Chapter 24

The Temporomandibular Joint

Overview

The stomatognathic system comprises the

temporomandibular joint (TMJ), the
masticatory systems, and the related
organs and tissues such as the salivary
glands
Due to the proximity of this system with
the other structures of the head and neck,
an intimate relationship exists
This relationship begins in the early stages
of human embryology

ANATOMY

Bones
Mandible
Maxilla
Zygomatic arch
Temporal bone

Temporomandibular
Joint

The articular surfaces of the

temporomandibular joint are lined
by fibrous tissue - this reflects the
development of the joint
Unlike all other synovial joints
whose articular surfaces develop
endochondrally and are therefore
lined by hyaline cartilage, the
temporomandibular joint develops
in membrane

Intra-articular Disc

Fibrous in structure
Divides the joint cavity into two
regions
Thinnest centrally
Attaches anteriorly to the lateral
pterygoid
Attaches posteriorly to the condyle

Joint Capsule
Capsular ligaments fibers only
pass between the temporal bone
and mandible on the lateral side
Intrinsic ligaments short fibers
which pass from the bone to the
intra-articular disc

Ligamentous support
Lateral TMJ ligament
Stylomandibular ligament

Muscles
Lateral pterygoid

Origin

Upper head arises from the infratemporal surface of the

greater wing of the sphenoid
Lower head arises from the lateral surface of the lateral
pterygoid plate

Insertion - The anterior aspect of the neck of the

mandibular condyle and capsule of the TMJ
Innervation - A branch of the mandibular division of the
trigeminal nerve
Function

Upper head - involved mainly with chewing, and functions to

anteriorly rotate the disc on the condyle during the closing
movement
Lower head - exerts an anterior, lateral, and inferior pull on
the mandible, thereby opening the jaw, protruding the
mandible, and deviating the mandible to the opposite side

Muscles
Medial pterygoid
Origin - Deep origin situated on the medial
aspect of the mandibular ramus
Insertion - The inferior and posterior aspects of
the medial subsurface of the ramus and angle
of the mandible
Innervation - A branch of the mandibular
division of the trigeminal nerve
Function - Working bilaterally - assists in
mouth closing. Working unilaterally
deviation of the mandible toward the opposite
side

Muscles
Masseter - two-layered quadrilateral shaped
muscle.
Origin

The superficial portion arises from the anterior two-thirds of the

lower border of the zygomatic arch
The deep portion arises from the medial surface of the zygomatic
arch.

Insertion - On the lateral surface of the coronoid process

of the mandible, upper half of the ramus and angle of the
mandible
Innervation - A branch of the mandibular division of the
trigeminal nerve
Function - The major function of the masseter is to elevate
the mandible, thereby occluding the teeth during
mastication.

Muscles
Tempororalis
Origin - The floor of the temporal fossa and
temporal fascia
Insertion - On the anterior border of the
coronoid process and anterior border of the
ramus of the mandible
Innervation - A branch of the mandibular
division of the trigeminal nerve
Function - assists with mouth closing/sideto-side grinding of the teeth. Also provides
a good deal of stability to the joint

Muscles
Digastric

Origin - The posterior belly arises from the

mastoid, or digastric, notch immediately behind
the mastoid process of the temporal bone.
Insertion - The posterior belly passes downwards
and forwards towards the hyoid bone where it
becomes the intermediate digastric tendon and
joins with the anterior belly.
Nerve Supply - derived from the digastric branch of
the facial nerve.
Vasculature - arterial blood supply from the
posterior auricular and occipital arteries.
Action - The muscle depresses the mandible and
can elevate the hyoid bone. The posterior bellies
act in unison and are particularly active during
swallowing and chewing.

