Authors:

Sally Ho, PT, DPT, MS, OCS

David J. Magee, PhD, BPT, CM
Robert C. Manske, PT, DPT, MED, SCS, ATC, CSCS
Mohamed Abdelmegeed, PT, DPT, MSc, DSc, OCS

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 Introduction:
The temporomandibular joint (TMJ) is the most used joint in the body during daily activities.
Every time one swallows, chews, or speaks, the TMJ is in action. It has been estimated that one
uses the TMJ approximately 1500 to 2000 times daily, excluding the parafunction of clenching
and/or bruxing. Temporomandibular disorder (TMD) is a collective term of multiple symptoms
that affects the craniofacial- mandibular complex. The TMJ itself, the muscles of mastication,
and the structures in the vicinity, may all be involved. The cause of TMD is multifactorial: it can
be caused by macrotrauma such as whiplash injury or a direct blow to the jaw, microtrauma from
parafunctional clenching and bruxing, or degenerative osteoarthritis (OA).

The clinical manifestation of TMD includes, but is not limited to, pain, limited opening, joint
noises, headaches, dizziness, neck symptoms, earache, tinnitus, and swallowing difficulty.1

Figure 4.1 osseous structures of the TMJ Figure 4.2 the articular surface of the TMJ

The Temporomandibular Joint

The TMJ is a diarthrodial, synovial joint. The osseous structure of the TMJ (Figure 4.1) includes
two major bones: the temporal and the mandibular bones. The mandibular condyle lies within the
mandibular fossa to form the TMJ (Figure 4.2). A dense fibrocartilaginous disk separates the
joint into superior and inferior cavities. These cavities are filled with synovial fluid to maintain
the lubrication of the joint. 1

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 The Disk and Retrodiskal Pad
The articular disk in the sagittal plane is bow-tie shaped to conform to the shape of the
mandibular fossa and the mandibular condyle (see Figure 4.3). The biconcave shape of the disk
allows congruency of the TMJ during range of motion (ROM). The disk also provides
lubrication to the articulating surfaces, transmits contact force, stabilizes the joint, and endures
long-term stress. The anterior and posterior portions of the disk have neural innervations and
vascular supply, but the intermediate portion is avascular and aneural.2 The posterior portion of
the disk attaches to the bilaminar connective tissue that further connects to the bone. The
retrodiskal pad between the superior and inferior laminae contains nerve fibers, blood vessels,
and fat. Inflammation in this area usually produces pain with palpation over the posterior aspect
of the joint. 1

Figure 4.3 the morphology of the articular disk

Muscles of Mastication:
The TMJ is innervated by branches of the mandibular division of the trigeminal nerve (CN-5).
Blood supply of the TMJ is through the superficial temporal and maxillary arteries. 1 Please refer
to your anatomy books for the muscle attachments. Below is a summary of the muscle actions

Table 4.1 summary of the actions of the muscles of mastication 1

Masseter (figure) • Unilateral contraction of the masseter causes slight lateral deviation to the same side,
1.4 while bilateral contraction initiates elevation of the mandible with further force added for
chewing and grinding hard food.

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 • Contraction of bilateral superficial fibers produces protrusion while contraction of
bilateral deep fibers contributes to retraction of the mandible
Temporalis • Bilateral contractions of the temporalis elevate and retract the mandible, while unilateral
(figure) 4.4 contraction of the temporalis also produces lateral excursion (deviation) of the same side.
Medial pterygoid • Bilateral contraction of the medial pterygoid produces elevation and protrusion of the
(figure) 4.5 mandible, while unilateral contraction produces contralateral deviation.
Lateral pterygoid • Unilateral contraction of the lateral pterygoid muscle produces contralateral excursion.
(figure) 4.5 Bilateral contraction of both superior and inferior heads of the lateral pterygoid muscles
produces protrusion.
Suprahyoids • Include the anterior and posterior belly of the digastric, mylohyoid, geniohyoid, and
stylohyoid muscles.
• All suprahyoid muscles are responsible for depression and retrusion of the mandible
during closing of the mouth, when the hyoid bone is fixed.
Infrahyoids • Include sternohyoid, sternothyroid, thyrohyoid, and omohyoid
• The infrahyoid muscles work together to stabilize the hyoid bone to form a firm base for
the suprahyoid muscles.
• Together with suprahyoid muscles, they also are involved in the function of speech,
swallowing, and tongue movement.

