TMJ

what is vertical dimension?

(p. 8) superior-inferior relationship of maxilla and mandible when teeth are situated in max intercuspation.

differentiate stabilization from repositioning splint

- both should be worn as much as possible, but with repositioning you must also wear when eating -stabilization splint aims to keep mandible in the centric occlusion position to relax the masticatory stabilizing muscles -repositioning spling aims at maintaining the condyle in a forward position from centric (1-3 mm)& should be work 3 months. (p.25)

describe ther ex for clicking due to anterior disk displacement with reductio (p.22)

-do 5 min after each meal -open mouth maximally -close along protruded path -contact teeth at protruded position

trigger points and refer from these muscles to where: -masseter -temporalis

-masseter refers to maxillary & manibular teeth -temporalis refers to maxillary teeth (p.9)

will the jaw click louder with opening or closing with anteriorly displaced disk that reduces?

...

what are some ways that ear symptoms are triggered with TMD?

1. Cspine dysfunction affects cranial nerve 5 that sends the auriculotemporal nerve to the TMJ as well as the ear 2. lateral pterygoid dysfunction can interfere with the eustachian tube, causing nonneurological tinnitus (p.11)

describe how upper Cspine can create vertigo symptoms (p.11)

1. S-O tightness compresses greater occipital nerve and compromises vertebrobasilar blood flow, resulting in dizziness. 2. malalignment affects tonic neck reflex, which can affect vetibular nuclei

describe condylar remodeling exercise (p.21-22)

1. bite down on rubber tubing with incisors. 2. translate rubber tubing to contralateral side. If not painful, add bite.

describe treatment for trismus (p.23)

1. heat pack with opening 2. soft diet to avoid excessive masseter contractions for 2 weeks 3. US, TENS, soft tissue mob, passive stretch 4. 2-4 visits over 1-2 weeks

what are some signs of TMJ hypermobility?

1. jaw opening; over 55 mm 2. protrusion of lateral poles with opening; indicates too much anterior translation

cluster signs of anterior disk displacment with reduction?

1. joint sounds with opening & closing 2.limited opening with or without pain 3.mandible deflects to same side during opening 4.altered mandibular dynamic shown by "C" or "S" (p.15)

define 3 classes of occlusion

1. normal 2. overjet (layman's "overbite") 3. mandibular arch is protruded in front of the maxilla arch ("underbite")

list Rocabado's 6x6 exercises for TMD (from EIM review)

1. tongue clucking 2. controlled opening 3. mandibular rhythmic stabilization 4. cervical distraction with "hand collar" 5. cervical retraction 6. scapular retraction

list acupressure area for HA relief

1.frontal 2. temple 3. zygomatic 4. occipital area

Overbite: What is normal?

1/3 of the mandibular center incisor

normal retrusion?

3 mm

Normal overjet?

3-6 mm

what is the normal fingers width of mandible depression?

4 fingers width (try it), or 35 mm

what percentage of patients had a positive outcome after scope of TMD?

50%

how frequently should the controlled opening exercise be performed daily?

6 reps, 6x/day (6x6). Do every 2 hours, regardless of symptoms

Normal protrusion?

6-9 mm

Swallowing & speech difficulty relate to TMD thru what nerve connection?

CN 5,7,9,10,11 thru the trigeminocervical connection

True or false: splints should only require one adjustment and then be good

False. Continuous adjustment required, especially if in PT.

How are the teeth counted?

Right upper is one. Left upper is 16. Left lower is 17. Right lower is 32. (clockwise if you face the patient)

what muscle can end up coactivating with masseter?

SCM (p.16)

what causes jaw clicking?

WHEN OPENING: disk reducing back over the condyle when opening mouth WHEN CLOSING: disc displaces again, due to excessive lateral pterygoid contraction and tightness of the posterior stratum fibers

differentiate C vs S patterns with mouth deviation

a C curve is capsular. S curve indicates lack of motor control This is the deviation of the mandible from central pathway during opening.

define trismus

acute closed lock of jaw after dental procedure. Caused by masseter spasm after prolonged opening.

