Pathology and Medical Management TMJ Disorders and Diseases

2

Symbols this is for your

information only, it won’t be used for the

exam

important to know for exam

3

Temporomandibular Joint ImagingRadiography:

◦ Fractures which might occur.

◦ Can also get an idea of the joint position

Generally not as useful as other types of imaging studies

Standard Views:◦ Transcranial View◦ Submentovertex

view◦ Cephalometry:

lateral views

MRI: T1-weighted sagittal images are the method of choice for TMJ examination.◦ Articular disk position

T2 weighted images◦ Periarticular changes◦ Joint effusions

CT

4

Figure 5.  a, Sagittal and b, coronal MR images (770/27) of a normal TMJ with jaw in closed position.

Sommer O J et al. Radiographics 2003;23:e14-e14

©2003 by Radiological Society of North America

5

TMJ Dysfunctions

Non-Inflammatory Inflammatory MPDS

Articular Non Articular

Articular Disk Displacement

With Reduction

Deviation in Form

Dislocation and Subluxation

Fibrosis

Without Reduction

Ankylosis

Bony

Synovitis and Capsulitis

Arthritic Disorders

Osteoarthritis

Rheumatoid Arthritis

Other

Myositis

Spasm

Muscle Contracture

www.geocities.com/dentalsem/Temporomandibular...

6

Articular Disk Displacements with ReductionPartial Anteromedial Disk

Displacement◦Disk slides anterior on the condyle◦Posterior band is more anteriorly

placed than normal◦Etiology:

Thinning of the posterior band Minimal elongation of diskal ligaments

◦TX: intro-oral appliances in combination with stress reduction

7

Disk DisplacementAnteromedial Disk Displacement with

Reduction◦ Definition: Change in the disk-condyle

structural relation during mandibular translation with mouth opening and closing

◦ Etiology: Articular surface irregularity Disk-articular surface adherence Synovial fluid degradation Myofascial imbalances around the joint Increased elongation of diskal ligaments and

posterior attachment

www.urmc.rochester.edu/smd/Rad/tmj.htm

8

5 Progressive StagesStage I Disk Displacement

◦Temporal mandibular ligament becomes elongated

◦Disk drops medially - subluxes which reduces upon closure

◦Ligament brings the disk back into place upon closure

9

Symptoms of Stage 1:Very little pain

Inconsistent click occurs early in opening phase.

Subluxation on opening and a lateral reduction in closing

10

11

Stage II Disk DisplacementTM ligament continues to

elongate, disk moves more medial and anterior on mandibular head.

Reduction on mouth opening,

subluxation on closingClicking: Early on opening and

Late on closing

12

Figure 11.  Partial anterior disk displacement.

Sommer O J et al. Radiographics 2003;23:e14-e14

©2003 by Radiological Society of North America

13

Symptoms of 2:◦ Reciprocal click early

on opening and late on closing

◦ Pain

Signs: C curve upon mouth opening: goes back and lateral towards dysfunctional side.

14

Open Lock: Potential to occur from Stage II

on

Signs: two opening clicks Two closing clicks Condyle can be prevented from slipping

back in place if disk lies too posterior to the condyle

15

Stage IIISignificant TM ligament

elongation overstretching occurs causing posterior ligament elongation, disk shape distorted.

Condyle loses vertical height Capsule becomes shortened

16

Symptoms 3: click is more consistentClick occurs later on opening and earlier on closing◦ Most painful stage

Signs: ◦ C curve ◦ Limited range of mouth opening to 25 to

30 mm, just below functional: 35mm is limit.

17

Closed Lock conditionClosed lock: sudden limitation of

jaw opening◦Disk is permanently lodged

anteriorly and interferes with normal rotation and translation of the joint

◦Hard end-feel

18

Stage IV: Rotational DisplacementSymptoms: Pain

Signs:◦Clicking rare or single opening click

19

Stage V:Signs: radiographic degenerative

changes on condylar head, articular eminences (less often)

Evidence of remodeling (sclerosis) and osteophytes

Marked deformity of disk, thickening of disk and shape change

20

C. Anteromedial Disk Displacement with Intermittent LockingDisk is displacedShape is deformed over time

from biconcave to biconvex

Symptoms: intermittent locking in the am or after a period of clenching or chewing on involved side, brucsizum (teeth clenching @ night)

