Tmj Conditions

7/26/2019 Tmj Conditions

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TMJ CONDITIONS


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Craniomandibular JointO Synovial, condylar, modified hinge joint

O HAS FIBROCARTILAGINOUS articular disc;

this disc completely divides each joint intotwo cavities

O TRIVIA


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O Resting position: Mouth slightly open, lips together,teeth not in contact

O Close-packed position: Teeth tightly clenched

O Capsular pattern: Limitation of mouth opening

O Innervation: branches of the auriculotemporal andmasseteric branches of the mandibular nerve.

O The upper head of the lateral pterygoid muscle

draws the disc, or meniscus, anteriorly andprepares for condylar rotation during movement.


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ArthrokinematicsO Translation/Gliding - occurs at upper part of

cavity

O Rotation - occurs at lower part of cavityO Distraction


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OsteokinematicsO Protrusion = 7 mm

O Retrusion = 3 4 mm

O Lateral deviation = 10 15 mm

O Opposite condyle forward, down and toward themotion side

O Condyle on same side = stationary and prominent

O Lateral deviation during protrusion: lateral

pterygoid, masseter, or temporalis muscle, thedisc, or the lateral ligament on the opposite sideis affected.


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MUSCLES


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Normal End Feel at the

Temporomandibular JointsO Opening: Tissue stretch

O Closing: Bone to bone


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OPENING OF MOUTH

O 23-35 mm Functional mouth

opening 35-50 mm N mouth

opening (2-3 FLEXED PIP JOINTS)

O Early Phase:

O Rotation POST (26 mm) inferior

jt. space

O Late PhaseO Anterior translation (50-65),

inferior movement superior jt.

space


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ACTIVE MOVEMENTSNECK FLEXION

O Mandible moves up and forward

O Posterior structures tight

NECK EXTENSION

O Mandible moves down and back

O Anterior structures tight


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ACTIVE MOVEMENTSOpening and Closing of the Mouth

- Slowly


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DEVIATIONSDeviation towards L upon mouth opening

(a C-type curve) or to the right (a reverse C-

type curve),

(+) hypomobility is evident toward the side of

the deviation caused either by:

O a displaced disc without reduction or

O unilateral muscle hypomobility


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S-type or reverse S-type curve,

the problem is probably :

O muscular imbalance or

O Medial displacement as the condyle walks around the

disc on the affected side.

O The chin deviates toward the affected side, usually

because of:

O spasm of the pterygoid or masseter muscles or

O an obstruction in the joint.

O Early deviation on opening is usually caused by muscle

spasm,

O Late deviation on opening is usually a result ofO capsulitis or a tight capsule.

O Pain or tenderness, especially on closing, indicates

posterior capsulitis.


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PATIENT HISTORYExtra-articular problem

O Pain in the fully opened position (e.g., pain

associated with opening to bite an apple,

yawning)

Intra-articular problem

O whereas pain associated with biting firm

objects (e.g., nuts, raw fruit and vegetables)

Limited opening may be due to:O the disc displaced anteriorly,

O inert tissue tightness,

O muscle spasm


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PATIENT HISTORYO

Early clicking - implies a developing dysfunction,O Late clicking - is more likely to mean a chronic problem


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PATIENT HISTORYO There may be a partial anterior displacement (subluxation) or dislocation of

the disc, which the condyle must override to reach its normal position when

the mouth is fully open (Figure 4-8). This override may also cause a click.


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PATIENT HISTORYO If clicking occurs in both directions, it is called

reciprocal clicking

O The opening click occurs somewhere during the

opening or protrusive path, and the click indicates

the condyle is slipping over the thicker posterior

border of the disc to its position in the thinner

middle or intermediate zone.

O Theclosing reciprocal) click occurs near the end of

the closing or retrusive path as the pull of the

superior lateral pterygoid muscle causes the disc to

slip more anteriorly and the condyle to move over its

posterior border.


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RECIPROCAL CLICK


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PATIENT HISTORYO Clicks may also be caused by adhesions (Figure 4-10), especially in people

who clench their teeth (bruxism).