Figure 4.4 the masseter and temporalis Figure 4.5 the medial and lateral pterygoid
muscles muscles
N.B. Remember that muscles of mastication include elevators, depressors, protrusors, retrusors,
and lateral deviators. Muscles responsible for each movement can be summarized in Table 4.2 1

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 Table 4.2 Movement of the TMJ and the muscle involved
TMJ movement Muscles involved
Elevation (closing) Masseter, temporalis, medial pterygoid, superior fibers of lateral pterygoid
(stabilize the disk)
Depression (opening) Inferior fibers of lateral pterygoid, suprahyoids, infrahyoids (indirectly)
Protrusion Superficial masseter, medial pterygoid, lateral pterygoid
Retrusion Deep fibers of masseter, temporalis, suprahyoids (digastrics)
Lateral excursion (deviation) Ipsilateral temporalis and masseter, contralateral medial and lateral pterygoids.

Know how to count your teeth and important dental terminologies to remember:
• Normally, we have 32 teeth in the mouth: 16 upper (maxillary) and 16 lower
(mandibular)
• Counting starts from the last right upper molar (number 1) and counting toward the last
left upper molar (number 16)
• Then continue counting from the last left lower molar (number 17) to the last right lower
molar (number 32).

Overbite:
This indicate how much of the maxillary central incisor covering the mandibular central incisor
when the mandible is in the maximally occluded position (figure 4.6). Normal range of overbite
is approximately one-fourth to one-third of mandibular central incisor. 2

Overjet:
This is the horizontal distance between the maxillary arch and the mandibular arch when the
mandible is in the maximally occluded position (figure 4.6). Normal range of overjet is 3-6 mm. 2

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 Figure 4.6 overbite and overjet
measurements
Openbite:
This is an abnormal occlusal condition that occur when the maxillary front teeth do not contact
their mandibular counterparts during any mandibular position. This can affect the chewing and
swallowing function of the TMJ. 2

Crossbite:
An occlusal irregularity where the mandibular and maxillary teeth are not in line with the center
incisor (shifts away from the center incisor during occlusion).2

Clenching:
This happen When the posterior maxillary molars and mandibular molars are touching each other
with excessive contraction of the masseters and temporalis muscles. This is a parafunctional
behavior that can occur during the day or while sleeping at night.2

Bruxism
Bruxism is characterized by the grinding of the teeth, especially while sleeping. This nocturnal
parafunction is typically accompanied by clenching of the jaw and is usually heightened under
stress.2

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 Trismus:
It is defined as an acute closed lock of the jaw after a dental procedure due to acute spasm of
masseter muscle after a prolonged jaw opening. Clinical finding includes limited opening
(<25mm) and palpable tenderness/tightness over the masseter muscle belly.2

Temporomandibular disorders (TMDs)

According to the American Academy of Orofacial Pain,3 the TMD condition can be classified
into three groups

• Disk-condyle • Myofascial pain • Capsulitis

incorordination disorders syndrome • Synovitis
• Disk displacement (MPDS) • OA
• Fracture • Myositis • RA
• Ankylosis • Dystonia • Psoriatic arthritis
• Neoplasia
Articular Masticatory
Arthritides
disorders muscle disorders

ARTICULAR DISORDERS:

Anterior Disk Displacement with Reduction (ADDwR)3 figure 4.7:

• Internal derangement of the disk-condyle complex
• The disk abnormally rests anterior to the condylar head when the mouth is closed
• During opening, the disk reduces back on top of the condylar head that causes a reduction
click and then translates anteriorly with the condyle as a unit through the rest of the
opening phase
• As the mouth starts to close, the disk-condyle complex translates together posteriorly. At
the end of the closing range, the disk displaces anteriorly again due to the excessive
contraction of the superior head of the lateral pterygoid muscle and the decrease in

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 elasticity of the posterior stratum fibers. This produces a second reduction click.
Therefore, opening and closing clicks are referred to as “reciprocal clicks”
• The first (opening) click is usually louder than the second (closing) click
• The disk reduces with opening of the mouth with the first noise, and dislocates during
closing of the mouth with the second noise

