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