TMJ CONDITIONS

Craniomandibular Joint
O Synovial, condylar, modified hinge joint
O HAS FIBROCARTILAGINOUS articular disc;

this disc completely divides each joint into

two cavities
O TRIVIA

O Resting position: Mouth slightly open, lips together,

O
O

O
O

teeth not in contact

Close-packed position: Teeth tightly clenched
Capsular pattern: Limitation of mouth opening
Innervation: branches of the auriculotemporal and
masseteric branches of the mandibular nerve.
The upper head of the lateral pterygoid muscle
draws the disc, or meniscus, anteriorly and
prepares for condylar rotation during movement.

Arthrokinematics
O Translation/Gliding - occurs at upper part of

cavity
O Rotation - occurs at lower part of cavity
O Distraction

Osteokinematics
O Protrusion = 7 mm
O Retrusion = 3 4 mm
O Lateral deviation = 10 15 mm
O Opposite condyle forward, down and toward the

motion side
O Condyle on same side = stationary and prominent
O Lateral deviation during protrusion: lateral

pterygoid, masseter, or temporalis muscle, the

disc, or the lateral ligament on the opposite side
is affected.

MUSCLES

Normal End Feel at the

Temporomandibular Joints
O Opening: Tissue stretch
O Closing: Bone to bone

OPENING OF MOUTH
O 23-35 mm Functional mouth

opening 35-50 mm N mouth

opening (2-3 FLEXED PIP JOINTS)
O Early Phase:
O Rotation POST (26 mm) inferior

jt. space
O Late Phase
O Anterior translation (50-65),
inferior movement superior jt.
space

ACTIVE MOVEMENTS
NECK FLEXION
O Mandible moves up and forward
O Posterior structures tight
NECK EXTENSION
O Mandible moves down and back
O Anterior structures tight

ACTIVE MOVEMENTS
Opening and Closing of the Mouth
- Slowly

DEVIATIONS
Deviation towards L upon mouth opening
(a C-type curve) or to the right (a reverse Ctype curve),
(+) hypomobility is evident toward the side of
the deviation caused either by:
O a displaced disc without reduction or
O unilateral muscle hypomobility

S-type or reverse S-type curve,

the problem is probably :
O muscular imbalance or
O Medial displacement as the condyle walks around the
disc on the affected side.
O The chin deviates toward the affected side, usually
because of:
O spasm of the pterygoid or masseter muscles or
O an obstruction in the joint.
O Early deviation on opening is usually caused by muscle
spasm,
O Late deviation on opening is usually a result of
O capsulitis or a tight capsule.
O Pain or tenderness, especially on closing, indicates
posterior capsulitis.

PATIENT HISTORY
Extra-articular problem
O Pain in the fully opened position (e.g., pain
associated with opening to bite an apple,
yawning)
Intra-articular problem
O whereas pain associated with biting firm
objects (e.g., nuts, raw fruit and vegetables)
Limited opening may be due to:
O the disc displaced anteriorly,
O inert tissue tightness,
O muscle spasm

PATIENT HISTORY
O Early clicking - implies a developing dysfunction,
O Late clicking - is more likely to mean a chronic problem

PATIENT HISTORY
O There may be a partial anterior displacement (subluxation) or dislocation of

the disc, which the condyle must override to reach its normal position when
the mouth is fully open (Figure 4-8). This override may also cause a click.

PATIENT HISTORY
O If clicking occurs in both directions, it is called

reciprocal clicking
O The opening click occurs somewhere during the
opening or protrusive path, and the click indicates
the condyle is slipping over the thicker posterior
border of the disc to its position in the thinner
middle or intermediate zone.
O The closing (reciprocal) click occurs near the end of
the closing or retrusive path as the pull of the
superior lateral pterygoid muscle causes the disc to
slip more anteriorly and the condyle to move over its
posterior border.

RECIPROCAL CLICK

PATIENT HISTORY
O Clicks may also be caused by adhesions (Figure 4-10), especially in people

who clench their teeth (bruxism).

