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tion during occlusion). is type of occlusal disharmony may
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or may not aect TMJ function.
Centric Relation
is term, rst developed for fabrication of dentures, has
been used by dentists for decades, with approximately 26 de-
16
nitions.
Centric relation is a position where the condyle sits
most superiorly and posteriorly in the mandibular fossa with
the articular disk stabilized between the condyle and fossa. It
provides a harmonious environment for all the TMJ structures.
is denition is similar to the physical therapy denition of
“open packed” position where all joint connective soft tissues
have the least tension and the joint has the least compression.
Some dentists believe that maintaining occlusion in a centric
relationship during occlusal adjustment and reconstruction can
lead to an optimal outcome. However, not all dentists agree
with this philosophy.
Vertical Dimension
Also known as vertical dimension of occlusion, vertical dimension is a term used in dentistry to indicate the superior-inferior relationship of the maxilla and the mandible when the
teeth are situated in maximum intercuspation. Imagine a mandible without teeth compared to a mandible with all teeth with
perfect occlusion. e mandible without teeth (as in the case of
edentulous condition) would have to close further, resulting in
more TMJ compression and more contractile forces from the
muscles of mastication when compared to normal.
Freeway Space
Freeway space (FWS) is the space between the occluding
surfaces of the maxillary and mandibular teeth when the mandible is in its physiologic resting position. e normal range of
values for FWS is 2 to 4 mm, and it can only be determined
clinically or measured through imaging lm.
Clenching
“Clenching” is a parafunctional behavior that can occur
during the day or while sleeping at night. It is characterized
by excessive activation of the masseter and temporalis muscles
which result in excessive compressive force between the posterior maxillary and mandibular molars.
Bruxism
Bruxism is excessive teeth grinding, most frequently while
sleeping. is nocturnal parafunction typically is accompanied
by clenching of the jaw and is usually heightened when the individual is under stress. Bruxism may cause tooth wear and increased tone (or tension) of the masticatory musculature.
PATHOLOGIC CONDITIONS
According to the American Academy of Orofacial Pain
21
(AAOP),
TMD can be classied into 3 groups: articular dis-
orders, masticatory muscle disorders, and arthritides. Articular
disorders include disk-condyle incoordination, disk displacement, fracture, and ankylosis. Masticatory muscle disorders
include myofascial pain disorder syndrome (MPDS), myositis,
myospasm, dystonia, myobrotic contracture, and neoplasia.
Arthritides include capsulitis, synovitis, OA, rheumatoid arthritis, and psoriatic arthritis. is classication was published in
22,23
2008,
and still is widely accepted by most clinicians due to
its simple and clear denitions.
ere have been continuing developments in the area
of TMD classication by many organizations such as AAOP,
the International Association for the Study of Pain (IASP),
and the American Academy of Craniomandibular Disorders
24,25
(AACD).
e processes are arduous and complicated in this
complex body area. Currently, the most accepted system for researchers is the Research Diagnostic Criteria for TMD (RDC/
TMD or DC/TMD). is classication system, which includes
a second axis to address the psychosocial aspects of the patient
with TMD, was designed primarily for clinical research. Future
classications that include genetic, epigenetic, and neurobiolog-
26
ical variables have been recommended.
A clinician who is faced with the challenge of making a differential diagnosis must consider behavior-psychosocial factors
in addition to the underlying musculoskeletal condition. e
physical therapy diagnoses will be discussed in detail later in
this monograph.
PHYSICAL THERAPY EVALUATION
Interview/History
is done for any other condition. Information should be gathered
in the initial interview on the patient’s medical history; family
history; onset of symptoms; mechanism of injury; and severity,
irritability, nature, and stage (SINS) of the condition. It is also
important to determine any underlying cause of the current
symptoms, when possible. Examples might be the occurrence
of a sudden stressful event or a change in coping mechanisms,
a recent dental procedure, or a history of recurrent symptoms.
In addition to these, it is also important to obtain information
on the history of any dental interventions (eg, orthodontic procedure, night splint for nocturnal clenching or bruxing, splint
therapy). e Jaw Functional Limitation Scale
questionnaire developed for measuring the global functional
limitation of the jaw. It can serve as an outcome measurement
tool for both clinical and research purposes (Appendix).
Psychological assessment is also important for the management of patients with TMD, especially in the case of chronic myofascial pain. While it is beyond the scope of practice
of physical therapist to perform a psychological assessment, a
simple screening can be benecial in revealing patient’s psychosocial status, which can guide the physical therapist towards effective management or timely referral to a behavioral specialist,
28
if needed. Harrison et al
recommended 2 questionnaires: e
27
is a validated
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17
Patient Health Questionnaire for Depression and Anxiety and
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the Graded Chronic Pain Scale. Both questionnaires have been
validated and are readily accessed through an internet search.
Examination
A comprehensive physical therapy examination for patients
with TMD must include at least the upper quadrant, which
includes the head, TMJ, cervical spine, shoulder girdle, and
thoracic spine. Several studies have focused on the inuence of
29-31
posture on TMJ function and symptoms.
It is widely recognized that a forward head posture places a negative strain on
the TMJ, and proper posture during activities of daily living
(ADLs) reduces symptoms.
Potential contributory impairments in other regions such
as the spine, pelvis, and lower extremities should also be taken
32
into consideration during a comprehensive assessment.
