KenOlsonPT,DHSc,OCS,FAAOMPT EricFurto PT,DPT,FAAOMPT

Purpose
y Thisbreakoutsessionwillincludedescriptionofthe

kinematicsandfunctionalanatomyofthe temporomandibular joint(TMJ)andrelated structures,andthephysicaltherapyexamination, classification,andtreatmentofTemporomandibular disorders(TMD).

Objectives
y DescribethefunctionalanatomyandkinematicsoftheTMJ y IdentifytheclassificationofTMDanddescribethecomponentsof y y

y y

eachdisorder PerformacomprehensiveexaminationoftheTMJandrelated structures PerformtreatmentproceduresfortheTMJincludingsofttissue mobilization,jointmobilization/manipulation,andexercise instruction DescribethefunctionalinterrelationshipsbetweentheTMJand cervicalspine Describetheevidencetosupportaphysicaltherapyapproachfor treatmentoftemporomandibular disorders.

Craniomandibular Anatomyand Kinematics

Occlusionalplane

Anatomy
OsseousStructures Temporalbone Postglenoid spine Mandibular Fossa Articular Eminence Articular Crest Articular Tuberle Mandible Condyle medialandlateralpole NeckofCondyle Coronoid Process Ramus Body Teeth Mandibular andMaxillary

MusclesofMastication
Temporalis,Masseter, Buccinator,Medial/Lateral pterygoid

Medial/lateralpterygoids

HyoidMuscles
Supra hyoid Digastric Mylohyoid Stylohyoid InfraHyoid Omohyoid thyrohyoid Sternohyoid

IntercapsularStructures
y y y y y y y y y y y

Articulardisc 3bands Anterior 2mm Middle 1mm Posterior 3mm Attachments Medialandlateralcollateralligaments PosteriorAttachments/BilaminarZone SuperiorLaminae InferiorLaminae Retrodiscalpad LateralPterygoid

ArticularDisc

Arthrokinematics
y Depression y LateralExcursion y Protrusion

MandibularDepression

Mandibular Depression Arthrokinematics

DepressionKinematics
y First25mmofopeningthatoccursprimarilyasarotational

motion(rollgliding)ofthecondyle intheinferiorjointspace. y Oncethecollateralligamentstauten,theopeningcontinuesas primarilyatranslatory glidingmotionintheupperjointspace until35mmisreachedandtheposteriorandcollateralligaments aretaut. y Openinggreaterthan35mmresultsfromfurthertranslation withoverrotation andfurtherstretchingappliedtotheposterior andcollateralligaments.12 y Thelateralpterygoid,inferiorhead,providesaprotractingforce onthecondyles anddiscs;thegeniohyoid anddigastic muscles produceadepressingandretractingforceonthechin;andthe mylohyoid musclepullsdownwardonthebodyofthemandible tocombinetoproducetherotatory andtranslatory movements ofthejawthatoccurwithmandibular depression

Mandibulardepression

MuscularActionwithOpen/closing

LateralExcursion

LateralExcursionKinematics
y Lateralexcursionoccurswhenthecondyle anddiscofthe

contralateral sidearepulledforward,downward,and mediallyalongthearticular eminence. y Thecondyle ontheipsilateral sideperformsminimal rotationaroundaverticalaxisandaslightlateralshift.12 y Thesemotionstakeplaceprimarilyintheupperjoint space. y Lateralexcursioniscreatedbycontractionofthelateral pterygoid musclesonthecontralateral sideofthedirection ofthemotioncombinedwiththeipsilateral sidetemporalis musclecontractingtoholdtherestpositionofthecondyle topreventthemandiblefromdeviatinganteriorly.12

Protrusion

ProtrusionKinematics
y Protusion ofthemandibleiscreatedwithsymmetricalanterior

translationofbothcondyle/disccomplexesonthearticular eminence y Themotionoccursatthesuperiorjointspace. y Protrusioniscreatedbycontractionoftheinferiorheadofthe lateralpterygoid andholdingactionofthemasseter andmedial pterygoid muscles.12 Thelateralpterygoid pullsthecondyle and discforwardanddownalongthearticular eminencewhilethe elevatoranddepressormusclesmaintainthemandibular position.12 y Retrusion isthereturntorestpositionfromtheprotrusion positionandiscreatedbythecontractionofthemiddleand posteriorfibersofbothtemporalis muscleswhilethedepressors andelevatorsmaintainaslightopeningofthemouth.12