What are risks with nocieptive trigeminal inhibition-tension suppression system splints? (NTI-tss)

adverse effects have been noted: -aspiration -ingestion -occlusal changes ... yet they can help manage bruxism. proper selection is needed.

what is "closed lock"?

anterior disk displacement withou reduction. limited ability to open mouth because disk is blocking it.

in most cases of internal derangement, the disk is displaced which direction?

anterior-medially. But rarely it can displace posteriorly to condylar head

how does the disk move with protrusion?

anteriorly and inferiorly

how do you assess TMJ capsule mobility?

apply longitudinal distraction on posterior mandibular molar along vertebral axis of the mandibular ramus. Check medial & lateral play.

what is current though on most effective procedure for TMD when conservative treatment has failed?

arthrocentesis and lavage of upper joint space, along with manipulation. (p.26)

what is the most important advice for posterior disk displacement?

avoid max mouth opening (p.22)

how do you palpate the retrodiskal pad?

behind condylar head with mouth open, or with small fingertips thru the external auditory canal.

where can the greater occipital nerve get trapped to cause cervicogenic headache?

between upper trap up near scull

muscle actions of lateral pterygoid

bilateral contraction: protrusion unilateral: contralateral excursion inferior head depresses mandible during mouth opening. Superior head likely works eccentrically during mouth closing to monitor disc position. (p.3)

bilateral & unilateral contraction of medial pterygoid

bilateral: elevate & protrudes unilateral: contralateral deviation

temporalis bilateral and unilateral contractions?

bilateral: elevate & retract mandibleunilateral: ipsilateral deviation/excursion

list retrusors of TMJ

deep fibers of masseter, temporalis, suprahyoids

what is deflection and when do you see it?

deflection occurs to ipsilateral side of displaced disk with mouth opening. Jaw shifts without return

what is function of suprahyoids?

depression & retrusion during closing of mouth when hyoid is fixed

list the suprahyoids

diagstric mylohyoid geniohyoid sylohyoid

True or false: traditional orthodontic treatment increases the prevalence of TMD

false. (p.26) sometimes it reduces TMD prevalence.

True or False: the TMJ disk rotate after the condylar head translates anteriorly

false. They move together as a unit

how palpate medial pterygoid?

finger follows mandibular arch to pass posterior molar, move superiorly towards maxila and ask patient to gently elevate mandible. (p.39)

when would you use an anterior repositioning splint (since it is more of a hassle than the stabilization splint)?

for anterior displacement with reduction

What is freeway space? what is normal range? how is it measured?

freeway space is between occluding surfaces of maxillary & mandibular teeth when in physiological resting position. Normal range is 3 mm and can only be measured on xray.

Tight S-O muscles can compress what nerve?

greater occipital

how might you discriminate muscular from joint involvement with TMD?

have patient bite cotton roll. If pain is ipsilateral, more muscular. If contralateral, more joint.

what can overbite and overjet measurements tell the clinician?

if muscles are involved with TMD dysfunction. Relieve spasm and see if these measures improve

list the depressors of TMJ

inferior fibers of lateral pterygoid suprahyoids infrahyoids (indirectly)

what will you get with anterior displacement without reduction

ipsilateral deviation. No longer a C or S deviation.

what do the condyles do with lateral deviation?

ipsilateral rotates/spins. Contralateral horizontally translates.

with capsular involvlement, what side does the convex C side go to?

ipsilateral side because that is the tight side.

what is a technique you could use to reflexively inhibit hyperactive mandibular elevators?

isometric contraction for the depressor of the TMJ. Have patient open mouth against resistance of dorsal hand (chin presses down into hand. p.20-21)

how do you palpate the lateral pterygoid?

it is not palpable directly, but you can get to the "lateral pterygoid area" if you use the tip of small finger to lateral-superior aspect of back molar.

what is the disk postion with anterior disk displacement with reduction, while mouth is closed?

it rests in front of the condylar head when mouth is closed.

what is the role of the superior retrodiscal lamina at the initiation of closing?

it retracts the disk

what is the TMJ position during isometric exercise?

keep tongue on roof of mouth, open mouth slightly

what's the normal ratio of lateral excursion to mouth opening range?

lateral excursion is one fourth. Relavance: PT can use to predict desirable opening range or vice versa.

what's more common, medial or lateral glide?

lateral glide (p.19)

are you more likely to use medial or lateral glides for treating TMJ hypomobility?

