Presents
The Evaluation, Treatment and Management of Temporomandibular Disorders, Craniofacial Pain And Orofacial Pain April 20, 2017 By Michael Karegeannes PT/MHSc/LAT/MTC/CFC/CCTT/CMTPT Jeff Verhagen PT/MBA/CMTPT Mike Verplancke DPT/CSCS/CMTPT
Freedompt.com Treatingtmj.com
Michael Karegeannes, PT, MHSc, LAT, MTC, CFC, CCTT, CMTPT, is the owner of Freedom Physical Therapy Services , 4 clinics in WI, since 1997 and a practicing physical therapist since 1989. His specialties in the field of physical therapy include: TMD, spine and pelvic dysfunctions, myofascial pain, and orthopedic therapies. Michael graduated from the University of Wisconsin-Madison in 1989 with a Bachelor’s of Science Degree in Physical Therapy. After he graduated, he received his athletic training license from the University of Wisconsin-Milwaukee, and later, Michael completed his manual therapy certification and Masters of Health Science from the University of St. Augustine in Florida. In 2005, Michael had the honor of being trained by Dr. Mariano Rocabado, (in conjunction with the University of St. Augustine) who is the leading national expert in the field of craniofacial therapies. Michael holds a Craniofacial Certification with the University of St. Augustine. In addition, Michael has attended an orofacial pain and TMD residency with the University of Minnesota Dental School. He is a member of the American Academy of Orofacial Pain (AAOP), a board member with the Physical Therapy Board of Craniofacial and Cervical Therapeutics (PTBCCT) and is one of the few physical therapists in the United States recognized as a certified cervical and temporomandibular therapist with the AAOP. In 2011, Michael received thorough and extensive training in the technique of intramuscular dry needling and is certified through Myopain Seminars, the premier post-graduate medical and physical therapy continuing education company in the United States with a focus on myofascial trigger points. Michael is also on faculty with Myopain Seminars. Michael is also one of the few PTs in the USA trained in the CRAFTA approach to TMD. His diverse experience, knowledge, and manual skills allow Michael to be highly effective in the evaluation and treatment of his clientele. Michael is a member of the APTA, WPTA, NATA, AAOP, PTBCCT, AES, PAMA and IMS. Jeffrey Verhagen started his career as a Physical Therapist in 1990 after graduating from the University of Wisconsin -Madison. He furthered his breadth of knowledge by attending several post-graduate continuing education opportunities with a focus on manual therapy for orthopedic, spine and sports injuries. He soon learned that he enjoyed treating spine problems and patients with headaches. In order to properly assess the etiology of headaches, he expanded his studies to include the evaluation and treatment of TMD/craniofacial pain and in 2013 completed a certification in Intramuscular Dry Needling through Myopain Seminars. Dry Needling treats myofascial trigger points and their affect on localized and referred pain. He soon learned that he could successfully treat TMD and craniofacial pain for patients that had tried other treatment approaches and still were left with pain and loss of function. Jeff has attended several courses and has reviewed the literature to expand his ability to successfully treat this challenging population. Freedom Physical Therapy Services, commissioned Steve Kraus PT, a well known TMJ therapist and educator, to come to the Milwaukee area and teach the latest treatment techniques and research on TMD/craniofacial pain to our therapy staff. Jeff looks forward to continuing to expand his knowledge to better serve this patient population. Jeff has been with Freedom Physical Therapy Service since July of 2000 and currently serves as the Clinical Operations Administrator for the practice. He earned his Master of Business Administration from Cardinal Stritch University in 1999. He also served 21 years in the Army Reserves and is a Desert Storm veteran. Jeff resides in Brookfield with his wife and two children and enjoys many hobbies to include golf, fishing and reading. Michael Verplancke left his roots of St. Louis, Missouri, to both attend and play ice hockey at St. Mary’s University of Minnesota, where Mike graduated in 1998 with a Bachelor of Arts degree in Biology. He then attended Finch University of Health Sciences/The Chicago Medical School in North Chicago, Illinois, to obtain his physical therapy degree. He graduated in 2001 with a Doctorate of Physical Therapy. Mike has participated in numerous continuing education seminars with a focus on manual therapy techniques, evaluation and treatment of the spine and TMJ/craniofacial pain, mobilization techniques, and intramuscular dry needling. In 2002, Mike obtained his credentials as a Certified Strength and Conditioning Specialist (CSCS), which has assisted him with exercise prescription, as well as progression of overall health and wellness for patients. In 2014, Mike completed his certification in Intramuscular Dry Needling through Myopain Seminars. This treatment approach has provided a technique that improves treatment of Myofascial Trigger Points and their affect on localized and referred pain, as well as muscle activation patterns throughout the body. In addition, Michael has attended an Orofacial Pain and TMD residency with the University of Minnesota Dental School. Mike has been trained in Temporal Mandibular Disorders (TMD) and Craniofacial Pain (CFP) by Dr. Mariano Rocabado, a world renowned leader in the field of TMD and CFP. Mike is currently working towards his Craniofacial Certification in conjunction with Dr. Rocabado and the University of St. Augustine. Mike has been an employee at Freedom Physical Therapy since July of 2005, and is currently the Lead Physical Therapist and clinic director of the Grafton location. Mike has a wide range of hobbies and interests, which include playing ice hockey, softball, golf, and basketball. He also enjoys spending quality time with his wife, Marion, their three daughters, Sophia, Liliana, and Emilia, and their Golden Retriever, Stan.
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Time Ordered Agenda 4-20-2017 9:00 – 9:45am
Introduction and TMJ Anatomy and TMJ Biomechanics
9:45 – 10:30am
Pathomechanics, abnormal mechanics and parafunction, etiology, imaging
10:30 – 11:00pm
Break
11:00 – 12:00pm
Epidemiology, Lab Evaluation of ROM of TMJ, Lab Muscle Palpation, Hypermobility Screen, muscle treatment
12:00 – 2:00pm
Lunch
2:00 - 2:45 pm
TMJ Arthralgia and various Disc related TMJ Dysfunction
2:45pm – 3:30pm
Lab Mobilization Techniques for the TMJ
3:00 - 3:45pm
Break
3:45 – 4:15pm
TMJ Exercise, Rocabado 6 x 6, self help
4:15 – 5:00pm
Cervical spine as it relates to TMJ, Ergonomics, Lab C spine assessment/treatment, dry needling Demo to facial and selected neck muscles
5:00pm
Adjourn, Thank you!
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The Evaluation, Treatment and Management of Temporomandibular Disorders, Craniofacial Pain and Orofacial Pain By
Michael Karegeannes PT/MHSc/LAT/MTC/CFC/CCTT/CMTPT
CRANIO-CERVICO-MANDIBULAR RELATIONSHIP
Cranio-Vertebral
Cranio-Mandibular
ASSIMILATION
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Tragus of the ear
Anatomical Video Clip
The condyle (anterior view). The medial pole (MP) is more prominent that the lateral pole (LP). Copyright ©2013 by Mosby, an imprint of Elsevier Inc.
(A) Lateral view and (B) diagram showing the anatomic components. RT, retrodiscal tissue, SRL, superior retrodiscal lamina (elastic); IRL, inferior retrodiscal lamina (collagenous); ACL, anterior capsular ligament (collagenous); SLP and ILP, superior and inferior lateral pterygoid muscles. AS, articular surface; SC and IC, superior and inferior joint cavity; the discal (collateral) ligament has not been drawn.
Medial and Lateral Discal Collateral Ligament
TMJ ( anterior or coronal view). AD, articular disc; CL, capsular ligament; LDL, lateral discal ligament; MDL, medial discal ligament; DC, superior joint cavity; IC, inferior joint cavity. Courtesy of Per-Lennart Westeson, M.D., Rochester, NY.
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TMJ Mechanics/Disc
TMJ pain primarily originates from tissues in the posterior and lateral aspect of the TMJ, ie capsule, TMJ ligament, Lateral collateral ligament , synovium and retrodiscal tissue.
Osteokinematics
Mandibular Biomechanics
• Depression (opening) – 40 to 50mm normal- 36 mm for most dental procedures • Elevation (closing) • Protrusion- 5 to 7 mm from incisor to incisor • Retrusion to protrusion 10mm, be specific and consistent • Lateral excursion – 10 mm 4:1 Ratio For every 1mm of lateral excursion, 4mm of opening.
TMJ AUTOPSY SPECIMEN (Normal Joint)
Green Bay, WI April 20, 2017
TMJ AUTOPSY SPECIMEN (Reducing Disc)
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Mandibular Opening Patterns
TMJ AUTOPSY SPECIMEN (Non-Reducing Disc)
• Deflection: Movement away from midline but it does NOT return to midline
Mandibular Opening Patterns (cont) Deviation: “S” Movement away from midline but returns to midline as it gets to end range.
Mandibular Opening Patterns (cont) • Midline: Could be normal, or could be bilateral Disc dislocation without reduction, depends on??
A man with reducing disc displacement of the right joint. (a) On mouth opening, there is an early transient locking and a slight deflection of the mandibular midline to the right affected side. (b) When the condyle slides over the posterior edge of the disc, there is a rapid exaggeration of the mandibular shift, and the mandibular midline then returns to center. At further mouth opening, the mandibular movement is symmetrical. (c) Lateral excursion to the contralateral side is impaired before the click, but not necessarily after. (d) Lateral excursion to the ipsilateral or affected side is typically normal. (e) Protrusion there is a slight deflection of the mandible to the right affected side, after the “click” the mandible tends to track in the center.
Mandibular ROM (LAB)
Hypermobility Screen
Will Cover In Lab
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Hypermobility
Revised 1998 Brighton Diagnostic Criteria For JHS
Beighton 9 Point Scoring System
Generalized hypermobility is one of the most important etiological factors in the development of craniomandibular disorders. Professor Rocabado presented the following summary of etiological factors and we can see that clenching/bruxism and mobility rank much higher than history of trauma or orthodontics.
Chapter 2 Assessment of Hypermobility P. Beighton et al., Hypermobility of Joints Springer-Verlag London Limited 2012
Rodney Grahame, CBE, MD, FRCP, Joint Hypermobility Syndrome Pain, Current Pain and Headache Reports 2009, 13:427-433.
Green Bay, WI April 20, 2017
The importance of systemic hypermobility is evident when we consider the association between parafunction and hypermobility. It has been found that 79% of patients with systemic hypermobility and clenching/grinding of teeth (or nail biting) go on to develop a TMJ problem. A control, with clenching/grinding of teeth but without systemic hypermobility, were found to have only 16% incidence. The implications seem to be that hypermobile individuals do not tolerate the added stress of parafunction. So most patients have hypermobility and parafunction going hand in hand.