33
tino et al
reported the existence of an association between the
occlusal plane and the plantar arches of the feet. Golden
Valen-
34
postulated that weak abdominal muscles, weak neck exor muscles,
and abnormal spinal curve all may contribute to TMD. Nico-
35
lakis et al
reported that postural and muscle function abnormalities appeared to be more common in patients with TMD
compared to sex and age-matched controls, leading the authors
to recommend postural training for patients with TMD. In a
36
later study, Nicolakis et al
also reported that a more comprehensive program that included local TMJ exercises, postural
training, and relaxation techniques was eective in treatment
of ADDwoR. To provide eective treatment for patients with
TMD, a physical therapist must consider a more comprehensive
approach than focusing solely on treatment to the TMJ area.
A patient’s general posture (forward head, slouching), facial
features (asymmetry of facial development), swallowing, and
speech patterns can indicate underlying causes of the patient’s
symptoms. A quick cranial nerve screening is important to rule
out any brain lesion. Measurement of the cervical spine range of
motion (ROM) and amount of TMJ opening, lateral excursion,
protrusion, retrusion, overbite, and overjet can provide a baseline for future comparison. Auscultation of joint sounds may
help support the hypothesis of a joint condition. Palpation of
masticatory muscles and joint capsules can help identify soft
tissue and connective tissue injury or dysfunction. Joint play
assessment of the TMJ and cervical mobility evaluation can
guide treatment. Kinematic MRI and ultrasound imaging can
provide information on disk stability. Despite the prevalence (as
37
high as 33%) of false-positive MRI ndings
kinematic MRI, if
available and indicated, can help conrm a clinical suspicion of
38
anterior disk displacement with or without reduction.
e following is a brief description of some examination
procedures focusing on the TMJ and surrounding structures.
Functional activity
e rst step in the examination process is the observation
of posture, speech pattern, parafunctional habits (eg, lip biting,
cheek sucking, nail biting, thumb sucking), mouth breathing,
and tongue or jaw thrust during speech or swallowing. Abnormal breathing and position of the tongue on the oor of
the mouth, can alter the alignment between the head, cervical
spine, and shoulder girdle via the muscular ring of the maxilla and mandible. e muscular ring consists of the superior
pharyngeal constrictor, buccinator, and orbicularis oris muscles,
and is connected to the occiput. When tongue thrust or mouth
breathing occurs, the ring draws the occiput anteriorly and affects the balance (homeostasis) of the TMJ and cervical spine,
32
resulting in a forward head posture. e forward head posture
also results in a posterior rotation of the cranium on the cervical spine that can further impact the alignment of the shoulder
girdle and the entire spine. erefore, it is important to assess
tongue thrust and breathing pattern as part of the initial assessment before treatment planning
Range of motion
While cervical spine ROM can be measured with a goni-
ometer or an inclinometer, TMJ opening is measured by either
39
a regular ruler or a specially designed disposable tool.
e
measurement tool is placed on top of one of the mandibular
central incisors and the measurement is taken from the distance between that mandibular incisor and the corresponding
maxillary central incisor (Figure 7). Both pain-free as well as
maximum (within pain tolerance) mouth opening can be measured. Lateral excursion is measured from the line between the
mandibular central incisors to the line between the maxillary
central incisors when the patient’s mandible is moved from the
center to one side (Figure 8). e amount of lateral excursion is
usually one-fourth of TMJ opening. For example, if the opening is 40 mm, the estimated lateral excursion should be 10 mm
in each direction. Knowing this ratio, the clinician can predict
opening range from lateral excursion range, or vice versa. Similarly, mandibular opening will improve in direct proportion to
regaining lateral excursion ROM. Protrusion is the amount of
anterior translation of the mandible, which is normally 6 to 9
mm. Retrusion is posterior translation and is normally 3 mm.
Values less than normal in any direction may indicate TMJ hypomobility, capsular tightness, masticatory muscle spasm, or
fear of movement due to pain.
Opening and closing patterns
Aberrant movement of the mandible during opening and
closing of the mouth is indicative of muscular or joint dysfunction. An “S” curve of opening (mandible deviates in an “S”shaped pathway during opening) without pain, may indicate
muscle imbalance or muscle incoordination, or potentially
ADDwR. If pain or limited opening is present, this may indicate
involvement of the disk or the capsule. A “C” curve of opening (mandible deviates to one side in the middle of opening
and returns to center at the end of opening) may be caused by
18
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Figure 7.
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Measurement of Mouth Opening
Figure 8.
Measurement of Lateral Excursion
ADDwR and is reective of the jaw returning to the center once
the disc is relocated.
When the mouth deects to one side during opening without returning to the center at the end of the range, this is termed
deection. Deection is indicative of an asymmetry in the
amount of anterior translation of the articular condyle on the
articular eminence between the right and left TMJ. Deection
at the end of mouth opening can occur in 3 clinical scenarios.
(1) It can be indicative of ADDwoR, with deection occurring
to the side of the ADDwoR, because the anteriorly displaced
disk prevents anterior translation of the condyle on the aected
side while the condyle on the contralateral side continues to
translate forward, causing deection of the mandible toward the
aected side. (2) It could also be an indication of limited capsular mobility (tightness). In this clinical scenario, the patient will
have limited TMJ opening with deection to the ipsilateral side,
again due to the limited anterior translation of the condyle on
the aected side. In both of the above scenarios, protrusion will
similarly result in deection of the jaw toward the aected side
and the patient will show normal lateral excursion toward the
aected side but limited lateral excursion toward the contralateral side.
