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SURGICAL MANAGEMENT .....................................................................................................................................................................................41
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Arthroscopic Surgery and Arthrocentesis ..................................................................................................................................... 41
Orthognathic Surgery .................................................................................................................................................................42
Open Joint Surgery ..................................................................................................................................................................... 42
PSYCHOSOCIAL MANAGEMENT
RELEVANT RESEARCH
..............................................................................................................................................................................................42
........................................................................................................................................................................42
Summary of Relevant Research ................................................................................................................................................... 45
CONCLUSIONS
CASE SCENARIOS
............................................................................................................................................................................................................. 45
........................................................................................................................................................................................................ 46
Case Scenario 1 ........................................................................................................................................................................... 46
Case Scenario 2 ........................................................................................................................................................................... 47
Case Scenario 3 ........................................................................................................................................................................... 47
Case Scenario 4 ........................................................................................................................................................................... 48
APPENDIX
.......................................................................................................................................................................................................................50
REFERENCES..................................................................................................................................................................................................................51
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Opinions expressed by the authors are their own and do not necessarily reect the view of the
Academy of Orthopaedic Physical erapy. e authors declare no conict of interest.
e publishers have made every eort to trace the copyright holders for borrowed material.
If we have inadvertently overlooked any, we would be willing to correct the situation at the rst opportunity.
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Course content is not intended for use by participants outside the scope of their license or regulations.
7
ACRONYM LIST
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AACD: American Academy of Craniomandibular Disorders
AAOP: American Academy of Orofacial Pain
ADDwoR: anterior disk displacement without reduction
ADDwR: anterior disk displacement with reduction
ADLs: activities of daily living
ARA: anterior repositioning appliance
ATP: adenosine triphosphate
BIGAT: bilateral inferior glide with anterior translation
BiPAP: bilevel positive airway pressure
CBD: cannabidiol
CNS: central nervous system
CPAP: continuous positive airway pressure
CT: computed tomography
DC/TMD: Diagnostic Criteria for Temporomandibular Disorder
DDS: Doctor of Dental Surgery
EMG: electromyography
ENT: ear, nose, & throat
FWS: freeway space
HA: hyaluronic acid
HRQOL: health related quality of life
IASP: International Association for the Study of Pain
LLL: low-level laser
MCP: metacarpophalangeal
MENS: microcurrent electrical nerve stimulation
MET: muscle energy technique
MPDS: myofascial pain disorder syndrome
MRI: magnetic resonance imaging
NSAIDs: nonsteroidal anti-inammatory drugs
NTI-tss: nociceptive trigeminal inhibition-tension suppression system
OA: osteoarthritis
OSA: obstructive sleep apnea
PNE: pain neuroscience education
PPT: pressure pain threshold
PRP: platelet-rich plasma
RCT: randomized control trial
RDC/TMD: Research Diagnostic Criteria for Temporomandibular Disorder
ROM: range of motion
SCM: sternocleidomastoid
SINS: severity, irritability, nature, and stage
SNAG: sustained natural apophyseal glide
TENS: transcutaneous electrical nerve stimulation
TMD: temporomandibular disorder
TMJ: temporomandibular joint
UIGAT: unilateral inferior glide with anteromedial translation
8
The Temporomandibular Joint:
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Evidence-Informed Physical
Therapy Patient Management
Sally Ho, PT, DPT, MS, OCS
University of Southern California
Los Angeles, California
Ho Physical erapy
Beverly Hills, California
Kai-Yu Ho, PT, MSPT, PhD
University of Nevada, Las Vegas
Las Vegas, Nevada
ABSTRACT
In this temporomandibular joint monograph, we summarize the functional anatomy, review the normal and pathological kinematics of the joint, expand the dierential diagnoses
(including diagnostic imaging), introduce new approaches of
management (such as a biopsychosocial model), report new evidence-based research published in the recent 5 years, and share
our clinical pearls. Four clinical scenarios are also presented.
e reader will have the opportunity to dierentiate between
myofascial pain disorder syndrome, internal joint derangement,
temporomandibular joint associated conditions, and chronic
pain. Optimal management for each case will also be discussed.