Mandibular Mapping

CervicalSpineandTMJ interrelationships

Relationship BetweenPostureand TheTMJ

TheEffectofOcclusionon RestingPostureofTMJ Normal

zNormalIntermolar

relationship(red).
zAllowsNormalseating

ofMandibledisccondyle relationship(blue).

Kraus

TheEffectofOcclusionon RestingPostureofTMJ Pathological

zPoorocclusionbetween

molars(red).
zPullsmandibleforward

(green).
zPlacesanteriorstresson

thediscoftheTMJ.

zJawandfacialpain.

Kraus

EffectofFHPonmandible

Neumann

Pseudomalocclusion
y Changerestpositionofmandiblecanchangehead/

neckposture (Daly) y IncreaseFHPplacesmandibleinmoreretruded position (Darling) y IncreaseFHPchangesthetrajectoryofthemandible (Goldstein)

DalyP.1982Posturalresponseoftheheadtobiteopeninginadultmales.American JournalofOrthodontics.82:157160. DarlingDW,etal.1984Relationshipofheadpostureandtherestpositionofthe mandible.JournalofProstheticDentistry.52(1):111115. GoldsteinDF,KraussS,WilliamsWB,GlasheenWrayMB.1984Influenceofcervical postureonmandibular movement.JournalProstheticDentistry.52(3):421426.

HowtheMusclesandJoints WorkTogether
Increaseforwardhead posture. Tightposteriorneck musculaturewillrotatethe craniumbackwardleaving themouthopenatrest. Musclesofmastication overworktomaintainjaw closure.

Cailliet

Referralpatternsfrom Cervicalspineto Mandibular region

S/Omusclesand mastoidmuscles Greaterandlesser occipitalnerves Cervicalplexus C2C3facet

Summary
y FunctionalandAnatomicalinterrelationshipsbetween

TMJcomplexandCervicalspinedictatethata thoroughexaminationandtreatmentofbothregions isnecessarytoobtainpositiveclinicaloutcomes

y Thisanopportunityforphysicaltherapiststoplayan

activeroleinmanagementofcervicalspineandTMD conditions

Evaluation
y History y Structure y ActiveRangeofMotion Cervical y ActiveRangeofMotion Mandible y PassiveAccessoryMotion Cervical y PassiveAccessoryMotion TMJ y Provocation/Palpation

MandibularDynamics

TMJPassiveAccessoryMobilityTesting

Provocationtesting

TMDClassification
y Capsulitis/Synovitis y CapsularFibrosis y Hypermobility y ArticularDiscDisplacement y Withreduction y Withoutreduction y Post SurgicalTMJ

Capsulitis/Synovitis
y TendertopalpationatTMJlateralcondyleorposterior

compartment y Painwithbitingonoppositeside y Painwithretrusiveoverpressure y Painwithaccessorymotiontesting

MasticatoryMuscleDisorders
y Nojointsounds y Painwithpalpationmusclesofmastication y Inconsistentalterationsinmandibularcontrol y Parafunctionaloralbehaviors y Painwithbitingonsameside

CapsularFibrosis
y Capsularpattern y Deviationtowardlimitedsidewithopeningand protrusion y Limitedcontralaterallateralexcursion y LimitedAROMmandibulardynamics y LimitedmobilitywithTMJaccessorymotiontests y Nojointsounds y Historyoftraumaorsurgery

TMJCapsularpattern

Hypermobility
y Endrangeclickwithdeviationawayfromhypermobile

side y ?Symptomatic y Mayleadtodiscdisplacementcondition y ExcessiveAROMwithopening>40mm y Jointsoundatendrangeofopening y Hypermobilitywithaccessorymotiontesting