BIOMECHANICS

Biomechanics

TMJ motions involve a

combination of rolls and glides of
the mandibular head and disc
All TMJ motions involve all or
some of the following:

Anterior/posterior glide
Medial/lateral glide
Inferior/posterior glide

Opening and closing

Mouth opening

Anterior glide
Lateral glide
Inferior glide

Mouth closing

Posterior glide
Medial glide
Superior glide

Lateral Deviation

Contralateral deviation
Anterior, inferior and lateral glide of
the mandibular head and disc

Ipsilateral deviation
Posterior, superior and medial glide
of the mandibular head and disc

Protrusion and
Retrusion

Protrusion
Anterior, inferior and lateral glide of
the mandibular head and disc

Retrusion
Posterior, superior and medial glide
of the mandibular head and disc

EXAMINATION

Examination

As with any other synovial joint,

there are a number of possible
causes/scenarios:

Local cause
Referred cause
Loss of motion with or without pain
Excessive motion with or without
pain

History

There are three cardinal features of

temporomandibular disorders (TMD):
Restricted jaw function (intermittent or
progressive)
Joint noise (significant if associated with other
factors)
Orofacial pain (Pain that is centered immediately
in front of the tragus of the ear and projects to
the ear, temple, cheek, and along the mandible is
highly-diagnostic for TMD)

It is important to observe the patients

mouth while they talk

History

Attempt to determine a specific

mechanism:
Trauma (including surgery controlled
trauma)
Posture
Emotional factors
Parafunctional habits (cheek biting, nail
biting, pencil chewing, teeth clenching
(day), bruxism (night))
Symptom-provoking motions of the TMJ or
neighboring joint(s)

History

The patients past dental and

orthodontic history
Whether the patient has
experienced any locking of the
jaw
Whether the symptoms are
improving or worsening

History

Systems review
Pain or dysfunction in the orofacial
region can often be due to nonmusculoskeletal causes:
Otolaryngologic disease
Neurologic disease
Vascular disease
Neoplastic, and infectious disease
Psychogenic disease

Observation

The forward head posture is frequently

associated with TMD..try it
A lateral deviation of the jaw, evidenced
by a malalignment or malocclusion of
the upper and lower teeth, may cause
an adaptive shortening of the
mastication muscles on one side, and a
lengthening of the mastication muscles
on the contralateral side.

Observation

Cavities, wear patterns, and restored and

missing teeth should be noted
Tooth wear and fracture are often destructive signs
of parafunctional habits

The rest position of the TMJ should be noted

The rest position of the TMJ is determined by
gently placing the little finger with the palmar
portion facing anteriorly into the external auditory
meatus. From an open mouth position, the patient
is asked to slowly close their mouth. At the point
of the resting position, the patients mandibular
heads should be felt to gently touch the finger.

Range of Motion

The range of motion of the

cervical spine, craniovertebral
joints and the shoulders should be
assessed
The range of motion of the neck
and jaw should then be assessed:
Active range of motion with passive
overpressure to assess the end feel.

Range of Motion

All movements should be smooth

and without noise or pain
If pain occurs, a determination should
be made as to where in the range the
pain occurs, and the location of the pain

The type and temporal sequence of

joint clicking can provide the
clinician with information

Joint Noise

Reciprocal clicking is defined as

clicking that occurs during opening
and again during closing.
Early clicking usually indicates a small
anterior displacement
Late clicking usually indicates that the disc
has been further displaced

Often due to articular hypermobility, and is

accompanied by a deviation of the jaw toward
the contralateral side.

Mouth Opening

Mouth opening is the most revealing and

diagnostic movement for TMD
Normal motion tested using knuckle test
(approximately a two-three-knuckle width of the
non-dominant hand) or more objectively by
measuring (closer to 40 mm)
A limited opening of the jaw may indicate joint
hypomobility, muscle tightness, or the presence of
trigger points within the elevator muscles: the
temporalis, masseter and medial pterygoid
Other causes of diminished mandibular opening include
structural disorders of the TMJ, such as ankylosis,
internal derangements, and gross osteoarthritis

C and S Curves

A C-pattern of motion occurs if the

hypomobility is due to internal derangement
The mandible deviates toward the involved side in the
midrange of opening before returning to normal.