Key Words: dierential diagnoses, imaging, manual therapy,
pathokinematics
LEARNING OBJECTIVES
Upon completion of this monograph, the course participant will be able to:
1. Describe the functional anatomy of the temporomandibu-
lar joint (TMJ).
2.
Understand normal TMJ kinematics.
3. Gain knowledge of pathological conditions involving the
TMJ.
4. Interpret dental factors relevant to various TMJ disorders
(TMDs).
5.
Identify surgical indications for TMDs.
Recognize dierential diagnoses of TMDs.
6.
7. Perform the evaluation of patients with TMDs and associ-
ated conditions.
8. Provide appropriate physical therapy interventions for pa-
tients with TMDs and associated conditions.
9. Understand the treatment rationale for chronic TMDs.
10. Gain an understanding of research relevant to evi-
dence-based practice.
INTRODUCTION
e temporomandibular joint (TMJ) is the most used
joint in the body during daily activity. Every time one swallows,
chews, or speaks, the TMJ is in action. e TMJ is used approximately 1500 to 2000 times daily, excluding the parafunctions
of clenching or bruxing.
Temporomandibular disorder (TMD) is a collective term
for multiple symptoms that aect the cranio-facial-mandibular complex. e TMJ itself, the muscles of mastication, and
other structures in the vicinity may all be involved. e cause
of TMD is multifactorial, including (1) macrotrauma such as
a whiplash injury, a direct blow to the jaw, or iatrogenic dental procedures; (2) microtrauma from parafunctional clenching
and bruxing; (3) degenerative osteoarthritis (OA); (4) systemic
conditions; or (5) mental health disorders. e clinical manifestations of TMDs include, but are not limited to, pain, limited
mouth opening, joint noises, headaches, dizziness, neck symptoms, earache, tinnitus, and swallowing diculty.
Epidemiological studies have shown that 50% to 75% of
the population suer from one symptom of TMD at some time
1-4
in their lives.
Temporomandibular joint disorder aects people of all ages and sexes, from children to older adults (60 years
and older), with a large preponderance (3 to 5 times more prev-
3,5-7
alent) of women around reproductive age.
Anastassaki et al1
conducted a retrospective survey of 3194 patients and reported
that non-surgical treatments that included interocclusal appliances, jaw exercises, and selective occlusal adjustment were effective in managing the vast majority of individuals with TMD.
Some researchers have reported that symptoms of TMD may
uctuate over time, may be remitting, are self-limiting, and the
7-9
progression to severe pain and dysfunction is rare,
suggesting that treatment for TMD is not necessary. However, many
others have suggested that patients with TMD do not improve
spontaneously, and that skilled treatment leads to signicant
10-12
improvement.
In recent years, research in this area has pro-
vided evidence that treatment for TMD is eective to reduce
13-15
symptoms and improve function.
We will discuss this evi-
dence throughout this monograph.
Historically (before 1980), TMD was managed by dentists
using medication, occlusal adjustment, splinting, or bracing.
Oral surgeons would perform surgery when indicated. Physical
therapists were not part of the management team in the United
States until the late 1970s, when Dr. Mariano Rocabado (Santiago, Chile) introduced his method of physical therapy evaluation and treatment. However, due to the continued lack of
curriculum emphasis in this area, most physical therapists still
are not entirely comfortable with managing TMD. But after
almost 40 years of eort, the signicant clinical contribution
of physical therapy in this niche patient population has been
demonstrated, is supported through increased yet still limited
research, and is recognized by the medical and dental professions. rough this monograph, we hope to guide therapists
unfamiliar with this topic toward contemporary competency
in the management of TMD, and provide seasoned therapists
with a more comprehensive, evidence-based approach to management. It is the intent of the authors to present the TMJ as
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9
a “physical therapist-friendly” joint and to empower all readers
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with condence in providing care to this special patient population.
