Document 134721

Richard Ogden, DO, FACOFP, FAAFP
Kansas City University of Medicine and
Biosciences
College of Osteopathic Medicine
Understand the incidence of temporomandibular
joint (TMJ) dysfunction.
Understand and describe the anatomy of the TMJ
Understand and describe the pathophysiology of
the TMJ dysfunction.
Understand and describe the clinical
manifestations and clinical diagnosis of TMJ
dysfunction.
Develop and demonstrate a treatment plan using
both Osteopathic Manipulative Medicine and
home exercises for TMJ dysfunction.
Stress and subsequent jaw clenching.
Jaw malocclusion
Nighttime bruxism (tooth grinding). In some
studies 78% of subjects had teeth
grinding.(controls and TMJ).
In controls: Tooth contact 360 times/night.
TMJ and bruxism: 1325 times/night.
Six patients with TMJ without known bruxism:
Tooth contact 999 times/night.
TMJ is the 2nd most common source of facial
pain, second to toothache.
Ten million people in the US are affected by
TMJ.
Adults 20 - 40 years of age are most commonly
affected.
Female to male ratio: 3 – 4 : 1.
Sub-types of TMJ: Myofascial pain dysfunction;
internal derangement; and degenerative joint
disease.
Unilateral facial pain in the area of the muscles
of mastication, bitemporal headache, neck pain,
tinnitus.
Frequently there is an audible or palpable click
if there is an articular disc displacement. A
click by itself is not diagnostic of TMJ
dysfunction.
Facial asymmetry: the affected side is more
concave or “the affected side of the face is
smaller.”
©2008 UpToDate®
TMJ has both hinge and gliding motion.
Mandibular condyle glides along the squamous
portion of the temporal bone.
Articular disc separates the mandibular
condyle from the articular surface.
The articular disc is bi-concave and is a thick,
thin and thick structure from anterior to
posterior.
With the mouth closed, the thick part separates
articular surfaces.
With the mouth open, the thin part separates
the articular surfaces.
With opening (depression) the suprahyoid
muscles activate (mylohyoid, geniohyoid, and
digastric).
With anterior glide the inferior division of the
lateral pterygoid activates.
With elevation (closure) the temporalis,
masseter and medial pterygoid muscles
activate.
With lateral displacement the ipsilateral
temporalis and contralateral medial and lateral
pterygoid muscles activate.
With protraction the suprahyoid , and medial
and lateral pterygoid and masseter and
temporalis muscles activate.
Articular
Disc
Articular
Tubercle
Lateral Pterygoid
Muscle
Sphenomandibular
ligament
Medial Pterygoid
Muscle
Buccinator
Muscle
Temporalis Muscle
Deep Part of
Masseter Muscle
Superficial Part of
Masseter Muscle
Buccinator Muscle
Sphenomandibular
Ligament
Lateral
Pterygoid Plate
TemporomanDibular Joint
Lateral Pterygoid
Muscle
Medial Pterygoid
Muscle
Medial Pterygoid
Plate
Medial Pterygoid
Muscle
This is the most common cause of TMJ pain.
Occlusion asymmetries jaw clenching, bruxism,
stress and anxiety.
Muscle hyperactivity and dysfunction.
Cervical and upper thoracic strains can cause
or intensify TMJ pain.
Sympathetic facilitated segments for the head
and neck are found in T 1 – T 4.
Anterior disc displacement is the most
common cause of this type.
Anterior disc displacement reduces with
opening causing an opening click.
Anterior disc dislocates again with closing
causing a closing click.
Disc displacement and interposing of posterior
band between condyle and articular eminence
causes pain.
Articular
Disc
Articular
Tubercle
Lateral Pterygoid
Muscle
Sphenomandibular
ligament
Medial Pterygoid
Muscle
Buccinator
Muscle
This is generally secondary to micro-trauma.
Dental procedures
Osteoarthritis
Rheumatoid arthritis
Ankylosing spondylitis
Jain pain, clicking, decreased jaw range of
motion, headaches and earache.
Jaw pain worsened by chewing.
