Transcript Temporomandibular Joint Dysfunction

Jonathon R. Kirsch, D.O., C-NMM/OMM
Associate Physician
Neuromusculoskeletal Medicine/OMM
Marshfield Clinic Stevens Point Center
Stevens Point, Wisconsin
Presenting at WAOPS Fall Seminar, Sept. 25-26, 2015
Learning Objectives
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6.
7.
Describe significance and patient demographics of
temporomandibular joint (TMJ) dysfunction
Discuss the anatomy and function of the TMJ.
Discuss the etiology and pathophysiology of TMJ
dysfunction
Describe and perform physical examination procedures
and discuss management of TMJ dysfunction
Assess and treat important tender points in the cranial
and cervical regions, relative to TMJ dysfunction.
Perform muscle energy treatment for TMJ dysfunction.
Perform myofascial release compression and
decompression treatment for TMJ.
Definition
 TMJ Dysfunction refers to a problems involving the
muscles of mastication, the TM joint, and/or its
associated structures
-Seffinger, Hruby, 2007
Demographics and Extent
 Affects estimated 10 million Americans (1 in 25)
 Adults 20 to 40 years of age
 Affects women more than men (4:1), and more
frequent during the childbearing years
Nelson, Glonek, 2007, SDOFM, pp.208
E.B is a 34-year-old Caucasian woman who presents to
my office with a chief complaint of headache.
 CHIEF COMPLAINT: Headache
 HISTORY OF PRESENT ILLNESS:
C: burning, aching, and pressure in the ear, hairline, and gum
line on the right side.
O: Three weeks.
P: At first the pain was intermittent and more severe. Now it
is constant, but somewhat less severe.
M: Symptoms are lessened with OTC analgesics, and
worsened by chewing, such that she avoids eating tough
foods.
A: associated right sided neck pain, as well as a “ticking” in
the right ear which is heard and felt when she chews.
P: Denies previous occurrence of current jaw and head
symptoms, but does admit to a history of neck pain.
Common Patient Presentations
 Pain, tenderness, and/or
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stiffness of the TMJ
Joint sounds
Motion restrictions
Muscle and/or joint
tenderness
Headache, commonly
periauricular
Ear ache, orofascial pain
Head, neck, shoulder
associated symptoms
Tinnitus or ear fullness /
hearing loss
Malocclusion
-Seffinger, Hruby, 2007
• Limited jaw movements, preauricular
pain, ear, facial pain, (and)...headache”
may also be present.
• Possible causes for TMJ dysfunction:
malocclusion, trauma,...the
neuromuscular apparatus, and the
general health of a patient...(and) dental
procedures such as forceful extractions
can be considered traumatic.
-Ferris and DiGiovanna(2) 1997
Associated Symptoms
 Neck and shoulder pain
 Ears, face, sinuses, salivary glands, eyes, teeth may be
affected
 Pain may be intermittent, and often difficult to
describe and localize
Osteopathic Considerations
 A major cause of TMJ is trauma
 Sometimes the cause is not clear
 Thorough diagnostic evaluation important
 TMJ is part of the entire body
 Full structural examination is indicated from “atlas to
coccyx”
 Pain can result from muscle or joint dysfunction, or
both
 TMJ loss of integrity
Case…
PAST MEDICAL HISTORY: The past medical
history includes neck and low back strain, and
asthma.
PAST SURGICAL HISTORY: The past surgical
history includes a tonsillectomy.
PAST TRAUMA HISTORY: The past trauma
history includes motor vehicle accidents in 1984
and 1988, and, starting about three months
ago, a series of dental visits that required her
jaw to be held open for extended periods.
Also, she began gum chewing 6-7 weeks ago.
 ALLERGIES: erythromycin, seasonal allergies
 MEDICATIONS: Advil (over-the-counter ibuprofen
200 mg) , 2-4 tablets, 2-3 times per day.
 SOCIAL: The patient is single with no children. She is
employed in clerical work.
 HABITS: The patient has about 6 drinks of alcohol per
week, has smoked a half pack per day for 10 years, and
drinks 1 cup of coffee per day.
 REPRODUCTIVE: G1P0; periods regular; last pap 9
months ago was normal.