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What other problems might a person with hypermobility have to suggest there is an underlying medical condition? The things individuals might most often present with beyond joint problems include: • Easy bruising, scarring that is stretched, thin and often wrinkled, and stretch marks that appeared at a young age and in many places across the body. The skin often feels soft and velvety; • Weakness of the abdominal and pelvic wall muscles that presents as hernias (such as hiatus hernia) or prolapse of the pelvic floor causing problems with bowel and bladder function;
http://hypermobility.org/ This diagram illustrates that people with CWP, CFS and FM can be hypermobile or may have JHS; that JHS and EDS may present in similar ways; and that the very complex systemic problems of the bowel, lungs, heart and blood vessels are features of conditions such as EDS and MFS, and not JHS. CWP – Chronic Widespread Pain; FM - Fibromyalgia; CFS - Chronic Fatigue Syndrome; JHS - Joint Hypermobility Syndrome; EDS - Ehlers Danlos Syndrome; MFS – Marfan Syndrome
• Symptoms that sound like Irritable Bowel Syndrome with bloating, constipation, and cramp-like abdominal pain; • Shortness of breath, perhaps diagnosed as asthma because the symptoms seem the same, but not responding to inhalers in the way the doctor might have expected, because it is not true asthma;
• Unexplained chest pains – perhaps the individual has been told they have a heart murmur and mitral valve prolapse; • Blackouts or near blackouts that may be associated with low blood pressure or fast heart rate, and often triggered by change in posture from lying/sitting to standing, or after standing in one position for even just a few minutes; http://hypermobility.org/
Cervical Spine Joint Hypermobility: a possible predisposing factor for new daily persistent headache, TD Rozen, JM Roth and N. Deneberg, Michigan Head-Pain and Neurological Institute, Ann Arbor, MI, USA
• Noticing that local anesthetics, used for example in dentistry, do not seem to be very effective or require much more than might be expected; • Severe fatigue; Anxiety and phobias. http://hypermobility.org/
History • 1934 James Costen described a group of symptoms centering around the ear and TMJ, the term Costen Syndrome was developed. • While much of what Costen had suggested has been disproved his interest certainly was a catalyst to foster more work and understanding in the area of TMD
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“Temporomandibular Disorders” Fast forward through various other terms over the years such as TMJ disturbances, TMJ dysfunction syndrome, Functional TMJ disturbances, occlusomadibular disturbance, myoarthropathy of the TMJ, Craniomandibular disorders, to what Bell in 1992 coined,
The term does not merely suggest problems that are isolated to the TMJs, but includes all disturbances associated with the function of the masticatory system rather than a single diagnosis:
• • •
“Temporomandibular Disorders”
Arthrogenous Myogenous Atrhrogenous and Myogenous
TMD Uncommon Classifications of TMDs • Ankylosis • Aplasia or hyperplasia • Pathology such as an infection, fracture or neoplasm ( malignant or benign)
The American Dental Association adopted the term TM disorders or Temporomandibular Disorders.
In 1993 the AAOP collaborated with the International Headache Society (IHS) to integrate TMD into an already existing medical diagnostic classification system.
Common Classifications/ ICD 10 Coding of TMDs
Common Symptoms/Signs of TMD • • • • • • •
Pain in the area of the TMJ and jaw muscles Pain with mouth opening, chew and /or yawn Joint sounds with jaw movements Intermittent locking closed or open Limited mouth opening Headache Earache or pain
Myogeneous Masticatory Muscle Pain: Muscle Spasms ICD 10 # M79.1/ICD 9 # 728.85 Contracture of muscle, unspecified site ICD 10 #M62.40 Adhesions and ankylosis of temporomandibular joint #M26.61 Artrhogeneous Arthralgia: ICD 10 # M26.62/ICD 9 # 524.62 Primary osteoarthritis, unspecified site M19.91 Disc Displacements: ICD 10 #M26.62/ICD 9 # 524.63
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Treatment – Insurance Issues and TMD Diagnosis
other specified disorders of TMJ ICD 10 #M26.69
It is about 50/50 as far as which insurances will
Dislocation of jaw, initial encounter ICD10 #S03.0XXA Cervicalgia
cover the diagnosis of TMJ/TMD. If they do, sometimes small TMD cap applies (say
ICD 10 #M54.2/ ICD 9 #723.1
only $1250), others fall into same coverage for other MS issues Most patients have a combo of cervical and TMD sx’s, therefore it is not unreasonable to use a cervical dx. For Medicare you will need a script from their medical doctor, not the dentist as Medicare does not cover TMD
Myofascial Syndrome ICD 10 # M79.1/ICD 9 #729.1 Headache
ICD 10 #R51/ ICD 9 #784.0
Chronic tension-type headache, intractable G44.221 /339.12 CTTH
Per Rocabado must have centric relation or balance of CV joints
Craniovertebral Junction
Copyright ©2013 by Mosby, an imprint of Elsevier Inc.
This is a graphic model depicting the relationship between various factors that are associated with the onset of TMD. The model begins with a normally functioning masticatory system. There are five(6) major etiologic factors that may be associated with TMD. Whether these factors influence the onset of TMD is determined by the patient’s individual adaptability. When the significance of these factors is minimal and adaptability is great, the patient does not report any TMD symptoms. Management of Temoromandibular Disorders and Occlusion by Jeff Okeson, 7 th edition, 2013
Craniovertebral Junction
Craniovertebral Junction
Copyright ©2013 by Mosby, an imprint of Elsevier Inc.
Copyright ©2013 by Mosby, an imprint of Elsevier Inc.
In this graphic model, the etiologic factor of occlusion is depicted as being significant (perhaps a newly placed poorly fitting crown). If this factor exceeds the patient’s adaptability, TMD symptoms may now be reported by the patient. In this instance, improvement of the occlusal condition (adjustment of the crown) would reduce this etiologic factor, thereby bringing the patient within adaptability and thus resolving the TMD symptoms. The same effect can be associated with any of the five etiologic factors and helps explain why data show that treatment of any of these factors may reduce symptoms.
This graphic model depicts the concept that some patients may present with less adaptability or a reduction in adaptability. When this occurs, the various etiologic factors that did not originally create symptoms may now lead to symptoms. When adaptability is very limited, attempts at reducing any of the five factors may be ineffective.
Management of Temoromandibular Disorders and Occlusion by Jeff Okeson, 7 th edition, 2013
Management of Temoromandibular Disorders and Occlusion by Jeff Okeson, 7 th edition, 2013
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Parafunctional Activity Copyright ©2013 by Mosby, an imprint of Elsevier Inc.
Craniovertebral Junction
Managing this etiologic factors May no longer be adequate
Copyright ©2013 by Mosby, an imprint of Elsevier Inc.
This graphic model depicts a much more difficult management problem. As symptoms become prolonged, the pain condition can move from acute to chronic. As pain becomes chronic, the central nervous system can be altered, making management more complicated. Some of these alterations may involve the hypothalamus-pituitary-adrenal axis, central sensitization, and/or a reduction in descending inhibitory control. When this occurs, more chronic pain conditions may develop, which cannot be managed by addressing the five etiologic factors. Management of Temoromandibular Disorders and Occlusion by Jeff Okeson, 7 th edition, 2013
Some clinical signs associated with parafunctional activity. A, Evidence of cheek biting during sleep. B, Here the lateral borders of the tongue are scalloped, conforming to the lingual surfaces of mandibular teeth. During sleep a combination of negative intraoral pressure and forcing of the tongue against the teeth produces this altered tongue shape. This is a form of parafunctional activity. Management of Temoromandibular Disorders and Occlusion by Jeff Okeson, 7 th edition, 2013
Masseter hyperplasia secondary to chronic bruxism
TMD Diagnostic Guidelines
• For over 20 years it has been the most widely used and heavily cited publication of diagnostic protocol in clinical and research settings
• 1992- Research Diagnostic criteria for TMDs – Dworkin SF, LeResche L., Research Diagnostic Criteria for Temporomandibular Disorder 1992; 6:301-355. – RDC is a landmark paper providing operational definitions to distinguish TMD patients from controls and to diagnose, with reasonable reliable and valid tests and measurements, the most common subtypes of TMD
• It was never intended to be a final document but rather a work in progress • The Journal of Oralfacial Pain 2010, volume 24, Issue 1 offers several articles validating and recommending updates to the 1992 RDC paper
– http://www.rdc-tmdinternational.org/Home.aspx
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The new DC/TMD protocol is a necessary step toward the ultimate goal of developing a mechanism and etiology based DC/TMD that will more accurately direct clinicians in providing personalized care for their patients.
Steenks, M, De Wijer, A; Validity of the Research Diagnostic Criteria for Temporomandibular Disorders Axis in Clinical Research settings: Journal of Oralfacial Pain 2009;23:9-16.
Summary of RDC/TMD diagnostic Guidelines A. To diagnose all common subtypes of TMD involves taking a history and performing a physical examination that is reliable and valid. B. Does NOT require: 1. Electronic Equipment a) Sonograph b) EMG c) Jaw Tracking Devices
Panoramic X-Ray 2. Radiographs -Radiographs are indicated if recent trauma, red flags are present, patient not responding to conservative care and surgery is being considered for disc replacement
• Is a two-dimensional dental x-ray that can show the maxilla and mandible, all the teeth including the "wisdom teeth," the frontal and maxillary sinuses, the nasal cavity and the temporomandibular joint and other near by head and neck anatomy. • Can determine bony changes of the condyle and fractures or severe dislocations of the condyle. Does not image soft tissue, so the position of the disc cannot be determined by this test.
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Computed Tomography • The latest advancement in this technology is called Cone Beam tomography • It allows for viewing the condyle in multiple planes so that all surfaces can be visualized. • This technology is capable of reconstructing 3D images • Cone beam technology can image both hard and soft tissues, but MRI GOLD standard for soft tissue
Patient positioned in a cone beam CT scanner.
Computed tomographic scan. A, A typical CT projection of the TMJ. Hard tissue (bone) is visualized better than soft tissue with this technique B, A threedimensional CT reconstruction of an edentulous mouth.
From Wilkinson T, Maryniuk G. J Craniomandib Pract 1:37, 1983.
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MRI • Gold Standard for evaluating the soft tissue of the TMJ, especially disc position • Major advantage of not introducing radiation • Disadvantages include: expensive, not typically available in a dental setting, quality of images may very from facility to facility • Cine or dynamic MRI on its way A three-dimensional image reconstructed from a cone beam image. These three-dimensional images can be rotated on the computer screen so that the clinician can visualize the precise area of interest. (Courtesy of Dr. Allan Farmer and Dr. William Scarf, Louisville, KY.)
Copyright ©2013 by Mosby, an imprint of Elsevier Inc.
Magnetic resonance image (MRI). A, When the mouth is closed, the articular disc (dark) is dislocated anterior to the condyle (arrows).B, During opening, the disc is recaptured into its normal position on the condyle.
The clinician should note that the presence of a displaced disc in an MRI does not constitute a pathological finding. IT has been demonstrated that between 26% and 38% of normal, asymptomatic subjects are found to have disc position abnormality on MRI. Therefore the clinician should rely primarily on history and examination findings to establish the diagnosis and use imaging information only as contributing data.