30
(3) In contrast to the above scenarios where mouth
opening is expected to be somewhat limited, the third clinical
condition where deection may occur is with unilateral TMJ
hypermobility. In this scenario, excessive mouth opening will
likely be noted with deection away from the hypermobile side
secondary to the excessive anterior translation of the condyle on
the articular eminence on that side. With jaw protrusion, deection will also occur away from the hypermobile side. Finally,
in this third scenario, lateral excursion will be normal toward
the aected side and will be excessive when performed away
from the aected side.
Note that all 3 scenarios described in the previous paragraph imply unilateral dysfunction; in contrast, bilateral TMJ
dysfunction would result in limited mouth opening without
deection in the rst 2 scenarios and excessive mouth opening
without deection in the third scenario. However, the pattern
of opening and TMJ motion should not be the only criteria
used to make a diagnosis.
Occlusal measurements
e measurement of overjet, indicating how far the maxillary teeth are protruding in front of the mandibular teeth (Fig-
ure 6) is performed by asking the patient to perform maximal
intercuspation by biting down with the back molars (closed
40
pack position) after swallowing.
en, a ruler is placed under
the maxillary central incisors to measure the distance between
the maxillary central incisors and the mandibular central incisors. e normal overjet is 3 to 6 mm which is Class I (normal) occlusion. In Class II occlusion, overjet is greater than 6
mm. In Class III occlusion, the overjet is negative which means
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19
the mandibular teeth are either edge to edge with the maxillary
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teeth or protruded in front of the maxillary teeth.
Overbite indicates the portion of the mandibular central
incisors that is overlapped by the maxillary central incisors (Fig-
ure 6). Keeping the ruler in place on the mandibular central
incisors, the patient is asked to open their mouth gently. e
overbite is quantied by measuring the distance between the
mark from the ruler to the top margin of the mandibular central incisors. e normal range of overbite is one-fourth to onethird of the height of the mandibular central incisors.
Overbite and overjet measurements can indicate the type
of occlusion but may also be inuenced by dysfunction in the
TMJ musculature. Changes in these measurements may occur
following treatment focused on muscle guarding and spasm,
suggesting the need to address the TMJ musculature prior to
occlusal treatment by the dentist.
lar ligament, (5) posterior inferior synovium, (6) posterior superior synovium, (7) posterior ligament-bilaminar zone, and (8)
retrodiskal pad. Figure 9 provides a detailed description of Ro-
56
cabado’s pain map.
is is an advanced skill that needs training and practice for accuracy, but the reliability and validity of
this palpation have not been tested.
e retrodiskal pad can be palpated behind the condylar head when the patient opens their mouth and the condyle
translates anteriorly. It can also be palpated with the tip of the
small nger located in the external auditory canal, using a slight
anteriorly directed force with the pad of the nger. is technique makes it possible to palpate the area with mouth either
open or closed. Pain will be elicited in the presence of an inammatory process.
Intraoral examination
Scalloping of the tongue (ridges on the edge of the tongue)
are caused by impressions of the teeth from parafunctions such
as nocturnal bruxism. Irregularity on the buccal tissues also indicates the possibility of clenching or bruxing.
Palpation of masticatory muscles
e muscles of mastication (masseter, temporalis, suprahyoid, and infrahyoid muscles) and of the cervical spine (posterior cervical, sternocleidomastoid [SCM], scalene muscles,
etc) should be palpated to identify the presence of tenderness,
tightness, or trigger points. ese muscles can be located using
standard anatomical landmarks and are palpated extraorally.
Palpation of the pterygoid muscles can be done intraorally.
e medial pterygoid muscle can be located by following the
maxillary arch to the area posterior to the back molar, or by
following the mandibular arch to the posterior molar and moving superiorly. e patient is then asked to close the mandible
gently; the belly of the medial pterygoid muscle will contract
under the palpating nger, conrming its location.
e ability to palpate the lateral pterygoid muscle is debated among researchers. Based on their systematic review, Turp
41
and Minagi
concluded that the lateral pterygoid muscle was
not palpable. e so-called “pterygoid region” is considered the
closest area to the lateral pterygoid muscle; the examiner palpates this region by moving the small nger to the area posterior
and superior to the maxillary back molar. Although this area is
usually sensitive in healthy people, increased tenderness on the
involved side is almost always reported by patients with TMD.
Palpation of joint capsule, ligaments, and retrodiskal pad
42
A pain map was developed by Rocabado
to help guide a
systematic palpation process for the TMJ structures, including
the capsule, ligaments, and retrodiskal pad. ere are 8 palpation sites: (1) anterior inferior synovium, (2) anterior superior
synovium, (3) lateral collateral ligament, (4) temporomandibu-
Figure 9.
