Temporomandibular Disorders and Physical Therapy Interventions Brittany Annis, Physical Therapy Student Ithaca College, February 2009
Temporomandibular Disorders(TMDs) • Different pathologies affecting the masticatory muscles, the temporomandibular joint (TMJ), and related structures • Affects more than 25% of the population • 90% of those seeking treatment are women
Facial pains/Muscle spasms Pain/tenderness in the muscles of mastication and joint Joint sounds (popping, clicking) Limited jaw motion Jaw locking open or closed Headaches Teeth grinding Abnormal swallowing Uncomfortable “off” bite Inability to comfortably open/close mouth Dizziness/vertigo Ringing in the ears Visual disturbances Insomnia Tingling in hands/fingers Deviation of jaw to one side Signs/Symptoms
Additional Symptoms • People with temporomandibular dysfunctions frequently report symptoms of depression, affected sleep quality, and a decrease in energy. • It may also interfere with personal relationships and normal social activities.
Trauma Excessive stress Arthritis of the TMJ Whiplash injury Postural abnormality Ligamentous laxity Psychosocial distress (stresses) Bruxism (teeth grinding) Unaligned teeth Congenital Jaw abnormalities Prolonged mouth breathing Thumb sucking Causes
TMJ Anatomy • Osseous Anatomy • The articulation between the condyles of the mandible and the temporal bone, which is part of the cranium. • The articular surface of the condyle is convex and the articular eminence of the temporal bone is concave.
TMJ Anatomy • Meniscal Anatomy • Oval-shaped fibrocartilaginous articular disk (meniscus) between the osseous components of the joint. • The central, intermediate portion of the disk is thin while the anterior and posterior aspects, or bands, are thicker. • The bilaminar zone attaches to the posterior disc assists the head of the condyle in moving forward. • Ligaments • Temporomandibular ligament • Stylomandibular ligament • Sphenomandibular ligament
TMJ Musculature • Four muscles of mastication that move the mandible: • Masseter • Temporalis • Medial Pterygoid • Lateral Pterygoid
TMJ Biomechanics • Two motions: • First 20mm of motion is rotation. The mandible and meniscus move anteriorly together beneath the articular eminence while opening or closing. • Second motion is translation, which slides the jaw further forward or from side to side.
Normal TMJ • The TMJ allows the jaw to open, close, protrude, retract, and deviate laterally. • Mainly used for chewing and speaking • Normal opening 35-40” • 2 to 3 knuckles
TMD Treatment • Working together: • Dentists • Orthodontists • Psychologists • Physical Therapists • Ear, Nose, Throat Doctor • Physicians • Alternative Medicine
TMD Examination • MRI • X-Ray • Dental examination for bite alignment
Physical Therapy Treatment • Physical Therapy is an important aspect in the treatment for TMD to: • Relieve musculoskeletal pain • Decrease inflammation • Restore normal joint/muscular movements for oral motor function • Correct poor posture
TMJ Evaluation • History • Posture • Watch, feel, listen to jaw with AROM • Opening between 40-50mm • Protrusion/retraction between 8-10mm • Lateral deviation while opening (S or C curve) • Lateral excursion 8-10mm • Ligamentous Laxity testing • Transverse Ligament • Alar Ligament • Cervical ROM testing • Palpate joints/muscles for tenderness
Postural Examination Forward head Thoracic kyphosis Soft tissue dysfunctions ADLs/Occupational activities
Therapeutic Exercises Manual Therapy Modalities Electromyographic (EMG) Biofeedback Dental Splint Types of Treatment
Improve muscular coordination Increase muscular strength Postural exercises Active ROM exercises Muscles of mastication Cervical spine muscles General mobility Therapeutic Exercise
Make a “clicking” sound with the tongue on the roof of the mouth. This slightly opens the jaw with the tongue on the palate behind the front teeth, which is the resting position of the jaw and the first portion of relaxation exercises. Place tip of tongue on palate behind teeth and draw small circles. Place tip of tongue on hard palate and blow air out, rolling the tongue, or making a “r r r r” sound. Techniques: Tongue Proprioception and Control
Techniques: Control ofJaw Muscles • Begin with proper resting position of the jaw. Teach the patient control while elevating and depressing the mandible throughout the first half of the ROM. • Keeping the tongue on the roof of the mouth, the patient opens the mouth while trying to keep the chin in midline. Use a mirror for visual reinforcement. • If the jaw deviates to one side, teach the patient to practice lateral deviation to the opposite side without creating pain or excessive motion.