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This study suggests that disc displacement is relatively common (34%) in asymptomatic volunteers and is highly associated with patients (86%) with TMD.
Although there was a 33% prevalence of disc displacement in asymptomatic volunteers, there was a highly significant difference in the prevalence of internal derangement in symptomatic subjects. Bruxing was statistically linked to TMJ disc displacement and could explain the anatomic variation in abnormal disc position.
In conclusion, panoramic radiography had poor reliability and low sensitivity, compared with CT, for detecting TMJ-related osseous changes. These findings suggest that this imaging modality has limited utility for assessing the TMJ. Magnetic resonance imaging had fair reliability and marginal sensitivity in diagnosing osseous changes compared with CT. Therefore MRI is not an ideal imaging technique for detecting osseous changes, and CT remains the image of choice for assessing osseous tissues. Regarding soft tissue assessment, MRI had excellent reliability for assessing disc position and good reliability for detecting effusions. Overall, the criteria proposed in this study for image analysis covered all possible osseous and nonosseous conditions of TMJ in a large group of participants in the multisite RDC/TMD Validation Project.17 The image analysis criteria presented in this paper are reliable for diagnosing osseous and nonosseous components of TMJ using CT and MRI, respectively. We recommend that they be used in both clinical and research settings.
Sagittal CT views of condyles representing examples of nonosteoarthritic or indeterminate osseous changes observed. A-B. Rounded condylar head, and well-defined cortical margin. C. Rounded condylar head, and well-defined noncortical margin. D-E. Indeterminate for OA: slight flattening of anterior slope and well-defined cortical margin. F. Indeterminate for OA: flattening of anterior slope and a pointed anterior tip that is not sclerosed, well-defined cortical margin, fossa is shallow. G. Well-defined cortical margin has a notch on the superior part, a deviation in form, fossa is shallow. H. Narrowed appearance of the condylar head near medial part, close position of the cortical plates gives the impression of sclerosis, a nonosteoarthritic condyle,
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Axially corrected coronal CT views of condyles representing examples of osseous changes observed, and corresponding osteoarthritis (OA) diagnoses. A-B. Nonosteoarthritic condyles, rounded condylar head, and well-defined cortical margin. C. Nonosteoarthritic condyle, flattened superior margin, and well-defined cortical margin. D. Nonosteoarthritic condyle, flattened lateral slope, and well-defined cortical margin. E. Indeterminate for OA: rounded condylar head and subcortical sclerosis. F. Indeterminate for OA: subcortical sclerosis. G. OA: subcortical sclerosis, surface erosion. H-I. OA: surface erosion. J. OA: generalized sclerosis, and subcortical cysts. K. Nonosteoarthritic condyle, well-defined corticated margin, bifid appearance, deviation in form. L. Nonosteoarthritic condyle, subcortical sclerosis in nonarticulating surface, bifid appearance, deviation in form.
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Eagle’s Syndrome
Epidemiology of TMDs
Eagle’s syndrome. A, An extremely long and calcified styloid process seen in the panoramic projection. This patient was suffering from submandibular neck pain, especially with movement of the head. B, A very large styloid process that has been fractured is seen in this panoramic projection. There is also a large radiolucency in the mandibular molar region secondary to a gunshot wound. (B courtesy of Dr. Jay Mackman, Radiology and Dental Imaging Center of Wisconsin, Milwaukee, WI.)
• Joint sounds or deviations on mouth opening occur in ~ 50% of non-patient samples • Other signs are relatively rare, mouth opening limitations occur in less that 5% of non-patient populations • Pain in the TM region is reported in ~10% of the population older than 18 years, it is primarily a condition of young and middle aged adults • Women:Men, 2:1 and as high as 9:1
• Cross sectional epidemiologic studies of selected non-patient populations show that 40% to 75% of those populations have at least one sign of joint dysfunction ( eg, movement abnormalities, joint noise, tenderness on palpation) • 33% of selected non-patient populations have at least one symptom of dysfunction (eg, face pain, joint pain)
• Only 3.6% to 7% of these individuals are estimated to be in need of treatment • Only 7% of patient population with benign TMJ clicking showed progression to bothersome clicking status over a 1 to 7.5 year period • Most patients with clicking remained stable or showed less or no clicking throughout evaluation period
Management of TMDs • Management goals for patients with TMDs are similar to those for other orthopedic or rheumatologic disorders: – Decrease pain – Decrease adverse loading – Restore function – Resume normal daily activities Orofacial Pain, Guidelines for Assessment, Diagnosis, and Management, 4 th edition, AAOP, 2008.
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Conservative (reversible) Therapy • • • • •
Physical Therapy Self Management/Patient Education Behavioral modification Medications Orthopedic Appliances
Long term follow up of TMD patients shows that 50% to more than 90% of patients have few or no symptoms after conservative treatment. From a retrospective study of 154 patients, it was concluded that most TMD patients have minimal recurrent symptoms 7 years after treatment. Furthermore, 85% To 90% of the patients in 3 longitudinal studies lasting 2 to 10 years had relief of symptoms after conservative treatment, and stability was achieved in most cases between 6 and 12 months after start of treatment. Orofacial Pain, Guidelines for Assessment, Diagnosis, and Management, 4 th edition, AAOP, 2008.
Even a Monkey can do it☺
3 Main TMD Categories • Masticatory Muscle Disorders • Arthralgia or Joint Disorders • Disc Derangement Disorders
Masticatory Muscle Disorders
Referral of myofascial trigger-point pain to the teeth. A, The temporalis refers only to the maxillary teeth.
C, The digastric anterior refers only to the mandibular incisors.
B, The masseter refers only to the posterior teeth.
The Trigger Point Manual, 2nd edition, Baltimore, Williams & Wilkins, 1999, pp. 331, 351, 398.)
The Trigger Point Manual, 2nd edition, Baltimore, Williams & Wilkins, 1999, pp. 331, 351, 398.)
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The medial pterygoid muscle refers pain in poorly circumscribed regions related to the The lateral pterygoid muscle refers pain deep mouth (tongue, pharynx, and hard palate), into the temporomandibular joint and to below and behind the temporomandibular the region of the maxillary sinus, can cause joint (TMJ), including deep in the ear, but not tinnitus as well. to the teeth. Stuffiness of the ear may be a symptom of medial pterygoid TrPs.
The Trigger Point Manual, 2nd edition, Baltimore, Williams & Wilkins, 1999, pp. 331, 351, 398.)
Symptoms related to Masticatory Muscle Disorders
Ear Symptoms
• Patients commonly report pain that is associated with functional activities such as chewing, swallowing, and speaking • Patient reports pain in the face, jaw, temple, in front of the ear or in the ear in the past month • Pain is aggravated by manual palpation of muscle(s) • Acute malocclusion (Lateral Pterygoid spasm) • Pain can awaken them at night and/or is present in AM upon awakening
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Ear Symptoms such as ringing/fullness in the ears may be related to an increase in activity of: – tensor typani – Tensor veli palatini – Levator veli palatini “it is understood that anatomically they are muscles of the middle ear although they are really muscles of mastication because they are modulated by motorneurons coming from the trigeminal motor nucleus”
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“jaw muscular activity may cause ear symptoms resulting from the tensor typani and tensor veli palatine muscles participation” RAMIREZ, A. L. M.; SANDOVAL, O. G. P. & BALLESTEROS, L. E.;Theories on Otic Symptoms in Temporomandibular Disorders:Past and Present; Int. J. Morphol., 23(2):141-156, 2005.
Stuffiness of the ear may be a symptom of medial pterygoid TrPs. In order for the tensor veli palatini muscle to dilate the eustachian tube, it must push the adjacent medial pterygoid muscle and interposed fascia aside. In the resting state, the presence of the medial pterygoid helps to keep the eustachian tube closed. Tense myofascial TrP bands in the medial pterygoid muscle may block the opening action of the tensor veli palatini on the eustachian tube producing barohypoacusis (ear stuffiness). Medial pterygoid tenderness was confirmed in all 31 patients who were examined and who had this symptom. The Trigger Point Manual, 2nd edition, Baltimore, Williams & Wilkins, 1999, pp. 331, 351, 398.) Drake: Gray’s Anatomy for Students, 2nd Edition. Copyright© 2009 by Churchill Livingstone, an imprint of Elsevier, Inc. All rights reserved.
Copyright ©2013 by Mosby, an imprint of Elsevier Inc. Biting on a tongue blade is being used to determine whether the patient’s pain has its origin in the joint structures or the muscles. Biting on the tongue blade on the right side will reduce right intracapsular pain while biting on the tongue blade on the left side will increase the pain in the right joint.
If symptoms increase on the side you are biting on, may incriminate muscle on that side
This illustration shows that when a patient is biting on a tongue blade, the tongue blade become a fulcrum with muscles on both sides. Therefore biting hard on the right side will reduce the pressure in the ipsilateral joint. If the tongue blade is moved to the left side and the patient is asked to bite, the pressure in the right joint will increase.
It is concluded that the bite test is of significant value for evaluation of TMJ disorders and can be useful for the indication of complementary radiological examinations
Julsvoll EH, Vøllestad NK, Robinson HS. Validation of clinical tests for patients with long-lasting painful temporomandibular disorders with anterior disc displacement without reduction. Man Ther. 2016 Feb;21:109-19 Konan E, Boutault F, Wagner A, Lopez R, Roch Paoli JR. Clinical significance of the Krogh-Poulsen bite test in mandibular dysfunction. Rev Stomatol Chir Maxillofac. 2003 Oct;104(5):253-9.
Copyright ©2013 by Mosby, an imprint of Elsevier Inc.
Green Bay, WI April 20, 2017
Michael Karegeannes PT
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Diagnosing Masticatory Muscle Pain
Muscles of Mastication
Subjective 1. Patient reports having pain in the face, jaw, temple, in front of the ear or in the ear in the past month. 2. Patient is asked if the pain; a. Increases during the day with chew, talk, yawn, and/or with parafunctional activities b. awakens them at night and /or present in AM upon awakening Examiner confirms pain location is a muscle(s) Objective Finding Plus 1. During digital palpation, a minimum of one site is painful in the masseter muscle or temporalis and/or 2. Patient reports having pain with maximum unassisted opening and/or 3. Mouth opening is limited (may or may not be painful) Pain that is reproduced or increased is familiar pain and is located in a muscle I (Mike) typically find ROM mechanics are normal, minimal or no joint noises I (Mike) like to assess temporalis insertion on coronoid for tendinitis
TEMPORALIS
Muscle Palpation (LAB) • • • • • • •
Temporalis Masseter Medial Pterygoid Temporalis Tendon Vicinity of Lateral Pterygoid Palatini Muscles Anterior and Posterior Digastrics Palpation of the anterior (A), middle (B), and posterior regions (C) of the temporal muscles. Copyright ©2013 by Mosby, an imprint of Elsevier Inc.