lateral glides more common. (p.20)

which muscle attaches to the anterior aspect of the TMJ disc?

lateral pterygoid.

what range of opening is considered hypmobile

less than 30 mm

where will you get neuralgia (what nerve)?

lesser occipital (p. 16)

what will you see with TMJ ankylosis?

limited translation of the involved side. Therefore, deviation to the ipsi side is seen with mouth opening

describe technique for "recapturing" displaced disk (p.19)

longitudinally distract, then add tilt of condylar head posteriorly

what innervates the TMJ

mandibular division of trigeminal deep temporal & masseteric (to anterior and medial aspects)

list the elevators of TMJ

masseter temporalis medial pterygoid superior fibers of lateral pterygoid, using eccentric movementduring elevation

how will patient present with posterior disk displacment?

my not be able to close their mouth

what is the most prevalent cause of TMD?

myofascial pain disorder

how does mouth breathing affect the Cspine?

occiput is drawn anteriorly, distrubing the balance of TMJ and Cspine

what's the normal lateral excursion of TMJ?

one forth of the opening range (ie, 10 mm)

what is centric relation?

open pack position, when condyle sits most superiorly and posteriorly in mandibular fossa with disk stabilized

what is over bite vs overjet?

overbite measures the tooth overlap in front with mouth closed. over jet measures the horizontal distance between top and bottom.

list clinical manifestations of myofascial TMD pain

pain in face, jaw, neck. Dizziness. tinnitus, earache, headache. (p.9)

how would you diagnose myofascial pain with TMD?

palpate trigger points.

how long might you use a resting splint?

permanently

does the condyle rotate posteriorly or anteriorly with depression?

posteriorly. that is, the body moves posteriorly as the head moves anteriorly

if patient with TMD myofascial pain disorder is not improving as well as hoped with pain edu, MFR, & relaxation techniques, what is your next course of action? (p.30)

refer to psychologist for cognitve behavior therapy

how would you assess CN 5 integrity?

reflex hammer taps chin. normal response is a slight jerk

how could you use gravity to assist anterior translation?

rest forehead on forearm (EIM)

Which occurs during depression of mandible, condylar rotation or translation?

rotation first 25-50%, then translation from50-100%

what's an exercise to improve post-op hypomobility of TMD

rubber band tongue blades together & place horizontally in mouth. Patient translates mandible f/b and sideways

what are intraoral signs of nocturnal bruxism?

scalloping of tongue or cheek indents

define the acronym SINS as it relates to pain

sensitivity irritability nature stage

function of infrahyoids

stabilize the hyoid to form a firm base for the suprahyoids. With the suprahyoids, are also involved with speech, swallow, & tongue movements

list the infrahyoids

sternohyoid, sternothyroid, thyohyoid, omohyoid

where might you see tension HA vs cervicogenic HA?

tension will frontal. Cervicogenic may be unilateral.

what causes the anterior translation of the condylar head during derpession/jaw opening?

the rolling of the condyle stretches the oblique fiber of the TMJ ligament, which initiates the late phase of jaw opening because of its increased tension.

what's most effective according to systemic review, stabilization splint, soft splint,physcal therapy, or acupuncture?

they are equitable (p.25)

with left anterior disk displacement, you will have restricted opening. Will lateral excursion be limited to left or to right?

to right

what is the term for electric-like, stabbing pain that lasts seconds or minutes and is unilateral?

trigeminal neuralgia. involves mandibular and maxillary divisions of this nerve.

with trismus, would you recommend chewing on the same or contralateral side?

trismus is a masseter muscle spasm. therefore chew on the opposite side.

unilateral and bilateral function of masseter?

unilateral: causes slight ipsilateral deviation. bilateral: initiates elevation of mandble with further force for cherwing and grinding

what causes posterior disk displacement?

wide opening of mouth with prolonged dental procedure or yawning. lateral pterygoid is over stretched.

are vertigo symptoms more prevalent the TMD?

yes

should TMD assessment include shoulders?

yes it should include TMD and UQ, including shoulders and Tspine

would spray and stretch be effective for myofascial pain syndrome?

yes, more so than modalities (p.30)

can clicking be normal?

yes.

will mandibular opening improve in direct proportion to regaining lateral excursion?

yes.

can gum chewing cause myospasm?

yes. (p.12)