O These adhesive clicks occur in isolation, after the period of clenching.

O If adhesions occur in the superior or inferior joint space, translation or

rotation will be limited.

O This presents as a temporary

closed lock, which then openswith a click.


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PATIENT HISTORYO

Soft or popping clicks that are sometimes heard innormal joints are caused by:

O ligament movement,

O articular surface separation, or

O sucking of loose tissue behind the condyle as it moves

forward.O These clicks usually result from muscle incoordination.

O Hard or cracking clicks are more likely to indicate joint

pathology or joint surface defects.

O Soft crepitus (like rubbing knuckles together) is a sound that

sometimes occurs in symptomless joints and is notnecessarily an indication of pathology

O Hard crepitus (like a footstep on gravel) is indicative of

arthritic changes in the joints.


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PATIENT HISTORYO Locked jaw

O Not full ROM (Open/Close)

O Preceded by reciprocal clicking

O often related to problems of the disc or joint degeneration.

O Locked jaw in closed position

O caused by a disc with the condyle being posterior or anteromedial

to the disc.

O Translation is blocked, mouth opening is 30 mm via rotation

O FUNCTIONAL DISLOCATION OF DISC WITH REDUCTION

O disc is usually positioned anteromedially, and opening is limited.


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O FUNCTIONAL DISLOCATION OF DISC WITHOUT

REDUCTION

O Results to: Closed lock implies there has been

anterior and/or medial displacement of the disc

so that the disc does not return to its normal

position during the entire movement of thecondyle.

O Opening: 25 mm, mandible deviates to

affected side, decreased ROM at C/L side

O

If locking occurs in open position, it is causedby: Posterior Disc displacement or joint

subluxation


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O With an open lock,

O there are two clicks on opening,

O when the condyle moves over the posterior rim of

the disc

O and then when it moves over the anterior rim of the

disc, and two clicks on closing.

O If, after the second click occurs on opening, the disc lies

posterior to the condyle, it may not allow the condyle to

slide back (Figure 4-12 - locking).

O If the condyle dislocates outside the fossa, it is a true

dislocation with open lock; the patient cannot close themouth, and the dislocation must be reduced.


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OBSERVATIONTMJ


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O Occlusion

O occurs when the teeth are in

contact and the mouth is closed.

O Malocclusion

O is defined as any deviation fromnormal occlusion.


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O Class I occlusion

O normal anteroposterior relation of the maxillary teeth to mandibular

teeth.

OClass I malocclusion.

O A slight modification with only the incisors affected and overjet slightly

larger

O Class II malocclusion overbite)

O Occurs when the mandibular teeth are positioned posterior to their

normal position relative to the maxillary teeth.

O This malocclusion deformity involves all the teeth, including the molars.O Class II Division 1 malocclusion AKA l rge overjet or horizontal overlap)

O Indicates that the maxillary incisors demonstrate significant overjet.

O Class II Division 2 malocclusion AKA deep overbite or vertical overlap)

O implies that overjet is not significant but that there is overbite and

lateral flaring of the lateral maxillary incisors.

OClass III malocclusion i.e., underbite)

O occurs when the mandibular teeth are positioned anterior to their

normal position relative to the maxillary teeth.

O If maxillary and mandibular teeth are on the same vertical plane, a

Class III malocclusion would be present.


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Crossbite- With the teeth of the mandible are lateral to the

upper (maxillary) teeth on one side and medial on

the opposite side.

- There is abnormal interdigitation of the teeth.

- With anterior crossbite, the lower incisors are ahead

of the upper incisors.

- With posterior crossbite, there is a transverse

abnormal relation of the teeth.


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Underbite- Teeth are unilaterally,

bilaterally, or in pairs

in buccoversion (i.e.,

they lie anterior to

the maxillary teeth


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Overbite- anterior maxillary incisorsextend below the anterior

mandibular incisors when

the jaw is in centric

occlusion.

- A small amount of overbite

(2 to 3 mm) anteriorly is the

most common position of

the teeth.- This is because the

maxillary arch is slightly

longer than the mandibular

arch.