Masseter
Masseter
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Medial Pterygoid
Medial Pterygoid
Temporalis Tendon
Vicinity of Lateral Pterygoid I prefer to use my pinky finger vs. Index
Using Pinky medial to coronoid process, press superiorly into recess and have patient open into your finger.
Palpation of the tendon of the temporalis. The clinician’s finger is moved up the anterior border of the ramus until the coronoid process and the attachment of the tendon of the temporalis are Copyright ©2013 by Mosby, an imprint of Elsevier Inc. felt.
Tensor and Levator Veli Palatini
Palpation of the lateral pterygoid region in TMD-where is the evidence? J.C. Turp, S. Minagi, Journal of Dentistry, 29, 2001, 475-483 Conclusion: Considering the lack of validity and reliability associated with the palpation of the lateral pterygoid area, this diagnostic procedure should be discarded. Evidence - The intraoral palpability of the lateral pterygoid muscle – A prospective study. Stelzenmueller W, Umstadt H, Weber D, Goenner-Oezkan V, Kopp S, LissonJ.Ann Anat. 2015 Dec 17 The intraoral palpability of the inferior caput of the lateral pterygoid muscle is verified. The basic requirement for successfully palpating the lateral pterygoid muscle is the exact knowledge of muscle topography and the intraoral palpation pathway. After documented palpation of the muscle belly in cadaverous preparations, MRI and EMG also visualized palpation of the lateral pterygoid muscle in vivo. The palpation technique seems to be essential and basically feasible.
Green Bay, WI April 20, 2017
Drake: Gray’s Anatomy for Students, 2 nd Edition. Copyright© 2009 by Churchill Livingstone, an imprint of Elsevier, Inc. All rights reserved.
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Anterior and Posterior Digastrics I will also palpate digastrics intraorally
To treat the two palatini muscles, insert the index finger or little finger into the mouth and stay just lateral to the midline. Feel for the end of the hard palate and do not press upward until you fall off the hard palate. Press upward to affect the palatini muscles. Sweep laterally with your finger hooked on the posterior part of the soft palate and continue all the way out to the hamulus.
Treatment for Masticatory Muscle Pain (MMP) • No Chew Diet • Behavioral Modification • Modify daily activities that may perpetuate MMP – Discontinue oral parafunctional activity Modalities Intraoral Massage Patient Self Massage Self Help
Modalities • US, US with ketoprofen rub or Dexamethasone
• Iontophoresis – Schiffman, E. TMJ Iontophoresis: A double blind randomized clinical trial, JOP;1996 10:2
LLLT
ESTIM
• LLLT (Low Level Laser Therapy) is the application of red and near infra-red light over injuries or lesions to improve wound and soft tissue healing, reduce inflammation and give relief for both acute and chronic pain. Petrucci, A., Effectiveness of LLLT in TMD: A Systematic Review and Meta-Analysis. J Orofac Pain, 2011;25:298-307.
Green Bay, WI April 20, 2017
• • • • • • •
Rich-mar Unit Pre Mod IF Estim on Surge, Ramp up 10 secs on/10 off 2x2 dual lead 2 leads 1R, 1B Purpose is to inhibit pain and to relax muscle
Michael Karegeannes PT
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CONTROLLED MOUTH OPENING TEMPORALIS SELF MASSAGE
--Place heel of hands on temporal area --Gently clench teeth and feel muscle contract under the heel of your hands --massage using pressure to your tolerance for 2 to 3 minutes, several times a day
MASSETER SELF MASSAGE --Place tongue in the “No” or “Never” position --Tip of tongue should be against the hard palate NOT pressing against the back of your teeth --This exercise focuses on the “rolling” movement occurring in the TMJ and is less traumatic --You should not hear or feel any clicking --This controlled amount of opening should dictate how wide you should open when you yawn and what size bite of food you should take --Perform this exercise in good postural alignment, tongue remains in contact with the hard palate --Perform 10 reps, slow and controlled --Every 2 hours during the day
Using index and thumb finger gently massage the muscles used for chewing 2 to 3 minutes several times a day to your tolerance
Experiment, move tongue further back to limit opening, or put tongue along upper back right molars to promote more movement of left condylar head or vice versa, put tongue along left upper back molars to promote increase movement of right condylar head
Temporalis Tendon Ice Massage
Occasional Muscle disorders • Lateral Pterygoid Spasm, patient is unable to bring their back teeth together on the side of the pterygoid spasm( subjectively and objectively) • May occur after unexpected resistance when chewing food, yawning, wearing CPAP appliance, wearing ARA • Rx: dry needling, gentle sustained posterior glide of mandible, • Other causes of why a patient cannot bring back teeth together
I
– TMJ Arthralgia – Prolong use of posterior coverage appliance
• Trismus- is a tonic contraction of the muscles of mastication. In the past, this word was often used to describe the effects of tetanus, also called “lock Jaw”. The term trismus is now used to describe significant restriction to mouth opening, (11mm) pain: No ___ Yes ___ • Posterior attachment “inside ear” pain: No ___ Yes ___
Tests primarily provides a base line to reassess the effects of treatment and nothing else.
In my opinion palpation here is assessing Lateral Collateral Ligament tenderness and assessing posterior disc attachments, informing you of position of condyle as possibly being more Superior and Posterior in the Temporal fossa
One test tells you nothing, multiple tests (when using clinical reasoning) tells you more.
I tend to prefer lateral excursion to opposite side. Copyright ©2013 by Mosby, an imprint of Elsevier Inc.
Copyright ©2013 by Mosby, an imprint of Elsevier Inc.
Palpation of the TMJ. A, Lateral aspect of the joint with the mouth closed. B, Lateral aspect of the joint during opening and closing. C, With the patient’s mouth fully open, the clinician moves a finger behind the condyle to palpate the posterior aspect of the joint.
Biting on a tongue blade is being used to determine whether the patient’s pain has its origin in the joint structures or the muscles. Biting on the tongue blade on the right side will reduce right intracapsular pain while biting on the tongue blade on the left side will increase the pain in the right joint.
TMD Arthralgia ROM
Joint Pain Map Synovial Spaces 1, 2, 5, 6
Green Bay, WI April 20, 2017
• Assess ROM as demonstrated earlier • Jaw dynamics may or may not be limited • I like to use a stethoscope to listen from crepitation type sounds, grating, grinding, vs. a discrete “click” • Here is where Condylar asymmetry is important to at least file away in your memory banks
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Copyright 2013 by Mosby an imprint of Elsevier Inc.
A, Sometimes significant osteoarthritic changes occur in only one joint. When this happens rapidly, the affected condyle can collapse, resulting in a shifting of the mandible to that side. This is referred to as idiopathic condylar resorption. B, In this patient there has been a midline shift to the patient’s right. This shift is evident even in the relationships of the posterior arches. This idiopathic condylar resorption was isolated to the patient’s right condyle. C, A cone beam CT of the right condyle showing the degenerative changes. D, The loss of condylar support in the right condyle caused a shift to the right, so that only the right second molar is contacting. Copyright 2013 by Mosby an imprint of Elsevier Inc.
A, This radiograph reveals idiopathic condylar resorption of the left condyle. The majority of this bone loss occurred in a 3-month period. B, As a consequence of this significant and rapid bone loss, the mandible was shifted to the left side, where only the left second molars contact. C, As the left masseter and temporal muscles contract, the mandible is shifted to the left, so that only the second molars contact on the affected side. D, The heavy contact on the second molar accompanied by the elevator muscle activity has caused a posterior open bite on the patient’s right side.
LAB Palpation of Lateral Poles, Bite Test Pain Map – we will not cover
Copyright 2013 by Mosby an imprint of Elsevier Inc.
Rheumatoid arthritis commonly causes a significant and relatively rapid loss of the articular bone of both condyles. With this loss of posterior support to the mandible, the posterior teeth begin to contact heavily. These teeth act as fulcrums by which the mandible rotates, collapsing posteriorly and opening anteriorly. The result is an anterior open bite.
Treatment for Arthralgia • No Chew Diet • Gentle Mandibular Mobilizations to gate pain/flush joint • Treat Masticatory pain ( if diagnosed) • Controlled mouth opening • Control Yawn • Avoid elective dental work • Discuss with Dentist possible NSAIDs • Modalities – Heat or ice – US (phono) – Ionto – LLLT
Green Bay, WI April 20, 2017
Hypermobility • Patient will report the jaw “goes out” when opening wide • At the later stage of opening, the condyle will jump forward leaving a small depression in the face behind it • A deviation can be present and greater and much closer to the maximally open position that that seen with Disc Derangement disorder
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• An eminence click may or may not be felt or heard • In my opinion loading the mandible with opening brings out subluxation or eminence click so that it is more noticeable • S: jaw goes out when opening wide, joint noises end of mouth opening or beginning of mouth closing, jaw catches on closing from fully opened position • O: A jutter is felt at end of mouth opening and the beginning of mouth closing, eminence click may or may not be felt or heard
With unilateral hypermobility, the mandibular midline shifts to the contralateral side at the very end of mouth opening, when the condyle passes the articulating eminence, and you end up with a deflection.
DEFLECTION
Treatment for hypermobility • Patient education • Control mouth opening – – – –
Eat smaller bites of food Limit mouth opening with dental cleanings No Jimmy John subs☺ Control yawning (tongue up against palate, far back if necessary) – Controlled mouth opening – Neuromuscular reed- hyperboloid training, deep masseter and lateral pterygoid retraining
a
b
Manipulation after TMJ dislocation: (a) The condyle is dislocated anterior to the articular eminence (red shadow). (b) During manipulation, the posterior part of the mandible is distinctly guided downwards-backwards to aid the condyle in passing the articulating eminence and retrude into the articulating fossa. (c) After successful manipulation, the condyle is seated in the articulating fossa behind the articulating eminence at intercuspal position. c
A, Clinical appearance of a spontaneous dislocation (open lock). The patient is unable to close the mouth. B, A panoramic radiograph of a patient experiencing a spontaneous dislocation. Here the condyles are bilaterally positioned anterior to the eminences.
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Michael Karegeannes PT
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Normal Stable Disc/Condyle Disc/Eminence
Disc Displacement An anterior or anterior medial disc displacement is the most common form of a disc displacement that potentially effects jaw range of motion A, In the closed-joint position, the pull of the superior lateral pterygoid muscle is in an anteromedial direction (arrows). B, When the mandible translates forward into a protrusive position, the pull of the superior head is even more medially directed (arrows). Note that in this protruded position the major directional pull of the muscle is medial and not anterior. C, From a superior view, the entire disc may be displaced anteriorly medially. D, In some instances, the lateral portion of the disc may be more displaced than the medial portion. E, In still another instance, the medial portion of the disc may be more displaced than the lateral portion. Parts A, B courtesy of Dr. Samuel J. Higdon, Portland OR.
