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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

 

Masseter

Elevates Mandible

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
 

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
 
Acupun­cture
 
Special Imaging
 
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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