 REVIEW OF SYSTEMS: Review of systems includes
wearing contacts. A history of intermittent neck and
lower back pain is noted, which began with a car
accident in 1984. Moderate but temporary relief from
this pain is obtained with chiropractic adjustments,
which she receives once per week.
% of TMJ Patients with somatic
dysfunction elsewhere
 Cranial dysfunction of some kind – “nearly all”
 OA – 9%
 C3-C4 dysfunction – 50%
 C4-5 – 30%
 T2-3 – 14%
 T3-4 – 14%
 Lumbosacral junction – 29%
 Sacroiliac joints – 32%
 Scoliosis – 14%
Blood, SD, 1986 (6)
Classifications
 Myofascial pain dysfunction (MPD):
 Influence of somatic dysfunction and psychological
factors on muscles of mastication (psychophysiologic)
 Internal derangement (ID)
 Malposition of articular disc
 Degenerative joint disease (DJD) (Less common)
 Organic change at articular surface
 Eg. arthritis (DJD, RA), and capsulitis
Myofascial Pain Dysfunction
 Related to “poor coordination and increased spasm of
the masticatory muscles, rather than to derangement
of the joint itself.” (Trigger Point Manual, 2nd ed.)
 Muscle pain: diffuse, dull, gradual onset after eating or
with turning the head.
 Examine patient for muscle spasm, tender points, and
trigger points
Signs/Symptoms of Internal
Derangement
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Reduced jaw opening
Asymmetric jaw opening (abnormal tracking)
Locking of jaw
Painful popping, clicking, or grating in TMJ with
opening or closing
Malocclusion
Typically sharp, well localized pain
Pain can occur with opening of jaw
Patient will often point at the joint
Joint is often tender
The Mandible
 Condyles
 Coronoid process
 Ramus
 Angle
 Body
Temporomandibular Joint Anatomy
•Compound synovial joint
•Contains non-vascular
fibrous connective tissue
•Fibrocartilaginous surface
on TMJ articulation involves
a fibrocartilaginous surface
(Grey's Anatomy, 38th ed.)
Figure 4
Anatomy: TMJ Disc
•Articular disc between condyle and
glenoid fossa
•Disc divides joint into upper and
lower compartments
•Thin in middle; thick on both ends
•Disc connected anteriorly to joint
capsule
•Posteriorly disc becomes continous
with bilaminar zone (posterior
attachment tissues)
Figure 4
Normal
TMJ Function
•Requires intact joint and
balanced, coordinated muscular
function
Initial opening (A-B in
figure):
rotation of condyle against
inferior surface of disk. (2030mm of opening)
Continued opening (C-D in
figure): translatory motion of
disk and condyle together as a
unit, within superior synovial
joint
Figure 9
•Motion Limiting:
Posteriorly, the superior
lamina is stretched and the
inferior lamina limits endrange of motion (D)
Normal TMJ Function
•Side-to-side movement is
normal at 10-12 mm.
•Total normal adult
opening 50 mm.
Figure 10
Motion range
 <40 mm opening = hypomobile
 >70 mm opening = hypermobile
TMJ Range of Motion
• McDonalds did research to
determine the normal adult
jaw opening distance, and
discovered it was 52mm.
• This measurement
determined the size of their
Big Mac sandwich
Myofascial Pain Referral
Masseter: Superficial portion
 Arises from anterior
zygomatic arch and
attaches to the angle and
lower ramus
 Major function – closure
 Trigger points symptoms:
 Upper teeth pain
 Lower teeth pain
 Maxillary pain (which can
be confused with sinusitis)
Figure 6
Masseter: Deep portion
 Arises from posterior
zygomatic arch and
attaches to coronoid
process and upper ramus
 Major function: closure of
mandible
 Trigger points signs/
symptoms:
 Ear pain
 Reduced opening
 Tinnitus
Figure 6
Masticatory muscle sling. Oblique posterior view.
Revealed: Muscular sling formed by the masseter and medial pterygoid muscles that embed
the mandible.
