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51

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For personal use only. No other uses without permission.

The Temporomandibular Joint:
https://t.me/med1917
Evidence-Informed Physical
Therapy Patient Management
Independent Study
Course 31.2.3
Sally Ho, PT, DPT, MS, OCS
University of Southern California
Los Angeles, California
Ho Physical Therapy
Beverly Hills, California
Kai-Yu Ho, PT, MSPT, PhD
University of Nevada, Las Vegas
Las Vegas, Nevada

The Temporomandibular Joint:
https://t.me/med1917
Evidence-Informed Physical Therapy
Patient Management
Guy G. Simoneau, PT, PhD, FAPTA—Editor
Gordon Riddle, PT, DPT, ATC, OCS, SCS, CSCS—Associate Editor
Cover Illustration by Joseph Kinstler
Dear Colleagues,
I am pleased to welcome you to e Temporomandibular Joint: Evidence-Informed Physical erapy Patient Management monograph written by Sally
Ho, PT, DPT, MS, OCS and Kai-Yu Ho, PT, MSPT, PhD. is work is part of the Academy of Orthopaedic Physical erapy Independent Study
Course series 31.2, Current Concepts of Orthopaedic Physical erapy, 5th Edition.
Dr. Sally Ho received her B.S. degree in Physical erapy from the National Taiwan University, Taiwan; her M.S. degree in Physical erapy from the
Medical College of Virginia, Virginia; and her advanced doctorate degree in Physical erapy from the University of Southern California, California.
Dr. Ho is an adjunct associate professor in the Department of Biokinesiology and Physical erapy at the University of Southern California. She also
holds an associate professorship position at the National Taiwan University, Taiwan. Dr. Ho has written textbook chapters, published research articles in
peer reviewed journals, and lectured nationally/internationally on topics related to the temporomandibular joint, chronic pain, and general orthopedic
disorders. Dr. Ho is an American Physical erapy Association board certied Orthopedic Clinical Specialist (OCS). In addition, Dr. Ho is director
and owner of her own private practice, Ho Physical erapy, in Beverly Hills, California, which she established in 1981 with the goal of providing the
best quality care to patients. Under her leadership, Ho Physical erapy has been a reputable practice in the Beverly Hills area for nearly 40 years. Her
specialty is in the areas of head, neck, and temporomandibular joint disorders and chronic pain management. But her expertise extends beyond these
areas to include general orthopedic and neurologically challenging conditions.
Dr. Kai-Yu Ho received her bachelors and masters’ degrees in Physical erapy from the National Cheng Kung University, Taiwan in 2002 and 2004.
After practicing for approximately 3 years in sports physical therapy, she came to the United States to pursue her PhD, which she completed in Biokinesiology at the University of Southern California in December 2012. She joined the Department of Physical erapy at the University of Nevada,
Las Vegas, where she is currently an Associate Professor, in August 2013. She is an author of more than 20 scientic publications. Dr. Ho’s research is
primarily focused on understanding the potential biomechanical factors and imaging markers associated with degenerative joint diseases. One area of
Dr. Ho’s current research is to examine temporomandibular joint dysfunction with the use of diagnostic imaging. Using ultrasound imaging, Dr. Ho has
documented the improvement in joint space in a case with temporomandibular joint ankylosis after physical therapy intervention. Her recent work also
establishes the association between arthrokinematics and osteokinematics of the temporomandibular joint, which provides the foundation for physical
therapy practice.
In this monograph, the authors rst introduce the reader to the functional anatomy and kinesiology of the temporomandibular joint complex. Normal
kinematics and pathokinematics are then reviewed prior to providing an extensive section on evaluation of the temporomandibular joint, which include
considerations for dental conditions. e authors then discuss common pathological conditions classied as articular disorders, masticatory muscle
disorders, and arthritides. Associated conditions such as headaches, ear symptoms, and vertigo are also presented. Subsequently, general and specic
intervention techniques for the temporomandibular joint region are discussed within the context of a comprehensive evidence-based approach to the
multifaceted factors involved in the management of this patient population. e monograph concludes with clinical scenarios to provide additional
clinical context to the information provided.
My sincere thanks to the authors for their contribution to the Current Concepts series.