Pain Map of the Temporomandibular
Joint
1, anterior inferior synovium: anterior inferior to
condylar neck. 2, anterior superior synovium: anterior superior to condylar neck. 3, lateral collateral
ligament: lateral protrusion of condylar head during
mouth opening. 4, temporomandibular ligament:
posterior inferior to #3. 5, posterior inferior synovium: posterior inferior aspect of condylar head when
patient moves mandible to contralateral side. 6, posterior superior synovium: posterior superior aspect of
condylar head when patient moves mandible to contralateral side. 7, posterior ligament-bilamina zone:
physical therapist moves patient’s mandible posterior-superiorly, with thumb on back molar intraorally.
8, retrodiskal pad: maintain #7 position, then move
the mandible anteriorly to pressure the retrodiskal
tissue. Reprinted with permission from Mariano Ro-
42
cabado.
Joint Pain Map: Dierential Diagnosis of
the Synovial Temporomandibular Joint. Santiago,
Chile: CEDIME Publications; 2010.
20
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Capsular mobility
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Capsular mobility of the TMJ is assessed by applying a longitudinal distraction force on the posterior mandibular molar
along the vertical axis of the mandibular ramus. Gentle medial
and lateral movement can also be applied to assess the exibility
or stiness of the capsule. More details on the techniques are
provided later in the treatment section.
Joint sounds
Joint sounds can be assessed by palpation or auscultation.
To palpate the TMJ, which is typically done for both TMJs at
the same time, place the index ngers in front of the tragus and
ask the patient to open and close their mouth. Feel for vibration
of the sound through the skin or listen for the joint sound by
using a stethoscope.
e quality of the joint sound can be described as clicking, crackling, popping, or crepitus. Crepitus and crackling are
usually associated with arthritic changes; clicking and popping
sounds may be caused by an ADDwR, or by the condyle gliding
over the articular eminence if near the end of mouth opening.
Reciprocal clicks are audible sounds during opening and
closing of the mouth. ey usually indicate reduction of the
anteriorly displaced disk during opening (louder opening click)
and re-dislocation of the disk at the end of closing (softer closing click). Timing of the clicking noise may also be of clinical
interest; the expectation would be that an early opening click
would be accompanied by a late closing click. Over time, the
posterior structures may progressively become more elongated with reduction of the disk over the condyle occurring later
during mouth opening. erefore, with progression of the condition, the opening click may occur progressively later during
mouth opening, and accordingly, the closing click will occur
earlier during mouth closing. Individuals with ADDwoR do
not have reciprocal clicks.
A clinical progression of the internal derangement of
the TMJ has been described as starting with reciprocal clicks
(ADDwR), then progressing to absent joint noise with limited opening (ADDwoR) that is often described as a closed lock
43
joint, eventually leading to OA.
A single joint sound may be
due to a variety of reasons, including the condyle touching the
disk or articular surface during mouth opening or closing.
e physical therapist should educate the patient regarding
the benign nature of some of the joint sounds. In many cases,
the joint sounds and deviations of the jaw do not indicate signicant pathology, and the goal of abolishing all joint sounds
29
is not realistic.
Often, proper neuromuscular re-education can
control the joint sounds. In the case of an unstable disk where
the patient demonstrates catching and deviation during mouth
opening and closing, then the amount of controlled mouth
opening (with tongue on the palate) should be limited within
asymptomatic range and rhythmic stabilization exercises should
44
be emphasized.
Joint play and mobility
Joint play can be dened as movement (gliding, distraction, rotation) of the joint surfaces that occurs as a result of an
applied external force (therapist’s hands). Joint play of the TMJ
can be performed in an inferior, medial, and lateral direction,
as well as for anterior and posterior rotation. Normal joint play
is crucial for maintaining a functional relationship between the
TMJ and the occlusal structures (teeth) for eective chewing
and speaking.
e rst step of mobility testing is to test joint play by
gently depressing the mandible to “take up the slack.” e clinician places the thumb intraorally on top of the mandibular
back molar and depresses gently in a caudal direction, distracting (gapping) the joint surfaces. e clinician can also maintain
the hold for 6 to 7 seconds to achieve optimal release of the
connective tissue. is preliminary step is necessary for all joint
mobilization techniques, to avoid excessive stresses across the
TMJ articular structures.
At this stage, a number of techniques can be completed. A
long axis distraction is performed by applying an inferior force
on the posterior mandibular molar along the axis of the ramus.
Mobility of the TMJ can also be assessed for medial glide, lateral
glide, anterior rotation, posterior rotation, and anterior translation along the direction of the body of the mandible. e classications of joint mobility are rated as normal, hypomobile, or
hypermobile using the other side or clinical experience as reference. e same techniques used to assess motion can be used as
a mobilization treatment for a hypomobile joint.
Cotton roll test
is test is used to dierentiate between muscular and joint
involvement. Biting down on an object with the back molars
will result in gapping (unloading) the ipsilateral TMJ and compressing (loading) the contralateral TMJ. When a patient complains of pain on one side of the jaw, the clinician may have the
patient bite down on a cotton roll with the back molars on the
side of complaint. If pain increases, then the cause of symptoms
may be muscular in origin due to the activation of the ipsilateral
masticatory muscles. If pain decreases while biting down on the
cotton roll, then the cause of the original pain may be joint related (ie, disk or retrodiskal pad) because unloading the joint results in a decrease in pain. is hypothesis of joint involvement
can be further conrmed by asking the patient to bite down on
the cotton roll with the back molars of the contralateral side. It
should result in pain on the involved side due to loading of the
joint on that side.
