Documente Academic
Documente Profesional
Documente Cultură
Purpose
y Thisbreakoutsessionwillincludedescriptionofthe
Objectives
y DescribethefunctionalanatomyandkinematicsoftheTMJ y IdentifytheclassificationofTMDanddescribethecomponentsof y y
y y
eachdisorder PerformacomprehensiveexaminationoftheTMJandrelated structures PerformtreatmentproceduresfortheTMJincludingsofttissue mobilization,jointmobilization/manipulation,andexercise instruction DescribethefunctionalinterrelationshipsbetweentheTMJand cervicalspine Describetheevidencetosupportaphysicaltherapyapproachfor treatmentoftemporomandibular disorders.
Occlusionalplane
Anatomy
OsseousStructures Temporalbone Postglenoid spine Mandibular Fossa Articular Eminence Articular Crest Articular Tuberle Mandible Condyle medialandlateralpole NeckofCondyle Coronoid Process Ramus Body Teeth Mandibular andMaxillary
MusclesofMastication
Temporalis,Masseter, Buccinator,Medial/Lateral pterygoid
Medial/lateralpterygoids
HyoidMuscles
Supra hyoid Digastric Mylohyoid Stylohyoid InfraHyoid Omohyoid thyrohyoid Sternohyoid
IntercapsularStructures
y y y y y y y y y y y
Articulardisc 3bands Anterior 2mm Middle 1mm Posterior 3mm Attachments Medialandlateralcollateralligaments PosteriorAttachments/BilaminarZone SuperiorLaminae InferiorLaminae Retrodiscalpad LateralPterygoid
ArticularDisc
Arthrokinematics
y Depression y LateralExcursion y Protrusion
MandibularDepression
DepressionKinematics
y First25mmofopeningthatoccursprimarilyasarotational
motion(rollgliding)ofthecondyle intheinferiorjointspace. y Oncethecollateralligamentstauten,theopeningcontinuesas primarilyatranslatory glidingmotionintheupperjointspace until35mmisreachedandtheposteriorandcollateralligaments aretaut. y Openinggreaterthan35mmresultsfromfurthertranslation withoverrotation andfurtherstretchingappliedtotheposterior andcollateralligaments.12 y Thelateralpterygoid,inferiorhead,providesaprotractingforce onthecondyles anddiscs;thegeniohyoid anddigastic muscles produceadepressingandretractingforceonthechin;andthe mylohyoid musclepullsdownwardonthebodyofthemandible tocombinetoproducetherotatory andtranslatory movements ofthejawthatoccurwithmandibular depression
Mandibulardepression
MuscularActionwithOpen/closing
LateralExcursion
LateralExcursionKinematics
y Lateralexcursionoccurswhenthecondyle anddiscofthe
contralateral sidearepulledforward,downward,and mediallyalongthearticular eminence. y Thecondyle ontheipsilateral sideperformsminimal rotationaroundaverticalaxisandaslightlateralshift.12 y Thesemotionstakeplaceprimarilyintheupperjoint space. y Lateralexcursioniscreatedbycontractionofthelateral pterygoid musclesonthecontralateral sideofthedirection ofthemotioncombinedwiththeipsilateral sidetemporalis musclecontractingtoholdtherestpositionofthecondyle topreventthemandiblefromdeviatinganteriorly.12
Protrusion
ProtrusionKinematics
y Protusion ofthemandibleiscreatedwithsymmetricalanterior
translationofbothcondyle/disccomplexesonthearticular eminence y Themotionoccursatthesuperiorjointspace. y Protrusioniscreatedbycontractionoftheinferiorheadofthe lateralpterygoid andholdingactionofthemasseter andmedial pterygoid muscles.12 Thelateralpterygoid pullsthecondyle and discforwardanddownalongthearticular eminencewhilethe elevatoranddepressormusclesmaintainthemandibular position.12 y Retrusion isthereturntorestpositionfromtheprotrusion positionandiscreatedbythecontractionofthemiddleand posteriorfibersofbothtemporalis muscleswhilethedepressors andelevatorsmaintainaslightopeningofthemouth.12
Mandibular Mapping
CervicalSpineandTMJ interrelationships
relationship(red).
zAllowsNormalseating
ofMandibledisccondyle relationship(blue).
Kraus
molars(red).
zPullsmandibleforward
(green).
zPlacesanteriorstresson
thediscoftheTMJ.
zJawandfacialpain.
Kraus
EffectofFHPonmandible
Neumann
Pseudomalocclusion
y Changerestpositionofmandiblecanchangehead/
HowtheMusclesandJoints WorkTogether
Increaseforwardhead posture. Tightposteriorneck musculaturewillrotatethe craniumbackwardleaving themouthopenatrest. Musclesofmastication overworktomaintainjaw closure.