Open lock occurs with the condyle dislocated
anterior to the articular eminence
Closed lock occurs with anterior dislocation of
the articular disc.
Observation of facial symmetry (lateral
deviation of the mandible or muscle
hypertrophy).
Chin deviation can be a C or S shaped curve.
Average opening of the mouth is 40mm.
Osteopathic examination: Frequently find
sacral base unleveling, scoliosis, somatic
dysfunction at OA, C 2 C 3 and cranio-sacral
somatic dysfunction in the temporal bones and
sacrum.
Tip of the chin deviates toward the side of
dysfunction.
If an S shaped curve is noted, there are bilateral
somatic dysfunctions.
Palpation of the TMJ is best performed 1 – 2 cm
anterior to the tragus, inferior to the zygomatic
arch.
Palpation of the posterior wall of the TMJ can
be performed through the external auditory
meatus.
Useful only to screen for rheumatoid or other
metabolic causes of joint pain (gout, pseudogout, etc)
Not usually indicated unless there is acute
trauma. Then, plain radiography is adequate.
MRI is very expensive and is reserved for preoperative diagnosis.
Treat any underlying causes: anxiety,
orthodontics referral.
Recommended OMM is gentle, relaxing and
typically can be taught to the patient for home
exercise.
Osteopathy in the Cranial Field evaluation and
treatment
The patient is supine and the physician is seated at
the head of the table, palms gently applied to the
lateral mandible bilaterally.
The physician places a gentle cephalad traction
along the axis of the ascending ramus of the
mandible.
Asymmetrical movement may occur as the tissues
relax.
When no further movement appears to occur,
reverse the direction and apply a gentle bilateral
caudal stretch in the direction of the ramus of the
manbible.
Asymmetrical movement may occur again as
one side then the other relaxes.
This is a very gentle technique so that the
forces do not activate the muscle spindle reflex
or the golgi tendon reflex.
Treat the muscles that elevate (close) the jaw.
The patient is supine with the mouth open and
the physician is seated at the head of the table.
The physician places two fingers against the
chin and asks the patient to try to close the
mouth and the physician resists this.
This cycle is repeated 3 – 5 times or until no
new barriers are encountered.
The patient is re-assessed.
Treat the muscles that open the jaw
The patient is supine with the mouth closed
and the physician is seated at the head of the
table.
The physician places two fingers under the
chin and asks the patient to try to open the
mouth and the physician resists this.
This cycle is repeated 3 – 5 times or until no
new barriers are encountered.
The patient is re-assessed
Treat the muscles that control lateral glide.
The patient is supine with the mouth slightly open
and the jaw moved away from the affected side to
engage the barrier and the physician is seated at the
head of the table.
The physician places the palms of both hands against
the mandible asks the patient to try to move the jaw
toward the dysfunctional side (toward the side of the
deviated chin) and the physician resists this.
This cycle is repeated 3 – 5 times or until no new
barriers are encountered.
The patient is re-assessed
The patient is supine and the physician is
seated or standing at the head of the table.
The physician places the 4th and 5th fingers on
the posterior aspect of the ramus of the affected
side.
The other hand is placed palm against the
contralateral mandible.
The 4th and 5th fingers apply an anterior force
and the index and long fingers apply a
cephalad
Maintaining those forces, the left hand then
applies an isolytic force (moves the jaw toward
the right).
This technique attempts to reseat the articular
disc against the condylar process of the
mandible.
The patient is supine and the physician is
seated at the head of the table.
The tenderpoint is located in the belly of the
masseter muscle and is assigned a pain rating
of the (10).
The opposite hand gently deviates the jaw to
the involved side until the tenderness is only a
3.
This position is held for 90 seconds and then
gently the jaw is returned to a neutral position
and the tenderpoint is reassessed.
The patient is supine and the physician is
seated at the head of the table.
The physician places the fingertips in the suboccipital sulcus and allows the patient’s head to
settle in the palms of the hands.
Gentle cephalad traction may be added as the
fingertips sinks deeper into the relaxing
muscles.
Temporalis Muscle
Deep Part of
Masseter Muscle
Superficial Part of
Masseter Muscle
Buccinator Muscle
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