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TemporoMandibular Joint


TemporoMandibular Joint (TMJ) problems are treated following a careful treatment of all possible elements affecting this problem. We have Contact with specialist orhodontists who work with TMJ, who you may be referred to during the course of the treatment. Problems in the TMJ area includes pain, clicking, occlusion problems affecting range of movement and poor alignment. Some of the techniques used to help TMJ problems include spinal and TMJ mobilisation techniques and postural adjustment.

Theoretical introduction to TMJ problems

TemporoMandibular Joint (TMJ) pathology. Pain of the jaw joint - an introduction to some theoretical principles.

TMJ disorders may arise a s a result of systemic diseases such as rheumatoid arthritis or osteoarthrosis, or may be pure local in origin, for example capsular trauma, condylar fracture or merely dysfunction. The latter is regarded as being multifactorial in its aetiology - elements during movement cycle.

Considerable help to patients can be afforded when the hysiotherapist is working in conjunction with the clinician (dentist rather than the doctor), but knowledge of the function of the masticatory system as a whole should lead to a greater understanding of the scope and limitation of such an approach.

Predisposing factors for pathology of the TMJ can be anatomical abnormalities such as a small caput mandibulae or a deep articular fossa (the disc will have to glide out of a deep fossa). Predisposing factors are likely to be bilaterally but symptoms is however often located to one side only.

Symptoms of TMJ

Symptoms in the TMJ area are often related to the cervical spine either by referred pain, by affected trigeminal nerve or by altered biomechanics of the cervical spine, leading to altered biomechanics of the TMJ. Altered biomechanics of the joint is seen as a major causal factor of TMJ pathology. This would lead to a change in the rhythm of the opening / closure procedure.

In order to develop an initial treatment plan a complete overview of the patient's musculoskeletal health must be established. In the temporomandibular system three major symptoms are;

An abnormal resting position of the tongue, is a frequent alteration found in patients with an active craniovertebral dysfunction, especially when occiput is in an extended position on the atlas. These patients will typically first develop and alteration on their occlusal Contact pattern with increasing Contact in the last molar region.

Strongly associated with these abnormal movement and occlusal patterns is the presence of a forward head and shoulder girdle posture and increased hyiod and anterior neck muscle activity. For this reason the front of the neck should always be cleared before any other treatment is approached. Since these dysfunctions co-exist and interact, it is necessary to evaluate and treat both areas.

Dental and bony abnormalities

Dental and bony abnormalities are seen as a causing factor of altered biomechanics.

In the dental terminology, the position of the mandible is graded:

The pterygoids have (minimum) two functions and the overbite position can lead to overuse dysfunction of both a) and b).

a) Control of medial / lateral glide of the mandible and thereby stability of the mandible in the medial / lateral plane. The Contact of the incisors gives a passive stability in the medial / lateral plane of the mandible. When this is not present, the demand of the pterygoid muscles for stability is increased. This overuse of the muscles is seen as a cause of radiating pain to a tooth and can be provoked by palpation.
b) The opening of the mouth causes two movements of the TMJ: rotation and protraction. Protraction of the TMJ disc during the protraction of the mandible in the last phase of the opening of the mouth can dominate movement. If underbite is present, the patient will try to eliminate the underbite by protracting the mandible. This is done with the pterygoids and as these muscles are active, they will pull the disc anteriorly and increase the wear and tear of the joint, possibly leading to clicking noises, inflammation and eventually slack of retrodiscal ligaments and displacement of disc.

Muscle function

Show pictures of corrective operation for short mandible.

The physiotherapist should make a gross check of the state of the molars and incisors. If the patient present with lack of posterior support because a lack of molars or has lack of support because of underoccluded teeth . This would lead to increased elevator muscle activity and thereby increased load on the TMJ.

Posture and TMJ function

Functional altered occlusion of mandible - can be caused by altered position of the collis. e.g. torticollis or poking chin / underbite:

A change in UPPM (Upright Posture Position of the Mandible) will influence the trajectory of jaw closure to the initial teeth Contact. Altered cervical spine dynamics affects the UPPM, which results I a change in the trajectory of jaw closure. Extension of the head on the neck produces more posteriorly placed habitual closing pathways, with the initial occlusal Contact occurring behind the maximum intercuspated position. Conversely, flexion of the head on the neck produces more anteriorly placed habitual closing pathways. If the UPPM contains upper cervical extension, the head is shifted forward with a flexion of the lower cervical spine in order to keep the eyes in the horizontal plane (Kraus 1994).

The retraction of the disc is partly depending on the elasticity of the stratum ligaments, especially the superior. The passive restraint provided by the normal length and tension of the stratum inferior plays the most important role for proper disc-condyle co-ordination.

If the jaw is constantly protracted, e.g. due to poor posture or "underbite", these ligaments will slack and possibly thinnen. This can cause inflammation of the ligament or lead to anterior displacement of the disc in the retraction phase during elevation of the mandible. This can cause the clicking of during closure movement and irritation of the disc, possibly causing erosive irregularities of the temporal surface or adhesions between the temporal and cranial surfaces of the disc. Finally a displacement of disc is possible.

Arthroscopic repositioning of the disc such as lysis, lavage, debridement produces a very significant improvement of function and reduction of pain, even thoug the disc remains displaced.

Correction of cervical posture and instruction in correct amount of rotation / protraction of chin. Distraction of mandible in order to relocate disc.

Treatment is often multi-disciplinary. Can require dental treatment as well as psychological counselling.

Psychological factors

Psychological factors can be an important part of the causing factors. Anxiety and psychological stress can cause bruxism (grinding teeth). "One of the most common findings is an element of psychological stress and the patiens can therefore be susceptible to a placebo effect of any treatment carried out. As the placebo effect for a variety of treatments has been shown to be effective in 40% to 60% of cases, the problem of assessing the actual effect of treatment becomes apparent. Many of the techniques used in the practice are based on principles first described by the Brazilian physiotherapist Rocabado