Cailliet
Summary
y FunctionalandAnatomicalinterrelationshipsbetween
activeroleinmanagementofcervicalspineandTMD conditions
Evaluation
y History y Structure y ActiveRangeofMotion Cervical y ActiveRangeofMotion Mandible y PassiveAccessoryMotion Cervical y PassiveAccessoryMotion TMJ y Provocation/Palpation
MandibularDynamics
TMJPassiveAccessoryMobilityTesting
Provocationtesting
TMDClassification
y Capsulitis/Synovitis y CapsularFibrosis y Hypermobility y ArticularDiscDisplacement y Withreduction y Withoutreduction y Post SurgicalTMJ
Capsulitis/Synovitis
y TendertopalpationatTMJlateralcondyleorposterior
MasticatoryMuscleDisorders
y Nojointsounds y Painwithpalpationmusclesofmastication y Inconsistentalterationsinmandibularcontrol y Parafunctionaloralbehaviors y Painwithbitingonsameside
CapsularFibrosis
y Capsularpattern y Deviationtowardlimitedsidewithopeningand protrusion y Limitedcontralaterallateralexcursion y LimitedAROMmandibulardynamics y LimitedmobilitywithTMJaccessorymotiontests y Nojointsounds y Historyoftraumaorsurgery
TMJCapsularpattern
Hypermobility
y Endrangeclickwithdeviationawayfromhypermobile
Hypermobility
ArticularDiscDisplacement
y Withreduction
muscledysfunction)
DiscDisplacementwReduction
ArticularDiscDisplacement
y Withoutreduction
side
TMJCapsularpattern
Post SurgicalTMJ
y capsulitis/synovitis y AssessforunderlyingTMJdysfunction
Osteoarthritis
y TMJcrepitusasnotedwithstethoscope y PainwithTMJpalpation y Radiographicevidenceofosteoarthritis
PhysicalTherapyGoals
y RestoreNaturalMotionofTMJandCervicalSpine y ImprovePosturalAwareness y ImproveFunction(eating,talking,etc.) y DecreasePainandHeadaches y TeachPatientsHowtoPreventFutureOccurrencesof
HeadandFacialPain
TreatmentsforTMD
y Modalities y Manipulation y Cervical/thoracicspine y TMJ y PosturalEducation y Therapeuticexercise y Neuromuscularreeducation
Modalities
y Ultrasound y Iontophoresis y MoistHeat
Iontophoresis
y InastudybyMajwerandSwider,22 27of32casesof
CervicalManipulation
y Enhancecervical
TMJManipulations
z
Indications
Lossofjawmotion Limitedaccessorymotion Pain
y Techniques
y LongAxisDistraction y MedialGlide y LateralGlide
CaseSeries
y Nicolakis etal9 hadsuccessfuloutcomesinaseriesof
20patientswithOAoftheTMJwithimproved measuresofpainatrest,incisional opening,and function. y Theinterventionsincludedjointmobilizationofthe TMJ,softtissuetechniques,activeandpassiveTMJ exercises,andposturalexercises.9 y Datacollectedonthesepatientsata12monthfollow upexaminationcontinuedtosuggestfavorableresults fortheuseofexerciseandmanualphysicaltherapyin themanagementofTMD.10
10 Nicolakisetal
y 30patientswithTMJanteriordiscdisplacementwith
followupexamination;13%hadreductioninTMJsounds.10
y Thisstudysupportstheuseofexercisecombinedwith
gentlemanualtherapytechniquesfortreatmentofanterior discdisplacementwithreduction.
