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9/11/2015
4
Articular cartilage
Synovial Fluid
Functions of the synovial fluid include lubrication of the joint, phagocytosis of particulate debris, and nourishment of the articular cartilage. �
Joint lubrication is a complex function related to the viscosity of synovial fluid and to the ability of articular cartilage to allow the free passage of water within the pores of its glycosaminoglycan matrix. �
Application of a loading force to articular cartilage causes a deformation at the location. It has been theorized that water is extruded from the loaded area into the synovial fluid adjacent to the point of contact. �
The concentration of hyaluronic acid and hence the viscosity of the synovial fluid is greater at the point of load, thus protecting the articular surfaces.
Articular Disc
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Biomechanics
Functional Motion
Evaluation
The evaluation of the patient with temporomandibular pain, dysfunction, or both is like that in any other diagnostic work up. � This evaluation should include a thorough history, a physical examination of the masticatory system, and problem-focused TMJ radiography (if available)
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Questions
Jaw specific Pain-talking, chewing, yawning
Popping or clicking
Catching or locking
Issues opening or closing
Grinding/clinching
Dental work-type (orthodontics)
Night guard- or oral appliance
Cranio-facial specific Ear symptoms
Change with neck motions
Hx of HA
Trauma hx including whiplash
Stress- Work/Life
Other pathoanatomical considerations
Functional Questionnaires
Jaw Functional Limitation Scale Ohrbach R. et al J Orofac Pain 2008
Oral Health Impact Profile Montero-Martin J. et al J Clin Exp Dent 2009
Temporomandibular Disorder Disability Index Streigerwald and Maher created
“Reliability and validity not yet measured” Cleland J. Palmer J. J Orthop Sports Phys Ther. 2004
Psychological Evaluation
Many patients with temporomandibular pain and dysfunction of long-standing duration develop manifestations of chronic pain syndrome behavior.
May include gross exaggeration of symptoms and clinical depression.
Comorbidity of psychiatric illness and temporomandibular dysfunction can be as high as 10% to 20% of patients seeking treatment �
1/3 suffering from depression at the time on initial presentation, whereas more than two thirds have had a severe depressive episode in their history.
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Imaging
Radiographic Evaluation
Panoramic Radiography One of the best overall radiographs for screening evaluation of the TMJs is the panoramic radiograph
Tomograms The tomographic technique allows a more detailed view of the TMJ.
Imaging continued
Temporomandibular Joint Arthrography was the first technique available that allowed visualization (indirect) of the intra articular disk
Computed tomography (CT) provides a combination of tomographic views of the joint, combined with computer enhancement of hard and soft tissue images.
Magnetic Resonance Imaging
The most effective diagnostic imaging technique to evaluate TMJ soft tissues
Allows excellent images of intra articular soft tissue, making MRI a valuable technique for evaluating disk morphology and position
Can be obtained showing dynamic joint function in a cinematic fashion, providing valuable information about the anatomic components of the joint during function.
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Examination
The physical examination consists of an evaluation of the entire masticatory system.
The head and neck should be inspected for soft tissue asymmetry or evidence of muscular hypertrophy. �
The patient should be observed for signs of jaw clenching or other habits.
The masticatory muscles should be examined systematically. The muscles should be palpated for the presence of tenderness, fasciculations, spasm, or trigger points.
Facial Symmetry
Scars- under chin, behind ears
Masseter muscle
Lateral eye to mouth corner length versus nose-chin length
Top 1/3 of the face should equal bottom 1/3 of the face
Ipsilateral long mandible
Posture
Sitting versus standing
Occiput and C7 alignment
Finger space between C0-C2
McGregor’s plane-horizontal
Orthognathic -neutral
Retrognathic -posterior
Prognathic- anterior
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Forward head posture
Very common
Creates functional malocclusion
Hypertonicity of the SC(O)M
Hypertonicity of the lateral pterygoid
Hypertonicity of the masetter.
Forward Posture Kinetic Chain
Cervical Spine
The examination of the TMJ requires the examination/ screening of the cervical spine and its accessory motion.