21

D. Anteromedial Disk Displacement without ReductionDefinition: change of the disk-condyle

structural relationship which is maintained during mandibular translation◦ Disk remains displaced with a closed-lock

occurring◦ Lose: contact with condyle, disk and articular

eminence of condyle which prevents posterior translation from occurring

Signs: ◦ Deviation of mandible towards involved side◦ Marked limitation of lateral deviation to

contralateral side

22

Internal Derangement of the Disk Deviation in Form

◦Frictional Disk Incoordination: Definition: intra-articular disk adheres to

the eminence Onset: Etiology: loss of lubrication, roughness in

the articular surface Signs: loss of translatory glide

opening click Symptoms: minimal discomfort with the

click

23

Deviation in FormArticular Surface Defects

◦ Definition: articulating surface has a roughed area or a change in the articular cartilage which doesn’t allow smooth rolling or gliding during opening and closing of the mouth

◦ Etiology: ◦ Signs: reciprocal click during opening and

closing of the mouth Lateral deviation on opening

24

Deviation in FormDisk Thinning and perforation

◦Etiology: application of excessive pressure on the TMJ, overloading with teeth together

◦Symptoms: variable joint tenderness, muscle pain

◦Signs: grating sound, crepitus during opening and closing

◦DX: made with medical imaging studies

25

Hypermobility and Dislocation

-Hyper: at risk for a locked open mouth.

Subluxation

Dislocation

Hypomobility: capsular vs adhesive disk

26

A. Joint SubluxationMandibular Head Subluxation

1. Biomechanical considerations

2. Arthrokinematic dysfunctions

a. max. rotation occurs before translation begins

b. maximum translation occurs and a shift of condyle and disk as a unit occurs

27

Subluxation versus Reduction of Displaced DiskSubluxed Disk:

◦Occurs only on wide opening◦Does not occur with protrusion or

lateral deviation◦Pain is not always present

Reduction Disk:◦Occurs on opening for stage I,

closing (except in stage 1) and protrusion and contra-lateral lateral deviation

28

B. Joint DislocationCondyle moves outside of the physiological

boundaries of the joint

Etiology: yawning (to wide), singing, sleeping with head on forearm, excessive tooth abrasion, malocclusion, over-closure and trauma

Sx: open lock position mouth is unable to close, locked open

Rx: manipulation, splint

29

Ankylosis: stuck

Fusion of TM joint◦ Fibrosis

◦ Bony

Symptoms: ◦ Opposite side may

become painful

Signs: ◦ Decreased ROM◦ C curve on mouth

openingTx

◦ How to f(x) with it.

30

Adhesive Disk HypomobilityDefinition: intra-articular

formation of adhesions within the disk◦Usually in the superior joint cavity,

causes loss of condylar translation

◦Condylar displacement of disk may occur

◦Distortion of disk on mouth opening

31

Adhesive HypomobileEtiology:

◦Trauma: mild may only cause frictional disk incoordination or articular surface defect

◦Major: intra-articular bleeding, swelling, fibrosis can result Restricts ROM May progress to joint degeneration

32

Sx: Click – ◦ Early is within 10 mm of opening, ◦ Intermediate between 10 and 20 mm, ◦ Late after 30 mm of opening. ◦ C/o a locking sensation

Signs: ◦ mandible deviates away from the

dysfunctional side during mouth opening ◦ S-curve: jaw goes to both sides

correcting and over-correcting.

33

Inflammatory ConditionsSynovitis and Capsulitis

◦RetrodiscitisArthritic Conditions

◦Osteoarthritis◦Rheumatoid Arthritis◦Other Arthritic Conditions

34

Capsulitis

◦ SX: continuous deep constant pain Originates in joint area Pain with mouth opening

◦ Signs: palpable pain with compression to the lateral pole of condyle Limitation of mouth opening Myospasms secondary to pain Tissue stretch end feel or empty end feel Decreased protrusion , may deviate to side of

dysfunction Increase pain with passive stretch

35

Retrodiscitis

Anterior displacement of disk, condyle presses on posterior tissue causing an inflammatory reaction

Hx: trauma, chronic bruxing

SX: constant, dull, aching pain, aggravated by joint movement

-closure puts it back into place.