O These adhesive clicks occur in isolation, after the period of clenching.
O If adhesions occur in the superior or inferior joint space, translation or
rotation will be limited.
O This presents as a temporary
closed lock, which then opens
with a click.

PATIENT HISTORY
O Soft or popping clicks that are sometimes heard in

normal joints are caused by:

O ligament movement,
O articular surface separation, or
O sucking of loose tissue behind the condyle as it moves
forward.
O These clicks usually result from muscle incoordination.
O Hard or cracking clicks are more likely to indicate joint
pathology or joint surface defects.
O Soft crepitus (like rubbing knuckles together) is a sound that
sometimes occurs in symptomless joints and is not
necessarily an indication of pathology
O Hard crepitus (like a footstep on gravel) is indicative of
arthritic changes in the joints.

PATIENT HISTORY
O Locked jaw
O Not full ROM (Open/Close)
O Preceded by reciprocal clicking
O often related to problems of the disc or joint degeneration.
O Locked jaw in closed position
O caused by a disc with the condyle being posterior or anteromedial

to the disc.
O Translation is blocked, mouth opening is 30 mm via rotation
O FUNCTIONAL DISLOCATION OF DISC WITH REDUCTION
O disc is usually positioned anteromedially, and opening is limited.

O FUNCTIONAL DISLOCATION OF DISC WITHOUT

REDUCTION
O Results to: Closed lock implies there has been
anterior and/or medial displacement of the disc
so that the disc does not return to its normal
position during the entire movement of the
condyle.
O Opening: 25 mm, mandible deviates to
affected side, decreased ROM at C/L side
O If locking occurs in open position, it is caused
by: Posterior Disc displacement or joint
subluxation

O With an open lock,

O there are two clicks on opening,
O when the condyle moves over the posterior rim of

the disc
O and then when it moves over the anterior rim of the
disc, and two clicks on closing.
O If, after the second click occurs on opening, the disc lies
posterior to the condyle, it may not allow the condyle to
slide back (Figure 4-12 - locking).
O If the condyle dislocates outside the fossa, it is a true
dislocation with open lock; the patient cannot close the
mouth, and the dislocation must be reduced.

OBSERVATION
TMJ

O Occlusion
O occurs when the teeth are in

contact and the mouth is closed.

O Malocclusion
O is defined as any deviation from

normal occlusion.

O Class I occlusion
O normal anteroposterior relation of the maxillary teeth to mandibular
O

O
O

teeth.
Class I malocclusion.
O A slight modification with only the incisors affected and overjet slightly
larger
Class II malocclusion (overbite)
O Occurs when the mandibular teeth are positioned posterior to their
normal position relative to the maxillary teeth.
O This malocclusion deformity involves all the teeth, including the molars.
Class II Division 1 malocclusion (AKA large overjet or horizontal overlap)
O Indicates that the maxillary incisors demonstrate significant overjet.
Class II Division 2 malocclusion (AKA deep overbite or vertical overlap)
O implies that overjet is not significant but that there is overbite and
lateral flaring of the lateral maxillary incisors.
Class III malocclusion (i.e., underbite)
O occurs when the mandibular teeth are positioned anterior to their
normal position relative to the maxillary teeth.
O If maxillary and mandibular teeth are on the same vertical plane, a
Class III malocclusion would be present.

Crossbite
- With the teeth of the mandible are lateral to the
upper (maxillary) teeth on one side and medial on
the opposite side.
- There is abnormal interdigitation of the teeth.
- With anterior crossbite, the lower incisors are ahead

of the upper incisors.

- With posterior crossbite, there is a transverse
abnormal relation of the teeth.

Underbite
- Teeth are unilaterally,

bilaterally, or in pairs
in buccoversion (i.e.,
they lie anterior to
the maxillary teeth

Overbite
- anterior maxillary incisors
extend below the anterior
mandibular incisors when
the jaw is in centric
occlusion.
- A small amount of overbite
(2 to 3 mm) anteriorly is the
most common position of
the teeth.
- This is because the
maxillary arch is slightly
longer than the mandibular
arch.