FUNCTIONAL ANATOMY
e TMJ is a bilateral diarthrodial joint that connects the
temporal bone to the mandibular bone through a brocartilaginous disk, ligaments, and enclosed joint capsule. e TMJ is
a synovial joint, and therefore, possesses all the characteristics
of any other synovial joint. It often is considered an extension
of the spinal column due to its connection with the cervical
spine via the skull. e TMJ is located in front of the external
auditory meatus. It can be palpated by placing the index nger
anterior to the tragus of the ear or using the tip of the small nger in the external auditory canal, while having the patient open
and close the mouth. Palpation usually is performed bilaterally
at the same time so the examiner can detect any dierences between sides.
e TMJ has some special features, including (1) both the
articular surfaces and the disk are covered with brocartilage
that has superior reparative potential and resistance to wear and
tear; (2) the disk divides the joint into superior and inferior cavities (or compartments); (3) during mouth opening, rotation of
the condyle occurs in the inferior cavity and translation occurs
in the superior cavity; (4) each TMJ has to function synchronously with the contralateral joint for daily oral function; and
(5) dental occlusion can aect the kinematics of the TMJ.
Osseous Structures
e osseous structures of the TMJ (Figure 1) are part of
two major bones: the temporal and the mandibular bones. e
temporal component forms the roof of the TMJ. It is composed
of the styloid process, the mandibular fossa, the articular eminence, and the articular tubercle. e temporal, frontal, parietal, zygomatic, and sphenoid bones all connect to the mandibular fossa. e mandibular condyle is the oor of the TMJ.
e condylar neck is the insertion site of the inferior bers of
the lateral pterygoid muscle. e coronoid process, part of the
mandibular ramus, is the attachment site of the temporalis muscle. e body of the mandible houses the mandibular teeth. e
maxilla houses the maxillary teeth. In addition to the maxilla,
mandible, and temporal bones, the zygomatic, sphenoid, and
hyoid bones are all part of the TMJ complex.
The Temporomandibular Joint
e mandibular condyle lies within the mandibular fossa
(of the temporal bone) to form the TMJ (Figure 2). A dense
brocartilaginous disk separates the joint into superior and
inferior cavities. e superior cavity is between the temporal
fossa and the superior aspect of the disk. e inferior cavity
is between the inferior aspect of the disk and the mandibular
condyle. ese cavities are lled with synovial uid that main-
Figure 1.
Osseous Structures of the Temporoman-
dibular Joint
tain the lubrication of the joint. e action of mouth opening
and closing is the result of combined rotation of the mandibular condyle (under the disk) in the inferior cavity and anterior
translation of the disk and condyle (along the articular eminence) in the superior cavity.
The Disk and the Retrodiskal Pad
In the sagittal plane, the articular disk is bow-tie shaped to
conform to the shape of the mandibular fossa and the mandibular condyle (Figure 2). e biconcave shape of the disk allows
congruency of the TMJ when moving the jaw. e disk also
provides lubrication to the articulating surfaces, transmits contact forces, stabilizes the joint, and endures long-term stresses.
e high-density collagen bers that compose the disk tissue
have the ability to withstand wear and tear and possess greater
reparative potential than the hyaline cartilage found in other
joints.
e disk can be subdivided in 3 portions: anterior, intermediate, and posterior. e anterior and posterior portions have
neural innervation and vascular supply, in contrast to the intermediate portion, which is avascular and aneural and receives its
16
nutrition from the synovial uid.
e densest brous tissue of
the intermediate portion serves as a pressure-bearing interface
between the condylar head and articular eminence during TMJ
movements. e anterior portion of the disk is attached to the
superior condylar neck, the anterior capsule of the TMJ, the
superior head of the lateral pterygoid muscle, and the temporal
bone just anterior to the articular eminence. e medial and
lateral portions of the disk attach to the medial and lateral poles
10
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Figure 2.
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Articular Disk Regions of the Temporomandibular Joint
Reprinted with permission from Neumann D.17 Kinesiology of the Musculoskeletal System. Elsevier; 2010.
of the condylar head through the medial and lateral collateral ligaments. e posterior portion of the disk attaches to the
bilaminar connective tissue with the superior lamina attaching
to the tympanic plate of the temporal bone and the inferior
lamina attaching to the posterior margin of the articular surface
of the condyle. e retrodiskal pad between the superior and
inferior laminae contains nerve bers, blood vessels, and fat.
