrudes (juts)
jaw forward
Push open jaw
laterally away from
TP side
Pt. relaxes.
Apply stabilizing
force w/ forearm of
motion hand
Lateral Pterygoid (LPT)
References:
Chila, A, Foundations of Osteopathic
Medicine, 3rd ed by Lippincott, Williams &
Wilkins, 2011, Ch.37: Head and Suboccipital
Region by Heinking, KP, Kappler, RE and
Ramey, KA, 510-511.
Meyers, HL, et al, Clinical Application of
Counterstrain, TOMF Osteopathic Press,
compendium ed, 2012, Treatment of
Headache, Neck Pain, and TMJ Dysfunction
with Counterstrain.
87
References:
DiGiovanna, EL and Schiowitz, S, The
Temporomandibular Joint by Donald Phykitt, in An
Osteopathic Approach to Diagnosis and Treatment,
Lippincott Williams & Wilkins, 3rd ed, 607-611.
Magoun, HI, Temporomandibular Lesions, in Osteopathy
in the Cranial Field, 1976, 3rd ed, The Journal Printing
Company, Kirksville MO, 155,162-163, 201-202.
Upledger, JE and Vredevoogd, JD, TemporoMandibular
Joint Evaluation and Treatment in CranioSacral
Therapy,1983, Eastland Press, 199-202.
Seffinger, M and Hruby, R, Evidence Based Manual
Medicine,Saunders Elsevier, 2007,129-187 (Mechanical
Neck Pain), 189-205 (Cervicogenic HA), 207-220 (TMJ).
88
References Greenman, PE,Craniosacral manipulation in
Phys Med Rehab Clin N Am, 1996, 7: 877-896.
Gehin, A, Atlas of manipulative techniques for
the cranium and face, 1985, Eastland Press.
Rimon, A, et al, Review for the Generalist:
Temporomandibular joint pain in pediatrics: the
clinical approach and differential diagnosis:
http://www.pedrheumonlinejournal.org/may-
june05/TMJ-Pain.htm
Eraso, F, TMJ Imaging: What should be the
Standard of Care?, Winter 2006 AADMRT
Newsletter,http://www.aadmrt.com/currents/eras
o_winter_06_print.htm