Temporomandibular Joint

Structure, Function, Dysfunction

and Treatment

Chris Keating
Overview
 Durable
 Can withstand 597N from women and
847N from men.
 Moved very often
 Phonation, mastication, swallowing, facial
expression
Anatomy-Bone

 Zygomatic
 Arch

 Sphenoid
 Temporal
 Mandible
 Head
Anatomy- Muscles
 Masseter
 elevates and protrudes
mandible
 Temporal
 elevates and retracts
mandible
Innervation:
Mandibular (V3)
Anatomy- Muscles
 Lateral Pterygoid
 Bilaterally- protraction
 Unilaterally-
contralateral swing
 Medial Pterygoid
 Elevation, protrusion,
unilaterally: grinding

Innervation:
Mandibular (V3)

Digastric-opening
Anatomy- Nerves
 Auriculotemporal
(sensory) MMA*
 Inferior alveolar
(sensory)
 mylohyoid nerve-
mylohyoid m.
 Lingual (sensory)
 Buccal (sensory)
 muscular branches (to
muscles of mastication)
Chorda tympani
Anatomy- Arterial Supply
 Deep Auricular
 Anterior Tympanic
 Middle Meningeal
 Maxillary
 External carotid
Anatomy- Ligaments
Sphenomandibular
Joint capsule

Lateral
ligament
-limits
Stylomandibular depression,
posterior
-limits protrusion movement
movement
Anatomy- The 4 Joints
 Synovial joint
 Articular disc
(fibrocartilage)
 Two joint
cavities
 (upper cavity)
protrusion/retrusion
 (lower cavity) hinge
motion
 Extracapsular
ligaments
Anatomy- Joint Surfaces
 Glenoid fossa formed by Posterior
Glenoid Spine and Articular Eminence
 Mandibular head of the mandible
(medial and lateral poles)
 Fibrocartilage
 Traebecular Bone (thin/translucent)
 Deep perpendicular
 Superficial parallel
Biomechanics
 Disk is a biconcave (Bow
Tie/Danish)
 Convex mandible
 Convex glenoid fossa
 Lower joint- hinge
 Upper joint- gliding
 Increases congruency of
boney structures
 Pressure mainly on center
of disk
 CPP- Teeth tightly clinched
 Capsular pattern- Limits in
mouth opening
Capsule
 Highly vascular and
innervated
 Fiber runs from temporal to
mandible
 Very strong and tight in
lateral/inferior fibers
 Loose and Thin
superior/anterior/medial
fibers
 Prone to anterior
dislocation due to
capsule weakness and
incongruence
 Articular Disk
 Collegen, GAGs, Elastin *changes may occur in proportion
 Anterior and Posterior are innervated and vascular
 Middle load bearing portion avascular and not innervated
 Maintains congruency

Bilaminar
retrodiskal pad*
Disk attachments
 Medial and laterally to the mandible- firmly
 Anteriorly to capsule/lateral pterygoid
tendon (restricting posterior motion)
 Posterior has 2 portions separated by fat pad

 Superior attaches to SGF and is elastic and allows

for disk movement during mouth opening
 Inferior to the neck of the mandible and is
nonelastic
Movement
Movement and Measurement