A, Normal position of the disc on the condyle in the closed-joint position. B, Functional displacement of the disc. Its posterior border has been thinned and the discal and inferior retrodiscal ligaments are elongated, allowing activity of the superior lateral pterygoid to displace the disc anteriorly (and medially. C, In this specimen the condyle is articulating on the posterior band of the disc (PB) and not on the intermediate zone (IZ). This depicts an anterior displacement of the disc. (Part C courtesy of Dr. Julio Turell, University of Montevideo, Uruguay.)
Piper Classification
Rocabado has 4 Phases of Disc Displacement Disorders
http://www.pipererc.com/tmj.asp
Musculoskeletal Approach to Maxillofacial Pain, by Rocabado and Iglarsh,1991
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• Phase I- the disc drops medially as the LCL elongates beyond 70% or 80% • With Phase 1 no joint sounds, and there is actually a medial subluxation in opening and a lateral reduction in closing (opposite from phase 2 and 3, in which the disc reduces with opening and subluxes with closing) • Causes could be occlusal fulcrum, cross bite, posterior rotation of cranium Musculoskeletal Approach to Maxillofacial Pain, by Rocabado and Iglarsh,1991.
Musculoskeletal Approach to Maxillofacial Pain, by Rocabado and Iglarsh,1991
• Phase II- click will occur at about 10-20mm of opening, an early opening click, a late closing click • Pattern of dysfunction in Phase II is opposite I, In Phase II with opening the click is the disc reducing, and the click on closing is the disc subluxating again • So the disc is now more anterior and probably medial • Frequently accompanied by parafunction, i.e. nocturnal grinding or nail biting Musculoskeletal Approach to Maxillofacial Pain, by Rocabado and Iglarsh,1991
• Phase III- there is significant LCL and posterior ligament overstretching • The shape of the disc can become distorted, more convex • Late opening click at 20-30mm, and a click upon closure • Can develop capsular tightness, and hence mobilizations are performed to address this
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Couple of key points
• Phase IV- The disc may be completely deformed in front of the condyle. • The condyle will rotate deep within the mandibular fossa, but cannot translate forward, in the initial stages of disease, although later normal motion may return • There is no joint sound. • Limitation of the translation phase of opening may result in a loss of up to 50% of total opening, with a deflection of the mandible to the side with limited motion • This is called a posterior-superior condylar-disc luxation with an anterior disc-temporal luxation. • Disc is not reducible
• The further anteriorly the disc is on the temporal eminence, the more displaced it is and the greater opening (or protrusion according to the 4:1:1 rule) needed for the condyle to reduce into the disc • The disc can also displace laterally and (more commonly) medially. • Note that the condyle and the disc luxate in opposite directions. • A therapist who assesses a sound with 40-50mm of opening with loading is usually not subluxated. The sound is due to the condyle going over the anterior border of the disc or temporal eminence- this is an over-rotation subluxation due to hypermobility (overrotation because all the translation has been used up). It is not a phase 4, but may lead to a phase 1 later on.
Classification of Disc Displacement
Factors contributing to a disc displacement
Stage 1 Disc displacement with Reduction (DDWR) Stage 2 Disc Displacement without Reduction with limited opening (DDWoR WLO) Stage 3 Disc Displacement without Reduction without limited opening (DDWoR WoLO)
• • • •
Trauma Anteriorly displaced by muscles ( sup Lat Ptyer) Superior retrodiscal lamina becomes elongated Tanaka identified a ligamentous attachment of the medial portion of the condyle-disc complex to the medial wall of the fossa, if this ligament was bound down, forward movement of the condyle might create a tethering of the disc medially • LCL laxity – Repetitive – Sustained – Excessive joint loading
Evaluation and Treatment of TMD by Steve Kraus, Jan 2013 course presentation
DDWR- STAGE I
DDWR • Subjective – patient reports having a click in their jaw(s) while opening their mouth – Patient may or may not have a prior experience of their jaw locking intermittently so that it would not open all the way
Copyright ©2013 by Mosby, an imprint of Elsevier Inc.
Reciprocal click. Between positions 2 and 3 a click is felt as the condyle moves across the posterior border of the disc. Normal condyle-disc function occurs during the remaining opening and closing movement until the closed-joint position is approached. Then a second click is heard as the condyle once again moves from the intermediate zone to the posterior border of the disc (between 8 and 1).
• Definition- Click or a snap, pop or crack is a distinct sound, of brief and very limited duration, with a clear beginning and end that emanates from the TMJ
Management of Temoromandibular Disorders and Occlusion by Jeff Okeson, 7 th edition, 2013
Green Bay, WI April 20, 2017
Michael Karegeannes PT
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DDWR
DDWoR WLO- STAGE II (close lock)
• Objective Findings – A palpable irregularity of a reciprocal clicking is felt and maybe heard – Opening click is louder that the closing click – Opening click at 5 to 10mm or greater of interincisal opening with the closing click less than 5mm – Clicking may occur during lateral excursion or protrusion – Clicking is eliminated on protrusive opening and closing
Copyright ©2013 by Mosby, an imprint of Elsevier Inc.
Functional disc dislocation without reduction (Closed lock). The condyle never assumes a normal relationship on the disc but instead causes the disc to move forward ahead of it. This condition limits the distance it can translate forward.
DDWoR WLO- STAGE II • Subjective– Limited opening that is severe enough to interfere with eating, yawning, brushing of teeth, flossing, singing, etc. – History of clicking w/or w/o intermittent locking – Intermittent locking would be when a patient experiences a sudden episode of limited mouth opening. Mouth opening returns to normal with spontaneous resolution or resolution in response to force or movement (lateral, protrusive and/or opening) exerted by patient Evaluation and Treatment of TMD by Steve Kraus, Jan 2013 course presentation
DDWoR WLO- STAGE II • Objective– Maximum unassisted mouth opening 30mm of MIO Palpable crepitus may or may not be identified during opening and closing Evaluation and Treatment of TMD by Steve Kraus, Jan 2013 course presentation
TMJ AUTOPSY SPECIMEN (Normal Joint)
TMJ AUTOPSY SPECIMEN (Non-Reducing Disc)
TMJ AUTOPSY SPECIMEN (Reducing Disc)
DDWR Subjective-clicking Objective –feel/hear a click during mandibular opening and closing --elimination of click on protrusive opening and closing DDWoR WLO Subjective—limited function ---prior history of popping with or without intermittent locking Objective –mandibular opening< 30mm --limited mandibular movement with deflection towards the involved joint during opening and protrusion --a decrease in lateral excursion towards the opposite side of the involved joint DDWoR WoLO Subjective– may complain of limited function --prior history of popping with or without locking, crepitus may or may not be present Objective—normal or near normal (>30mm) mouth opening --palpable irregularities of crepitus may or may not be identified during opening and closing Evaluation and Treatment of TMD by Steve Kraus, Jan 2013 course presentation
Green Bay, WI April 20, 2017
Michael Karegeannes PT
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Lab Session—Diagnosing Stage I, II, III
Physical Therapy for DDWR without Pain • Explain and educate patient as to what is going on, popping may continue indefinitely, they may experience brief moments of locking, • Reassure what they have is common, their condition rarely deteriorates to the level of having chronic pain and loss of oral function • Try to ease their fears so as not to create anxiety or somatize their joint condition Evaluation and Treatment of TMD by Steve Kraus, Jan 2013 course presentation
Physical Therapy for DDWR with Pain • Treat other sources of symptoms that may be unrelated to the DDwR such as: – Arthralgia – Muscle pain – Cervical spine pain
Physical Therapy for DDWR with Intermittent locking • Objective is to decrease joint loading which may: – Decrease intermittent locking and/or – Decrease loudness of the pop and/or – Increase mouth opening before the pop (in essence increasing translation, by probably moving the disc more anterior) – Improving opening, while decreasing loudness or intensity of pop, maybe eliminating click all together. Decrease joint loading by – Decreasing jaw muscle tension – Decreasing neck muscle tension Evaluation and Treatment of TMD by Steve Kraus, Jan 2013 course presentation
• Then I will follow up all mobilizations with controlled mouth opening • Then I have patient perform lateral excursion with 2 tongue depressors or hyperboloid
Manual Techniques • Intraoral/Extraoral Massage of muscles identified on evaluation • Mobilization techniques to TMJ – Long axis distraction – Laterally mobilize condyle for medial joint distraction – Stabilize condyle and mobilize Cranium laterally for lateral joint distraction (superior compartment per Rocabado)
Green Bay, WI April 20, 2017
– Active, active/assistive, passive – I do not do protrusive movements until pain and inflammation are significantly down. – Protrusion, or translation is irritating to joint, if you regain lateral excursion which is less irritating to joint, protrusion will come, as will opening ROM
Michael Karegeannes PT
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• I always finish Jaw techniques with a courtesy suboccipital distraction • I then proceed to slowly progress patient thru postural correction program • I will typically show the rest position of the jaw and add jaw wiggle • I will add chin nod to begin decompressing suboccipital area. • If necessary I will finish with modalities, laser, ice etc for pain relief • Over time add stabilization exercise with Hyperboloid, deep masseter (laterally) and Lateral Pterygoid (medially) to the disc
Physical Therapy for DDWoR WLO
TMJ MOBILIZATION LAB
Green Bay, WI April 20, 2017
• Increase condyle/disc translation • Manual massage techniques • Mobilization techniques/ Mobilization with guided movement into translation or lateral excursion – Gentle techniques – Min to no pain – Add cervical extension with mobilization techniques if needed • Controlled mouth opening (tongue on left or right maxillary molars) • Lateral excursions • Mandibular isometrics • Tongue depressor stretch • Cervical treatment • Modalities as needed
Michael Karegeannes PT
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neutral
left lateral excursion
right lateral excrusion Self Long Axis Distraction Technique
Finger Spread Technique
Protrusion
Tongue depressor stretch
Home Program
Physical Therapy for DDWoR WoLO
• Handouts • Postural correction exercises • Measuring tongue depressor so patient knows what their opening was when they left treatment. Goal is to maintain opening between sessions, but not uncommon to lose a few mm between sessions • I like to gain 3 to 5mm each session, with the goal being maintaining about 5 mm range each week.
• Requires no treatment other than explain what they are experiencing • Crepitus may continue indefinitely if present • What they have is common • If pain is present, then Treat: – Arthralgia – Masticatory Muscle Pain – Referred pain from Cervical spine Evaluation and Treatment of TMD by Steve Kraus, Jan 2013 course presentation
Concurrent diagnostic subsets identified in this study are similar to those of other studies, which show that a 1category diagnostic subset of TMD is scarce in the clinical environment. The largest subset of TMD is myofascial pain, and the most common concurrent diagnostic subset identified in group II and group III is myofascial pain. The most prudent thing to do therefore in the clinical setting would be to manage myofascial pain. Managing myofascial pain often reduces pain and dysfunction associated with group II and III diagnoses. Treating only myofascial pain may work well for the majority of patients. For other patients, it may be necessary that their concurrent diagnostic subsets be dealt with simultaneously. Characteristics of 511 patients with temporomandibular disorders referred for physical therapy by Steven L. Kraus, PT Oral Surg Oral Med Oral Pathol Oral Radiol 2014;118:432-439
Green Bay, WI April 20, 2017
Characteristics of 511 patients with temporomandibular disorders referred for physical therapy by Steven L. Kraus, PT Oral Surg Oral Med Oral Pathol Oral Radiol 2014;118:432-439
Michael Karegeannes PT
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Hyperboloid Exercises for ROM and Neuromuscular Reeducation
Rocabado 6 x 6
Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders: Systematic Review and Meta-Analysis Susan Armijo-Olivo, Laurent Pitance, Vandana Singh, Francisco Neto, Norman Thie, Ambra Michelotti Phys Ther. 2016 Jan;96(1):9-25.