An S-pattern of movement while opening the

mouth may indicate a muscle imbalance. An arc
may indicate a muscle imbalance
Lateral excursion of the mandible with mouth
opening implicates contralateral structures such
as the contralateral disc, masseter, temporalis,
lateral pterygoid, or the lateral ligaments

Palpation

Palpation of the TMJ is used to

assess tenderness, skin
temperature, muscle tone, swelling,
skin moisture, and the location of
trigger points
Palpations of the lateral and posterior
aspects of the temporomandibular
joints are performed bilaterally and
simultaneously

Strength Testing

It is important to be able to
selectively stress the muscles of
mastication and facial expression
to determine whether they are
implicated in the symptoms

Ligament Stress Tests

The ligament stress tests assess the

integrity of the capsule and ligaments
Positive findings include excessive
motion as compared to the other side, or
pain

Two structures are primarily tested:

Temporomandibular ligament
Joint capsule

Passive Articular
Mobility

The passive articular mobility tests assess the

joint glides and the end feels
Findings are compared with each side
Pain or a restricted glide are positive findings and
may indicate articular involvement or a capsular
restriction.

It is important to check the specific glides that

are related to the loss of active motion. For
example, if a patient demonstrated
diminished mouth opening mouth, the
combined anterior, inferior, and lateral glide is
assessed for each joint.

Articular glides

Mouth opening, contralateral

deviation, and protrusion all involve
an anterior, inferior and lateral glide
of the mandibular head and disc
Mouth closing, ipsilateral deviation,
and retrusion all involve an
posterior, superior and medial glide
of the mandibular head and disc

Conclusions

If the joint glides are normal the joint is

OK
Check ligaments and surrounding tissues

If the joint glides are restricted, the cause

could indicate a joint/joint capsule
restriction, a ligamentous adhesion or
adaptive shortening of the surrounding
tissues need to mobilize the offending
joint and re-assess
The intervention should always match the
diagnosis!!

Articular tests

Dynamic loading
The patient bites forcefully on a cotton roll
or tongue depressor on one side. This
maneuver loads the contralateral TMJ.

Joint compression
The clinician, standing behind the seated or
supine patient, places the fingers of each
hand under each side of the mandible, with
the thumbs resting on the ramus. The
mandible is then tipped posteriorly and
inferiorly to compress the joint surfaces

Neurological tests

Trigeminal sensation
Trigeminal reflex

INTERVENTION

Intervention

Based on:
Stage of healing. Chronic TMD pain
often occurs because of secondary
factors:
A fixed head forward posture
Abnormal stress levels
Depression
Oral parafunctional habits

Structure involved

Acute Stage

The acute patient typically

demonstrates:
A capsular pattern of restriction (decreased
ipsilateral opening and lateral deviation to
the contralateral side), with pain and
tenderness on the same side

There may be associated ligamentous

damage (positive stress tests), or
muscular damage (positive strength
tests)

Acute Stage

The usual methods of decreasing

inflammation are recommended:
PRICEMEM

Protection
Rest
Ice
Compression
Elevation?
Manual therapy
Early motion
Medications

TMJ Exercises

Acute stage:

6x6 exercise protocol of Rocabado

Cork exercise
Tongue positioning during mouth
opening and closing

TMJ Exercises

Functional Stage:
Strengthening exercises for the
cervicothoracic stabilizers, and the
scapular stabilizers
Stretching exercises for the
scalenes, trapezius, pectoralis
minor, and levator scapulae; and the
suboccipital extensors

Home
(Automobilization)
Exercises
Mouth opening exercise

Tongue depressor exercise

Toothpick exercise
Distraction mobilization

Functional (Chronic)
Stage

Postural and patient education should

form the cornerstone of any plan of care
for TMD
Psychotherapy referral
Manual techniques
Exercise
Thermal and electrotherapeutic
modalities
Trigger point therapy