SingleCasedesign
y ClelandandPalmer27 showedagoodclinicaloutcomeina
singlecasedesignstudyofapatientwithbilateralarticular discdisplacementwithoutreductionthatwasconfirmed withMRI. y ThetreatmentapproachincludedTMJmobilization techniques,cervicalspinemobilization/manipulation techniques,posturalandneckexercises,andpatient educationregardingparafunctional habits,softdiet, relaxationtechniques,activitymodification,andtongue restingposition. y Thepatienthadareturnofnormalmouthopeninganda reductioninpainanddisabilitymeasuresasaresultofthe physicaltherapyapproach.27
NeuromuscularReeducation
y Tongue/teethposition y Controlledopening y Gentleisometrics y Theutilizationofacocontractionofthemusculature surroundingajointtofacilitatestability
y y y
HomeExerciseProgram
y Everypatientreceivesahomeexerciseprogram y Exercisestake<1minutetoperform y Exercisesaretobeperformedevery2hoursfor6
repetitions
y Encouragesposturalcompliance GoodPostureNever
Rests y Trainsenduranceandfunctionofposturalmuscles
y Allexercisesarereviewedateachsession
Randomizedclinicaltrial,Yodaet al26
y Comparedanexerciseprogramwitheducation y Fortytwopatientswithanteriordiscdisplacementwith y y y y
reduction Theresultsshowedthattheexercisegrouphadbetteroutcomes fordecreasedpainandincreasedROM(P =.0001).26 61.9%oftheexercisegrouphadfavorableoutcomes(13/21 patients),and0%ofthecontrolgrouphadfavorableresults.26 Successwasmeasuredontheseverityofjointsoundsorpain withmaximalmouthopening. Ofthe13patientswithasuccessfuloutcome,onlythreeofthe patientsTMJarticular discs(23.1%)wererecapturedwith reexaminationwithmagneticresonanceimaging(MRI).26
CondylarRemodeling Theory
y Hyperboloidencouragesproperjawtodisc
CondylarRemodeling
y RestPosition
y Gentlyrestdevice
CondylarRemodeling Theory
y Contralaterallateraldeviationwillgapand
CondylarRemodeling
CondylarRemodeling Theory
y Thereturntomidlinewhilemaintainingthe
contractioncreatesacouplingforce.
y Approximatesthenaturalcondylardisceminence
ExercisePhasesforRehab
y Restdevicegentlybetweenfrontteeth
y PhaseI Rolldeviceawayfromaffectedside. y PhaseII Afterroll,gentlybitedownasif tomakean
y Doallexercisessixtimesthreetimesperday.
CondylarRemodeling Modifications
Background&Purpose
y Temporomandibulardisorder(TMD)isarelatively
y Allpatients(14/15female)receivedacomprehensiveupperquarter
Methods
examination,includingamanualphysicaltherapyassessmentof thebilateraltemporomandibularjoints(TMJ),thecervicalspine, andtheupperthoracicspineandribcage. y Manualphysicaltherapytechniqueswereusedtoaddress identifiedimpairmentsintheTMJandupperquarter.Home exerciseswereprescribedtoreinforcethemanualtherapy interventions. y Patientscompletedaselfreportquestionnairesatbaselineand2 weekfollowup.OutcomesincludedtheTemporomandibular Index,bodydiagram,thePatientSpecificFunctionalScale,and theGlobalRatingofChangescale(GROC).
DataAnalysis
y Descriptiveinformation,includingpatientgender,ageand
y PatientshadexperiencedsymptomsintheTMJregionforamedian
Results
durationof6months(range0.07120months).Thirteenhad associatedheadachesymptomsforamediandurationof6months (range0.0760months). y Atthetimeofthetwoweekfollowupsession,thegrouphadreceived ameanof4.3(0.98)physicaltherapyinterventionsessions. y ThemeanTMDDisabilityIndexscoreswere32.1%(15.4%)atbaseline and18.3%(12.5%)atthe2weekfollowup,representingan improvementof13.9%(CI:8.2%,19.5%)(p<0.05). y Seventythreepercent(11/15)ofpatientsreportedtheyweresomewhat bettertoaverygreatdealbetterontheGROC,andPatientSpecific FunctionalScale(PSFS)scoresimproved3.1points(CI: 2.3,3.9) (p<0.05).
PSFS: 0 = unable to do activity due to the problem, 10=able to do activity as before the problem; Score is average of 3 activity scores
TMD Score
2-Week
TMD
Score of -7= a very great deal worse, 0=no change, +3=somewhat better, +7=a very great deal better.
y Patientswithtemporomandibulardisorderwhoaretreatedwitha
Discussion
TMDClassificationInterventions
Capsulitis Hypermobility Capsular Fibrosis
Classification Criteria
Classification Criteria
Classification Criteria
ExerciseIontophoresis
TMDClassificationInterventions
Post surgical Muscles of Mastication Disorders
Classification Criteria
Classification Criteria
TMDClassificationInterventions
Disc dislocation with reduction Disc dislocation without reduction
Classification Criteria
Classification Criteria
Education
y Limitparafunctional activities:nailbiting,gumchewing,clenching y y y y y y y y y y
andgrindingteeth Tongueposition:atrest,thetipofthetongueshouldbeattheridgeof theroofofthemouthwiththefrontonethirdofthetongueontheroof ofthemouth Teethposition:theteethshouldbe2to3mmapartatrest Lipsshouldbelightlytogetherwithbreathingthroughthenose Keepthetipofthetongueupontheroofofthemouthwhenyawning Avoidsleepingintheproneposition Donotrestchininhands Softdiet:avoidhardcrunchyfoods Cutfoodupintosmallbites Warmwaterrinses PosturalandTMJexercises56timesperday