Inammation in this area usually results in pain with palpation
over the posterior aspect of the joint.
Capsular and Ligamentous Structures
Capsule
e entire TMJ is covered by capsular tissue. Superiorly,
the capsule is attached to the border of the mandibular fossa
and the articular eminence. Inferiorly, the capsule thickens into
the medial and lateral collateral ligaments, which connect to
the periphery of the disk before attaching to the medial and
lateral poles of the condyle, respectively. Posteriorly, the capsule attaches to the bilaminar structure. Anteriorly, the capsule,
along with part of the disk, attaches to the superior head of the
lateral pterygoid muscle. e capsule provides stability to the
TMJ. It is rm medially and laterally, yet loose anteriorly and
posteriorly. Because of this arrangement, the joint is more mobile in the anterior-posterior direction, allowing the disk-condyle complex to translate during opening and closing of the
mouth. Medial-lateral movement is more stabilized and limited
during the chewing function. e capsule is lined with a synovial membrane and receives its nutrition from the synovial uid.
e capsule is also highly vascularized and innervated.
16,17
Ligaments
e temporomandibular ligament (also known as the
lateral ligament) supports the lateral wall of the capsule. e
supercial oblique bers of the ligament arise from the lateral surface of the articular tubercle and the zygomatic process
and insert on the posterolateral surface of the condylar neck.
e ligament’s function is to limit rotation of the condylar head
during jaw opening. e deeper horizontal bers arise from the
same area and insert on the lateral pole of the condyle (and the
posterior disk). is structure limits posterior displacement of
the condyle; therefore, it protects the retrodiskal pad.
e collateral ligaments attach to the medial and lateral borders of the disk and insert on the medial and the lateral
poles of the condyle, respectively. eir function is to restrict
excessive medial and lateral movements of the disk, so the disk
is centered on top of the condyle and moves as a unit with the
condyle in the anterior-posterior direction.
e accessory ligaments include the stylomandibular and
sphenomandibular ligaments. e stylomandibular ligament
goes from the styloid process to the mandibular angle. e
sphenomandibular ligament goes from the spine of the sphenoid bone to the middle surface of the inferior ramus. Both lig-
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11
aments lie medial to the joint capsule. ey have limited func-
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tion other than assisting in suspending the mandible from the
cranium and preventing excessive protrusion of the mandible.
Muscles of Mastication
One of the major functions of the TMJ is chewing food.
is action requires a combination of tearing, chopping, and
grinding motions. Without coordination among all muscles of
mastication and neural input, this function cannot be accomplished.
Masseter muscle
e masseter is a strong muscle that functions as one of
the major contributors to mastication. e supercial portion
originates (proximally) from the anterior two-thirds of the
zygomatic arch and inserts (distally) onto the lateral border
of the mandibular angle. e smaller deep portion originates
(proximally) from the posterior third of the zygomatic arch and
inserts (distally) on the superior border of the mandibular ramus. Unilateral contraction of the masseter muscle causes slight
lateral excursion to the same side, while bilateral contraction
initiates elevation of the mandible with the potential to produce sucient force to chew and grind harder food. Bilateral
contraction of the supercial bers produces protrusion of the
mandible, while bilateral contraction of the deep bers contributes to retraction. e multiple functions of the masseter muscles provide eective mastication from the tearing of food by
the central incisors of the maxillary and mandibular teeth and
grinding with the back molars.
Temporalis muscle
e temporalis muscle is a large fan-shaped muscle that
originates (proximally) from the entire temporal fossa and inserts (distally) onto the coronoid process and the medial border
of the mandibular ramus. Bilateral contraction of the temporalis muscle elevates and retracts the mandible, while unilateral
contraction produces lateral excursion to the same side.
