1. Pathology and Medical Management TMJ Disorders and Diseases

2. Symbols this is for your information only,
it won’t be used for the exam
important to know for exam

3. Temporomandibular Joint Imaging
Radiography:
Fractures which might occur.
Can also get an idea of the joint position
Generally not as useful as other types of imaging studies
Standard Views:
Transcranial View
Submentovertex view
Cephalometry: lateral views
MRI: T1-weighted sagittal images are the method of choice for TMJ examination.
Articular disk position
T2 weighted images
Periarticular changes
Joint effusions CT

4. Figure 5.  a, Sagittal and b, coronal MR images (770/27) of a normal TMJ with jaw in closed position.
Figure 5.  a, Sagittal and b, coronal MR images (770/27) of a normal TMJ with jaw in closed position. 1, Mandibular head; 2, articular fossa; 3, disk (3a, anterior band; 3b, intermediate zone; 3c, posterior band); 4, bilaminar zone; 5, lateral pterygoid muscle.
Sommer O J et al. Radiographics 2003;23:e14-e14
©2003 by Radiological Society of North America

5. TMJ Dysfunctions Articular Non Articular Non-Inflammatory Inflammatory
MPDS
Articular Disk
Displacement
Synovitis and
Capsulitis
Myositis
With Reduction
Spasm
Arthritic Disorders
Without
Reduction
Muscle
Contracture
Osteoarthritis
Deviation in Form
Rheumatoid
Arthritis
Dislocation and
Subluxation
Other
Ankylosis
Bony
Fibrosis

6. Articular Disk Displacements with Reduction
Partial Anteromedial Disk Displacement
Disk slides anterior on the condyle
Posterior band is more anteriorly placed than normal
Etiology:
Thinning of the posterior band
Minimal elongation of diskal ligaments
TX: intro-oral appliances in combination with stress reduction
Condlye always on disk. Displacement is that the condyle has slipped off the condyle
Reduction the condyle moves back on to disk = this will have noice (clicks, crakles)

7. Disk Displacement Anteromedial Disk Displacement with Reduction
Definition: Change in the disk-condyle structural relation during mandibular translation with mouth opening and closing
Etiology:
Articular surface irregularity
Disk-articular surface adherence
Synovial fluid degradation
Myofascial imbalances around the joint
Increased elongation of diskal ligaments and posterior attachment

8. 5 Progressive Stages Stage I Disk Displacement
Temporal mandibular ligament becomes elongated
Disk drops medially - subluxes which reduces upon closure
Ligament brings the disk back into place upon closure
Each stages has a different associated clicking from when it slips

9. Symptoms of Stage 1: Very little pain
Inconsistent click occurs early in opening phase.
Subluxation on opening and a lateral reduction in closing

11. Stage II Disk Displacement
TM ligament continues to elongate, disk moves more medial and anterior on mandibular head.
Reduction on mouth opening, subluxation on closing
Clicking: Early on opening and Late on closing

12. Figure 11. Partial anterior disk displacement.
Figure 11.  Partial anterior disk displacement. Sagittal MR image (2,800/15) of TMJ with the jaw closed shows the posterior band (arrow), which is at the 10 o'clock position.
Sommer O J et al. Radiographics 2003;23:e14-e14
©2003 by Radiological Society of North America

13. Symptoms of 2:
Reciprocal click early on opening and late on closing
Pain
Signs: C curve upon mouth opening: goes back and lateral towards dysfunctional side.

14. Open Lock: Potential to occur from Stage II on
Signs: two opening clicks
Two closing clicks
Condyle can be prevented from slipping back in place if disk lies too posterior to the condyle

15. Stage III
Significant TM ligament elongation overstretching occurs causing posterior ligament elongation, disk shape distorted.
Condyle loses vertical height
Capsule becomes shortened

16. Symptoms 3: click is more consistent Click occurs later on opening and earlier on closing
Most painful stage
Signs:
C curve
Limited range of mouth opening to 25 to 30 mm, just below functional: 35mm is limit.