Facial Profile
O The orthognathic profile is the normal,

straight-jawed form. With this facial profile,

a vertical line dropped perpendicular to the
bipupital line would touch the upper and
lower lips and the tip of the chin.
O Retrognathic profile, the chin would lie
behind the vertical line and the person would
be said to have a receding chin.
O With the prognathic profile, the chin would be
in front of the vertical line and the person
would have a protruded or strong chin

Tongue thrusting
O May be due to hyperactivity of the

masticatory muscles.
O When one swallows, the hyoid bone should
move up and down quickly.
O If it moves only upward and slowly, and the
suboccipital muscles posteriorly contract =
(+)

Cranial Nerve Testing

CN I Smell coffee or some similar substance with eyes closed
CN II (optic nerve): Read something with one eye closed
CN III, IV, VI: Eye movements; note any ptosis
CN V (trigeminal nerve): Contract muscles of mastication (masseter and
temporalis)
CN VII (facial nerve): Move eyebrows up and down, purse lips, show teeth.
This cranial nerve is the most commonly injured one. If the patient is unable
to whistle or wink
or close an eye on one side, the symptoms may be indicative of Bell
palsy (paralysis of the facial nerve).
CN VIII (auditory nerve): Eyes closed; talk to patient and have him or her
repeat what was said
CN IX: Have patient swallow
CN X (vagus nerve): Have patient swallow
CN XI (spinal accessory): Have patient contract sternomastoid
CN XII: Have patient stick out tongue, move it to right and left

FUNCTIONAL ASSESSMENT
O Research Diagnostic Criteria for
O

O
O
O

Temporomandibular Disorders (RDC/TMD)

Limitations of Daily Function Questionnaire
(TMJ)
Jaw Functional Limitation Scale
Mandibular Function Impairment
Questionnaire (MFIQ)
History Questionnaire for Jaw Pain
TMJ Scale.

SPECIAL TESTS
O Chvostek Test

AUSCULTATION
O listen to (auscultate) the

temporomandibular joints during

movement4
O Opening
O Closing
O Lateral deviation
O Protrusion
Slipping sound = single solid sound
heard only in occlusion
O Grating noise (crepitus) is usually
indicative of degenerative joint disease
or a perforation in the disc.
O Clicking is more likely to occur in
hypermobile joints.

Dermatomes of the head

Referred pain patterns to and from

the temporomandibular
joint in the teeth, head, and neck.

Temporomandibular
disorders (TMDs)
.

TMD
O Three cardinal features of TMD are:
O orofacial pain,
O restricted jaw motion,
O and joint noise

TABLE 4-2
Checklist of Psychological and Behavioral Factors*
1. Clinically significant anxiety or depression
2. Evidence of drug abuse
3. Repeated failures with conventional therapies
4. Evidence of secondary gain
5. Major life events; for example, new job, marriage or
divorce, death
6. Pain duration greater than 6 months
7. History of possible stress-related disorders
8. Inconsistency in response to drugs
9. Inconsistent, inappropriate, and vague reports of pain,
or both
10. Overdramatization of symptoms
11. Symptoms that vary with life events

TMJ DISC DISPLACEMENT

O (+) CLICK Upon mouth opening

TMJ CAPSULITIS
O (+) Pain upon mouth opening
O (+) LOM: Lateral deviation C/L

TMJ SYNOVITIS
O (+) PAIN UPON MOUTH OPENING
O LOM (I/L Lateral deviaiton)
O Swelling

TMJ HYPORMOBILITY
O (+) LOM towards mouth opening
O LOM: (C/L: Lateral deviation)

TMJ HYPERMOBILITY
O (+) Excessive mouth opening and C/L lateral

deviation

Stages Of Disc
Displacement

Bruxism
O Is the forced clenching and grinding of the

teeth, especially during sleep.

O This may lead to facial, jaw, or tooth pain, or
headaches in the morning along with
muscle hypertrophy.