Hypermobility

ArticularDiscDisplacement
y Withreduction

Articular DiscDisplacementwith reduction

y Reciprocaljointsoundwithopeningandclosing y Scurvewithopening y FullAROM(unlesscombinedwithacutecapsulitisor

muscledysfunction)

DiscDisplacementwReduction

ArticularDiscDisplacement
y Withoutreduction

Articular DiscDisplacement withoutreduction

y Historyofjointsounds y Limitedopening<25mmifacute y Deviationofmandiblewithopeningtowardlimited

side

TMJCapsularpattern

Post SurgicalTMJ
y capsulitis/synovitis y AssessforunderlyingTMJdysfunction

Osteoarthritis
y TMJcrepitusasnotedwithstethoscope y PainwithTMJpalpation y Radiographicevidenceofosteoarthritis

PhysicalTherapy TreatmentofTMJ Dysfunction

PhysicalTherapyGoals
y RestoreNaturalMotionofTMJandCervicalSpine y ImprovePosturalAwareness y ImproveFunction(eating,talking,etc.) y DecreasePainandHeadaches y TeachPatientsHowtoPreventFutureOccurrencesof

HeadandFacialPain

TreatmentsforTMD
y Modalities y Manipulation y Cervical/thoracicspine y TMJ y PosturalEducation y Therapeuticexercise y Neuromuscularreeducation

Modalities
y Ultrasound y Iontophoresis y MoistHeat

Iontophoresis
y InastudybyMajwerandSwider,22 27of32casesof

posttraumaticTMDbenefitedwithdecreasedpain fromtheapplicationofdexamethasone(n=8)or xylocane(n=24)throughiontophoresis

CervicalManipulation
y Enhancecervical

mobilityandfunction y Improveposture y Indirectlyencourage aproperrestposition ofthecondyle

TMJManipulations
z

Indications
Lossofjawmotion Limitedaccessorymotion Pain

y Techniques
y LongAxisDistraction y MedialGlide y LateralGlide

CaseSeries
y Nicolakis etal9 hadsuccessfuloutcomesinaseriesof

20patientswithOAoftheTMJwithimproved measuresofpainatrest,incisional opening,and function. y Theinterventionsincludedjointmobilizationofthe TMJ,softtissuetechniques,activeandpassiveTMJ exercises,andposturalexercises.9 y Datacollectedonthesepatientsata12monthfollow upexaminationcontinuedtosuggestfavorableresults fortheuseofexerciseandmanualphysicaltherapyin themanagementofTMD.10

10 Nicolakisetal
y 30patientswithTMJanteriordiscdisplacementwith

reduction y treatmentwithtemporomandibular jointandsofttissue mobilization,rangeofmotionandisometricexercises,and posturaleducationforanaverageofninevisitswitha physicaltherapist. y Seventyfivepercentofthepatientshadsuccessful outcomes

y painlevelandmouthopeningmeasurementsatthe6month

followupexamination;13%hadreductioninTMJsounds.10

y Thisstudysupportstheuseofexercisecombinedwith

gentlemanualtherapytechniquesfortreatmentofanterior discdisplacementwithreduction.

SingleCasedesign
y ClelandandPalmer27 showedagoodclinicaloutcomeina

singlecasedesignstudyofapatientwithbilateralarticular discdisplacementwithoutreductionthatwasconfirmed withMRI. y ThetreatmentapproachincludedTMJmobilization techniques,cervicalspinemobilization/manipulation techniques,posturalandneckexercises,andpatient educationregardingparafunctional habits,softdiet, relaxationtechniques,activitymodification,andtongue restingposition. y Thepatienthadareturnofnormalmouthopeninganda reductioninpainanddisabilitymeasuresasaresultofthe physicaltherapyapproach.27

NeuromuscularReeducation
y Tongue/teethposition y Controlledopening y Gentleisometrics y Theutilizationofacocontractionofthemusculature surroundingajointtofacilitatestability
y y y

PosteriorTemporalis(Anteriorly) DeepMasseter(Laterally) SuperiorLateralPterygoid(Medially)