Anterior Disk Displacement without Reduction (ADDwoR) 3 figure 4.8:

• If the ADDwR is not treated properly, very often, the disk will stay displaced in front of
the condyle and not be able to return to its normal position (due to the decrease in
elasticity of the posterior stratum fibers). This condition is described as ADDwoR
• There will be no clicking noise during opening/closing,
• The patient may have limited opening (when the disk is blocking the condylar head) or
no limitation in opening (when the disk is completely displaced anteriorly).
• Limited opening may be associated with deflection of the mouth to the involved side
during.
• Limited opening is referred to as “closed lock” or inability to open the mouth

Figure 4.7 ADDwR during opening Figure 4.8 ADDwoR during opening
and closing of the mouth and closing the mouth

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Posterior Disk Displacement:
• Very rare, yet possible
• Usually occurs after wide opening of the mouth such as in the case of prolonged dental
procedure or yawning.
• The lateral pterygoid muscle is overly stretched and results in posterior displacement of
the disk.
• Patients demonstrate an open-lock (inability to close the mouth) and may report closing
clicks in the case of reduction. 4

N.B: it is not uncommon that disk displacement disorders are asymptomatic. According to
Katzberg et al.5 there were about 33% of their 76 volunteers who had disk displacement but were
asymptomatic. Some researchers believe that the disk has a remodeling property that often
repairs itself or replaces its original position with a “pseudo” disk.

Dislocation of condyle: 3
• Occurs when the condylar head is displaced beyond the articular tubercle, out of the
mandibular fossa, and unable to return to its physiological position.
• The mouth is kept in an open position.
• It may be caused by acute trauma, neurogenic muscular hyperactivity, connective tissue
disorder such as Ehlers-Danlos disease, or a hypermobile body type.

Subluxation of condyle:
• A temporary dislocation that can be reduced by the patient.
• It can be caused by a joint laxity or systemic hypermobility. 6
• Excessive translation in this condition is usually noted by observation or palpation of the
lateral pole during mouth opening. 7

Ankylosis:
• Characterized by restricted mandibular mobility and ROM of TMJ.

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 • The restriction is usually manifested by limited translation of the involved side; therefore,
deviation to the ipsilateral side is observed during mouth opening. In turn, this will also
limit mandibular opening.
• Ankylosis can be the result of joint inflammation from trauma or a systemic condition
such as polyarthitic disease.6

Masticatory muscle disorders

• Can be caused by direct or indirect trauma to the TMJ (e.g., a blow to the jaw, or
whiplash injury to the neck; or repetitive microtrauma from nocturnal clenching and
bruxing).
• Forward head posture may also contribute to myogenous muscle disorder due to the
alteration of proper alignment.
• Psychosocial factors such as stress, anxiety, depression, avoidance of activities,
secondary gain behavior, etc., play a significant role in precipitating or perpetuating the
symptoms of myogenous TMD.8
• Patients tend to clench their jaw more under stressful situations, which triggers the
vicious cycle of spasm and pain.

Myofascial Pain Disorder Syndrome (MPDS):

• Set of symptoms that originates from the myofascial structure and is characterized by
trigger points that may cause local tenderness and referred pain.
• The trigger points are tender points in the taut muscle band or its associated tendon or
fascia that refer pain to the distant area. They can be active or latent.
• According to Travell and colleagues,9 trigger points in the temporalis muscle (Figure 4.9)
can refer pain to the maxillary teeth, and trigger points in the masseter muscles (Figure
4.10) can refer pain to the maxillary and mandibular teeth.
• Therefore, accurate diagnosis must be made to differentiate the cause of a toothache
before any irreversible procedure (e.g., distraction) is performed on a patient.

