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Temporomandibular Disorders (Part of Facial pain + HA)
Causes of TMD
Functional - extra-articular (muscle imbalance - Trps in masticatory muscles) |
Structural - intra-articular (tears of the disc, arthritis) - TRUE TMD |
Psychological factors - Bruxism |
Occulusal disturbances |
Risk Factors
Female |
Bruxism |
Gum Chewing |
Jaw Play - stretching/moving jaw alot |
Arm leaning |
Somatisation |
Life Dissatisfaction |
Negative Psychologial symptoms |
Muscles of Mastication + Trigger points
Temporalis
Attaches onto coronoid process - Elevates mandible
Medial Pterygoid
Elevates Mandible - forms a tendinous sling around the angle of mandible, Trp work done intra-orally
Lateral Pterygoid
Protrusion + Anterior translation of disc condyle - activates too early in opening of the jaw in TMD. Intraoral TrP therapy
Digastric
Depressor - posterior draw/stabilisation of the TMJ
Underactive in TMD
Muscles imbalances
Tight |
Weak |
Elevators & Protruders |
Depressors & Retractors |
Masseters |
Digastric |
Medial & Lateral Pterygoid |
Suprahyoid muscles |
Temporalis |
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RED FLAGS
New/Abrupt onset of pain >50y |
Progressively severe |
Sleep loss due to pain |
Systemic symptoms |
Neurological S&S |
Trauma |
Examination
Rule out other pathologies |
Dental pain |
Neck Pain + headaches |
Clicking |
ROM |
Bruxing |
Parafunctional habits |
Ear disorders |
Hx of trauma (Transient capsulitis) |
Physical Exam |
ROM (normal = 45-55mm) |
Movement patterns |
Condylar exclusion |
Centric relation test (pain in joint = intra-articular pathology) |
Palpate muscles of mastication |
Occulsion/dentition |
Cx spine - look for upper crossed |
Management
Advice: |
Treatment |
Soft diet |
NSAIDs/Paracetamol |
Avoid Stimulants |
SMT, Mobilisation of the TMD |
Keep lips together, teeth apart + tongue up |
Release tight muscles (PIR, TPT, MFR) |
Upright posture - head retracted |
Stabilisation exercises |
Chew bilaterally |
Correction of posture |
Avoid gum chewing & grinding |
Advanced |
Avoid prone sleeping |
Splint therapy |
Avoid excessive mouth opening, lip biting, self manipulation, jaw stretching, fingernail biting |
Relaxation therapy |
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Acupuncture |
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Special Imaging |
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Occlusal therapy |
Joint disturbances
Anterior Disc Displacement |
Recapture of an anteriorly displaced disc |
Causes - clicking + lateral deviation |
Sometimes, condyles cannot recapture the disc - reduced ROM |
| |
OA |
RA |
Occlusional imbalance |
Disc tear/crack |
Causes of Bruxism
Sleep Apnoea (Dry mouth causes teeth grinding to create saliva) |
Alcohol and stimulants |
Tobacco |
Stress/Anxiety |
Sleep disturbance |
Abnormal occlussion |
Normal/abnormal movement patterns
Normal |
Abnormal |
Tip of chin moves in a continous, smooth line |
Tip of the chin - moves in a non-smooth, non-continous line |
Goes inferiorly & Posteriorly |
Protrusive movement/lack of posterior glide |
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