P2 oral physio

• Temporomandibular Disorders


  A collective term that includes a number of clinical problems involving the masticatory muscles and/or the Temporomandibular Joint (TMJ)
• TMJ Noises

  • Click
  • Crepitus
  • Dull Thud
• Click


  Happens with anterior disc displacement
• Click (open)


  The disc clicks over the anteriorly moving condyle (condyle clicks past the thick posterior band of articular disc)
• Click (closed)


  Condyle moves posteriorly past the disc. Can also hear this click with lateral excursions to the contralateral side
• Crepitus


  Associated with osteoarthritis of the condyle (degenerative disease)
• Dull thud


  With self-reducing subluxation of the condyle
• TMD Symptoms and Signs

  • Masticatory muscle or TMJ pain
  • TMJ noise
  • Mouth opening limitation/restricted mandibular movement

  
• Risk factors for TMD

  • Age (around 35 to 45 years)
  • Sex (female)
  • Estrogen
  • Patients with pain in other body sites
  • Depression
  • Bruxism
• Examination for TMD

  • Interview
  • Inspection
  • Palpation (TMJs, muscle)
  • Auscultation (TMJ noise)
  • Mandibular movement
  • Occlusal check
  • Images (x-ray, MRI)

  
• Interview questions


  • Chief complaint
  • History of present illness
  • Time course
  • Accompanying symptom
  • Risks that the patient feels
  • Treatment history
  • Previous medical history
• Maximal Interincisal Distance


  The normal range of mouth opening when measured interincisally is between 53 and 58 mm

  
• Even a 6-year-old child can normally open to a maximum 40 mm or more
• Measuring maximal comfortable opening

  The patient is asked to open slowly until pain is first felt. The distance between the incisal edges of the maxillary and mandibular anterior teeth is measured.

  
• Measuring maximal opening


  The patient is asked to open the mouth maximally even if it is painful. This is recorded as the maximal opening.

  
• A restricted mouth opening is considered to be any distance less than 40 mm
• Only 1.2% of young adults open less than 40 mm
• 15% of the healthy elderly population open less than 40 mm
• End feel

  The characteristics of the restriction that limits the full range of joint movement
• Soft end feel


  Increased opening can be achieved slowly, suggesting muscle-induced restriction
• Hard end feel


  No increase in opening can be achieved, more likely associated with intracapsular sources (e.g., a disc dislocation)
• Classification of TMDs


  • Arthrogenous disorders (joint related)
  • Masticatory muscle disorders/myogenous tmd (muscle related)
  • Derangement of tm joint
• Arthrogenous Disorder of the Jaw


  • Localized arthralgia of the TM joint
  • Local osteoarthritis of the TM joint
  • Polyarthritic disorder of the TM joint
• Osteoarthritis


  Chronic degeneration and destruction of the articular cartilage leading to bony spurs, pain, stiffness, limitation of motion, and change in the size of joint
• Masticatory Myalgia


  Usually results from overwork, fatigue or tension of the jaw and supporting muscles resulting in jaw ache, headache and sometimes neckache
• Myofascial Pain


  A chronic muscle pain condition characterized by regional pain associated with specific sites of local tenderness
• Derangements of TM joint

  • Disk-condyle Incoordination
  • Closed Locking
  • Open Dislocation
  • Open Locking
  • Posterior Disk Displacement
• Tetanus is a serious bacterial infection that affects the nervous system and causes muscles throughout the body to tighten, while jaw lock or dislocated jaw is caused by an injury or excessive mouth opening
• Osteoarthritis of the TMJ can be treated like any other case of osteoarthritis with oral corticosteroids, NSAIDs, heat application, soft diet and restriction of jaw movement
• Mastication

  Act of chewing food, the initial stage of digestion
• Mastication


  • It is an enjoyable activity utilizing the senses of taste, touch and smell
  • It may have a relaxing effect by decreasing muscle tonus and fidgeting
  • It has a soothing quality
  • It is a complex function that utilizes the muscles, teeth, periodontal supportive structures, lips, cheeks, tongue, palate and salivary glands
• Complete chewing stroke


  Has a tear-shaped movement pattern
• Opening phase


  The mandible drops downward from the intercuspal position to a point where the incisal edges of the teeth are about 16 to 18 mm apart, then it moves laterally 5 to 6 mm from the midline as the closing movement begins

  
• Closing phase - Crushing phase

  First phase of closure which traps food between the teeth
• Closing phase - Grinding phase


  The teeth are positioned so that the buccal cusps of the mandibular teeth are almost directly under the buccal cusps of the maxillary teeth on the side to which the mandible has shifted

  
• Maximal biting force


  For males: 118- 142 lb / 53.6 – 64.4 kg, for females: 79- 99 lb / 35.8 – 44.9 kg
• Range of maximal force on molars vs incisors

  First molars: 91 -198 lb / 41.3 – 89.8 kg, Central incisors: 29 -51 lb / 13.2 -23.1 kg
• Swallowing/Deglutition

  A series of coordinated muscular contractions that move a bolus of food from the oral cavity through the esophagus to the stomach
• Somatic swallow


  The normal adult swallow utilizing the teeth for mandibular stability

  
• Infantile/visceral swallow


  When teeth are not present, the mandible is braced by placing the tongue forward and between the dental arches or gum pads