Medial pterygoid muscle
e medial pterygoid muscle has two heads. e deeper
larger head originates (proximally) from the medial surface of
the lateral pterygoid plate of the sphenoid bone. e supercial smaller head originates (proximally) from a region of the
tuberosity of the maxilla just superior-posterior to the third
molar. Both heads of the medial pterygoid muscle insert (distally) on the medial surface of the mandibular angle. Bilateral
contraction of the medial pterygoid muscle produces elevation
and protrusion of the mandible, while unilateral contraction
produces contralateral excursion.
Lateral pterygoid muscle
e superior head of the lateral pterygoid muscle originates
(proximally) from the greater wing of the sphenoid bone and
inserts (distally) on the anterior aspect of the disk, although
there is disagreement as to the percentage of bers inserting on
17,18
the disk.
e inferior head of the lateral pterygoid muscle
originates (proximally) from the lateral border of the lateral
pterygoid plate of the sphenoid bone and inserts (distally) on
the condylar neck. Unilateral contraction of the lateral pterygoid muscle produces contralateral excursion. Bilateral contraction of both superior and inferior heads of the lateral pterygoid
muscles produces protrusion. e individual function of the
inferior head of the lateral pterygoid muscle is depression of
the mandible during mouth opening. However, the true function of the superior head is still debated, with most researchers
believing that due to its connection to the disk, it contracts eccentrically during mouth closing to monitor disk position and
avoid excessive anterior displacement.
16,17
Suprahyoid muscles
e suprahyoid muscles include the anterior and posterior
belly of the digastric, mylohyoid, geniohyoid, and stylohyoid
muscles. e anterior digastric muscle goes from the midline
of the inferior mandible to the hyoid bone, while the posterior
digastric muscle goes from the hyoid bone to the mastoid notch
of the temporal bone. e mylohyoid muscle attaches from the
mylohyoid line along the entire length of the inner mandible
border to the hyoid bone. e geniohyoid muscle lies superior
to the mylohyoid muscle and goes from the mandible to the hyoid bone. e stylohyoid muscle goes from the styloid process
to the hyoid bone. All suprahyoid muscles are responsible for
depression and retrusion of the mandible during mouth opening, when the hyoid bone is xed.
Infrahyoid muscles
e infrahyoid muscles include the sternohyoid, sternothyroid, thyrohyoid, and omohyoid muscles. All these muscles
originate at the inferior aspect of the hyoid bone and insert on
the sternum, the thyroid cartilage, or the scapula. e infrahyoid muscles work together to stabilize the hyoid bone to form
a rm base for the action of the suprahyoid muscles. Together
with the suprahyoid muscles, they are involved in the functions
of speech, swallowing, and tongue movements.
In summary, muscles of mastication can produce mandibular elevation, depression, protrusion, retrusion, and lateral
excursion. Muscles contributing to elevation are the masseter,
temporalis, medial pterygoid muscles, and the superior bers
of the lateral pterygoid muscles (eccentric contraction during
elevation to stabilize the disk). Muscles contributing to depression are the inferior bers of the lateral pterygoid muscles, the
suprahyoid muscles, and indirectly, the infrahyoid muscles.
ose contributing to protrusion are the medial pterygoid, lateral pterygoid, and supercial bers of the masseter muscles.
Retrusion is performed by the deep bers of the masseter, the
12
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temporalis, and the suprahyoid muscles. Lateral excursion is
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performed by the contralateral medial pterygoid, the contralateral lateral pterygoid, and the ipsilateral temporalis and masseter muscles (Table).
Neurovascular Structures
e TMJ is innervated by branches of the mandibular division of the trigeminal nerve (cranial nerve V3). e anterior and
medial regions of the TMJ are innervated by the deep temporal
nerve and the masseteric nerve. e posterior and lateral regions of the TMJ are innervated by the auriculotemporal nerve.
Blood supply to the TMJ is through the supercial temporal
and maxillary arteries.
For the purpose of this monograph, only a summary of
functional anatomy is presented. For more detailed anatomy,
please refer to the textbook by Dr. Neumann.