HomeExerciseProgram
y Everypatientreceivesahomeexerciseprogram y Exercisestake<1minutetoperform y Exercisesaretobeperformedevery2hoursfor6

repetitions
y Encouragesposturalcompliance GoodPostureNever

Rests y Trainsenduranceandfunctionofposturalmuscles

y Allexercisesarereviewedateachsession

Randomizedclinicaltrial,Yodaet al26
y Comparedanexerciseprogramwitheducation y Fortytwopatientswithanteriordiscdisplacementwith y y y y

reduction Theresultsshowedthattheexercisegrouphadbetteroutcomes fordecreasedpainandincreasedROM(P =.0001).26 61.9%oftheexercisegrouphadfavorableoutcomes(13/21 patients),and0%ofthecontrolgrouphadfavorableresults.26 Successwasmeasuredontheseverityofjointsoundsorpain withmaximalmouthopening. Ofthe13patientswithasuccessfuloutcome,onlythreeofthe patientsTMJarticular discs(23.1%)wererecapturedwith reexaminationwithmagneticresonanceimaging(MRI).26

CondylarRemodeling Theory
y Hyperboloidencouragesproperjawtodisc

alignment. y Utilizationofmusclecontraction biting increasesthenaturalstabilityandconvexityof thejointstructure. y Throughmultiplerepetitions(6timesevery2 hours),thejointwillberetrainedtomaintain normalcondylaralignmentwithmovement.

CondylarRemodeling
y RestPosition
y Gentlyrestdevice

betweenteeth betweenincisors. y Maintainnormal airwayforbreathing.

CondylarRemodeling Theory
y Contralaterallateraldeviationwillgapand

glidethecondyleanteriorlyontheeminence whilethediscremainspositionedcorrectly. y Bitinginthispositioncreatesacocontraction ofthemusculatureactingonthediscand facilitatesstabilization

y PosteriorTemporalis y DeepMasseter y SuperiorLateralPterygoid

CondylarRemodeling

CondylarRemodeling Theory
y Thereturntomidlinewhilemaintainingthe

contractioncreatesacouplingforce.
y Approximatesthenaturalcondylardisceminence

relationshipswithmotion. y Theorysuggeststhebiconcavedisccanreformtothe approximatedcondyleandeminence.

ExercisePhasesforRehab
y Restdevicegentlybetweenfrontteeth
y PhaseI Rolldeviceawayfromaffectedside. y PhaseII Afterroll,gentlybitedownasif tomakean

impressiononthedevice. y PhaseIII Afterbite,maintainforceontodeviceand returntomidline

y Doallexercisessixtimesthreetimesperday.

CondylarRemodeling Modifications

Protrusion Whilemaintainingbite, protrudejaw

WithResistance Providegentledistractionon devicewhilemaintaining gentlebite

Furto ES, Olson KA, Whitman JM, Cleland JA.

Furto ES,ClelandJA,WhitmanJM,OlsonKA.ManualPhysicalTherapy interventionsandexerciseforpatientswithtemporomandibular disorders.JofCraniomandibular practice.2006;24(4):283291

Background&Purpose
y Temporomandibulardisorder(TMD)isarelatively

commonandoftendisablingcondition,yetlittle evidenceexiststosupporttheeffectivenessof rehabilitationprogramsforthispatient population. y Thepurposeofthisstudywastoinvestigatethe outcomesofaconsecutiveseriesofpatientswith TMDwhoweretreatedwithmanualphysical therapyinterventionsandexercise.

y Allpatients(14/15female)receivedacomprehensiveupperquarter

Methods

examination,includingamanualphysicaltherapyassessmentof thebilateraltemporomandibularjoints(TMJ),thecervicalspine, andtheupperthoracicspineandribcage. y Manualphysicaltherapytechniqueswereusedtoaddress identifiedimpairmentsintheTMJandupperquarter.Home exerciseswereprescribedtoreinforcethemanualtherapy interventions. y Patientscompletedaselfreportquestionnairesatbaselineand2 weekfollowup.OutcomesincludedtheTemporomandibular Index,bodydiagram,thePatientSpecificFunctionalScale,and theGlobalRatingofChangescale(GROC).