Upper quadrant
It has been suggested that the functional state of the
stomatognathic system is closely related to the function of the
29
upper quadrant (ie, neck, shoulder, and upper back).
Patients
with TMD have a higher prevalence of cervical spine symptoms, and patients with cervical spine disorders also frequently
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21
show signs and symptoms of TMD. erefore, evaluation of
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the cervical spine, including a detailed assessment of the upper
cervical spine, and rest of the upper quadrant is of vital impor-
29,45
tance in the management of TMD.
Information on how to
perform a detailed assessment of this region is not included in
this monograph.
Reex
Tapping the chin with a reex hammer will elicit a reex
response of the mandible if cranial nerve V (trigeminal nerve) is
46
If the reex is diminished or absent, it may be indica-
intact.
tive of pathology of the trigeminal nerve.
Ultrasound imaging (ultrasonography)
Ultrasonography as a diagnostic tool for TMD has been
reported to be reliable in identifying internal derangement,
condylar erosion, articular eusion, and degenerative OA.
47-51
Ultrasonography has many advantages over radiographs, MRI,
and computed tomography (CT) scan as it is noninvasive and
non-radioactive; it also has a relatively low cost as well as acceptable sensitivity and specicity.
52
While physical therapists usually rely on panoramic radiographs, MRI, or CT scan to provide medical diagnosis of a TMJ
condition, the availability of ultrasonography may add a new
dimension to the assessment and management of TMD. Ho
53
presented a case using ultrasound imaging to demon-
et al
strate the positive eect of manual mobilization of the TMJ
for a patient with the diagnosis of ankylosis (Figure 10). In
addition, the authors described a standardized ultrasound imaging approach to quantify anterior translation of the mandibular condyle during mouth opening (Figures 11 and 12). eir
work further identied a linear model to describe the relationship between condylar anterior translation and mouth open-
54
ing ROM.
Ultrasound imaging also can be used as a tool to
provide biofeedback in re-education for relaxation and balance
of the masticatory musculature. Consistent with the increased
interest in using ultrasound imaging for other parts of the body
(eg, transversus abdominis, multidus, posterior tibialis muscles) ultrasonography can be a valuable adjunct for physical
therapy assessment, management, and research for TMD.
Figure 10.
e Transverse Section of Ultrasonographic Imaging of the Right Temporomandibular
Joint at Maximal Mouth Opening Position
A, pre-physical therapy. B, post-physical therapy images. On each image, the dashed line represents the
articular capsule and the solid line outlines the lateral surface of the mandibular condyle. e distance
between the articular capsule and the lateral surface
of the mandibular condyle (between the 2 yellow
arrowheads) is dened as the lateral capsule-condyle
distance. A 1.2 mm increase in lateral capsule condyle
distance was noted after physical therapy intervention. Reprinted with permission from Ho KY, Ho S,
Colletti PM.
53
Copyright 2016, JOSPT®, Inc.
DIFFERENTIAL DIAGNOSIS
Physical therapists should possess the knowledge to recognize suspicious medical conditions that may cause orofacial
pain. Medical screening should be used to rule out any red or
yellow ags, and appropriate referrals made if indicated. More
information about medical screening for TMJ can be found
55
elsewhere.
A physical therapy diagnosis can be hypothesized for treatment planning based on the information gathered through
history taking and the examination and evaluation procedures
described earlier. In many patients, the cause of TMD is multifactorial; therefore, overlapping of diagnoses is not unusual.
Common diagnoses with their typical clinical signs and symptoms are described below.
Articular Disorders
Disk-condyle incoordination-internal derangement
Internal derangement is dened as a localized mechanical
fault in a synovial joint that interferes with its smooth action.
ere are 2 kinds of internal derangement of the TMJ: (1) disk
displacement with reduction and (2) disk displacement without
reduction. In most cases, the disk is displaced anteromedially,
and in rare conditions, a posteriorly displaced disk may occur.
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22
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56
Figure 11.
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Measuring Anterior Translation of the
Mandibular Condyle During Mouth Opening
Ultrasound transducer placement for A, closed and B,
open mouth positions. Reproduced with permission
of the Society of Physical erapy Science.
54
Anterior disk displacement with reduction (ADDwR)
is condition is characterized by a noticeable opening
click and a more subtle closing click. ese reciprocal joint
noises (popping or clicking), with or without pain, indicate
the reduction of the disk during mouth opening with the rst
noise, and dislocation of the disk during mouth closing with
the second noise. In addition to reciprocal joint sounds during
opening and closing, limited opening with or without pain, and
altered mandibular dynamic shown by a “C” curve or “S” curve
during mouth opening, form a cluster of signs that may indicate
an ADDwR.
Anterior disk displacement without reduction (ADDwoR)
e patient usually reports a history of reciprocal joint
noises. At this stage, the patient no longer has joint noise, but
may complain of limited mouth opening (less than 35 mm), accompanied by ipsilateral deection of the jaw and pain during
mouth opening. e limitation of mouth opening and deection may progressively disappear as the condition becomes
more chronic.