 Protrusion and Retrusion strictly gliding

motion without rotation (6-9cm, 3cm)
 Depression/Elevation gliding and rotation
simultaneously (2 fingers Proximal IP)
 Lateral Deviation- rotation on ipsilateral side
with translation on contralateral side (1 central
incisor)
Dysfunction
 Degenerative Conditions
 Internal Derangement
 Inflammation
 Capsular Fibrosis
 Osseous Mobility Conditions
 Posture
 Pulmonary Issues
Dysfunction- Degenerative
 OA- One TMJ
 RA- Both TMJ
 Severe internal derangements lead to higher
chances of degenerative changes
 Tanaka, 2000
 Degeneration of the TMJ is not a normal
part of aging and degeneration is not
necessarily associated with symptoms or
dysfunction.
 Nannmark, 1990 and Leeuw, 1996
Dysfunction- Derangement
Dysfunction- Derangement
 Clicking or popping indicates severity of
derangement (reciprocal click)
 Mainly anterior due to structural weakness
 Hypertrophy of lateral pterygoid
 Overstretching of retrodiskel tissue
 Sound is mandible moving in and out of disk
with reduction
 Without reduction there is a mechanical
blocking of mouth opening
Dysfunction- Inflammation
 Rheumatoid Arthritis- Systemic
 Gout- Urate crystals
 Psoriatic Arthritis- Joint pain
 Ankylosing Spondylitis- Spinal pain Systemic
 lupus Erythematosus- Autoimmune disease
***Capsular Fibrosis can be result of long term
 inflammation, trauma or immobilization***
Dysfunction- Osseous Mobility
 Hypermobility due to many causes but can
result in endrange sticking or feeling of jaw
going out of place.
 Palpation of lateral pole reveals large
indentation
 Deviation to the contralateral side
 Dislocation creates same symptoms
 No significant difference in occurrence
between pt with or without symptoms of
TMJD
Dysfunction- Posture
 Signs and symptoms of cervical spine injury
parallel that of TMJ s/s
 Postural stresses that injure the c-s also
apply stresses to the TMJ (OA joint,
subocciptial, stylohyoid, digastric)
 Proper screening of TMJ can limit
progression of dysfunctions
 Pulmonary issues/distress can promote a
forward head posture recreating postural
stresses. (Restrictive Disease, Chronic use of
assessory muscles)
Patient History
 Is there pain on opening or
closing?
 Pain with eating?
 What movements cause
pain?
 Mouth breather?
 May lead to changes in
internal pressure due to
tongue placement which
in turn alters external
pressure
(buccinator/orbicularis
oris).
 Leading to balance
problem in the neck
Patient History
 Any clicking? (one or two?)
 Has your jaw or mouth ever locked?
 Oral habits?
 Teeth grinder (Bruxism)?
 Teeth sensitivity?
 Any difficulty swallowing?
 Ear problems?
 Headaches?
 Voice changes?
 Felt dizzy or faint?
 Dental splints?
 When is the last
time they saw a
dentist?
Observation
 Cervical posture
 Bite (under, over, cross, mal)
 Profile
 Tongue movement
 Bony contours
Examination
 AROM (neck, mouth)
 PROM- rarely done
 MMT
 Compensations?
 Abnormalities (C-type,
 deviation)
Chin movement normally towards painful
joint (Early-spasm of pterygoid :: Late-
 Capsular)
 Palpation
Functionality
Special Tests
 Imaging- X-ray, MRI
 Reflexes (jaw)
 Dermatome
 Cranial nerve testing
 Auscultation
 Crepitus (DJD)
 Clicking (Derangement)
 Chvostek test
 Tap parotid gland under masseter muscle
 + if facial muscles twitch
Treatment-Initial
 Splints
 Modalities (Heat, Ice, Laser*-more
effective?/Estim-TENS, US T/NT)
 Muscle Techniques
 Relaxation, Strengthening, Stretching, Massage
 Joint mobilization (one joint at a time)
 Caudal, Lateral, Medial, Posterior, Anterior
Treatment- Surgery
 Arthroscopic
 Lateral release, manipulation, injection
“lysis and levage”
 Walker repair reported as 86%
successful
 Very effective in conjunction
 with PT*
Significant decreases in pain and
 increases in function*
Therapy started within 24 post-op
Stage I- first 2 weeks post-surgery

 Ice pack
 Postural correction
 Resting tongue position instruction Active
 therapeutic exercises with tongue Active
 controlled condylar rotation
Stage II- 3–6 weeks post-surgery
 Moist hot pack
 Ultrasound Postural
 correction
 Gentle periauricular massage
 Active to assistive exercises
 Active vertical and lateral
 mandibular movement
 Isometric exercises
 Gentle stretching exercises
Home exercise program
Stage III- after 7 weeks

 Myofascial release technique for masticatory

muscles and neck muscles
 Intrinsic condylar mobilization
 Rhythmic stabilization technique

 Patients normally recover within 9-12wks

Reference
 Clinical Management of a Patient Following Temporomandibular Joint Arthroscopy
 Pbys Tber. 1992; 72:355-3G4.1
 Walker Repair of the Temporomandibular Joint
 2007 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 65:1958-1962, 2007
 A Systematic Review of the Effectiveness of Exercise, Manual Therapy, Electrotherapy,
Relaxation Training, and Biofeedback in the Management of Temporomandibular Disorder
 Physical Therapy . Volume 86 . Number 7 . July 2006
 The effect of physiotherapy on post-temporomandibular joint surgery patients
 D. W. OH, K. S. KIM & G. W. LEE Physiotherapy Section, Department of Rehabilitation Medicine, Yongdong
Severance Hospital, Seoul, South Korea
 Arthroscopic management of a temporomandibular closed lock
 Australian dental journal 1998:43;(5):301-304
 http://www.dentistrytoday.net/ME2/Segments/Publications
 http://www.activebodyclinic.com/common_TMJ_Thesis.html
 Orthopedic Physical Assessment
 4th, Magee
 Joint Structure and Function
 4th, Levangie and Norkin
 Grant’s Atlas of Anatomy
 11th, Agur and Dalley
 Essential Clinical Anatomy
 3rd , Moore and Agur