Illustrator: Karl Wesker
Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
Lateral
Pterygoid:
Superior division
 Arises from great wing of
sphenoid and attaches to
neck of condyle, and
attaches to articular disc
 Major functions:
 Maintains correct relationship
of condyle and disk in jaw
closure
 Lateral motion of jaw with
unilateral contraction
Figure 7
Lateral
Pterygoid:
Inferior Division
 Arises from lateral pterygoid
plate and attaches to neck
of condyle
 Major functions:
 Movement of condyle
anteriorly with jaw
opening
 Lateral motion of jaw
with unilateral
contraction
Figure 7
Lateral
Pterygoid:
 Trigger Point
Signs/Symptoms:
 Reduced opening
 Altered occlusion
 Maxillary region pain
 TMJ pain
 Clicking
Medial Pterygoid
 Arises from lateral pteryogoid
plate, and attaches to medial
aspect of angle of jaw
 Major function: closure of jaw
 Unilateral contraction:
deviation of jaw to one side
 Trigger points symptoms:
 Mouth and throat pain
 Painful swallowing
 “Stuffiness” related to ear
Temporalis:
 Arises from temporal fossa
and attaches to coronoid
process
 Major function: closure of
mandible
 Trigger point signs/symptoms:
 “Zig-zag” deviation pattern
 Headache
 Upper teeth pain
Figure 5
Mechanical Overview
 Integrity of joint is affected
 Traumatic or degenerative etiology
 Usually involves progressive anterior
displacement of articular disc
 Possible distortion of the disc
 May include remodeling of articular
surfaces
 More rarely involves degenerative
changes (DJD, RA)
What Causes Popping
and Clicking?
•Occurs with anterior
displacement of disc relative to
condyle
•As condyle translates forward, it
locates itself onto the central
portion of the disc, and a “click”
occurs
•Translation then continues,
allowing further jaw opening
•As jaw closes, condyle moves off
the disc and relocates behind the
disc, causing a reciprocal “click”
Figure 12
Note: Painless clicking with no loss of
range of motion is not considered a
problem by most dentists, yet still
represents the earliest stage of internal
derangement
Researchers on TMJ
 Magoun states, “A subluxation of the
temporomandibular is manifested by pain and
tenderness, as well as the click or pop which results
when the condyle slips anteriorly past the
meniscus and hits the articular eminence.1
 Kappler and Ramey state that in TMJ dysfunction “the
anterior gliding motion of the mandible and
articular disc is restricted.” They explain that when
the mouth is opened, this restriction “results in
deviation of the chin to the side of restriction.3
Abnormal Tracking
 Mandible not opening in a
straight line
 Usually opens toward the
affected side (deviation)
 May first open to one side,
then return to middle
(deflection)
Note: When unilateral medial
pterygoid is involved, jaw can
deviate to the opposite side
Figure 11
Jaw Locking
Figure 13
1.
2.
3.
4.
5.
6.
Clicking may progress to
Locking
Condyle fails to locate itself
on the disc
Disc blocks condylar
movement
Results in “closed lock”
Condyle pushes disc
forward as opening effort is
made
Disc can deteriorate and
•
change shape
•
Locking can be acute or chronic
Locking may reduce or progress
to become persistent
Observation
• Watch the patient as they talk
for degree of opening and
tracking
• Ask the patient to place their
teeth together in a comfortable
position, edge to edge and with
the lower jaw protruded.
• Watch for the alignment of the
mandible by observing the
alignment of the upper and
lower central incisors or the
upper and lower frenulum of
the lips.
Figure 11
Supine Exam
 Monitor TMJ anterior to ear
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lobes
Patient opens mouth slowly as
far as comfortably possible
Deviation occurs to side of
dysfunction (Kappler,Ramey)
The painful side is the side of
dysfunction.
Watch to see if they really open
their jaw or do they lift their
head backwards.
See page 232 of “Pocket Manual”
Measure the degree of opening:
• Place the bottom edge of a tongue depressor between
•
•
•
•
the two lower central incisors.
Have the patient open their mouth to a comfortable
distance.
Measure to the lower aspect of central upper incisors
and mark the tongue depressor. This is a pretreatment
value and measure the distance in millimeters.
Treat the patient
Repeat your measurement for a post treatment value.