Magnetic resonance imaging is considered the gold standard (95% accuracy) for diagnosing TMJ disk displacement;
however, it is expensive. Julsvoll et al
57
recommended a cluster
of clinical tests (positive in 5 of 7 tests) to be used to diagnose
chronic ADDwoR that had 71% accuracy (sensitivity and specicity for 5 of 7 tests were 0.71 and 0.91; for 6 of 7 tests 0.43
and 0.91; and for 7 of 7 tests 0.29 and 0.95, respectively). e 7
tests are the joint provocation test (mouth opening with pain),
mouth opening), the laterotrusion test (limited lateral excur-
Figure 12.
Measuring Anterior Translation of the
Mandibular Condyle During Mouth Opening
e transverse section of ultrasound imaging of the
temporomandibular joint at A, closed mouth and B,
open mouth positions. Each oval represents the lateral aspect of the mandibular condyle. e anterior
displacement distance was dened as the distance between the centers of the ovals at the 2 positions. Reproduced with permission of the Society of Physical
erapy Science.
54
sion, less than 9 mm, to the contralateral side), the joint mobility test (reduced anterior translation of the condylar head as
assessed with palpation extraorally), the joint sound test (absent
joint noise or crepitus is considered positive), the dental stick
test (a tongue depressor is placed between the back molars for
the patient to bite down on; pain elicited in either the ipsilateral
or contralateral joint is considered positive while pain in the
surrounding area is considered negative), and the isometric test
(manual isometric resistance to lateral excursion contralaterally,
with the test considered positive if pain is elicited). Clinician
may use this validated method to help determine if ADDwoR is
present and for proper intervention before determining if MRI
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23
is indicated. Ultrasound imaging as discussed in the previous
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section can be added as a new diagnostic tool for physical therapists.
surgical procedures, capsular tightness, structural disorders of
the joint (such as ankylosis), internal derangement, or advanced
60
OA.
Posterior disk displacement
is condition, referred to as “open lock,” is characterized
by the inability to close the mouth due to the posterior displacement of the disk. is condition is rare, but it can occur
after prolonged opening of the mouth for dental procedures or
after excessive yawning or laughing. ere are usually no joint
sounds and the patient may or may not experience pain. A denitive diagnosis of posterior disk displacement needs to be
conrmed by MRI. Non-surgical interventions, similar to those
used for anterior disk displacements, are also the rst option for
this condition.
58
According to Katzberg et al,
33% of their 76 volunteers
with disk displacement were asymptomatic. Some researchers
believe that the disk has remodeling properties leading to repair
or the development of a “pseudo” disk.
Fracture
Condylar fracture caused by trauma may aect the articular surfaces, ligaments, disk, and muscles of mastication. Its
sequelae could include synovitis, capsulitis, ankylosis, or OA.
59
Capsular involvement
Signs of capsular tightness include any or a combination of
the following: palpable tenderness over the lateral capsule of the
TMJ, pain with opening, limited opening with deection to the
ipsilateral side, limited lateral excursion to the contralateral side,
and deection towards the ipsilateral side during protrusion.
30
Ankylosis
Ankylosis of the TMJ is characterized by restricted joint
play mobility and mandibular ROM for mouth opening, protrusion, and contralateral lateral excursion (if unilateral). e
restriction is usually manifested by limited anterior condylar
translation of the involved side; therefore, deection of the
mandible to the ipsilateral side is also observed during mouth
opening and protrusion. Bony ankylosis is characterized by zero
mobility of the TMJ; whereas, capsular and brous ankylosis
would show some mobility even though hypomobile. Ankylosis can be the result of joint inammation from trauma (likely
unilateral) or a systemic condition such as a polyarthritic disease
(potentially bilateral).
59
Hypomobility
Hypomobility of the TMJ is demonstrated by a decrease in
jaw opening or limited accessory joint play movement during
mobility testing, with or without pain. An opening range of less
than 30 mm is usually considered hypomobility. Temporomandibular joint hypomobility can be caused by masticatory muscle
disorders, brous adhesion after trauma (such as fracture) or
Hypermobility
Hypermobility of the TMJ is dened as the condylar head
translating beyond the articular eminence, onto the articular
tubercle. e joint functions outside the physiological range
yet still stays within its anatomical range. Temporomandibular
joint hypermobility can be caused by joint laxity, systemic hypermobility, anatomical variance, dystonia of the masticatory
30
muscles, or simply lack of control of motion.
Clinically, bilateral hypermobility is identied based on
excessive jaw opening (greater than 55 mm), often along with
poor movement control as demonstrated by an aberrant “S”
curve movement pattern of the mandible during mouth opening. Protrusion of the lateral pole of the condylar heads will also
be noted; this indicates subluxation caused by excessive anterior translation of the condyles. Unilateral hypermobility will
demonstrate deection of the jaw to the contralateral side at the
end of opening and protrusion and excessive lateral excursion to
the contralateral side.
Dislocation of condyle
Dislocation occurs when the condylar head is displaced
beyond the articular tubercle, out of the mandibular fossa, and
is unable to return to its physiological position. e mouth is
kept in an open position. Dislocation may be caused by acute
trauma, neurogenic muscular hyperactivity, connective tissue
disorder such as Ehlers-Danlos syndrome, or systemic hypermobility. Bilateral dislocation of the condyles will exhibit excessive opening with no deection, in contrast to a unilateral
dislocation that will result in deection of the mandible to the
contralateral side.
