Temporomandibular Joint Dysfunction

Temporomandibular Joint Dysfunction Diane L. Viola Union County College June 14, 2011

Temporomandibular Joint Dysfunction

Abstract Effective treatment of Temporomandibular Joint Dysfunction (TMD) has changed over the past ten years. Malocclusion or a faulty joint was the common diagnosis and surgeries on the jaw and/or dental work were the preferred treatments. However, research on the sources of TMD pain are allowing patients more treatment options without surgery or permanent structural changes to the jaw or teeth. This paper gives a basic understanding of how the Temporomandibular joint functions, dysfunctions of the joint, and therapeutic options available. Physical therapy approaches to TMD have been detailed according to research studies documenting therapeutic interventions that provide the most significant relief from the myofascial pain of TMD.

Temporomandibular Joint Dysfunction

Temporomandibular Joint Disorder Temporomandibular Joint Disorder (TMD) refers to an altered functioning of the Temporomandibular Joint, however this term is somewhat generalized as it does not identify the pathology that is causing the dysfunction. This multifaceted musculoskeletal disorder can consist of many factors and conditions that can either be a cause or an effect of this disorder. The Temporomandibular Joint is connected to several different muscle groups which aides in the difficulty of isolating the symptoms from the problem. Determining which structures can be categorized as causation factors and which ones are effects of the disorder will help establish the most effective form of therapy the patient. Temporomandibular Joint The TMJ is a synovial joint that connects the temporal bone and the mandible. Superiorly it is a plane joint and inferiorly it is a hinge joint The temporal bone has a notch just in front of each ear. The mandible has condyles at each end that fit into the temporal notches to form the joint. There is an intra- articular disc that articulates with two surfaces. Superiorly, the disk articulates with the mandibular fossa of the temporal bone and inferiorly it articulates with the condyle of the mandible. The Temporomandibular ligaments limit motions of the joint in all directions and the main muscles of the joint are the Temporalis, Masseter, Medial Pterygoid and Lateral Pterygoid (Standard of Care: Temporomandibular Joint Disorder 2007 p. 2.). The following charts details the muscles and structures involved. Main muscles of TMJ Temporalis Masseter Action Bilaterally: elevation, retrusion Unilaterally: ipsilateral lateral deviation Bilaterally: elevation Unilaterally: ipsilateral lateral deviation

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Medial Pterygoid Lateral Pterygoid Suprahyoids

Bilaterally: depression, protrusion Unilaterally: contralateral lateral deviation Bilaterally: elevation Unilaterally: contralateral lateral deviation Mandibular depression

Structures Temporomandibular Ligament Sphenomandibular Ligament Stylohyoid Ligament Joint Capsule

Articular Disk

Attachments neck of mandibular condyle and disk to temporal tubercle Sphenoid styloid process to middle ramus of mandible Temporal styloid process to the hyoid bone Superiorly: articular tubercle and borders of the fossa of temporal bone. Inferiorly: attaches to the neck of the mandibular condlye Connected to capsule and tendon of lateral pterygoid. Biomechanics of the TMJ

Action limits downward, posterior and lateral motions of mandible Suspends mandible and limits excessive anterior motion Helps limit excessive anterior motion

Rotates anterior/posterior Glides anterior/posterior (Lippert,2011 p. 201-203)

The Temporomandibular joint is a highly active joint, opening and closing up to 2000 time per day accommodating the bodies need for chewing, talking, breathing, swallowing and yawning.. The motions that occur at the mandible are depression, protusion/retrusion, and lateral excursion with accessory motions of rotation in the inferior TMJ and translation that occurs in the superior TMJ (Standard of Care: Temporomandibular Joint Disorder 2007 p. 1). During the initial opening of the mouth, the mandible rotates in the mandibular fossa and as the mouth opens wider the condlyes of the mandible glides downward and forward under the articular eminence of the temporal bone. Ipsilateral rotation and contralateral translation of the condyles

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allow for lateral deviation. Re-establishment of normal joint mechanics is an integral part of rehabilitation and restoration of functional jaw movements (Lippert, 2011 p. 202-203)

Pathologies Most TMD can be classified into four groups: muscle disorders, internal disc derangement, subluxation of TMJ, and arthritic conditions (Standard of Care: Temporomandibular Joint Disorder 2007 p. 2.). Classification can overlap when problems with one system alter the balance of another. These imbalances can cause disturbances or impairments in mandibular pattern or functional movements. (Beale, 2008 p.2) Muscle disorders often involve spasms of the masticatory muscles. Repetitive stresses such as emotional tension may lead to bruxism or jaw clenching. Forward head posture can also cause repetitive stresses on these muscles. Symptoms can range from jaw, joint, cervical and facial muscle pain to earaches, headaches and dizziness. Internal derangement of the disk involves displacement of the intra-articular disk as it moves anterior or posteriorly between the temporal bone and mandibular condlye. Displacement can be permanent or with reduction, returning to normal position. Signs of anterior displacement are clicking and popping upon mouth opening and closing. Posterior displacement can cause jaw locking or catching in the open mouth position. Subluxation of the TMJ can occur from poor muscle control, joint ligament laxity and structural deformities whether trauma related or congenital. Subluxation can occurs as bilateral or unilateral and can affect both the translation and lateral deviation of the mandible. Conditions of arthritis, both OA and RA can affect the TMJ and increase the risk of TMJ disorders. Those with RA and juvenile RA have a higher risk of developing TMD due to cervical

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spine complications. Women are more prone to TMD than men are (Standard of Care: Temporomandibular Joint Disorder 2007 p. 2.) Interventions Noninvasive intervention is usually the first step in treating TMD. While there seems to be a lack of quality controlled studies comparing specific modalities and treatments of TMJ, literature does support physical therapy as a component of noninvasive care for TMD (Beale, 2008 p. 4). A system review, in 2006, of physical therapy interventions of TMD management offered the following clinical recommendation:

Active exercises and manual mobilizations may be effective for increasing Total Vertical Opening (TVO) for acute cases of disk displacement, arthritis, and mylofascial TMD.