DataAnalysis

y Descriptiveinformation,includingpatientgender,ageand

durationofsymptoms,wasrecordedforallpatients. y Themeanchangescoreandassociated95%confidence intervalswerecalculatedforalloutcomemeasures assessedatbaselineandatthe2weekfollowup. y Pairedttestswereperformedbetweenthebaselineand2 weekfollowupscores(a=0.05)toevaluateifthe experiencedchangewassignificant.

y PatientshadexperiencedsymptomsintheTMJregionforamedian

Results

durationof6months(range0.07120months).Thirteenhad associatedheadachesymptomsforamediandurationof6months (range0.0760months). y Atthetimeofthetwoweekfollowupsession,thegrouphadreceived ameanof4.3(0.98)physicaltherapyinterventionsessions. y ThemeanTMDDisabilityIndexscoreswere32.1%(15.4%)atbaseline and18.3%(12.5%)atthe2weekfollowup,representingan improvementof13.9%(CI:8.2%,19.5%)(p<0.05). y Seventythreepercent(11/15)ofpatientsreportedtheyweresomewhat bettertoaverygreatdealbetterontheGROC,andPatientSpecific FunctionalScale(PSFS)scoresimproved3.1points(CI: 2.3,3.9) (p<0.05).

Patient Specific Functional Scale

12 PSFS Score (0-10) 10 8 6 4 2 0 Basline 2-Week

PSFS: 0 = unable to do activity due to the problem, 10=able to do activity as before the problem; Score is average of 3 activity scores

TMD Disability Questionnaire

50 45 40 35 30 25 20 15 10 5 0 Basline
Higher scores mean higher levels of disability

TMD Score

2-Week

Global Rating of Change Scale (GRC)

GRC Score (range -7 to +7)
7 6 5 4 3 2 1 0

TMD

TMD & Associated Symptoms

Score of -7= a very great deal worse, 0=no change, +3=somewhat better, +7=a very great deal better.

y Patientswithtemporomandibulardisorderwhoaretreatedwitha

Discussion

rehabilitationprogramincludingmanualphysicaltherapyinterventions plusexercisecandemonstrateclinicallymeaningfulimprovementsin disabilityandoverallperceivedchangeinarelativelyshortperiodoftime.

y Continuedresearchisneededtoidentifythelongtermeffectsandto

determineifaspecificsubgroupofpatientsmostlikelytobenefitfroma manualphysicaltherapyapproachexistsaswellattodeterminewhether thismodeoftreatmentismorebeneficialthanothermanagement strategiesforpatientswithTMD.

TMDClassificationInterventions
Capsulitis Hypermobility Capsular Fibrosis

Classification Criteria

Classification Criteria

Classification Criteria

ExerciseIontophoresis

Stabilization exercises TMJ mobilization Mobility exercises Sustained stretch Ultrasound?

TMDClassificationInterventions
Post surgical Muscles of Mastication Disorders

Classification Criteria

Classification Criteria

Mobility,stabilityand proproprioceptionexercises STMtechniques

Jt mob ExerciseMobility, stability and proprioception

TMDClassificationInterventions
Disc dislocation with reduction Disc dislocation without reduction

Classification Criteria

Classification Criteria

Exercise-mobility, stability, and proprioception TMJ mobilization

Exercise-mobility, stability, and proprioception TMJ mobilization

Education
y Limitparafunctional activities:nailbiting,gumchewing,clenching y y y y y y y y y y

andgrindingteeth Tongueposition:atrest,thetipofthetongueshouldbeattheridgeof theroofofthemouthwiththefrontonethirdofthetongueontheroof ofthemouth Teethposition:theteethshouldbe2to3mmapartatrest Lipsshouldbelightlytogetherwithbreathingthroughthenose Keepthetipofthetongueupontheroofofthemouthwhenyawning Avoidsleepingintheproneposition Donotrestchininhands Softdiet:avoidhardcrunchyfoods Cutfoodupintosmallbites Warmwaterrinses PosturalandTMJexercises56timesperday