17. Closed Lock condition Closed lock: sudden limitation of jaw opening
Disk is permanently lodged anteriorly and interferes with normal rotation and translation of the joint
Hard end-feel

18. Stage IV: Rotational Displacement
Symptoms: Pain
Signs:
Clicking rare or single opening click

19. Stage V:
Signs: radiographic degenerative changes on condylar head, articular eminences (less often)
Evidence of remodeling (sclerosis) and osteophytes
Marked deformity of disk, thickening of disk and shape change

20. C. Anteromedial Disk Displacement with Intermittent Locking
Disk is displaced
Shape is deformed over time from biconcave to biconvex
Symptoms: intermittent locking in the am or after a period of clenching or chewing on involved side, brucsizum (teeth night)

21. D. Anteromedial Disk Displacement without Reduction
Definition: change of the disk-condyle structural relationship which is maintained during mandibular translation
Disk remains displaced with a closed-lock occurring
Lose: contact with condyle, disk and articular eminence of condyle which prevents posterior translation from occurring
Signs:
Deviation of mandible towards involved side
Marked limitation of lateral deviation to contralateral side

22. Internal Derangement of the Disk
Deviation in Form
Frictional Disk Incoordination:
Definition: intra-articular disk adheres to the eminence
Onset:
Etiology: loss of lubrication, roughness in the articular surface
Signs: loss of translatory glide
opening click
Symptoms: minimal discomfort with the click

23. Deviation in Form Articular Surface Defects
Definition: articulating surface has a roughed area or a change in the articular cartilage which doesn’t allow smooth rolling or gliding during opening and closing of the mouth
Etiology:
Signs: reciprocal click during opening and closing of the mouth
Lateral deviation on opening

24. Deviation in Form Disk Thinning and perforation
Etiology: application of excessive pressure on the TMJ, overloading with teeth together
Symptoms: variable joint tenderness, muscle pain
Signs: grating sound, crepitus during opening and closing
DX: made with medical imaging studies

25. Hypermobility and Dislocation
-Hyper: at risk for a locked open mouth.
Subluxation
Dislocation
Hypomobility: capsular vs adhesive disk

26. A. Joint Subluxation Mandibular Head Subluxation
1. Biomechanical considerations
2. Arthrokinematic dysfunctions
a. max. rotation occurs before translation begins
b. maximum translation occurs and a shift of condyle and disk as a unit occurs

27. Subluxation versus Reduction of Displaced Disk
Subluxed Disk:
Occurs only on wide opening
Does not occur with protrusion or lateral deviation
Pain is not always present
Reduction Disk:
Occurs on opening for stage I, closing (except in stage 1) and protrusion and contra-lateral lateral deviation

28. B. Joint Dislocation
Condyle moves outside of the physiological boundaries of the joint
Etiology: yawning (to wide), singing, sleeping with head on forearm, excessive tooth abrasion, malocclusion, over-closure and trauma
Sx: open lock position mouth is unable to close, locked open
Rx: manipulation, splint

29. Ankylosis: stuck Fusion of TM joint Symptoms: Signs: Tx Fibrosis Bony
Opposite side may become painful
Signs:
Decreased ROM
C curve on mouth opening Tx
How to f(x) with it.

30. Adhesive Disk Hypomobility
Definition: intra-articular formation of adhesions within the disk
Usually in the superior joint cavity, causes loss of condylar translation
Condylar displacement of disk may occur
Distortion of disk on mouth opening

31. Adhesive Hypomobile Etiology:
Trauma: mild may only cause frictional disk incoordination or articular surface defect
Major: intra-articular bleeding, swelling, fibrosis can result
Restricts ROM
May progress to joint degeneration

32. Sx: Click – Signs: Early is within 10 mm of opening,
Intermediate between 10 and 20 mm,
Late after 30 mm of opening.
C/o a locking sensation
Signs:
mandible deviates away from the dysfunctional side during mouth opening
S-curve: jaw goes to both sides correcting and over-correcting.

33. Inflammatory Conditions
Synovitis and Capsulitis
Retrodiscitis
Arthritic Conditions
Osteoarthritis
Rheumatoid Arthritis
Other Arthritic Conditions

34. Capsulitis SX: continuous deep constant pain
Originates in joint area
Pain with mouth opening
Signs: palpable pain with compression to the lateral pole of condyle
Limitation of mouth opening
Myospasms secondary to pain
Tissue stretch end feel or empty end feel
Decreased protrusion , may deviate to side of dysfunction
Increase pain with passive stretch

35. Retrodiscitis
Anterior displacement of disk, condyle presses on posterior tissue causing an inflammatory reaction
Hx: trauma, chronic bruxing SX: constant, dull, aching pain, aggravated by joint movement -closure puts it back into place. Signs: empty end feel, acute malocclusion, decrease protrusion, pain with compression

