Transcript Disc Displacements

Management of
Temporomandibular Joint
Dysfunction
Dr. James Escaloni, PT, OCS, Cert. MDT, Dip. Osteopractic
Dr. Rob Swayze, PT, OCS, COMT, FAAOMPT
James Escaloni
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Graduated from University of Kentucky in 2007 with Master’s in Physical Therapy
Regis University with clinical Doctor of Physical Theapy 2013
Board certified, residency & fellowship trained in orthopedics
Former board member for the Kentucky Strength & Conditioning Association
Faculty for Select Medical’s Orthopaedic Residency Program and the American Academy
of Manipulative Therapy’s Fellowship in Orthopedics
• Western NY transplant to central KY
• Currently managing KORT’s Versailles clinic
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Rob Swayze
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Graduated from the University of Mississippi with a BS in Physical Therapy
Regis University with a clinical Doctor of Physical Therapy 2011
Fellow of the American Academy of Orthopedic Manual Physical Therapists since 2014
Certified as Orthopedic Certified Specialist
Mississippi transplant to central KY
Currently managing KORT’s Hamburg clinic
Husband and father of 3 boys: 17,10 and 8
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The TMJ…..
Not just a “clicky and painful” jaw
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Modern Diagnosis Based Off of
Classification System
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Diagnostic Classifications
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Masticatory Muscle Disorders
(Myofascial Dysfunction)
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Masticatory Muscle Disorders
(Myofascial Dysfunction)
• Involves the lateral & medial pterygoid,
masseter, temporalis
• Can be directly injured through overuse and
/ or tensile strain
• Indirectly through muscle guarding &
centrally mediated myalgia
• Presence of TrPs may result in referred pain
in tissues outside of the muscle
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Masticatory Muscle Disorders
(Myofascial Dysfunction)
• Overstretching occurs with blows to the
mandible or occur during dental procedures
• Muscle shortening or guarding can result in
reduced ROM
• HAs, earache, toothache, vertigo, and facial
pain can result from this category
• Often occurs with parafunctions
– Gritting, bruxing (grinding during sleep), nail
biting, grinding
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Disc Displacements
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Disc Displacement
» “repeated microtrauma, as occurs with
parafunctional activities of gritting,
grinding, and bruxing, can cause
excessive force on the disc, resulting in
disc thinning or perforations and disc
displacement. Anterior disc
displacement is the most common type
of disc displacement.”
» TMJ Disc Video
» https://www.youtube.com/watch?v
=0Qu9JnPfQtM
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Disc Displacement
• A click or pop occurs when the
condyle glides onto the middle
aspect of the displaced disc
during mouth opening
• May result in excessive loading of
joint structures, such as the
retrodiscal tissue, causing injury,
inflammation (eg, retrodiscitis),
and joint pain in the preauricular
area
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Disc Displacement
• Most people with joint sounds do not have pain or dysfunction
• Suggests that the disc has the potential for healthy remodeling in response to the
altered condylar positioning
• During disc displacement with reduction, the disc may continue to migrate anteriorly,
and the disc displacement with reduction may progress to disc displacement without
reduction
• Decreased mandibular motion (mouth opening less than 40 mm) can result from the
inability of the condyle to glide anteriorly
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Joint Dysfunction
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Joint Dysfunction
• Can be caused by inflammation of the soft tissue around
areas such as the capsule, ligaments, synovium, and
retrodiscal tissue, or it can occur due to structural changes to
the joint surface
• Differentiating among synovitis, capsulitis, or retrodiscitis
will not alter physical therapy interventions
• Therapeutic decisions based off of chronicity of the
inflammation, the level of irritability, mobility impairments,
and the coexistence of masticatory muscle disorders
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Joint Dysfunction
• TMJ does demonstrate normal age-related changes
such as slight flattening of the condyle, but agerelated adaptive processes do not predispose one
to pain or dysfunction in this region
• Localized pain intracapsularly at the TMJ and
extracapsularly may cause muscle splinting of the
surrounding musculature…a reflex response to
protect a threatened part from damage
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Alternative Orthopedic Diagnoses
Temporalis
Masseter
SCM
Trapezius
Lateral Pterygoid
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Trigeminal Neuralgia
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Intervertebral Disc Referral From C3/4
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Orthotics
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Important Questions For Screening
Is TMD source of Pain?
• Have you had pain or stiffness in the face, jaw, temple, in front of the ear, or in the ear
in the past month?
– A positive response should be followed with a question about whether the
symptoms are altered by any of the following jaw activities: chewing, talking,
singing, yawning, kissing, moving the jaw
– Strong specificity and sensitivity
» Dworkin 1992, Gonzalez 2011
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Important Questions For Screening
To identify presence of a disc displacement?
• Have you ever had your jaw lock or catch so that it
would not open all the way? If so, was this limitation in
jaw opening severe enough to interfere with your ability
to eat? Have you ever noticed clicking, popping, or other
sounds in your joint?