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 Figure 4.9 temporalis muscle trigger Figure 4.10 masseter muscle trigger
point referral pattern.22 point referral pattern. 22

Arthritides:

Capsulitis:
• Can be caused by trauma or poor oral habits.
• Over-stretching of the capsule results in an inflammatory process. It is characterized by
pain upon palpation, pain with jaw movement, and an altered opening pattern of the
mouth.
• It usually shows a “C” curve in opening with deflection and protrusion towards the
ipsilateral (symptomatic) side. 7

Osteoarthritis (OA):
• Osteoarthritis of the TMJ can be caused by degeneration or excessive wear and tear of the
joint (e.g., bruxism).
• Crepitus, joint noises during opening and closing, pain with ROM, or limited opening are
some of the clinical signs of TMJ OA. 7

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 Differential diagnosis: Clinical pearls
(table 4.3, table 4.4, and table 4.5)

Table 4.3 differential diagnosis of articular disorders of TMJ

ADDwR ADDwoR Posterior disk displacement Capsular involvement

• Opening, closing clicks • No joint noise/clicks • Unable to close the mouth • Tenderness over TMJ
• Limited opening with • Limited opening or no (open lock) • Painful, limited opening with C-
or without pain limitation if chronic • May reports closing click in curve (deviation to ipsilateral
• Mandible deflects to • Ipsilateral deflection case of reduction side)
ipsilateral side of mandible with pain • Limited lateral excursion to
• C or S curve contralateral side, and
protrusion to ipsilateral side

Table 4.4 Classification and Clinical Patterns of Primary Recurrent Temporomandibular

Disorder

Myogenic Arthrogenic Disc Displacement Disc Displacement Cervical Spine

with without Reduction Involvement
Reduction
• Associated with • Associated with • Associated with • Associated with • Generally present
stress, joint joint blocked opening across all patients
anxiety, clenching, line pain, arthritis or noises (popping/ and with TMD
bruxism; secondary arthrosis, arthralgia, clicking) and possibly a history • Upper cervical spine
component to all hypermobility and blocked of and/or head pain
other forms of TMD joint pain with opening, may displacement with • Accessory movement
• Palpable tenderness movement resolve reduction restrictions
of musculature • Palpable joint line spontaneously • May have a • Multiple levels may
(temporalis, masseter, tenderness • Opening and/or history be involved
pterygoids) • Crepitus (palpable reciprocal noise of opening and/or • Unilateral or bilateral
• Palpable MTrPs of or • Generally not reciprocal noise • Confirmed through

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TMJ musculature audible to the patient associated with • Locking that does manual therapy and
• Provocation with and/or clinician) severe not permit symptom reduction
activity (mastication, • Positive joint locking of the joint functional (high error rate with
bruxing, etc.) compression test • Positive joint range diagnostic imaging)
• Often bilateral when • Accessory motion compression test • Positive joint
the primary disorder irregularities • Generally compression test
• Confirmed through • Confirmed through unilateral • Generally
muscular joint techniques • Confirmed unilateral
management including joint through • Confirmed
techniques and mobilization when response to joint through
patient applicable patient intervention, poor response to joint
education to reduce education for clinical intervention, poor
contributing factors hypermobile joints differentiation clinical
of different disc differentiation
displacements of different disc
displacements
MTrPs, Myofascial trigger points; TMD, temporomandibular disorder; TMJ, temporomandibular joint.
From Shaffer SM, Brismée JM, Sizer PS, Courtney CA: Temporal mandibular disorders. Part one:
Anatomy and examination/diagnosis, J Man Manip Ther 22(1):5, 2014.

Table 4.5 Differential Diagnosis of Cervical Spondylosis and Temporomandibular Joint

Dysfunction

Cervical Spondylosis Temporomandibular Joint

Dysfunction
History Insidious onset Insidious onset
May complain of referred pain May be related to biting something
into shoulder, arm, or head hard
Stiff neck Pain may be referred to neck or head
Observation Muscle guarding of neck muscles Minimal or no muscle guarding
Active movements Cervical spine movements limited Cervical movements may be limited if
TMJ movements normal they compress or stress TMJ
TMJ movements may or may not be
painful, but range of motion is altered

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 Passive movements Restricted Restricted
May have altered end feel: muscle
spasm or bone-to-bone
Resisted isometric Relatively normal Normal
movements Myotomes may be affected
Special tests Spurling’s test may be positive None
Distraction test may be positive
Reflexes and cutaneous Deep tendon reflexes may be No effect
distribution hyporeflexic See history for referred pain

Subjective assessment:
• History, onset of symptom, mechanism of injury, and SINS (severity, irritability, nature,
and stage)
• Dental history.
• Parafunctions and patient habits (lip and nail biting, cheek sucking, thumb sucking,
leaning on one arm, etc.)
• TMD disability questionnaire (can serve as a reference for patient’s symptoms)
• Psychological assessment (very important) especially in cases of chronic myofascial pain.
Therapists may need to refer to a specialist. Harrison et al.10 recommended two
questionnaires: the Patient Health Questionnaire for Depression and Anxiety, and the
Graded Chronic Pain Scale.