17
NORMAL KINEMATICS
Osteokinematics
e major function of the TMJ is mouth opening and closing as well as tearing and grinding of food. e osteokinematics
of the TMJ include depression (opening), elevation (closing),
protrusion, retrusion, and lateral excursion. e normal amount
of depression is between 40 to 45 mm for males, and 45 to 50
mm for females, which is approximately 4 ngers’ width of the
nondominant hand. e functional amount of opening is 35
mm, or 3 ngers’ width of the nondominant hand, for both
males and females. Lateral excursion should be one-fourth of
the opening amount (ie, 10 mm of lateral excursion in each direction for a 40 mm opening). Protrusion is usually 6 to 9 mm,
whereas retrusion is approximately 3 mm.
Arthrokinematics
Depression
In a relaxed resting position, the condylar head sits in the
glenoid fossa with the disk resting slightly anterior to the con-
dyle. In the early phase of depression, the rst 25% to 50%
of the opening range, the primary arthrokinematics movement
consists of an anterior rotation of the condylar head (condylar
head moves anteriorly, and the ramus moves posteriorly) taking
place in the inferior joint cavity between the inferior aspect of
the disk and the condylar head. In the late phase of jaw opening
(last 50%), the primary arthrokinematics motion occurs in the
superior cavity in the form of anterior translation of the disk
and the condylar head along the articular eminence. During
this late phase, the disk and the condylar head translate anteriorly together as a unit. Because jaw opening is the result of
a combination of rotation and translation, the instantaneous
axis of rotation is believed to be located in the anterior-inferior region of the condylar neck.
16,17
In the early phase of opening, the rolling of the condyle stretches the oblique bers of
the temporomandibular ligament, which, in turn, initiates the
late phase of jaw opening through increased tension.
17
e disk
moves slightly posteriorly at the initiation of opening due to increased tension in the posterior stratum bers. is action keeps
the non-innervated intermediate portion of the disk on top of
the condylar head while they both translate anteriorly as a unit
through the rest of the opening phase.
Elevation
During closing of the jaw, the opposite movement sequence
takes place. e condylar head and disk initially translate posteriorly along the articular eminence in the superior cavity of the
joint, and in the later phase of closing, the condylar head rotates
posteriorly under the articular disk in the inferior joint cavity.
roughout this movement, tension of the superior retrodiskal
lamina assists with posterior retraction of the disk, which is controlled anteriorly by eccentric activation of the superior head
of the lateral pterygoid muscle. At the end of mouth closing,
the disk glides slightly anteriorly as a result of the action of the
superior head of the lateral pterygoid and progressive relaxation
of the posterior stratum. Again, the noninnervated intermediate
Table.
Muscles Involved in Temporomandibular Joint Function
Temporomandibular
joint function
Elevation (closing) Masseter, temporalis, medial pterygoid, superior bers of lateral pterygoid (stabilize the disk)
Depression (opening) Inferior bers of lateral pterygoid, suprahyoids, infrahyoids (indirectly)
Protrusion Supercial masseter, medial pterygoid, lateral pterygoid
Retrusion Deep bers of masseter, temporalis, suprahyoids (digastrics)
Lateral excursion Ipsilateral temporalis and masseter, contralateral medial and lateral pterygoids
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Muscles involved
13
portion of the disk is maintained between the articular surfaces
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(condylar head and articular eminence) throughout the closing
phase. Figure 3 shows ultrasound imaging and magnetic resonance imaging (MRI) of a normal TMJ in a closed and open
mouth position.
Lateral excursion
Lateral excursion involves spinning of the ipsilateral con-
dyle, and horizontal anterior translation of the contralateral
condyle. e muscles involved are the ipsilateral masseter, the
posterior bers of the ipsilateral temporalis, and the contralateral medial and lateral pterygoid muscles.
Protrusion
During protrusion, the mandibular condyle (head) and the
disk translate anteriorly and inferiorly along the articular eminence in the superior cavity. e muscles of elevation (masseters
and temporalis muscles) and depression-retrusion (suprahyoid
muscle and inferior head of the lateral pterygoid muscle) have
to work synchronously to prevent depression of the mandible
and maintain balance during protrusion.