Subluxation of condyle
Subluxation is dened as a temporary dislocation that can
be self-reduced. Its cause can be joint laxity or systemic hyper-
59
mobility.
Excessive anterior translation of the condyle in this
condition is usually noted by observation or palpation of the
protruded lateral pole during mouth opening.
30
Masticatory Muscle Disorders
Myogenous TMD can be caused by direct or indirect macrotrauma to the TMJ (eg, a blow to the jaw or a whiplash injury) or repetitive microtrauma from nocturnal clenching and
bruxing. Forward head posture may also contribute to masticatory muscle disorders due to the alteration of proper alignment.
Psychosocial factors such as stress, anxiety, depression, avoidance of activities, secondary gain behavior, etc, may also play a
signicant role in precipitating or perpetuating the symptoms
of myogenous TMD.
60
24
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Myofascial pain disorder syndrome
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Myofascial pain disorder syndrome is dened by pain that
originates from the myofascial structures. Myofascial pain disorder syndrome is often aected by stress. Its clinical manifestation includes multiple complaints of facial pain, jaw pain,
headaches, joint noises, limited opening, tinnitus, earache,
dizziness, swallowing diculty, and speech disturbance. It is
characterized by trigger points in the aected muscles. Trigger points are exquisite tender points that are present in a taut
61
band of the muscle and can refer pain to a remote area.
points can be active or latent. Travell and Simons
Trigger
61
studied the
nature and referring patterns of trigger points and found that
trigger points in the temporalis muscle can refer pain to the
maxillary teeth and those in the masseter muscle can refer pain
to the maxillary and mandibular teeth. erefore, an accurate
diagnosis must dierentiate the cause of a toothache before any
irreversible procedure (eg, tooth extraction) is performed on
a patient. Myofascial pain is the most prevalent cause/form of
TMD. It may occur with or without TMJ involvement. e
diagnosis of MPDS can be made by palpation of trigger points,
patient symptoms, and the relief of symptoms with the spray
and stretch technique.
Trismus
An acute closed lock of the jaw after a dental procedure
is referred to as trismus. is is caused by spasm of the masseter muscle after prolonged jaw opening and results in limited
mandibular ROM. Clinical symptoms and signs include: history, limited opening range (<25 mm), and palpable tenderness/
tightness over the masseter muscle belly.
Myositis
Myositis is an acute inammation of a muscle. Its clinical manifestation in TMD includes palpable tenderness, pain
during ROM, and limited opening of the jaw. e cause of myositis may be overuse soreness, trauma, or local infection.
Myospasm
Spasm of the masticatory muscles can be caused by overstretching of the jaw, such as in the case of trismus (spasm of the
masseter muscle) resulting from a dental procedure. Myospasm
can also be caused by overuse of the masticatory muscles, such
as excessive chewing on gum or hard food.
Dystonia
Dystonia is a neurological condition with central nervous
system (CNS) origin (such as in the case of Parkinson’s disease)
in which the patient is unable to voluntarily control movement
of the jaw, lips, and tongue, in which case the functions of
chewing, swallowing, and speech are often aected. Medication
and Botox injection may be benecial in controlling the related
symptoms.
Myobrotic contracture
Myobrotic contracture is a chronic condition that is the
result of shortening of the masticatory muscles. It may be caused
by trauma, prolonged hypomobility, or infection.
Neoplasia
Neoplasia is dened as an abnormal growth of muscle tissue; it can be malignant or benign. Neoplasia may or may not
be associated with pain. An example of neoplasia of the masticatory muscle is myxoma.
59
Arthritides
Arthritides is dened as inammation of a joint. Arthritides of the TMJ can be categorized as OA, rheumatoid arthritis,
psoriatic arthritis, capsulitis, or synovitis. A brief description of
the dierent types of TMJ arthritides is provided below.
Osteoarthritis
Osteoarthritis of the TMJ can be caused by degeneration or
excessive wear and tear of the joint (eg, due to bruxism). Crepitus joint noises during opening and closing, pain with ROM,
and limited opening are some of the clinical signs of TMJ OA.
Rheumatoid arthritis
Rheumatoid arthritis of the TMJ is the result of a systemic
disease. Control of inammation and joint protection are keys
to management.
Psoriatic arthritis
Psoriatic arthritis is a syndrome in which psoriasis occurs
in association with inammatory arthritis. e management of
psoriatic arthritis is similar to the management of rheumatoid
arthritis.
Capsulitis
Capsulitis may be caused by trauma or poor oral habits.
Over-stretching of the capsule results in an inammatory process. It is characterized by pain upon palpation, pain with jaw
movement, and an altered opening pattern of the mouth. It
usually shows a “C” curve in opening with deection towards
the aected side with mouth opening and protrusion.
30
Synovitis
Synovitis is the inammation of a synovial membrane that
lines a joint. It is dicult to dierentiate clinically from capsu-
30,56
litis.
Associated Conditions
Neurovascular abnormality may cause symptoms in the
orofacial and TMJ area. Careful consideration to dierentiate
the cause of each pathology and understand the connection
between TMD and dierent symptoms can provide clinicians
with the correct path of management. A brief description of
each associated condition will follow.