Objective assessment:
• Observation: posture, upper quadrant (head, neck, TMJ, shoulder girdle, and thoracic
spine). A forward head posture places a negative strain on the TMJ, and proper posture
during activities of daily living reduces symptoms. Intraoral observation of scalloping of
the tongue or teeth marks may indicate excessive clenching or bruxing. Observe and
document the three classes of facial profile as it relates to the jaw positions:
▪ class I (orthognathic) or straight profile: mandible and maxilla are aligned (figure
4.11A)
▪ class II (retrognathic) profile: retrusion of mandible (figure 4.11B)
▪ class III (prognathic) profile: protrusion of mandible (figure 4.11C)

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• Palpation: palpate the masticatory muscles e.g., masseter (figure 4.12), joint capsule,
retrodiskal pad, intra oral joint play techniques, neck muscles, passive physiological
intervertebral movements (PPIVMs) and passive accessory intervertebral movements
(PAIVMs) cervical spine assessment.
N.B: mobility assessment of upper cervical spine (atlanto-occipital, antlanto-axial, C2-
C3) is important since upper cervical spine plays a significant role in normal function of
the TMJ.
• Measurement: cervical spine, TMJ ROM (figure 4.13- 4.16), overbite and overjet
measurements
• Imaging modalities: X-ray, CT scans, ultrasonography, and MRI (false positive finding
can be as high as 33%,11 Kinematic (cine) MRI can be beneficial especially for cases of
disk disorders.

Figure 4.12 Extra-oral palpation of masseter

muscle

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A B C

Class I (orthognathic) Class II (retrognathic) Class III (prognathic)

Figure 4.11 facial profile classification

TMJ Range of motion (ROM) table 4.6 and figures 4.13-4.16:

Opening (depression) figure Normal ROM is between 40 mm to 45 mm for males, and 45 mm to 50 mm
4.13 for females (approximately 4 fingers’ width of the nondominant hand).
Functional ROM is 35 mm for both males and females (approximately 3
fingers’ width)
Protrusion Usually between 6 mm to 9 mm
Retrusion Approximately 3 mm
Lateral excursion figure 4.14 ¼ of the opening (i.e. 10 mm of lateral excursion for a 40-mm opening)

Figure 4.13 Measurement of mouth opening Figure 4.14 Measurement of lateral excursion

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Functional or full active opening
The is determined by having the patient try to place two or three flexed proximal interphalangeal
joints within the mouth opening (Fig. 4.15).36 This opening should be approximately 35 to 55
mm.4 Normally only about 25 to 35 mm of opening is needed for everyday activity. If the patient
has pain on opening, the examiner should also measure the amount of opening to the point of
pain and compare this distance with functional opening.19 If the space is less than this, the TMJs
are said to be hypomobile.

Figure 4.15 Functional opening “knuckle” test.

Measuring TMJ range of motion using a ruler:

Protrusion of the Mandible
The examiner asks the patient to protrude or jut the lower jaw out past the upper teeth (Fig.
4.16A). The patient should be able to do this without difficulty. The normal movement is more
than 7 mm, measured from the resting position to the protruded position.4 The normal values
vary depending on the degree of overbite (greater movement) or underbite (less movement).

Retrusion of the Mandible

The examiner asks the patient to retrude or pull the lower jaw in or back as far as possible (Fig.
4.16B). In full retention or centric relation, the TMJ is in a close packed position. The normal
movement is 3 to 4 mm.21

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Lateral Deviation or Excursion of the Mandible
For lateral deviation, the teeth are slightly dis-occluded and the patient moves the mandible
laterally, first to one side and then to the other (Fig. 4.16C). With the joints in the resting
position, two points are picked on the upper and lower teeth that are at the same level. When the
mandible is laterally deviated, the two points, which have moved apart, are measured, giving the
amount of lateral deviation. The normal lateral deviation is 10 to 15 mm.4

During lateral deviation, the opposite condyle moves forward, down, and toward the motion side.
The condyle on the motion side (e.g., left condyle on left lateral deviation) remains relatively
stationary and becomes more prominent.21 Any lateral deviation from the normal opening
position or abnormal protrusion to one side indicates that the lateral pterygoid, masseter, or
temporalis muscle, the disc, or the lateral ligament on the opposite side is affected.