PHYSICAL EXAMINATION
 Vitals: BP=135/85; P=85, reg; R=14, reg; T=98.6. This
patient is a 34-year-old Caucasian female in no
apparent distress. She is alert and oriented X3, with a
normal affect.
 HEENT: Head is normocephalic with normal hair
texture and distribution. Pupils are equal and reactive
to light and accommodation. Red reflexes and
extraocular movements are normal. Tympanic
membranes have good color and position.
PHYSICAL EXAMINATION
 HEART: Auscultation of the heart reveals regular rate
and rhythm with no murmurs, clicks, or rubs.
 LUNGS: Auscultation of the lung fields reveals clear
breath sounds, with no wheezes, rales, or rhonchi.
 NEURO: Mental status is normal. Cranial nerves IIXII are normal. Muscle stretch reflexes are 2/4
bilaterally in the upper and lower extremities. Muscle
strength is bilaterally equal, at 5/5 in the upper and
lower extremities.
OSTEOPATHIC STRUCTURAL EXAM
 ASYMMETRY: On standing exam, elevation of the left shoulder
and the right iliac crest. On supine exam, the left medial
malleolus and the left anterior superior iliac spine were cephalad.
 TART: Tissue texture changes, and increased myofascial tension
were noted in the cervical and lumbar regions, and to a lesser
extent in the thoracic region as well. There was tenderness to
palpation in the cervical, thoracic, and lumbar paraspinal
musculature.
 TMJ: On jaw opening, the chin deviated to the right, and there
was a reduced anterior glide of the right mandibular head.
Hyperemia and tenderness to palpation were noted over the
right temporomandibular joint.
 SEGMENTAL: OASRRL; C2-4SLRL; T5(E)SLRL; T10-12(N)SRRL;
L3-5(N)SLRR. Right innominate anterior rotation; Sacrum (L) on
(L) anterior torsion. Cranium: left sphenobasilar synchondrosis
(SBS) torsion; Right occipitomastoid and right parietosquamous
sutural restrictions.
Conservative Management indicated in
cases of:
 Acute or recent onset
 Primarily muscle pain
 Opening is maintained with normal tracking
 No joint locking
 No signs of other major pathology
Conservative Treatment
 Patient education
 Osteopathic manipulative treatment
 Splinting (controversial)
 Night guards
 Repositioning appliances
 Medications
 NSAIDS
 Muscle relaxers
Evidence-Base for Manual
Treatments in TMJ Dysfunction
 Certain techniques effective for reduction of disc
displacement(1)
 Chiropractic and PT reported as beneficial(2-4)
 Various forms of manual treatment show a tendency to
be effective(5, 6, 7)
Seffinger, Hruby, 2007
Patient Education
• Soft foods, no gum chewing
• Do not open wide with yawning
• Do not open too wide for other reasons or for
prolonged periods
• The normal resting position of the jaw is lips together
and teeth slightly apart
• Do not rest your chin on your hand
• Do not sleep with your hands on your face and try not
to sleep on your stomach
Procedures
 Observation and
measurement
 Examination of function
 Muscle Energy
Treatment to TMJ
 Compression/Decompre
ssion to TMJ
 Counterstrain to:
1. Anterior temporalis
2. Masseter
3. Lateral pterygoid
4. Medial pterygoid
5. Omohyoid
6. Suprahyoid
7. Digastric
8. AC1
TMJ Compression
1. Fingertips
under body
of mandible
2. Pull
mandible
superiorly
(until slight
give occurs)
See page 247 of “Pocket Manual”
TMJ Decompression
Fingertips
to lateral
mandible
2. Push
mandible
caudad
(until
give is
equal on
both
sides)
1.
See page 247 of “Pocket Manual”
Muscle Energy Treatment -TMJ
 Open the jaw to the point of
deviation and engage the
barrier (away from direction
of deviation)
 Have patient push jaw back
toward midline for 5 secs
with mild force, then relax
jaw
 Stabilize head on opposite
side.