Signs: empty end feel, acute malocclusion, decrease protrusion, pain with compression

36

Non-Articular ConditionsMuscle Spasms

◦Masseter◦Temporalis◦Lateral Pterygoid◦Medial Pterygoid

MyositisMyofascial Pain Syndrome Muscle Contracture

37

Practice Pattern 4E:Muscle Spasms

◦Causes: trauma, occlusal imbalance, changes in vertical dimensions between teeth, immobilization, prolonged dental procedures, chronic teeth clenching, disease

38

Three Categories of Muscle Spasms1. Protective Co-contraction: muscle guarding

◦ Causes: Chronic inflammatory process, emotional stress, habit, muscle tendon injury

Sx: pain with active jaw movement

Signs: pain with resisted movements, pain at end range with passive movements, empty end feel or muscle spasm end feel

39

2. Local Muscle SpasmProtective muscle co-contraction,

◦ Leads to prolonged isometric contraction of muscle.

◦ Leads to decrease in blood flow, ◦ Inflammatory response, increase pain, increase

muscle guarding, more pain

History: blow to face, dislocation of jaw

SX: periarticular, pain with chewing

Signs: pain with AROM mouth opening, PROM, Resisted muscle testing, dec. in mouth opening pain with overpressure during mouth opening

40

3. Specific Muscles, Trigger Points1. Temporalis

a. HX: headaches in temporal region

b. SX: headaches, visual disturbances,

pressure behind eye, increase eye fatigue, difficulty with night

vision

41

c. Signs:

◦Muscle trigger point with referred pain pattern

◦S curve on mouth opening ◦Decrease in freeway space

(mouth opening at rest) ◦Abnormal protrusion of

condyle on contralateral side during lateral deviation

◦ Intermittent tooth ache

Restriction of mouth opening

Deviation of mouth toward affected side

Pain with palpationPain with resisted

motions of elevation but not protrusion

42

2. Masseter

a. HX:

b. SX: pain to lower jaw, molar

teeth and related gums,

pain with chewing or with increased jaw activity

unilateral tinnitus

Bruxism: jaw clenching

c. Signs: ◦ restriction of mouth opening

◦ deviation of mouth toward affected side

◦ pain with palpation

◦ referred pain pattern upon compression

◦ pain with resisted motions of elevation but not protrusion

43

3. Medial Pterygoid

Ache inside the mouth

a. HX:

b. SX: ◦ Pain with wide

mouth opening◦ pain with clenching

teeth◦ painful swallowing

c. Signs:◦ Restriction in mandibular

opening

◦ No deviation of jaw

◦ Rarely the primary muscle, Usually a 2ndary area

44

4. Lateral Pterygoid:

“TMJ” dysfunction

a. SX: ◦Pain in region

of TMJ and maxilla

◦Clicking sounds may occur, so need to be careful to d(x)

b. Signs: ◦ Pain with compression on

same side as dysfunction

◦ Slight restriction of mouth opening, occlusal abnormality

◦ ROM: for Lateral deviation away from the side of dysfunction is decreased

◦ ROM decreased

45

OncologicalA. Rare occurrences, but can get a

metastatic adenocarcinoma in the TMJ region

B. Signs: unrelenting pain of unexplained origin, neurological deficits, nausea, balance disorders, visual changes, cranial nerve disorders

C. Refer if suspect

46

PT TREATMENT OF TMJ DYSFUNCTIONSGoals are based on physical exam1. Treat pain: 2. Address biomechanical

asymmetries 3. Postural education: like forward

head4. Strengthen supporting

structures necessary to balance head, maintain new position

5. Stress reduction

47

Occlusional appliance:Splint: removable,

hard, acrylic “bite guard” a. muscle relaxation b. anterior (orthopedic) repositioning

appliance c. anterior bite plate d. posterior bite plate

48

Medical Treatment:Arthroscopic surgery done for

disk repositioning

Decrease adhesions

Take out osteophytes

49

Other References:1. Bourbon BM: “Craniomandibular

Examination and Treatment” in Saunders Manual of Physical Therapy Practice, WB Saunders Co. Philadelphia, 1995

2. Richardson JK and Iglarsh ZA. Clinical Orthopaedic Physical Therapy, W.B. Saunders Co., Philadelphia, 1994.

3. Magee D. Orthopedic Physical Assessment, 4th ed. 2002