Retrusion
During retrusion, the mandibular condyle and the disk
translate posteriorly along the articular eminence. e mandible is maintained in the horizontal position by the synergistic
action of the muscles of elevation and depression. All bers of
the temporalis muscles retract the mandible from a protruded position while only the posterior bers retract the mandible
from the resting position.
Figure 3.
Normal Kinematic
PATHOKINEMATICS
Trauma, disease, or chronic overuse of the TMJ can potentially alter the kinematics of the joint. is may be due to soft
tissue imbalance, posterior ligament insuciency, mechanical
derangement, or a combination of these factors.
balance will result in uncoordinated movement during mouth
opening and closing. Internal derangement of the disk-condyle
complex results in 2 major classications: anterior disk displacement with reduction (ADDwR) and anterior disk displacement
without reduction (ADDwoR). In most patients with internal
derangement, the disk is displaced anteriorly and medially to
the condylar head. In rare occasions, the disk can be displaced
posteriorly to the condylar head.
Anterior Disk Displacement
with Reduction
In the case of ADDwR, the disk rests in front of the condy-
lar head while the mouth is closed. During opening,
the disk “reduces” back on top of the condylar head,
which may create a clicking noise, and then it translates anteriorly as a unit with the condyle during
the rest of mouth opening. As the mouth starts to
close, the disk-condyle complex initially translates
together posteriorly. Near the end of mouth closing,
the disk displaces anteriorly, o the condylar head,
potentially due to a combination of excessive contraction of the superior head of the lateral pterygoid
muscle and a decrease in elasticity (tension) of the
posterior stratum bers. is anterior dislocation
of the disk may cause a second clicking noise. e
term “reciprocal clicks” refers to the combination
of an early “click” during mouth opening and late
“click” during mouth closing. Figure 4 shows ultrasound imaging and MRI of an ADDwR in both a
closed and open mouth position.
19
Soft tissue im-
High resolution ultrasonography of normal temporomandibular joint
in closed and open mouth positions, showing the condylar head (C),
with overlying hypoechoic disk as marked by arrows. In both open and
closed mouth positions the disk is seen above the condyle. Insets at the
bottom left of the image show patient’s MRI for comparison. Reprinted with permission from European Society of Radiology.
242
14
Anterior Disk Displacement
without Reduction
If ADDwR is not treated properly, over time,
the disk may stay displaced in front of the condyle
throughout the movement of mouth opening and
closing, due to a progressive decrease in elasticity of
the posterior stratum bers. is condition, called
ADDwoR, does not result in a clicking noise during
mouth opening or closing because the disk remains
located anterior to the condyle throughout the mo-
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© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
Figure 4.
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Anterior Disk Displacement with Reduction
High resolution ultrasonography image shows hypoechoic disk (ar-
row) lying anterior to the condylar head (C) in the closed mouth position. Reduction of the disk (arrows) to normal position over the head
of the condyle can be appreciated in the open mouth position. Note
the reduced joint space in closed mouth position as compared to open
mouth position. Insets at the bottom left of the image show patient’s
MRI for comparison. Reprinted with permission from European Society of Radiology.
242
the right, the last left lower molar is number 32.
Knowing the number sequence will help physical
therapists understand which tooth is involved when
the dentist refers to them by number.
Orthognathia
is is a branch of oral medicine dealing with
the cause and treatment of malposition of the bones
of the jaw, such as:
• Gross jaw discrepancies (anteroposterior, vertical,
or transverse)
• Skeletofacial discrepancies causing sleep apnea,
airway defects, and soft tissue discrepancies
• Skeletofacial discrepancies associated with docu-
mented TMJ pathology
It often involves open jaw surgery to realign
the maxilla-facial structure, or for correction of
malocclusion. An oral surgeon is the main specialist
responsible for the procedure. Other practitioners
such as reconstructive plastic surgeons and orthodontists are also potentially involved for optimal
outcome.
Stomatognathic System
is system includes the structure of the
mouth, teeth, jaw, and the associated soft tissues.
e functions of mastication, deglutition (swallowing), respiration, and speech are all under this collective term.
disk is blocking full anterior translation of the condylar head)
or no limitation in opening (if the disk is completely displaced
anteriorly). Figure 5 shows the ultrasound imaging and MRI of
ADDwoR in both a closed and open mouth position.