Although the overall level of evidence is low, exercises and MT are safe and simple interventions that could potentially be beneficial for patients with TMD. Active and passive exercise for the jaw, postural exercises, and neck exercises appear to have favorable effects for patients with TMD. Manual therapy alone or in combination with exercises shows promising effects. Exercises did not show clear superiority over other conservative treatments for TMD.
Here is the group I like to work with. There are so many kids with headaches, parafunction, mouth breathers, poor posture. This is the group to me that we have the greatest chance of helping and not allowing early degeneration of the TM joints and cervical spine!
Cervical Spine Evaluation
Green Bay, WI April 20, 2017
Michael Karegeannes PT
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Jules Hesse fysiotherapist☺ Amsterdam http://www.juleshesse.nl/
Characteristics of 511 patients with temporomandibular disorders referred for physical therapy by Steven L. Kraus, PT Oral Surg Oral Med Oral Pathol Oral Radiol 2014;118:432-439 A single blind examiner evaluated cervical range of motion (ROM) measures including axial rotation during the flexion-rotation test (FRT) and sagittal plane ROM. Twenty asymptomatic subjects were compared with 37 subjects with pain attributed to TMD, confirmed by the Revised Research Diagnostic Criteria. Subjects with TMD were divided according to the presence of headache (26 without headache TMDNHA, 11 with headache TMDHA). One-way analysis of variance and planned orthogonal comparisons were used to determine differences in cervical mobility between groups. All subjects with TMD were positive on the FRT with restricted ROM, while none were in the control group.
Neck pain was the second most common symptom in the present study, reported by 68% of the 511 patients. The coexistence of neck pain and TMD has been reported previously and its clinical implications should not be underestimated.
Green Bay, WI April 20, 2017
CONCLUSIONS: Subjects with TMD had signs of upper cervical spine movement impairment, greater in those with headache. Only subjects with TMD and headache had impairment of cervical spine sagittal plane mobility. This study provides evidence for the importance of examination of upper cervical mobility determined by the FRT in patients who suffer from TMD.
Michael Karegeannes PT
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POSTURE
FACIAL ASSYMETRY
Cervical Spine Treatment
6.5
101
6.5
5
SAGITAL CRANIOCERVICAL from ROCABADO.
C2-7V
PEDIATRIC
ADULT.
DEGENERATION IS NOT A PROBLEM OF AGE.
Rocabado Rocabado
Green Bay, WI April 20, 2017
Michael Karegeannes PT
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Convergence of the trigeminal and cervical nerves is an anatomic and physiologic explanation for referred pain from the cervical region to the trigeminal
The muscles of the jaw, tongue, face, throat, and neck work synergistically to execute multiple orofacial functions, but pain in these areas alters the movements. Neck or shoulder pain may result in impaired jaw movement and vice versa. A, Injury to the trapezius muscle results in the tissue damage. Nociception arising in this cervical region is transmitted to the second-order neuron and relayed on to the higher centers for interruption. B, As this input becomes protracted, note that the adjacent converging neuron is also centrally excited, which relays additional nociception on to the higher centers. The sensory cortex now perceives two locations of pain. One area is the trapezius region, which represents a true source of nociception (primary pain). The second area of perceived pain is felt in the TMJ area, which is only a site of pain, not a source of it. This pain is heterotopic (referred). (Adapted from Okeson JP. Bell’s Orofacial Pains. 5th ed. Chicago: Quintessence; 1995:66.)
Metal Mayhem
Perspective: The current study showed the existence of multiple active muscle TrPs in the masticatory and neck-shoulder muscles in women with myofascial TMD pain. The local and referred pain elicited from active TrPs reproduced pain complaints in these patients. Further, referred pain areas were larger in TMD pain patients than in healthy controls. The results are also in accordance with the notion of peripheral and central sensitization mechanisms in patients with myofascial TMD.
Combined treatment approach of Mobilization, Manipulation and Exercise provides relief!
Key Points
journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 |
Green Bay, WI April 20, 2017
● Mechanical neck disorders are common, costly, and can be disabling. ● This systematic review of 33 trials did not favor mobilizations and/or manipulations done alone or combined with other treatments like heat for relieving acute or persistent pain and improving function when compared to no treatment. ● Mobilization and/or manipulation when used with exercise are effective for alleviating persistent neck pain and improving function when compared to those who received no treatment. When compared to one another, neither mobilization nor manipulation was superior. ● There was insufficient evidence available to draw conclusions for mechanical neck disorder with radicular findings.
Michael Karegeannes PT
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Low to Moderate quality evidence supports the use of specific cervical and scapular stretching and strengthening exercise for chronic neck pain immediately post treatment and intermediate term and cervicogenic headaches in the long term! Individuals with neck pain who received a combination of thoracic spine thrust manipulation and cervical spine nonthrust manipulation plus exercise demonstrated better overall short-term outcomes on the numeric pain rating scale, the Neck Disability Index, and the global rating of change. journal of orthopaedic & sports physical therapy | volume 43 | number 3 | march 2013
Functional and Structural Changes in Muscles related to pain (adapted by Falla and Farina 2007)
THE ROLE OF THE PHYSICAL THERAPIST IS TO BE A
Treatment Approach Cervical Spine
Myofascial Mobilization
“STUDENT OF MOTION, SCULPTOR OF STRUCTURE, Joint Manipulation & Mobilization
AND FACILITATOR OF FUNCTION.”
Patient directed exercises to maintain myofascial mobility, And Joint mobility
Neuromuscular reeducation and strengthening of supporting musculature
As quoted from a 1991 article By Mannheimer and Rosenthal
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Ergonomics and Bad Habits
Michael Karegeannes PT
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Healing Hands by Joseph Ventura
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Soft tissue massage •
• •
Massage induces acute antinociceptive effects involving opioid and oxytocin interaction(hug) Massage may alter the sensitization state of the trigeminocervical nucleus Massage may influence the potential to change the neck muscle tone through alteration of the trigeminalreticular pathway
Dr. Kathleen C. Light, a professor at the University of North Carolina Department of Psychiatry
Effects of partner support on resting oxytocin, cortisol, norepinephrine, and blood pressure before and after warm partner contact. Psychosom Med. 2005 JulAug;67(4):531-8. Grewen KM, Girdler SS, Amico J, Light KC.
ANTERIOR CRANIAL LUXATION, DENTAL CASE, LACK OF DIAGNOSIS. PT/OT RESPONSIBILTY.
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Michael Karegeannes PT
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3 Primary Conditions That Could Contribute to Disruption of Strength and Integrity of These Ligaments
3 Quick Screens • Alar Odontoid Integrity Test
• Down’s Syndrome
• Transverse Ligament Test/Anterior Shear Test: • Rheumatoid Arthritis
– S/C Flexion or chin nod – Sharp Purser Test
• Cervical Spine Trauma, – MVA or CAD Injuries S3 Seminar manual by Stanley Paris, 2000 edition
Occult hypermobility of the craniocervical junction: a case report and review. Mathers KS, Schneider M, Timko M. J Orthop Sports Phys Ther. 2011 Jun;41(6):444-57.
S3 Seminar manual by Stanley Paris, 2000 edition Occult hypermobility of the craniocervical junction: a case report and review. Mathers KS, Schneider M, Timko M. J Orthop Sports Phys Ther. 2011 Jun;41(6):444-57.
Suboccipital Release
More aggressive suboccipital release with head pinning
Gentle Relaxation and Mobilization While Assessing
Distraction
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Michael Karegeannes PT
Downslide
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Stabilize C2 with lumbrical grip not pincher
C0-C2 Distraction
I will palpate transverse process of Atlas bilaterally either sitting or supine or both, to assess which one feels more prominent, which might suggest a rotational issue of C1, usually the one more prominent tends to be more tender. Then use FRT to confirm. If you have a hard time finding the TP of C1 have patient protruded their mandible to expose TPs.
Distract base of occiput with other hand and head pinning
ASSESSING C1C2 ROTATION RESTRICTIONS With Flexion-Rotation Test
MUSCLE ENERGY TECHNIQUE TO CORRECT C1C2 ROTATION RESTRICTION
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Muscle Energy Technique for Restricted Rotation to the Right at C1-2
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Muscle Energy Technique for Restricted Rotation to the Right at C1-2
MANUAL TOWEL TRACTION
1.The patient is supine, and the operator sits or stands at the patient's head. 2.With the palms of both hands (and/or belly), the operator supports the patient's head and flexes the neck as far as it easily goes, usually approximately 45 degrees or I will do chin to chest. 3. Monitoring on the posterior lateral aspect of C2, the operator turns the patient's head to the right, until C2 on the left just begins to move or you engage barrier, and then backs off the barrier by de-rotating slightly 4. The patient is asked to turn his or her head gently to the left (or don’t let me turn you right) or simply to move his or her eyes to the left. The effort is maintained for 3-5 seconds, while the operator resists any movement. 5. On relaxation, the operator rotates the patients head further to the right, and the patient is asked to look to the right to help facilitate further right rotation. 6. Steps 4 and 5 are repeated two or more times. 7. Retest to see if right rotation has been fully restored at this segment. ** Do the opposite for restricted rotation to the left at C1C2 **
P/A scooping motion with your fingers to upper thoracic spine
OSTEOPATHIC MANIPULATION • High Velocity/Low Amplitude • Create a barrier
Block cervical spine and occiput from going into too much extension
– A cumulative end of range vs. anatomical end of range – You “create” this barrier by combining many components: flexion, extension, sidebending, sideshifting, rotation and don’t forget compression!
Lean back on back leg to use your body vs. too much arms
OA SIDEBENDING MANIPULATION
Effects of manipulation • Mechanical – – – –
Stretch out tight capsules Stretch out adhesions Snap adhesions “pop” Alter positional relationships
• Psychological – Laying on of intelligent and skilled hands provides confidence and assurance something good will happen – Hearing or feeling the “pop”
• Neurophysiological – Firing type III inhibitory receptors reducing muscle holding
• Chemical effects Healing Hands by Joseph Ventura
– Possible release of endorphins
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Michael Karegeannes PT
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Trapezius
The present study shows that the dry needling treatment is effective in relieving the pain and in improving the quality of life of patients with MPS.