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25
Headaches
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e relationship between TMD and headaches has long
62-65
been reported and studied.
tional investigation of 1230 individuals, Goncalves et al
In a population-based, cross-sec-
63
found
that TMD symptoms were more commonly reported by patients with migraine headache, episodical tension-type headache, or chronic daily headache than by individuals without
headache. Some studies have suggested that TMD is a risk factor for increased headache frequency and chronic migraine.
Bruxism may be one cause of an increase in headaches.
69
cause bruxism is related to a person’s stress level,
as is chron-
ic headache, the connection seems logical. Magnusson et al
67,68
66
Be-
70
reported an increase in the prevalence of bruxism in young in-
71
dividuals during 1983 to 2003. Anastassaki Kohler et al
also
reported an increase in the prevalence of recurrent headaches in
20-year-old individuals over a 20-year period (1983 to 2003).
e stress level seen in our current society is thought to be the
reason for the increase in frequency of TMD and headaches.
Many types of headaches can be related to TMD. While a
detailed description of the causes and symptoms of each type of
headache is beyond the scope of this monograph, we will briey
discuss the most important related symptoms below:
•
Migraine headache: Even though this is a vascular type of
headache, it often has a tension component. Myofascial trig-
72
ger points are prevalent in migraine headaches.
Increased
tension in the musculature of the cervical spine and TMJ may
trigger migraine headaches.
Tension-type headache: Tension-type headache is the most
•
prevalent primary headache disorder. Tenderness in the pericranial tissue is associated with the intensity and frequency of
tension-type headache. Increased tension in the TMJ musculature and a forward head posture may exert pressure on the
trigeminal nerve and greater occipital nerve, which in turn
results in tension-type headaches in the cranio-facial area.
•
Cervicogenic headache: Unilateral cephalic radiating headache usually is caused by an upper cervical spine disorder.
Patients with TMD often demonstrate compromised cervical
spine alignment, such as a loss of cervical lordosis. erefore,
the incidence of cervicogenic headaches is high in individuals
with TMD.
73
Ear symptoms
ere has been an increasing awareness of ear symptoms
related to TMD in recent years. When a patient complains of
tinnitus, earache, or ear fullness, without true otological cause,
the TMJ and cervical spine are areas to be considered. Conrmation of the diagnosis is often based on the patient’s ear symptoms being relieved by treatment to the cervical spine and TMJ.
Patients with TMD often complain of ear symptoms such
74,75
as tinnitus, earaches, and stuness or congestion.
76
Toledo et al,
in their systematic review and meta-analysis,
Porto De
found a high prevalence of fullness (74.8%), otalgia (ear pain,
55.1%), tinnitus (52.1%), vertigo (40.8%), and hearing loss
(38.9%) in patients with TMD. In a prospective, observation-
77
al study, Maciel et al
reported that the number of otological
symptoms was considerably higher in patients with moderate
and severe TMD.
e association between ear symptoms and the TMJ is
complicated and multifactorial. e so called “non-otological tinnitus” also named “somatic tinnitus” can be elicited by
dysfunction of the cervical spine or the TMJ. e connection
among these structures is probably through the trigeminocervi-
78
cal nucleus and the auriculotemporal nerve.
vical nucleus is a neuron pool in the basal ganglion where infor-
e trigeminocer-
mation congregates from cranial nerves V, VII, IX, X, XI, and
79,80
cervical nerves 1, 2, and 3.
Due to the proximity of these
neurons, dysfunction of the cervical spine will inevitably aect
cranial nerve V (trigeminal nerve) that innervates the TMJ. e
auriculotemporal nerve, which is a branch of the third division
of the trigeminal nerve, innervates the lateral surface of the superior auricle, the external auditory meatus, and the tympanic
membrane. erefore, ear symptoms may occur as the result
of TMD and cervical spine dysfunction. Additionally, Travell
61
and Simons
described that dysfunction of the lateral pterygoid muscle can interfere with the eustachian tube, also causing
non-neurological tinnitus.
Clinically, it is often noted that treating the TMJ and cervical spine results in relieving the patient’s ear symptoms including earache, stuness, and tinnitus. It is postulated that
relieving upper cervical spine (C1, C2, C3) and TMJ symptoms
normalizes ear stimuli, causing a decrease in ear symptoms.
81,82
Vertigo/dizziness
e connection between the cervical spine and symptoms
of vertigo or dizziness is well-documented. Vertigo often is mentioned in the literature as one of the otologic symptoms that is
83
related to TMD. Chole et al
reported that vertigo symptoms
were signicantly more prevalent in the TMD population.
84
Marchiori et al,
based on their cross-sectional study, found
a signicant association between TMD and vertigo in older
85
adults. Zeigelboim et al
provide the following hypotheses for
the relationship between TMD and otologic symptoms: (1)
a close anatomic and structural connection, (2) a mechanical
transmission of force from the TMJ to the middle ear through
the discomalleolar ligament, (3) possible direct irritation of the
auriculotemporal nerve (a branch of the trigeminal nerve that
innervates the tympanic membrane), and (4) the convergence
of information at the trigeminocervical nuclei, which includes
information from cranial nerves V, VII, IX, X, XI and cervical
nerves 1, 2, and 3.
Patients with TMD usually demonstrate a forward head
posture and have cervical spine dysfunction. It is speculated
that suboccipital tightness caused by a forward head posture
can compress the greater occipital nerve and compromise vertebrobasilar blood ow, resulting in vertigo/dizziness. In addition,
26
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