Sincerely,
Sincerely,
Guy Simoneau, PT, PhD, FAPTA
Editor
2920 East Avenue South, Suite 200 | La Crosse, WI 54601 | Oce 608-788-3982 | Toll Free 800-444-3982 | Fax 608-788-3965

TABLE OF CONTENTS
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ACRONYM LIST ................................................................................................................................................................................................................8
ABSTRACT
LEARNING OBJECTIVES
INTRODUCTION
FUNCTIONAL ANATOMY
..........................................................................................................................................................................................................................9
..............................................................................................................................................................................................9
.............................................................................................................................................................................................................9
........................................................................................................................................................................................10
Osseous Structures ...................................................................................................................................................................... 10
e Temporomandibular Joint .................................................................................................................................................... 10
e Disk and the Retrodiskal Pad ............................................................................................................................................... 10
Capsular and Ligamentous Structures ......................................................................................................................................... 11
Capsule ................................................................................................................................................................................ 11
Ligaments ............................................................................................................................................................................ 11
Muscles of Mastication ................................................................................................................................................................ 12
Masseter muscle ................................................................................................................................................................... 12
Temporalis muscle ...............................................................................................................................................................12
Medial pterygoid muscle ...................................................................................................................................................... 12
Lateral pterygoid muscle ...................................................................................................................................................... 12
Suprahyoid muscles.............................................................................................................................................................. 12
Infrahyoid muscles ............................................................................................................................................................... 12
Neurovascular Structures ............................................................................................................................................................. 13
NORMAL KINEMATICS
............................................................................................................................................................................................. 13
Osteokinematics .......................................................................................................................................................................... 13
Arthrokinematics ........................................................................................................................................................................ 13
Depression ........................................................................................................................................................................... 13
Elevation .............................................................................................................................................................................. 13
Protrusion ............................................................................................................................................................................ 14
Retrusion ............................................................................................................................................................................. 14
Lateral excursion .................................................................................................................................................................. 14
PATHOKINEMATICS ................................................................................................................................................................................................... 14
Anterior Disk Displacement with Reduction ............................................................................................................................... 14
Anterior Disk Displacement without Reduction ......................................................................................................................... 14
Posterior Disk Displacement ....................................................................................................................................................... 15
DENTAL CONSIDERATIONS AND EXAMINATION ...................................................................................................................................... 15
Orthognathia .............................................................................................................................................................................. 15
Stomatognathic System ............................................................................................................................................................... 15
Overbite ...................................................................................................................................................................................... 15
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Overjet ........................................................................................................................................................................................ 15
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Lateral Excursion ........................................................................................................................................................................ 15
Deviation .................................................................................................................................................................................... 16
Deection ................................................................................................................................................................................... 16
Occlusion .................................................................................................................................................................................... 16
Open Bite ................................................................................................................................................................................... 16
Crossbite ..................................................................................................................................................................................... 16
Centric Relation .......................................................................................................................................................................... 17
Vertical Dimension .....................................................................................................................................................................17
Freeway Space ............................................................................................................................................................................. 17
Clenching ................................................................................................................................................................................... 17
Bruxism ...................................................................................................................................................................................... 17
PATHOLOGIC CONDITIONS
PHYSICAL THERAPY EVALUATION
..................................................................................................................................................................................17
....................................................................................................................................................................17
Interview/History ........................................................................................................................................................................ 17
Examination ............................................................................................................................................................................... 18
Functional activity ............................................................................................................................................................... 18
Range of motion .................................................................................................................................................................. 18
Opening and closing patterns .............................................................................................................................................. 18
Occlusal measurements ........................................................................................................................................................ 19
Intraoral examination ........................................................................................................................................................... 20
Palpation of masticatory muscles .......................................................................................................................................... 20
Palpation of joint capsule, ligaments, and retrodiskal pad .....................................................................................................20
Capsular mobility ................................................................................................................................................................ 21
Joint sounds ......................................................................................................................................................................... 21
Joint play and mobility ........................................................................................................................................................ 21
Cotton roll test .................................................................................................................................................................... 21
Upper quadrant ................................................................................................................................................................... 21
Reex ................................................................................................................................................................................... 22
Ultrasound imaging (ultrasonography) ................................................................................................................................ 22
DIFFERENTIAL DIAGNOSIS ....................................................................................................................................................................................22
Articular Disorders ...................................................................................................................................................................... 22
Disk-condyle incoordination-internal derangement ............................................................................................................. 22
Fracture ...............................................................................................................................................................................24
Capsular involvement .......................................................................................................................................................... 24
Ankylosis ............................................................................................................................................................................. 24
Hypomobility ...................................................................................................................................................................... 24
Hypermobility ..................................................................................................................................................................... 24
Dislocation of condyle ......................................................................................................................................................... 24
Subluxation of condyle ........................................................................................................................................................ 24
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Masticatory Muscle Disorders ..................................................................................................................................................... 24