SCM
Finger placement for photographic reasons
Anterior scalene
Levator
Oblique Capitas Inferior directed towards opposite eye (fingers removed for photographic reasons)
Chin Nod Start with back of head and spine against corner of wall
Nod your chin down about 15 degrees The back of your head should remain in contact with the wall Your eyes should remain level-imagine a string at the top of your head pulling up Do 15 reps x 5 secs each 5 times a day
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Michael Karegeannes PT
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CERVICAL JOINT LIBERATION (Rocabado)
Stabilize C2
The best available studies indicate that the C2/C3 zygapophysial joints are the most common source of cervicogenic headache
C1-C2 self-sustained natural apophyseal glide (SNAG) for cervical right rotation. Force is applied to the C1 level via horizontal pressure from the strap. At the same time, the subject actively turns his/her head to the right.
Cooper G, Bailey B, Bogduk N. Cervical zygapophysial joint pain maps. Pain Medicine 2007; 8: 344–53. Lord S, Barnsley L, Wallis B, Bogduk N. Third occipital headache: a prevalence study. J Neurol Neurosurg Psychiatr 1994; 57: 1187–90. Bogduk N, Marsland A. On the concept of third occipital headache. J Neurol Neurosurg Psychiatr 1986; 49: 775–80. Bogduk N, Marsland A. The cervical zygapophysial joints as a source of neck pain. Spine 1988; 13: 610–17.
Foam Roller Chest Stretch Sidebend your head to one side, slightly off the foam roller, gently grab your head to add in the sidebending component Place your arm in the position shown, experiment with arm straight or slightly bent
Make sure arms are just above 90 degrees Elbows should be bent at 90 degrees Hold position for 3 minutes, increase time as tolerated
Now rotate your head up and back to feel stretch in area as shown below
Do each side twice, 2 reps x 30 to 60 seconds,
Do exercise 1 to 2 times a day
Do 1 to 2 times a day.
**To enhance stretch nod chin down and pull your navel into your spine
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Michael Karegeannes PT
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PRONE CHIN NOD
DIAGNOL THERABAND SCAPULAR STRENGTHENING EXERCISE
Thumb is up!!
Start position
Edge of table should be about mid chest Arms at your side
Nod chin in as in standing wall exercise Imagine string at top of head pulling you tall
Sitting with excellent posture Be sure to reach way back Perform 2 sets of 10-15 reps each arm Perform 3x a week
Finish Position
Perform 15 reps x 5 secs each Perform exercise 1 to 2 times a day
Thumb is pointing back!!
LATISSIMUS THERABAND STRENGTHENING EXERCISE
HORIZONTAL ABDUCTION THERABAND SCAPULAR STRENGTHENING EXERCISE
Palms facing out!!
Start Position
Finish Position
Start Position
Lower only to shoulder height!!
Finish Position Sitting with excellent posture Be sure to reach way back Perform 2 sets of 10-15 reps each arm Perform 3x a week
Theraband should be behind head!!
Sitting with excellent posture Be sure to reach way back Perform 2 sets of 10-15 reps each arm Perform 3x a week
ALL-IN-ONE SCAPULAR/NECK STABILIZATION EXERCISE
Alternate View
Lower Trapezius
Nod your chin down 15 degrees Keep band pressed between your head and the wall Straighten arms without your head leaving wall Perform 2 sets x 10 reps each 3 to 4 times a week
Mid Trapezius
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Michael Karegeannes PT
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Latissimus Dorsi
Rhomboid
Serratus Anterior
Magnetic resonance imaging study of the morphometry of cervical extensor muscles in chronic tension-type headache C Fernández-de-las-Peñas, A Bueno, J Ferrando, JM Elliott, ML Cuadrado & JA Pareja
Rectus capitis posterior minor, left side is image of control group, right side is image of CTTH group In conclusion, RCPmin and RCPmaj muscles showed reduced rCSA in CTTH patients compared with healthy controls. Headache intensity, frequency and duration were greater in those CTTH patients with more reduced rCSA in both RCPmin and RCPmaj muscles.
Craniocervical Flexion Start with pressure biofeedback inflated to 20 mmHg. Make sure your chin and forehead are lined up. Nod your head, keeping the large neck muscles soft and bringing the reading up to 22 mmHg. Work up to ten 10-second holds. Then progress to 24, 26, and 28 mmHg. 5 to 10 reps, 5 to10 second hold times, increase as tolerated.
The Change in Deep Cervical Flexor Activity After Training Is Associated With the Degree of Pain Reduction in Patients With Chronic Neck Pain, Deborah Falla, PhD, Shaun O’Leary, PhD, Dario Farina, PhD, and Gwendolen Jull, PhD, (Clin J Pain 2012;28:628–634)
YAMUNA BODY ROLLING
Supportive Therapies & Ergonomics
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Michael Karegeannes PT
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http://www.rapidforce-phs.com/
Correlations between Posture and Jaw Relations, Danner, Jakstat and Ahlers, Journal of Craniomandibular Function, 2009;1(2):149-163
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Michael Karegeannes PT
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Better Reading posture
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Michael Karegeannes PT
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LUMOback, the first posture sensor and mobile application to support healthy backs. Now introducing the LumoLift
www.varidesk.com www.lumobodytech.com
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Michael Karegeannes PT
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ERGONOMICS/BAD HABBITS
So even though there is vast evidence showing the functional coupling between the musculoskeletal structures of the cervical spine and the masticatory system, there is only weak evidence for a direct biomechanical mechanism (such as the effect of poor head posture on the masticatory system) as a cause for TMDs.
“POSTURE IS A REFLECTION OF ONES ATTITUDE TO LIFE”
Dr. Stanley Paris
The association between head and cervical posture and temporomandibular disorders: a systematic review. Olivo SA1, Bravo J, Magee DJ, Thie NM, Major PW, Flores-Mir C. J Orofac Pain. 2006 Winter;20(1):9-23. The association between the cervical spine, the stomatognathic system, and craniofacial pain: a critical review. Armijo Olivo S1, Magee DJ, Parfitt M, Major P, Thie NM. J Orofac Pain. 2006 Fall;20(4):271-87.
Occlusal Appliance Therapy • An occlusal appliance is a removable device, usually made of hard acrylic, which fits over the occlusal and incisal surfaces of the teeth in one arch. – Occlusal Splint – Bite guard – Night guard – Interocclusal appliance – Orthopedic device Maxillary Occlusal Appliance Copyright ©2013 by Mosby, an imprint of Elsevier Inc.
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Michael Karegeannes PT
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Not enough evidence about whether stabilisation splints can reduce pain caused by painful temporomandibular (jaw) disorders. Pain dysfunction syndrome (PDS) is the most common TMD (temporomandibular disorder, from the joint between the lower jaw and base of the skull). PDS is also called facial arthromyalgia, myofacial pain dysfunction syndrome and craniomandibular dysfunction. One option is a splint (a type of bite plate) at night when people otherwise may grind their teeth more. The stabilisation splint (SS) is one type, also known as the Tanner appliance, the Fox appliance, the Michigan splint or the centric relation appliance. The review found there is not enough evidence from trials to show whether or not stabilisation splints can reduce PDS.
Conclusions that can be drawn from this evidence-based review include;
J Evid Base Dent Pract 2006;6:48-52
Since occlusal treatments are typically irreversible treatments and the evidence on its therapeutic or preventive effects on TMJD is insufficient, it is recommended that reversible treatment such as self-care, splints, physical therapy, and cognitive-behavioral therapy be used to initially manage signs and symptoms of TMJD.
1. There is insufficient evidence to suggest that any occlusal treatment as reviewed here is more or less effective than placebo in treating TMJD pain. 2. There is also insufficient evidence to suggest that any occlusal treatment is as or more effective than other rehabilitation treatments in treating TMJD pain. 3. There is also insufficient evidence to support the generalized preventive influence of occlusal adjustment and orthodontic correction of malocclusion on TMJD development.
Indications for an oral appliance per Kraus • To reduce AM jaw muscle pain and or HA if symptoms are triggered by sleep bruxism induced by mayalgia or arthralgia • To reduce AM locking/catching associated with a disc displacement related to nocturnal bruxism activity Copyright ©2013 by Mosby, an imprint of Elsevier Inc.
• To protect occlusal surfaces of teeth and dental restorations from sleep bruxism forces Evaluation and Treatment of TMD by Steve Kraus, Jan 2013 course presentation
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The nociceptive reflex is activated by unexpectedly biting on a hard object. The noxious stimulus is initiated when the tooth and periodontal ligament is stressed. Afferent nerve fibers carry the impulse to the trigeminal spinal tract nucleus. The afferent neurons stimulate both excitatory and inhibitory interneurons. The interneurons synapse with the efferent neurons in the trigeminal motor nucleus. Inhibitory interneurons synapse with efferent fibers leading to the elevator muscles. The message carried is to discontinue contraction. The excitatory interneurons synapse with the efferent neurons that innervate the jaw, depressing muscles. The message sent is to contract, which brings the teeth away from the noxious stimulus.
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Bruxism vs. Clenching • Bruxing is an oral parafunctional activity that can occur Diurnally or nocturnally. Bruxing is classified as a series of rhythmic contractions, tooth grinding. ~ 20 to 38% of children brux, and 25% to 50% of adults brux • Clenching is more of a single contraction episode, and this can occur as well during the day or night.
The purpose of an anterior positioning appliance is to temporarily bring the mandible forward in an attempt to improve the condyle-disc relationship. A, This specimen reveals a disc dislocation. B, The MRI shows the disc to be dislocated anterior to the condyle. C, When the mandible is brought forward, the condyle is repositioned on the disc. D, The MRI shows the disc in its normal position on the condyle. This is a temporary therapeutic position that will encourage adaptation of the retrodiscal tissues. (Courtesy of Dr. Per-Lennart Westesson, University of Rochester, Rochester, NY.)
What is the best occlusal appliance design? • All appliances have the potential to be therapeutic for reasons that are not known • All Appliances have the potential of causing adverse side effects:
• The best appliance design is one that causes the least amount of adverse side effects while providing for the most potential therapeutic benefit: – Reduce AM muscle pain/HA – Reduce AM locking – Protect occlusal surfaces
– Increase pain – Movement of teeth, extrusion or intrusion – Potentially could lead to orthognathic surgery
Appropriate features of an oral appliance • Maxillary or mandibular full coverage, Maxillary is preferred when possible • Hard Acrylic vs. soft • Thin as possible, thickness of appliance is determined by looking at thickness of the appliance in the posterior molar region
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• Even centric stops on the appliance- ask the patient if they hit evenly on the appliance, ask the patient to “tap-tap-tap” on the appliance and if they hit evenly on the appliance • Shallow inclines of the acrylic leading into the centric stops
• Anterior guidance during protrusive and lateral excursions- anterior guidance is the relationship of any of the lower anterior 6 teeth maintaining contact with any of the upper 6 teeth during protrusive and lateral excursions resulting in disclussion of the posterior teeth during such movement
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Why should a TMD specialist assess the design and understand the purpose of an oral appliance?