– Strong specificity and sensitivity
» Dworkin 1992, Schiffman 2010
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Anatomy and Biomechanics
• TMJ opening
– First 50% is a hinge or roll
– Second half of the opening has
anterior translation to continue the
movement
• Disc motion
– Translates upward and posteriorly
during mandibular elevation
– Moved by superior portion of the
lateral pterygoid eccentrically
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Anatomy and Biomechanics
• Chewing
– Lateral deviation one way,
then the other
– They need to laterally
deviate easily and
bilaterally
• This is especially important
if eating is the primary
complaints
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Anatomy and Biomechanics
• Mandibular depression
– Digastric muscles primary mover
– Passively insufficient in forward head posture
– Lateral pterygoid is also a depressor
• Lower portion
• Mandibular elevation
– Temporalis, masseter, medial pterygoid
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Anatomy and Biomechanics
• Mandibular protrusion
– Bilateral action of the masseter, medial pterygoid,
and lateral pterygoid
• Mandibular lateral deviation
– Unilateral action of the medial & lateral pterygoid
– Temporalis as well
• Functions as force couple
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Examination Components
• ROM
– Opening 40-45 mm males, 4550 mm females
• 3 fingerwidths for functional jaw
opening
– Lateral excursion 10 mm
– Protrusion 6-9 mm
– Retrusion 3 mm
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Examination components
• Posture
– Postural education and assessment important
– Per Religioso 2015
• Radiologically there is a different position that is dependent upon head /
neck position
• Jaw is attached to the neck. Forward head causes muscle and skin on the
front of the neck pull the jaw forward
• The TMJ is a few mm away from the ear, and can cause ear pain
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Examination components
• Posture
– Mandible gets pulled down and back with forward head
posture
– Keeps jaw constantly open
– To prevent looking like a “mouth breather” people often
keep their mouths shut in a forward head position
– This increases effort to a high degree on the masseter
muscles and other mandibular elevators
– This can cause facial pain
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Examination components
Cervical and thoracic ROM screening
– Every TMD patient is (almost) a cervical patient, but not every cervical patient is a
TMD patient
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Examination components
Joints sounds with mouth opening?
• Grinding vs. Clicking
– Grinding is more indicative of arthritic changes
– Clicking is more indicative of a disc dislocation with reduction
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Examination components
Joints sounds with mouth opening?
• Click vs clunk (Religioso 2015)
– Clink is disc popping
– Clunk is when the mandible protrudes past the temporal
“speed bump” known as the eminentia articularis
• This places people at risk of a dislocation with locked jaw
• Usually in really “lax” people
– Mandibular elevators will be hypertonic due to the trauma, and these
muscles need to relax in order for the bone to relocate
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“S” or “C” Shape Curve with AROM Opening
• “S” shape
– More indicative of disc dislocation with
reduction
– Looks more like a “Bell curve” than an
“S”
– Condyle moves over malpositioned disc
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“S” or “C” Shape Curve with AROM Opening
• “C” shape
– Moves away from mid-line
– Involved side doesn’t move past disc
and the deviation moves towards the
involved side
– Normally no “click”
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Mobilization Assessment
• Make sure to slightly depress first to take up
the slack before assessment
• Determine if hypomobile or hypermobile,
and document pain levels
• Longitudinal distraction
• Medial & Lateral movement
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Mobility Assessment &
Mobilization Demonstration
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Mobilization Demonstration
• Distraction
–Improves opening, lateral
excursion bilaterally, &
mastication which is a
bilateral lateral excursion
motion
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Mobilization Demonstration
• Lateral glide
– Moves mandible condyle on stationary disc
(inferior portion of joint moving on stationary
superior portion)
– Palpate on the lateral portion of the jaw to feel
the motion
– Hand inside mouth
– Improves lateral excursion to the opposite side
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Mobilization Demonstration
• Medial glide
– Stabilize the mandible, rotate cranium over stationary mandible
– Superior portion of TMJ motion; disc on condyle movement
• Capsular pattern on the left side, deflection towards left in a “C”
curve
– Work on distraction on the left
– Lateral glide on the left
– Medial glide on the right
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Diagnostic Tests
Biting on 3-4 tongue depressors
• Unilaterally
– Loads the contralateral side
– Reproduction of familiar pain suggests joint arthralgia
• Especially in the presence of painful palpation
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Diagnostic Tests
Biting on 3-4 tongue depressors
• Bilaterally
– Joints are unloaded
– Muscular source of pain should be suspected
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TREATMENT
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Education
• Posture
– Really has pronounced effect on pain and abnormal joint motion
• Keep the tip of the tongue up on the roof of the mouth
when yawning
• Do not rest chin in hands
• Resting tongue position should be at the ridge of the roof
of the mouth with the front one third of the tongue on the
roof of the mouth
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Masticatory Disorders
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Myofascial Based Pain
If trigger points in the muscles of
mastication:
STM techniques
Mobility work
Stability & Proprioceptive exercise
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• Evidence for the effect of electrophysiological modalities and surgery is insufficient, and
occlusal adjustment seems to have no effect
• The following can be effective in alleviating TMD pain:
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occlusal appliances
