Temporal Mandibular Joint Dysfunction

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Temporal Mandibular Joint Dysfunction

• NMS 670
• Dr. Deborah Denno, DC

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Definition

• Pain tenderness due to dysfunction of TMJ or
  surrounding musculature
• Divided into 3 subtypes (often co-exist)
• Myofascial pain dysfunction
• Internal derangement
• Degenerative joint disease

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Demographics

• Incidence 50 of population estimated to have
  some symptoms of TMJ
• Gender females gt males (41)
• Age highest incidence young adults 20-40

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Potential Causes

• TMJ synovitis or disc derangement
• Hyper/hypomobile TMJ
• Bruxism (grinding teeth)
• Muscle spasm
• Trauma or stress
• Dental conditions (ex. Poor fitting dentures)
• OA or RA

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History

• Jaw or facial pain
• Difficulty or pain with chewing
• Clicking /popping
• Crepitus
• Inability to open mouth fully
• Inability to close mouth
• Jaw fatigue
• Headache, earache neck pain
• Past head or facial trauma

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Joint Anatomy 2 compartments

• Superior
• Borders temporal bone
• and articular disc
• Function linear
• movement /translation of
• jaw
• Inferior
• Borders articular disc
• and condyle
• Function full rotation of
• condyle

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Articular Disc

• Borders
• Superiorly articular eminence Temporal bone
• Inferiorly Condylar head
• Posteriorly Retrodiscal tissue
• Anteriorly articular eminence of Temporal bone
• Structure
• Biconcave
• Made up of 3 bands (Ant, Intermed, Post)
• Dense fibrous CT
• Non-vascular, not pain sensitive

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Articular Disc

• Stabilized by collateral ligaments , capsular
  ligaments
• Function smooth gliding and rocking of
  mandibular condyle
• Elongation or degeneration leads to anterior
  displacement of disc
• Retrodiscal Tissue
• Highly vascular (venous plexus)
• Covered with synovial membrane
• i.e. capable of effusion pain

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Capsular Ligaments
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Other Ligaments

• Temporo-Mandibular
• Spheno-Mandibular
• Stylo-Mandibular

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Muscles of Mastication

• Masseter

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Temporalis
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Pterygoids
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Digastric assists opening of mouth
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Biomechanics

• Opening
• Initial step relaxation of Masseter and
  Temporalis (closing muscles)
• Intermediate Inf head of Pterygoid pulls disc
  condyle down
• End Digastric muscle pulls mandible down back

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Biomechanics

• Closing
• Superior head of Pterygoid stabilizes disc
  condyle
• Masseter Temporalis pull jaw up
• Posterior movement limited by TML

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Evaluation

• Past Medical Hx
• Direct trauma? Whiplash?
• Previous episode of jaw locking?
• Arthritis?
• Dental pathology?
• Mandibular gait

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Evaluation

• Tests
• 3 finger test
• ROM tests
• -Capsule stretch (capsulitis)
• -Synovial compression (synovitis)
• -Muscle contraction (Myofacial irritation)
• Palpation check for trigger points
• Imaging
• -X-ray not helpful till later DJD present
• -MRI in severe cases not respond to tx

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TMJ Disorders

• Capsulitis
• Pain increases with protrusion or lateral mvt,
  chewing on opposite side, opening mouth widely
• Hx of trauma
• Cause overstretching of capsule
• Test Condylar stretch test (mandible forward,
  mouth open)
• Mgt Ice, rest, avoid provoking mvts, check
  Occiput C1

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Disorders continued

• Synovitis
• TMJ pain worse with full closure on ipsilateral
  side
• Grinding teeth
• Cause acute direct trauma or chronic
  malposition
• Test Condylar compression test pull jaw
  posteriorly superiorly
• Mgt
• -Acute ice, soft diet, analgesics
• -Chronic adjustments, soft tissue work

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Disorders

• Disc derangement
• Popping or clicking while opening or closing
  mouth
• Cause anterior/ant-medial displacement of disc
  or condylar head posterior to disc
• Exam palpate in front or inside ear
• -opening closing causes clicks
• Management
• -dental appliance
• -Adjustments

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Closed Lock

• Presentation
• Difficulty opening mouth fully
• Pain tenderness w/o current popping
• Suboccipital pain, dysphagia, tinnitus
• Cause anteriorly displaced disc, in way of
  condyle
• Evaluation
• 3 finger test, no popping on opening
• Mgt Adjust, traction, gapping w/ active mvt by
  patient

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Acute Open Lock

• Presentation
• Acute locking of jaw when its fully open
• Pain due to spasm of closing muscles (Masseter
  Temporalis)
• Cause
• Trauma or hypermobility
• Condyle dislocated anterior to articular eminence
• Exam X-rays for fracture (if case of trauma)
• Mgt Bilateral Adjustment w/downward traction

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Treatment Considerations

• Frequency 2x/week for 2 weeks, then reassess
• If continuing treatment, 1 -2x/week for 2 months
• Treat myofascial component
• Adjustments stretching of hypomobile
  joints/muscles
• Postural correction (AHC)
• PT TENS, ultrasound every other day
• Decrease stress
• Lifestyle factors (chewing gum, sleep position)
• Splints (ex. Aqualizer)

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Co-management

• 75 of patients have resolution of symptoms
  within 3 months
• Refer to dentist if
• Conservative tx is ineffective despite pt
  compliance
• Acute TMJ locking or poor occlusion of upper
  lower jaw occurs
• Evidence of abscess appears
• Surgical referral last resort if disc damage,
  needs replacement