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Facial ProfileO Theorthognathic profile is the normal,

straight-jawed form. With this facial profile,

a vertical line dropped perpendicular to the

bipupital line would touch the upper andlower lips and the tip of the chin.

ORetrognathic profile, the chin would lie

behind the vertical line and the person would

be said to have a receding chin.O With the prognathic profile, the chin would be

in front of the vertical line and the person

would have a protruded or strong chin


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Tongue thrustingO May be due to hyperactivity of the

masticatory muscles.

O

When one swallows, the hyoid bone shouldmove up and down quickly.

O If it moves only upward and slowly, and the

suboccipital muscles posteriorly contract =

(+)


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Cranial Nerve TestingCN I Smell coffee or some similar substance with eyes closedCN II (optic nerve): Read something with one eye closed

CN III, IV, VI: Eye movements; note any ptosis

CN V (trigeminal nerve): Contract muscles of mastication (masseter and

temporalis)

CN VII (facial nerve): Move eyebrows up and down, purse lips, show teeth.

This cranial nerve is the most commonly injured one. If the patient is unable

to whistle or wink

or close an eye on one side, the symptoms may be indicative of Bell

palsy (paralysis of the facial nerve).

CN VIII (auditory nerve): Eyes closed; talk to patient and have him or her

repeat what was said

CN IX: Have patient swallow

CN X (vagus nerve): Have patient swallow

CN XI (spinal accessory): Have patient contract sternomastoid

CN XII: Have patient stick out tongue, move it to right and left


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FUNCTIONAL ASSESSMENTO Research Diagnostic Criteria for

Temporomandibular Disorders (RDC/TMD)

O Limitations of Daily Function Questionnaire(TMJ)

O Jaw Functional Limitation Scale

O Mandibular Function ImpairmentQuestionnaire (MFIQ)

O History Questionnaire for Jaw PainO TMJ Scale.


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SPECIAL TESTSO Chvostek Test


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AUSCULTATIONO listen to (auscultate) the

temporomandibular joints during

movement4

O Opening

O Closing

O Lateral deviationO Protrusion

Slipping sound = single solid sound

heard only in occlusion

O

Grating noise (crepitus) is usuallyindicative of degenerative joint disease

or a perforation in the disc.

O Clicking is more likely to occur in

hypermobile joints.


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Dermatomes of the head


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Referred pain patterns to and fromthe temporomandibular

joint in the teeth, head, and neck.


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Temporomandibular

disorders (TMDs).


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TMDO Three cardinal features of TMD are:

O orofacial pain,

O

restricted jaw motion,O and joint noise


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TABLE 4-2

Checklist of Psychological and Behavioral Factors*

1. Clinically significant anxiety or depression

2. Evidence of drug abuse

3. Repeated failures with conventional therapies

4. Evidence of secondary gain

5. Major life events; for example, new job, marriage or

divorce, death

6. Pain duration greater than 6 months

7. History of possible stress-related disorders

8. Inconsistency in response to drugs

9. Inconsistent, inappropriate, and vague reports of pain,

or both

10. Overdramatization of symptoms

11. Symptoms that vary with life events


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TMJ DISC DISPLACEMENTO (+) CLICK Upon mouth opening


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TMJ CAPSULITISO (+) Pain upon mouth opening

O (+) LOM: Lateral deviation C/L


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TMJ SYNOVITISO (+) PAIN UPON MOUTH OPENING

O LOM (I/L Lateral deviaiton)

O Swelling


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TMJ HYPORMOBILITYO (+) LOM towards mouth opening

O LOM: (C/L: Lateral deviation)


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TMJ HYPERMOBILITYO (+) Excessive mouth opening and C/L lateral

deviation


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Stages Of DiscDisplacement


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BruxismO Is the forced clenching and grinding of the

teeth, especially during sleep.

O

This may lead to facial, jaw, or tooth pain, orheadaches in the morning along with

muscle hypertrophy.


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Tmj Conditions

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