 Engage new barrier and
repeat until finished
Counterstrain for TMJ
1. Anterior temporalis
2. Masseter
3. Lateral pterygoid
4. Medial pterygoid
5. Omohyoid
6. Suprahyoid
7. Digastric
8. AC1
Anterior Temporalis:
TP Location
 Approx. 2 cm
posterior and lateral
to orbit of eye
 Superior to
zygomatic arch
 Check with pressure
medially
Anterior Temporalis:
Treatment Position
 Patient supine
 Push relaxed jaw
toward side of T.P.
 Stabilize head with
monitoring hand
and arm.
Masseter, TP Location
 In the masseter
muscle
 Check anterior
border of masseter
 Over anterior edge
of ascending ramus
 Check with pressure
posteriorly
Masseter Treatment
Position
 Patient
supine/Physician at
head
 One hand cups chin
 Pushes slightly open
jaw toward side of TP
 Other hand on
ipsilateral side of
frontal bone, pressure
toward opposite side
 TP found extraorally, with
mouth slightly open
 Just over the coronoid
process of mandible
 Inferior to the zygomatic
arch
 Monitor extraorally just over
the coronoid process.
Lateral Pterygoid:
TP Location
Lateral Pterygoid:
Treatment Position
 Jaw open slightly
 Push open jaw laterally
away from side of T.P.
 Stabilize head with motion
arm
 (cup chin and pull jaw with
fingers, away from side of
T.P.)
 (to the right in the picture
– T.P. is on the left)
Medial Pterygoid:
TP Location
 On medial surface of
ascending ramus
 Just superior to
mandibular angle
 Check with lateral
pressure
Medial Pterygoid:
Treatment Position
 Physician at head of
table
 Cup chin with one
hand, stabilizing head
with same arm
 Monitor TP with other
hand
 Draw slightly open jaw
laterally away from
side of T.P
Hyoid bone and larynx. Left lateral view.
Illustrator: Markus Voll
Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
Supra- and infrahyoid muscles
Left lateral view.
Illustrator: Karl Wesker
Gilroy et al: Atlas of Anatomy. © 2008 Thieme Medical Publishers, Inc. All rights reserved.
Omohyoid Tender Point
 Anterior surface of
inferior belly of muscle,
just above the mid
clavicle
 At the insertion point of
the inferior belly, onto
the superior border of
the scapula
Side View
Anterior View
Omohyoid Treatment Position
 Patient supine, physician
seated at head
 Patient hand on affected
side to opposite shoulder
(protracts scapula)
 Sidebend neck toward
T.P.
 Push hyoid bone toward
tender point side.
Suprahyoid Tender Point
(Mylohyoid Muscle Correlation)
Anterior and Medial to the Angle of the
Mandible
Suprahyoid Treatment Position
 Patient supine
 Slightly open mouth
 Push opened jaw toward
side of T.P.
 Stabilize head and
monitor point with other
hand and arm
Digastric Muscle
Digastric Tender
Point
 Posterior belly of digastric
muscle
 1cm posterior to the angle
of the mandible (approx.)
 Anterior to the
sternocleidomastoid
muscle
Digastric Treatment Position
 Patient supine, flex
neck with head on
pillow
 Tuck chin and open
mouth to 2cm
 Hand on chin – depress
and retract mandible
 Fine-tuning – lateral
shift toward side of T.P.
Anterior Cervical 1:
TP Location
 Posterior aspect of
ascending ramus
 Approx. 1 cm superior
to angle of mandible
 Check with anterior
pressure
Anterior Cervical 1:
Treatment Position
 Patient supine
 Physician at head of table
 Grasp side of head with
one hand
 Rotate markedly away from
side of TP
 Monitor TP with finger of
other hand
Case…OMM TREATMENT
 Indirect suboccipital release, indirect treatment of the
sacral torsion, and the indirect and myofascial treatment of
the cervical, thoracic, and lumbar somatic dysfunctions.
 Muscle energy and indirect treatment were applied to the
right mandibular head restriction, and muscle energy was
also used to treat the innominate rotation.
 Cranial treatment included a direct release of the noted
sutural restrictions, indirect treatment of the SBS torsion,
and incitative lateral fluctuation at the temporal bones.
 Following treatment, decreased myofascial tension and
improved mobility were noted in the cervical region. In
the cranium, improved mobility of the right temporal bone
and the right mandibular head was noted.