Postural training may reduce pain and improve TVO when combined with home exercise programs or other treatment techniques. The effects of postural training as single intervention have not been documented.

Patients with TMD secondary to disk displacement, may have decrease pain, improved lateral deviation and increased TVO with use of MID- laser therapy

In acute or chronic TMD use of relaxation training, biofeedback, EMG training, and proprioceptive training may produce more positive effects than occlusal splints or placebo by reducing pain and increasing TVO.

Combination programs of active exercise, manual therapy, postural correction and

relaxation techniques may provide increased TVO, decreased pain and impairment. It is impossible to determine if combination programs are more effective than individual treatments.(Medlicott and Harris, 2006 p961)

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In cases when non-invasive surgery does not provide significant pain relief or pathology modification surgery is another option. The following chart detail some types of TMJ surgery. Surgery Arthrocentesis Arthroscopy Condylotomy Arthrotomy Plication Condylectomy TMJ replacement Discectomy Description Creates hydraulic pressure within the joint space to clear out any extra scar tissue and increase mobility in the joint. Steroids or lubricants may be injected into the joint. Arthroscopic surgery to visual damage, clear out any adhesions, irrigate the joint and inject corticosteroids. Transection of madibular ramus to change condylar/disc/glenoid fossa relationship Open incision of joint to allow for multiple procedures. Repositioning or repairing disc. Removal of condyle Total joint replacement Removal of disc with or without replacement (Beale, 2009 p 2-4)

Surgery does provide beneficial effects on TMJ dysfunction, however, research data supports evidence that patients with TMD of a muscular origin get more relief from surgery than those with mainly articular origins (Dujoncquoy, Ferri, Raoul, Kleinheinz, 2010 p 6). Physical Therapy Interventions Research on individual methods of physical therapy have not been documented, however there have been studies on combinations of exercise and modalities that have showed significant pain relief for patients with TMD. The following chart outlines research data on the most effective therapeutic interventions for treatment of TMD pain and functional mandibular rhythms. Problems Interventions Research of Therapeutic Interventions

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Pain on palpation Pain with function of jaw unilaterally and bilaterally

Electrotherapeutic: US, shortwave diathermy, magapulse and laser. Physical Agents: Superficial heat and ice packs Manual Therapy: Manual mobilizations of the TMJ Massage

74% improvement of pain compared to placebo. Some studies indicate significant pain reduction and mouth opening with laser therapy (red and infrared light used to reduce pain and swelling and accelerate healing). May have palliative effect

Limited jaw opening Impaired posture

Therapeutic exercise

Decreased knowledge of habit modification, relaxation techniques

Home exercise program

Found to reduce pain and improve oral opening in a study of patients with anterior disk displacement. The study include mobilization in combination with massage of the temporalis and masseter muscles, manual joint distraction, isometric exercises, stretching, relaxation, breathing and postural exercises. Stretching exercises, stabilization exercises mobilization exercises ,condylar remodeling exercises provided significant improvement in limitation when used in combination with Postural correction, relaxation techniques, manual therapy, breathing training and massage. Patient education about the nature of the problem and prognosis. Educate to reduce over use of masticatory system. Mnemonic R.T.T.P.B R= relax T= teeth apart say the wore Emma T=cluck tongue and leave on roof of mouth P= posture, imagine strings from back of head and front of sternum pulling to ceiling B= breathing, naso-diaphragmatic Dentist and clinical psychologist along with physical therapist may work as a team to benefit the patient. Occluant splints may help with nocturnal bruxism and a study published in 2006 found cognitive behavior therapy helped reduce pain and mandibular impairment.

Referral to other disciplines

(Beale 2008, p 5-9)

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Conclusion While more detailed research needs to be compiled in order to provide the best care for those patients with TMD, current research supports a multi- disciplinary approach which includes massage, stretching, isometric exercises, occluent splints and cognitive behavior therapy. Surgery can offer relief to those patients whose TMD is a result of trauma or congenital deformity of the jaw or teeth, however physical therapy still plays and integral role in the healing and functional recovery from those surgeries.

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References Brigham and Women's Hospital - A Teaching Affiliate of Harvard Medical School. (n.d.). Standard of Care: Temporomandibular Joint Disorder. Retrieved June 4,

2011, from http://www.brighamandwomens.org Beale, K. (2008). Temporomandibular joint disorder. CINAHL Rehabilitation Guide, Oct. Retrieved June 2, 2011, from the EBSCO database. Beale, K. (2009). Temporomandibular joint disorder:postsurgical managmement. CINAHL Rehabilitation Guide, Nov 6(24). Retrieved June 2, 2011, from the EBSCO database. Dujoncquoy, J., Ferri, J., Raoul, G., & Kleinheinz, J. (2010). Temporomandibular joint dysfunction and orthognathic surgery:a retrospective study. Head and Face Medicine, 6(27). Retrieved June 4, 2011, from the Head & Face Medicine database. Lippert, L. (2011). Shoulder Girdle. Clinical kinesiology and anatomy (5th ed., pp. 201-204). Philadelphia: F.A. Davis. Medlicott, M., & Harris, S. (2006). A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibular disorder. Physical Therapy, 86, 955-973. Retrieved June 4, 2011, from www.ptjournal.apta.org