36. Non-Articular Conditions
Muscle Spasms
Masseter
Temporalis
Lateral Pterygoid
Medial Pterygoid
Myositis
Myofascial Pain Syndrome
Muscle Contracture

37. Practice Pattern 4E: Muscle Spasms
Causes: trauma, occlusal imbalance, changes in vertical dimensions between teeth, immobilization, prolonged dental procedures, chronic teeth clenching, disease

38. Three Categories of Muscle Spasms
Protective Co-contraction: muscle
guarding
Causes: Chronic inflammatory process, emotional stress, habit, muscle tendon injury
Sx: pain with active jaw movement
Signs: pain with resisted movements, pain at end range with passive movements, empty end feel or muscle spasm end feel
chronic inflammatory processes
Pain - afferent input from the joint receptors during joint dysfunction
Emotional stress -sympathetic nervous system response
Habit - clenching teeth
Muscle tendon injury

39. 2. Local Muscle Spasm Protective muscle co-contraction,
Leads to prolonged isometric contraction of muscle.
Leads to decrease in blood flow,
Inflammatory response, increase pain, increase muscle guarding, more pain
History: blow to face, dislocation of jaw
SX: periarticular, pain with chewing
Signs: pain with AROM mouth opening, PROM, Resisted muscle testing, dec. in mouth opening pain with overpressure during mouth opening

40. 3. Specific Muscles, Trigger Points
1. Temporalis
a. HX: headaches in temporal region
b. SX: headaches, visual disturbances,
pressure behind eye, increase
eye fatigue, difficulty with night vision

41. c. Signs: Restriction of mouth opening
Deviation of mouth toward affected side
Pain with palpation
Pain with resisted motions of elevation but not protrusion
Muscle trigger point with referred pain pattern
S curve on mouth opening
Decrease in freeway space (mouth opening at rest)
Abnormal protrusion of condyle on contralateral side during lateral deviation
Intermittent tooth ache

42. 2. Masseter
c. Signs:
restriction of mouth opening
deviation of mouth toward affected side
pain with palpation
referred pain pattern upon compression
pain with resisted motions of elevation but not protrusion
a. HX:
b. SX:
pain to lower jaw, molar teeth and related gums,
pain with chewing or with increased jaw activity
unilateral tinnitus
Bruxism: jaw clenching

43. 3. Medial Pterygoid c. Signs: Ache inside the mouth a. HX: b. SX:
Restriction in mandibular opening
No deviation of jaw
Rarely the primary muscle, Usually a 2ndary area
Ache inside the mouth
a. HX:
b. SX:
Pain with wide mouth opening
pain with clenching teeth
painful swallowing

44. 4. Lateral Pterygoid: “TMJ” dysfunction b. Signs: a. SX:
Pain in region of TMJ and maxilla
Clicking sounds may occur, so need to be careful to d(x)
b. Signs:
Pain with compression on same side as dysfunction
Slight restriction of mouth opening, occlusal abnormality
ROM: for Lateral deviation away from the side of dysfunction is decreased
ROM decreased

45. Oncological
A. Rare occurrences, but can get a metastatic adenocarcinoma in the TMJ region B. Signs: unrelenting pain of unexplained origin, neurological deficits, nausea, balance disorders, visual changes, cranial nerve disorders C. Refer if suspect

46. PT TREATMENT OF TMJ DYSFUNCTIONS
Goals are based on physical exam
Treat pain:
Address biomechanical asymmetries
Postural education: like forward head
Strengthen supporting structures necessary to balance head, maintain new position
Stress reduction

47. Occlusional appliance:
Splint: removable, hard, acrylic “bite guard”
a. muscle relaxation
b. anterior (orthopedic) repositioning
appliance
c. anterior bite plate
d. posterior bite plate

48. Medical Treatment: Arthroscopic surgery done for disk repositioning
Decrease adhesions
Take out osteophytes

49. Other References:
1. Bourbon BM: “Craniomandibular Examination and Treatment” in Saunders Manual of Physical Therapy Practice, WB Saunders Co. Philadelphia, 1995
2. Richardson JK and Iglarsh ZA. Clinical Orthopaedic Physical Therapy, W.B. Saunders Co., Philadelphia, 1994.
3. Magee D. Orthopedic Physical Assessment, 4th ed