Course of Treatment
 The patient returned 2 days after her initial visit with an
acute exacerbation of right sided headache refractory to
over-the-counter analgesics, but also with less neck pain.
 At that time, she was prescribed Ibuprofen 800 mg I PO q
6-8 hours as needed. She was treated twice over the next
week, at the end of which time she reported her headache
to be much less severe, such that she was able to reduce her
ibuprofen use to 800 mg once per day with good pain
control.
 From this point on she was seen once per week for 3 more
weeks. She reported at her 7th and last visit on 9/17/2001
that her head and jaw symptoms were completely resolved,
and had been for the previous week.
Case Conclusion:
 The history and findings in this case thus appeared to
support a diagnosis of TMJ dysfunction, and a short
course of osteopathic manipulative treatment was
given, directed at reducing the noted somatic
dysfunctions.
 During the course of treatment, pain and medication
usage were reduced.
 After six osteopathic manipulative treatments the
patient’s symptoms resolved and no further
intervention was required.
Case REFERENCES:
 1. Magoun, H.I., Sr.: Osteopathy in the Cranial Field, third
edition, Belen, NM: The Journal Printing Company, 1976: 162
 2. Ferris, M.T.: DiGiovanna, E.L.: “Evaluation and Treatment of
TMJ Dysfunction”. In DiGiovanna, E.L. and Schiowitz, S, eds. An
Osteopathic Approach to Diagnosis and Treatment. second
edition, New York: Lippincott-Raven, 1997: 369
 3. Kappler, R.E.: Ramey, K.A.: “Head Diagnosis and Treatment”.
In Ward, R.C. exec. ed. Foundations for Osteopathic Medicine.
first edition, Baltimore, MD: Williams and Wilkins Co.: 1997:
538-539.
Thanks to…
 Barry D. Malina, D.O., original co-author of this
presentation, first presented for AOMA, 2011.
 Tucson Osteopathic Medical Foundation, for permission to
use the Counterstrain illustrations.
 Rebecca Griffiths, BS, DMD
Sources
 Counterstrain diagrams -
Myers, Clinical Application of
Counterstrain, TOMF, Tucson, AZ
2006., pgs. 32-38.
 Muscle diagrams Gilroy et al: Atlas
of Anatomy. © 2008 Thieme
Medical Publishers, Inc. All rights
reserved.
 Atlas of Human Anatomy
Frank H. Netter, M.D.
 Figure 2
 The Pocket Manual of OMT,
 Indirect technique slides



Beatty, Steele, Comeaux, Garlitz,
Kribs, Lemley, Pages 247, 232
 Evidence Based Manual
Medicine, Seffinger and Hruby,
2007, pp. 207-208

Outline of Osteopathic
Manipulative Treatment, by
Paul Kimberly
Figure 10
Brendan C. Stack, Jr., MD
Figure 11
Brendan C. Stack Sr., DDS, MS
Somatic Dysfunction in Osteopathic
Family Medicine, Nelson and
Glonek, Chapter 15.
Muscle Energy Treatment for TMJ,
Osteopathic Approach to Diagnosis
and Treatment, D’Giovanni and
Schiowitz, 3rd edition
Manual Medicine Research
References
1.
2.
3.
4.
5.
6.
7.
Martini G., et al., MRI study of a physiotherapeutic protocol in anterior disk
displacement without reduction. Cranio 14:216-224, 1996.
Chinappi AS, The dental-chiropractic co-treatment of structural disorders of
the jaw and TMJ dysfunction. J Manipulative Physiol Ther . 18: 476-481, 1995
Hargreaves AS, The use of physiotherapy in the treatment of TM disorders.
Br Dent J 155:121-124, 1983
McCarty WL, Rehabilitation of the TMJ through the application of motion.
Cranio 11:298-307, 1993.
Hruby R: The total body approach to the osteopathic management of TMJ
dysfunction. J Am Osteopath Assoc 85:502-510, 1985
Blood S, The craniosacral mechanism and the temporomandibular joint, J
Am Osteopath Assoc 86:512-519, 1986
Saghafi D, Chiropractic manipulation of anteriorly displaced
temporomandibular disk with adhesion. J Manipulative Physiol Ther 18:98104, 1995.
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