acupuncture
behavioral therapy
jaw exercises
postural training
some pharmacological treatments
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Thrust manipulation to the OA joint produced
immediate effects in mouth opening and pain
pressure thresholds at the temporalis and
masseter muscles
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Thrust manipulation to the OA joint produced
immediate effects in mouth opening and pain pressure
thresholds at the temporalis and masseter muscles
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• Mandibular and upper cervical spine mobilization with
motion, thoracic spine manipulation, and dry needling
improved pain intensity, disability, and maximal mouth
opening
• Needling was directed at the temporalis and masseter
active trigger points
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Massage and dry needling with the needles left in
situ for 20 minutes decreased pain and improved
AROM mouth opening
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• Upper cervical passive flexion
• Contralateral lateral cervical
flexion through a side-shift
motion
• Lateral glide movement of the
mandible towards the
contralateral side
• Helpful for neurally mediated
facial pain
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Disc Displacements
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• Massage and myofascial release are more effective
than control & equal to botuilinum toxin
• Upper cervical thrust manipulation or mobilization
techniques are more effective than control
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Disc Dislocation with Reduction
• Mobility, Exercise (stability & proprioception) with TMJ mobilization
• Early click with temporalis based pain
(Religioso 2015)
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Rolling needs to be instructed at the TMJ
Temporalis serves as the primary mover without aid from other muscles
This will be felt with immediate translation instead of rolling occurring initially
If curve to the left occurs, often excessive translation can be on the right
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Anterolateral Disc Translation During Examination
(Disc Dislocation With Reduction)
• Condylar remodeling program by Olson & Furto 2010
– Theory is that lateral deviation will gap and glide the condyle anteriorly on the
eminence while the disc remains positioned correctly
– The return to midline while maintaining the contraction creates a coupling
force that approximates the natural condylar-disc-eminence relationships
with motion
– This theory suggests that the biconcave disc can reform to the approximated
condyle and eminence
– Disk is made of fibrocartilage, not hyaline cartilage, and therefore has a
greater capacity for remodeling
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Start position for TMJ
proprioception exercises with
rubber tubing
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ROM phase (phase 1): perform
active lateral deviation away from
painful TMJ within pain-free range
of motion and without joint sounds
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Bite phase (phase 2): at end of lateral deviation ROM, patient applies
submaximal bite onto tube and holds bite for 5 seconds. Mandible is then
returned to midline. This is repeated for 5-6 repetitions. Next progression
(phase 3) is to maintain bite as mandible is returned to midline
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Phases 4 to 6: protrusion range of motion, bite
at end range and bite as return to starting
position can be progressed in similar fashion
to lateral deviation progression
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Final progression is to gently pull tube
and resist in either protrusion or laterally
deviated position
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Disc Dislocation Without Reduction
Exercise
Mobility
Stability Exercise
Proprioception Exercise
Soft Tissue Tone Changes
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• Impairment based interventions utilized and directed at TMJ,
cervical spine, thoracic spine, posture, and use of iontophoresis as
indicated
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Joint mobility restrictions
Muscle length limitations
Neuromuscular deficits
Postural limitations
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• Self-mobilization with disc displacement without reduction
• Self-mobilization in patients with anterior disc displacement
without reduction more effective than splinting
• Self-mobilization involved opening the jaw to the restricted area,
then holding the mandible (gently) down to the point of
discomfort for 30 seconds
• 3 sets of 30 seconds, 4 times per day over 8 weeks
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• Interventions directed in a multi-modal manner,
including directing soft-tissue techniques at the lateral
pterygoid are beneficial for patients with TMD
• Exercise involved a condylar remodeling program for the
disk tissue
• Iontophoresis use did not alter outcomes in this study
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Joint Dysfunction
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Capsulitis
• Exercise & iontophoresis
– This is relevant if ROM is mostly pain restricted and in the acute phase of
injury
– Constant symptoms
• Capsulitis due to hypermobility
– Hypermobility based off of mobility assessment
• Capsular fibrosis is found with hypomobility of the joint
– TMJ mobilization, sustained stretches, and possibly US
– True capsular fibrosis is similar to immobilized tissue or adhesive capsulitis
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• Multi-modal treatment with exercise and manual therapy
for TMJ OA
• Included massage, mobilization, isometric exercise and
guided opening / closing exercise
• ROM improved in most patients and lasted until at least
the 6 month follow-up period
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Chronic structural changes may respond to localized and
specific needling of the capsule
• Escaloni 2015
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General Recommendations
• Maximal strength of the cervical flexors muscles
was found to be not significantly different among
patients with mixed TMD, patients with myogenous
TMD, and healthy subjects
– Armijo-Olivo 2010
• Glucosamine worked just as effectively as ibuprofen for
the management of TMJ OA
– De Souza 2012 (Cochrane review)
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