Can patient maintain occlussalcontact with flexion and extension allowing mandibular glide.
Cervical extension= mandible down and back
Cervical flexion = mandible up and back.
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Sub-cranial contributions
Possible posture implications
Mandibular Examination
AROM
Depression- normal 3 fingers- about 40-45 mm
Lateral Deviation- side to side excursion about 10mm
Protrusion- starts about 4 behind maxillary incisors and goes 4-6 mm past for a total of 8-10 mm.
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Palpate Condylar Motion
Use light pressure
Posterior aspect of the condyle
Anterior aspect of the condyle
Strength
Grade 0-5
Qualifiers
S/PF; S/P; W/PF; W/P
Accessory Motions
Distraction
Anterior
Lateral (Medial)
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Palpation
Will require extra-oral and intra-oral
Mandible in a resting position (may need to teach)
Identification of involved soft tissue structures
Temporalis
Make sure to assess the Anterior, Middle and Posterior sections.
Pay attention to the tendon that goes underneath the zygomatic process
Special Tests
Jaw Jerk (Masseter) Reflex- Tap the thumb of the examiner while the mouth is held slightly open
Chvostek Sign- Tap the parotid gland that is overlying the masseter look for momentary tetany
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Bite Test
Place a barrier (tongue depressor, cotton) between molars and slowly bite down and assess location and assess location and pain Done bilaterally
Ipsilateral=muscle/tendon
Contralateral=capsulitis/synovitis
TMD Classification
Capsulitis/Synovitis
Capsular fibrosis
Masticatory muscle disorders
Hypermobility
Anterior disc displacement w/ reduction
Anterior disc displacement w/o reduction
Osteoarthritis
Anterior Displaced Disc
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Anterior Disc w Reduction
Stage 1 Disc slightly anterior, little to no pain Repetitive trauma begins to deform disc
Stage 2 Reciprocal click early opening and late closing Loss of integrity of ligamentous/intracapsular structures Increased disc deformation and impingement May develop open lock
Stage 2
Anterior Disc w/o Reduction
Stage 3 Most painful stage Reciprocal click occurs later in opening and earlier in closing Closed lock disc becomes lodged anteriorly
Stage 4 Clicking is rare, or single opening click Chronic locking w soft tissue remodeling Anterior displacement common, but may be posterior
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Stage 3
Overview Stages 1-4
Osteoarthritis
Stage 5
Radiographic degenerative changes on the condylar head and articular eminences
Evidence of remodeling and osteophytes
Marked deformity and thickening of disc
Narrowed joint space
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Treatment
Education
Neutral positioning of the neck and jaw
Cervical neutral posture
Eating modifications
Avoid “bad” oral habits
Office ergonomics
Manual Therapy
Soft tissue techniques
Joint mobilization
Neuromotor Re-education (Exercises)
Stabilization Exercises
Rocabado 6x6 Program
Tongue Clucks
Controlled Opening (TMJ rotation)
Rhythmic Stabilization of the mandible
Upper Cervical distraction
Cervical spine extension
Scapular depression and retraction
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Post-operative
Arthrocentesis
Arthroscopy
Arthroplasty
Joint Replacement (partial or complete)
Inra-oral Appliance
Commonly used
Attempt to create even contact for occlusion
Type of appliance v. usage outcomes
Used in cases of bruxism with insufficient levels of evidence for support
Macedo CR, Silva AB, Machado MAC, Saconato H, Prado GF. Occlusal splints for treating sleep bruxism (tooth grinding). Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD005514. DOI: 10.1002/14651858.CD005514.pub2
Overall Treatment Considerations
Patients with post-traumatic TMJ problems or with recent-onset dysfunction that is largely posture-related will generally progress quickly. Once existing mechanical dysfunctions are corrected, emphasis of treatment can be education on maintenance of good posture and oral habits.
Patients with chronic TMJ dysfunction of a non-traumatic nature are less likely to progress quickly. Often, they are systemically hypermobile, with less than optimal connective tissue quality. It is important that patients understand this and recognize the need for a long-term personal commitment to rehabilitation and musculoskeletal fitness.