Strengthening Exercises • Periscapular mm • Trunk Extensors • Shoulder External Rotators
Rocabado’s 6x6 Program • Six components • Repeat six times each • Perform six times/day • Targets the craniocervical and craniomandibular systems • Educate/instruct patient during treatment, then issue for HEP
Rocabado’s Program • Tongue Rest Position • Lips together, teeth slightly apart. Anterior 1/3 of tongue against roof of mouth with slight pressure. • Breathe through nostrils, and use diaphragm for deep breathing. 2) Control TMJ Rotation • While opening jaw, keep anterior 1/3 of tongue on roof of mouth to limit movement to rotation only, no protrusion. • Instruct patient to chew in this manner- without translation/protrusion. 3) Rhythmic Stabilization Technique • Lightly resisted motions: opening, closing, lateral deviations
Rocabado’s Program 4) Cervical Joint Liberation • Distract the upper cervical vertebrae by clasping hands behind neck to stablize C2-C7, and flex head 15 degrees for distraction. • Not neck flexion exercise, but flexion of the head on the cervical spine. • Axial Extension of Cervical Spine • Push posteriorly on the upper jaw into lower cervical spine extension and slight flexion of the occiput. • This reduces unnecessary cervical mm. activity and improves the functional relationship between the head and cervical spine. • Shoulder Girdle Retraction • Draw shoulders back and down. • Restores shoulders to normal postural position to reduce tension and increase stability.
Manual Therapy • Massage • Joint Mobilizations • Muscle stretching (passive and active) • Myofascial Release • Manual Traction • Trigger Points • Relaxation techniques • Reduce pain • Increase mobility • Restore oral range of motion
Massage • Masseter mm • Thumb inside mouth, fingers on cheek- sweeping motion to angle of jaw • Cross-friction massage parallel to inner and outer fibers of mm. • If trigger point, focus there • Temporalis • Circular motions • Sternocleidomastoid • “Corn Cob” technique • Postural mm. • Face, shoulders, back of neck • Pressure on sensitive points, massage with hard, slow, short strokes
Stretching Tissues • If the jaw is restricted from opening, determine if the cause is: • A dislocated meniscus, which can be repositioned by joint mobilizations, or • Hypomobile tissues, which can be passively lengthened with stretching as well as joint mobilizations.
Also focus on: Upper and Lower Trapezius Sternocleidomastoid Masseter Temporalis Suboccipital/Posterior Cervical mm Scalenes Rotator Cuff mm. Pectorals Passively increase jaw opening by placing thumbs on last molars of lower jaw and adding slight caudal pressure until the patient can insert the knuckles of the index and middle fingers. Stretching
Mandibular Opening Open to widest point Place both thumbs inside mouth on molar surface Resist light closure for 6 seconds Relax 6 seconds Open further, repeat 3-5x Lateral Mandibular Movement Mouth slightly open Move mandible laterally Resist medial movement for 6 seconds Relax 6 seconds Laterally deviate further, repeat 3-5x Resisted Stretching
Long Axis Distraction: Sitting/Supine PT positioned opposite of affected side Use hand opposite of affected jt. side Thumb in mouth on last molar Apply gentle downward pressure with thumb Hold for ~30 seconds 2-3x/session Bilaterally Anterior Glide Same hand placement Slightly distract using DIP of thumb while gliding anteriorly Oscillate for 30 seconds Joint Mobilizations
Joint Mobilizations • Lateral Glide • Thumb on tongue side of last molar • Use whole hand to oscillate laterally • Medial Glide • Stand on affected side • Thumb on lateral side of last molar • Glide medially
Increase blood flow to the area Relax tense muscles Reduce inflammation Reduce pain Increase range of motion for joint opening and lateral deviation Moist Hot Pack Cold Pack Ultrasound Transcutaneous Electrical Nerve Stimulation (TENS) Laser Shortwave Diathermy Electrophysical Modalities
Avoid: Large bites Excessive chewing Removing food from teeth with tongue Gum chewing Chewy foods: bagels, sandwiches, steak, ice, crunchy fruits/vegetables, caramel, nuts etc. Relaxation techniques to reduce stress/muscle tension Maintain good posture Preventing TMD
Bibliography • McNeely, Margeret L., Susan Armijo Olivo, and David J. Magee. "A Systematic Review of the Effectiveness of Physical Therapy Interventions for Temporomandibular Disorders." PT Journal 86 (May 2006): 710-25. Physical Therapy. 27 Jan. 2009 <http://www.ptjournal.org/cgi/content/full/86/5/710?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=1&title=temporomandibular&andorexacttitle=and&andorexacttitleabs=and&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT>. • Medlicott, Marega S., and Susan R. Harris. "A Systematic Review of the Effectiveness of Exercise, Manual Therapy, Electrotherapy, Relaxation, and Biofeedback in the Management of Temporomandibular Disorder." PT Journal 86 (July 2006): 955-73. Physical Therapy. 27 Jan. 2009 <http://www.ptjournal.org/cgi/content/full/86/7/955#T3>. • Kisner, Carolyn; Lynn Allen Colby. Therapeutic Exercise, Foundations and Techniques. 2002 • http://www.nismat.org/ptcor/tmj • http://uwmsk.org/tmj/anatomy.html • http://www.nlm.nih.gov/medlineplus/ency/article/001227.htm • http://udel.edu/~spetter/TMJWebsite/anatomy.htm