Posterior Disk Displacement
Posterior disk displacement is very rare, yet possible. is
condition usually occurs after wide opening of the mouth such
as when yawning or during a prolonged dental procedure. In
this situation, the lateral pterygoid muscle is overly stretched,
which results in posterior displacement of the disk. Patients
demonstrate an open-lock (inability to close the mouth) scenario, and may report closing clicks in the case of reduction.
20
DENTAL CONSIDERATIONS
AND EXAMINATION
ere are 32 teeth in the mouth, including 16 maxillary
(upper) and 16 mandibular (lower) teeth. Dentists number the
32 teeth; starting with the far right upper molar as number 1
and counting towards the left, the last upper molar is number
16. e far left lower molar is number 17 and counting towards
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
Overbite
An overbite is measured by the portion of the mandibular
central incisors that is covered by the maxillary central incisors
when the mandible is in its maximally occluded position (Fig-
ure 6). Normal overbite should be the maxillary central incisors
covering approximately one-third of the mandibular central incisors.
Overjet
An overjet is measured by the horizontal distance between
the maxillary arch and the mandibular arch when the mandible
is in its maximally occluded position (Figure 6). Normal value
is 3 to 6 mm.
Lateral Excursion
Lateral excursion is the horizontal distance between the
dividing lines of the mandibular central incisors and the maxillary central incisors measured by asking the patient to move
the mandible to one side, then to the other side for comparison. Normal lateral excursion is usually 25% of the amount of
mouth opening.
15
Figure 5.
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Anterior Disk Displacement without Reduction
Deviation
is term is used to indicate that the mandible
deviates from the central pathway during mouth
opening and returns to the center at the end of
opening. e mandible can show a “C” curve or
an “S” curve pattern. A “C” curve usually indicates
a capsular pattern, whereas an “S” curve indicates
poor motor control (muscular imbalance) or asymmetry of condylar head rotation or translation in an
individual with ADDwR.
Deection
is term is used to indicate that during opening of the mouth, the mandible deects to one side
without returning to the center position at the end
of mouth opening. is most often occurs in patients with an ADDwoR. is may also occur with
capsular restriction or unilateral hypomobility, in
which the deection is towards the ipsilateral side
(the involved side).
High resolution ultrasonography image shows hypoechoic disk (D)
lying anterior to the condyle (C) in both open and closed mouth positions. Note the reduced joint space in both cases. Insets at the bottom
left of the image show patient’s MRI for comparison. Reprinted with
permission from European Society of Radiology.
Figure 6.
Measurement of Overbite and Overjet Between Maxillary
242
Central Incisors and Mandibular Central Incisors
Occlusion
Occlusion is the functional relationship between the maxillary teeth and the mandibular teeth,
with malocclusion referring to a malalignment of
the teeth or lack of symmetry (such as in the case of
cross bite) between the maxillary and mandibular
arches.
ere are 3 classes of occlusion. Class I is normal, where the maxillary teeth (arch) sit slightly in
front of the mandibular teeth (arch) and there is an
overjet of 3 to 6 mm. Class II is dened by excessive
overjet of more than 6 mm. is is frequently called
an overbite, which is not to be confused with the
actual denition of overbite measurement. When
the mandibular arch protrudes in front of the maxillary arch, this is referred to as Class III, also called
an underbite. With either overbite or underbite, the
condyle-disk relationship is altered, often aecting
the normal kinematics of the TMJ.
Open Bite
Open bite is a rare oral condition that occurs
when the maxillary front teeth do not make contact
with the mandibular front teeth during any mandibular position. is abnormal occlusal condition
aects chewing and swallowing function.
16
Crossbite
Crossbite is an occlusal irregularity where the
central incisors of the mandibular and maxillary
teeth are not perfectly aligned when the mouth is
closed (ie, either arch may shift in a lateral direc-
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For personal use only. No other uses without permission.
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