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Myofascial pain disorder syndrome ...................................................................................................................................... 25
Trismus ................................................................................................................................................................................ 25
Myositis ............................................................................................................................................................................... 25
Myospasm ............................................................................................................................................................................25
Dystonia .............................................................................................................................................................................. 25
Myobrotic contracture ....................................................................................................................................................... 25
Neoplasia ............................................................................................................................................................................. 25
Arthritides ................................................................................................................................................................................... 25
Osteoarthritis ....................................................................................................................................................................... 25
Rheumatoid arthritis ............................................................................................................................................................ 25
Psoriatic arthritis .................................................................................................................................................................. 25
Capsulitis ............................................................................................................................................................................. 25
Synovitis .............................................................................................................................................................................. 25
Associated Conditions ................................................................................................................................................................. 25
Headaches ............................................................................................................................................................................ 26
Ear symptoms ...................................................................................................................................................................... 26
Vertigo/dizziness .................................................................................................................................................................. 26
Swallowing and speech diculty .......................................................................................................................................... 27
Psychological aect .............................................................................................................................................................. 27
Trigeminal neuralgia (tic douloureux) .................................................................................................................................. 27
Temporal arteritis ................................................................................................................................................................. 27
Atypical odontalgia (phantom tooth pain) ........................................................................................................................... 27
Post-herpetic neuralgia (herpes zoster) ..................................................................................................................................27
Ménière disease .................................................................................................................................................................... 27
Cervical or postural cause..................................................................................................................................................... 27
Chronic pain, psychosocial factors, stress factors .................................................................................................................. 28
PHYSICAL THERAPY MANAGEMENT FOR TEMPOROMANDIBULAR JOINT DISORDERS
.................................................... 28
Patient Education ........................................................................................................................................................................ 28
Relaxation, Postural Correction, and Body Mechanics Instruction .............................................................................................. 28
Oral Habits Modication ............................................................................................................................................................ 28
Soft Diet ..................................................................................................................................................................................... 29
Electrophysical Agents ................................................................................................................................................................. 29
Soft Tissue Mobilization .............................................................................................................................................................. 29
Manual Lymphatic Drainage ....................................................................................................................................................... 29
Joint Mobilization ....................................................................................................................................................................... 29
Joint Manipulation ..................................................................................................................................................................... 30
erapeutic Exercises .................................................................................................................................................................. 30
Spray and Stretch ........................................................................................................................................................................ 31
Dry Needling .............................................................................................................................................................................. 31
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Kinesio Taping ............................................................................................................................................................................ 31
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Home Programs .......................................................................................................................................................................... 31
SPECIAL PHYSICAL THERAPY TECHNIQUES
................................................................................................................................................ 31
Soft Tissue Mobilization and Myofascial Release ......................................................................................................................... 31
Joint Mobilization ....................................................................................................................................................................... 32
Longitudinal distraction ....................................................................................................................................................... 32
Anteromedial translation ...................................................................................................................................................... 32
Lateral glide ......................................................................................................................................................................... 32
Medial glide ......................................................................................................................................................................... 33
Tongue-Controlled Mouth Opening Exercise .............................................................................................................................. 33
Isometric Temporomandibular Joint Exercise .............................................................................................................................. 34
Horizontal Tongue Depressor Exercise ........................................................................................................................................34
Spray and Stretch ........................................................................................................................................................................ 34
SPECIFIC PHYSICAL THERAPY INTERVENTIONS FOR SELECTED DISORDERS .......................................................................... 35
Anterior Disk Displacement ........................................................................................................................................................ 35
Condylar remodeling exercise program ................................................................................................................................ 36
erapeutic exercise for clicking due to anterior disk displacement with reduction .............................................................. 36
Posterior Disk Displacement ....................................................................................................................................................... 36
Myofascial Pain Disorder Syndrome ............................................................................................................................................ 36
Trismus ....................................................................................................................................................................................... 37
Postoperative ............................................................................................................................................................................... 37
Ear Symptoms ............................................................................................................................................................................. 37
Headaches ................................................................................................................................................................................... 37
Vertigo/Dizziness ........................................................................................................................................................................ 38
Chronic Pain ............................................................................................................................................................................... 38
Arthritides ................................................................................................................................................................................... 38
MEDICAL MANAGEMENT .......................................................................................................................................................................................38
Pharmacology ............................................................................................................................................................................. 38
Trigger Point Injection ................................................................................................................................................................ 39
Corticosteroid Injection .............................................................................................................................................................. 39
Hyaluronic Acid Injection ........................................................................................................................................................... 39
Platelet-Rich Plasma .................................................................................................................................................................... 39
Botulinum Toxin A Injection ...................................................................................................................................................... 39
Acupuncture ............................................................................................................................................................................... 39
Obstructive Sleep Apnea and Airway Screenings ......................................................................................................................... 39
DENTAL MANAGEMENT .......................................................................................................................................................................................... 40
Occlusal Adjustment ................................................................................................................................................................... 40
Splint erapy ............................................................................................................................................................................. 40
Orthodontic Treatment ............................................................................................................................................................... 41
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