Figure 4.16 Other active movements of the temporomandibular joint. (A) Protrusion. (B)
Retrusion. (C) Lateral deviation left and right. Note position of lower teeth relative to upper
teeth.

Resisted Isometric Movements

Resisted isometric movements of the TMJs are relatively difficult to test. The jaw should be in
the resting position. The examiner applies firm but gentle resistance to the joints and asks the
patient to hold the position, saying “Don’t let me move you.” It is also important to test the

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muscles of the cervical spine because there is a close correlation between muscles of the neck
and those of the TMJs

Opening of the Mouth (Depression). This movement may be tested by applying resistance at the
chin or, using a rubber glove, over the teeth with one hand while the other hand rests behind the
head or neck or over the forehead to stabilize the head (Fig. 4.17A).

Closing of the Mouth (Elevation or Occlusion). One hand is placed over the back of the head or
neck to stabilize the head while the other hand is placed under the chin of the patient’s slightly
open mouth to resist the movement (Fig. 4.17B). In a second method, the examiner uses a rubber
glove and places two fingers over the patient’s lower teeth (mandible) to resist the movement
(Fig. 4.17C).

Lateral Deviation of the Jaw. One of the examiner’s hands is placed over the side of the head
above the TMJ to stabilize the head. The other hand is placed along the jaw of the patient’s
slightly open mouth and the patient pushes out against it (Fig. 4.17D). Each side is tested
individually.

Figure 4.17 Resisted isometric movements for the muscles controlling the temporomandibular
joint. (A) Opening of the mouth (depression). (B) Closing of the mouth (elevation or occlusion).
(C) Closing of the mouth (alternative method). (D) Lateral deviation of the jaw.

N.B. the posterior TMJ compression test (also known as external auditory meatus test) is a
provocative compression test to reproduce posterior TMJ pain and/or clicking (figure 4.18) and

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can be performed bilaterally for comparison. The test can be performed in sitting or supine. In
this test, the clinician inserts the little (or index) finger into the ear of the patient to push the
mandibular condyle as the patient open and close the mouth and ask about level of
pain/discomfort and monitor joint clicks/noises.

It is important that the procedure is explained to the patient before performing the test. To avoid
false positive finding, it is important to ask the patient to report the familiar pain and to
distinguish it from the pain she may experience from the clinician’s finger. Up to the author
knowledge, psychometric properties of this test have not been established yet.

Figure 4.18 posterior TMJ compression test

Joint Compression Test.9

The patient is in side-lying position with the head supported. The examiner pushes the mandible
in a posterior and cranial direction with one hand to compress the condyle against the temporal
bone while the other hand provides a counterforce on the cranium (Fig. 4.19A). The test may
also be done with the patient in supine position and pushing both condyles in and up at the same
time (cranial loading; Fig. 4.19B). A positive test results in pain.

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Figure 4.19 Joint compression test. (A) In side-lying. (B) In supine lying. Both condyles are
compressed at the same time.

Reload Test.35
This test is used if clicking or popping is heard during the examination. The patient is seated and
asked to open the mouth to the point where the clicking occurred. The examiner inserts a tongue
depressor vertically between the molars on the clicking side (Fig. 4.20). With the tongue
depressor inserted, the patient is asked again to open and close the mouth. If the click is
eliminated with the tongue depressor in place, the splint is helping to reduce posterior loading of
the joint and allows the disc to reposition.

Figure 4.20 Reload test.

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Separation Clench Test.35
The patient is in sitting position and, starting with the unaffected side, is asked to bite down on a
cotton roll or similar object placed between the mandibles (Fig. 4.21). The test is repeated on the
other side. The placing of the cotton roll distracts the ipsilateral TMJ and compresses the
contralateral joint. If the pain is in the muscle that closes the mouth, the affected muscle could be
on either side. If the pain is in the joint on the distraction side, it suggests a capsular problem. If
the pain is on the contralateral side, it indicates inflammation in the joint.

Figure 4.21 Separation clench test.

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