OMM 13: TMJ Evaluation and Treatment

mm. responsible for lateral deviation of TMJ

(L/R) -contraction of lateral pterygoid => CONTRA-lateral deviation

attachments of lateral pterygoid

(recall responsible for protrusion and contralateral deviation of TMJ) -superior head = greater wing of sphenoid to articular disc of TMJ -inferior head = lateral pterygoid plate to condylar head

attachments of medial pterygoid

(recall responsible for protrusion and contralateral deviation of TMJ) -superficial head = tuberosity of maxilla/palatine to medial pterygoid tuberosity of mandibular angle -deep head = lateral pterygoid plate to medial pterygoid tuberosity of mandibular angle

components of TMJ

(temporomandibular joint) -hinge joint involving... -head of mandible -articular tubercle of temporal -mandibular fossa of temporal -covered by fibrocartilage capsule -divided into superior/inferior joint spaces by articular disc

components of masticatory mm. sling

-1' mm. of mastication including... -temporalis -masseter -medial pterygoid -lateral pterygoid

joint spaces involved in TMJ depression (opening)

-1st 1/2 (~25 mm) = inferior joint space -2nd 1/2 (>25 mm) = superior joint space (ie yawning, big bites, etc) -this is usually when pain occurs

medial/internal pterygoid counterstrain point and tx position

-TP = posterior surface of ascending ramus -~2 cm above angle of mandible pressing anteriorly -position = jaw slightly open then moved AWAY from TP side

masseter mm. counterstrain point and tx position

-TP = superficial/deep fibers of masseter -posterior towards anterior border of ascending ramus of mandible -position = jaw slightly open then moved TOWARDS TP side

TMJ joint spaces

-articular disc divides superior/inferior joint spaces -superior = btwn intraarticular disc and temporal fossa -inferior = btwn mandibular condyle and intraarticular disc

clinical characteristics of upper cross syndrome

-caused by poor posture leading to.... -forward head -inc C-lordosis + T-kyphosis -elevated/protracted shoulders -rotation/ABD/winging of scapula -may cause TMJ pain

TMJ lateral deviation ME

-contact dysfxn side mandible and apply gentle force towards barrier -pt tries to push chin opposite direction against resistance -hold, relax, take up slack, etc

steps for medial/lateral pterygoid release

-cradle occiput and insert gloved pinky into mouth -run along bottom gum line/teeth until at region of medial pterygoid (straight back) -gentler pressure/run along direction of fibers => softening -move superior and repeat over lateral pterygoid

inhibited/weak mm. in upper cross syndrome

-deep cervical flexors -mid trap -low trap -these require retraining

naming of deviation TMJ dysfxn's

-deviation to L/R w/ jaw movement can be in C or S shape -side of final deviation = side of dysfxn

mm. responsible for elevation/depression of TMJ

-elevation = closing mouth from rest involving contraction of... -temporalis -masseter -medial pterygoid -depression = opening mouth from rest involving... -GRAVITY assisted by... -digastric -geniohyoid -mylohyoid

tx of occipitomastoid suture restrictions

-gently try to spread OM sutures apart and compare both sides -compressed suture has "no give" = dysfxn side -make V w/ index on mastoid and middle on occiput -apply spreading tension to pull OM suture apart

jaw dislocation defn

-head of mandible sliding past articular tubercle -leads to locked protruded position = mouth can't close -requires EMERGENT reduction due to risk to vasculature/nerves

ME for hypertonic mm. of mastication

-hypertonicity of masseter/temporalis => restricted jaw opening -2x fingers on anterior surface of chin -gently open mouth to edge of restrictive barrier -pt tries to close mouth against resistance -hold, relax, take up slack etc

3 ligaments of TMJ

-lateral = temporomandibular -connects mandible to zygomatic arch -sphenomandibular -connects mandible to spine of sphenoid -stylomandibular -connects mandible to styloid process of temporal

steps to dx TMJ somatic dysfxn

-monitor TMJ just anterior to tragus -palpate as pt opens/closes mouth assessing for crepitus/ROM -watch chin for deviation (recall R/L C vs S curve)

steps for temporal rocking

-once in temporal hold will either encourage flexion/extension depending on restriction -encouraging flexion involves.... -ring/little finger exert medial pressure on lower mastoid process -thumb/index exert cephalad "lifting" of zygomatic arch -this encourages ER -resist motion of IR during extension phase (visa versa for encouraging extension/IR)

sx's of TMJ dysfxn

-pain/clicking w/ mandibular motion -TTP over TMJ -anterior displacement = doesn't close well -posterior displacement = doesn't open well

mm. responsible for protrusion/retraction of TMJ

-protrusion = mandible forward from rest involving contraction of... -lateral pterygoid -retraction = mandible back from rest involving contraction of... -posterior fibers of temporalis

steps for sphenopalatine release

-support frontal bone along coronal suture and insert gloved pinky into mouth -run along alveolar ridge past tuberosity of maxilla -hold w/ firm pressure vs run finger in soft tissue tx

nerves at risk w/ TMJ pathology

-those innervating TMJ capsule including.... -auriculotemporal -mesenteric -mandibular -deep temporal

joint spaces involved in retraction/protraction/lateral deviation of TMJ

-upper joint space

tight mm. in upper cross syndrome

-upper trap -levator scapula -pec major -pec minor -these require stretching

temporal hold position defn

-used for temporal rocking -thumb/index grasps zygomatic part of temporal bone -middle rests on EAM -ring/little rest on inferior portion of mastoid process