• Gain insight of the appropriateness of the oral appliance design • Communicate to the dentist necessary changes in oral appliance design-possibly as a result of your work on posture, cervical spine alignment, etc… • Not uncommon for a dentist to ask for your advise on design of an oral appliance • Be satisfied that the patient has the best oral appliance design (according to the evidence) to achieve the best possible outcomes
James Fricton, DDS, MS/John O. Look, DDS, PhD/Edward Wright, DDS, MS/Francisco G. P. Alencar, Jr, DDS, MS/Hong Chen, DDS, MS/Maureen Lang, DDS, MS/Wei Ouyang, DDS, PhD/Ana Miriam Velly, DDS, PhD, Summer 2010 Volume 24 , Issue 3,pages 237-254.
Conclusion: Hard stabilization appliances, when adjusted properly, have good evidence of modest efficacy in the treatment of TMJD pain compared to non-occluding appliances and no treatment. Other types of appliances, including soft stabilization appliances, anterior positioning appliances, and anterior bite appliances, have some RCT evidence of efficacy in reducing TMJD pain. However, the potential for adverse events with these appliances is higher and suggests the need for close monitoring in their use.
DDS
PT
Management and Treatment of Temporomandibular Disorders: A Clinical Perspective EDWARD F. WRIGHT, DDS, MS; SARAH L. NORTH, PT, MPT; THE JOURNAL OF MANUAL & MANIPULATIVE THERAPY, VOLUME 17, NUMBER 4. pg. 247-254.
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Michael Karegeannes PT
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It’s not about the nail
THANK YOU!
Michael Karegeannes--Owner PT, MHSc, LAT, MTC, CFC, CCTT, CMTPT Jeff Verhagen PT, MBA, CMTPT Mike Verplancke – DPT, CSCS, CMTPT
4 locations: Fox Point, WI Brookfield, WI Grafton, WI Mukwonago, WI 414-352-2082 work 414-352-5279 fax
[email protected] [email protected] [email protected] www.freedompt.com www.treatingtmj.com
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TMD EVALUATION FORM TMD HISTORY Health Professionals seen for current symptom(s): ____________________________________ Diagnostic procedure(s) done: _____________________________________________________ Onset; trauma/insidious/surgery/other: _____________________________________________ Previous treatment(s) ____________________________________________________________ Medications; anti-inflammatory/muscle relaxer/narcotic/anti-depressant/antianxiety Progression of symptoms: better / worse / no change ________________________________ Do you have jaw pain?
No ___ Yes ___ R ___ L ___
Is your jaw pain: constant ___, daily ___, weekly ___ What increases your jaw pain? ______________________________________________ What decreases your jaw pain? ______________________________________________ Does your jaw click / pop / grind?
No ___ Yes ___ R ___ L ___
Do you have limited mouth opening?
No ___ Yes ___ R ___ L ___
Has your jaw ever locked open ___ or close ___
No ___ Yes ___ R ___ L ___
Do you clench ___ grind ___ brace ___ ?
No ___ Yes ___ R ___ L ___
Do you have ear symptoms?
No ___ Yes ___ R ___ L ___
Is your ear symptom (_____________________)constant ___ daily ____ weekly ___ What increases your ear symptom? __________________________________________ What decreases your ear symptom? __________________________________________ Do you have headaches?
No ___ Yes ___
Location: ________________________________________________________________ Is your H/A: constant ___, daily ___, weekly ___
© 2015 Freedom Physical Therapy Services S.C. Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com
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Do you wake with Headaches? No___ Yes___ What increases your H/A? __________________________________________________ What decreases your H/A? __________________________________________________ Do you have neck / shoulder pain?
No ___ Yes ___ R ___ L ___
Is your N/S pain: constant ___, daily ___, weekly ___ What increases your N / S pain? _____________________________________________ What decreases your N / S pain? _____________________________________________ Other symptoms? _______________________________________________________________ ______________________________________________________________________________
A. Mandibular Dynamics: 1. Vertical Opening a. Opening w/o pain ___mm
Key: 1= Mild Pain 2 = Moderate Pain 3 = Sever Pain RIGHT LEFT b. Maximum opening w/pain ___mm 123 123 c. Opening Pattern w/mandibular loading: a. Straight: _______ b. Deflection: R____ L____ c. Deviation: R to L ___ L to R____
2. Excursions: a. Right lateral Excursion: limited: No ___ Yes___ Pain: No___ Yes___
Right 123
Left 123
b. Left lateral excursion limited: No ___ Yes ___ Pain: No ___ Yes ___
123
123
c. Protrusion: limited: No ___ Yes ___ Deflection: No___ Yes ___ Pain: No ___ Yes ___
123
123
© 2015 Freedom Physical Therapy Services S.C. Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com
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B. Muscle Palpation: 1. Temporalis pain/ tight No ___ Yes ___ 2. Masseter pain /tight No ___ Yes ___ 3. Medial Ptyergoid pain /tight No ___ Yes ___ 4. Temporalis Tendon pain/ tight No ___ Yes ___ 5. Vicinity of Lat Pty pain/ tight No ___ Yes ___ 6. Ant/Post Digastrics pain/ tight No ___ Yes ___ 7. SCM pain/tight No ___ Yes ___ 8. Subocc pain/tight No ___ Yes ___ 9. Levator pain/ tight No ___ Yes ___ 10. Trapezius pain/tight No ___ Yes ___ C. Joint Palpation: 1. Lateral Pole with back teeth together pain: No ___ Yes ___ 2. Lateral Pole with mouth open (>11mm) pain: No ___ Yes ___ 3. Posterior attachment “inside ear” pain: No ___ Yes ___
Right 123 123 123 123 123 123 123 123 123 123
Left 123 123 123 123 123 123 123 123 123 123
123 123 123
123 123 123
D. Pain Map
E. Joint Loading Right Left 1. Biting of fulcrum right molars pain: No ___ Yes ___ 123 123 If painful, response was joint (L) ___ muscle (R) ___ both ___ 2. Biting on fulcrum left molars pain: No ___ Yes ___ 123 123 If painful, response was joint(R) ___ muscle(L) ___ both ___ F. Patient can bring back teeth together: No ___ Yes ___ G. Hypermobile No ___ Yes ___ Identified by: “jutter” R/L and/or eminence click R/L H. Beighton Scale ___/9
© 2015 Freedom Physical Therapy Services S.C. Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com
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I.
Stage I (Disc Displacement with Reduction) Summary: No __ Yes __: R __ L __ 1. Palpable opening click No ___ Yes ___: R___ L ___ 2. Late closing click No ___ Yes ___: R ___ L ___ Click too soft to ID ___ 3. Opening click eliminated on protrusive opening and closing No: R _ L _ Yes: R _ L _ 4. Patient reports having had intermittent locking No ___ Yes ___
J.
Stage II (Disc Displacement without Reduction with Limited Mouth Opening) Summary: No __ Yes __: R _ L_ 1. Active Unassisted Mouth Opening is < 30mm (see mandibular dynamics) No _ Yes _ 2. Prior history of clicking with or without intermittent locking: No __ Yes __: R _ L _
K. Stage III (Disc Displacement without Reduction without Limited Mouth Opening) Summary: No_ Yes _: R _ L _ 1. Active Unassisted Mouth Opening is > 30mm (See mandibular mechanics) No __ Yes __ 2. Prior History of Clicking with or without Intermittent Locking: No __Yes __: R __ L __ L. M. N. O.
Crepitus: No __ Yes __: R __ L __ Occlusion: Anterior Open Bite __ Posterior Open Bite __ Cross Bite Yes/No R or L Parafunctions Identified: No ___ Yes ___ nail biting, scalloped tongue, cheek biting, etc Lip or Tongue Frenulum tightness No____ Yes____
P. Cranial Nerve Tests: a. Trigeminal i. Jaw Reflex ii. Corneal Reflex iii. Sensory testing (light touch and pin prick) iv. Isometric tests: 1. Direction of movements: a. Depression b. Elevation c. Lateral excursion b. Facial i. Muscle testing ii. Corneal reflex iii. Sense of taste iv. Salivary gland v. Tear gland
© 2015 Freedom Physical Therapy Services S.C. Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com
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Oral Appliance Evaluation 1. Maxillary Full Coverage Maxillary Anterior Coverage Mandibular Anterior Coverage Mandibular Full Coverage Mandibular Posterior Coverage Anterior Repositioning Appliance
yes yes yes yes yes yes
no no no no no no
2. Hard_____ Soft____ 3. Thin_____ Thick___ 4. Centric Stops on a full coverage hard appliance ( tap/tap/tap) NA ___ even all around ___ front___back right___back left ___ 5. Inclines leading into the centric stops
Shallow ___ Steep ___
6. Anterior Guidance: ___ balancing interference(s) were not present during protrusive And lateral movements ___ balancing interference (s) were present during: Protrusive movement R L no R lateral movement yes(left) no L lateral movement yes(right) no _____________________________________________________________________________________ Frequency in use of the oral appliance
24 hours a day 24 hours a day except for eating As needed during the day At night
Did your dentist tell you the purpose of the intraoral appliance
yes yes yes yes
no no no no
yes
no
If yes, what is the purpose: _______________________________________________________ ______________________________________________________________________________
© 2015 Freedom Physical Therapy Services S.C. Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com
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ROCABADO 6 X 6
The therapist should always implement a home treatment program to reinforce the clinical treatment plan of care and modify the patient's lifestyle and how the patient’s body functions in its working and home environment. As the craniomandibular and craniocervical environment is altered, it must be maintained. Exercises remove parafunctional habits and reinforce new postures and functions. The home program, the "6 x 6 program” is a sequence of exercises for the patient in dysfunction. This 6 x 6 exercise program complements the active clinical program performed by the therapist during the patient's acute and sub·acute dysfunctional stages. The home program exercises modify or reinforce the postural relationships of: the cranium to the upper cervical spine, the cervical spine(anterior, posterior, and lateral aspects) to the shoulder girdle, and the mandible to the maxilla. These inter-relationships make up the elements that impact on the orthostatic equilibrium of the entire upper body. Consequently, the practitioner must consider each of these components, the relationship of one component to another, and the impact of each component on the entire body. Therefore, the therapist treating temporomandibular pain must not restrict their evaluation and treatment to the structures or the face and jaw, but look at the entire body. The objectives of the home self-mobilization program are: I. To learn a neutral postural position and rest position of the mandible 2. To fight the “soft tissue memory" of the old position 3. To restore the muscle to its original functional length 4. To restore normal joint play and mobility 5. To restore normal balance among the body parts 6. To give the patient an ongoing exercise program to incorporate into their life activities. This program should be initiated as the patient's pain begins to diminish. At this point the exercises will not irritate an acute condition and a therapist-patient relationship is established to some degree. These factors will maximize effective patient compliance with the exercise program. Factors that promote patient compliance are:
© 2015 Freedom Physical Therapy Services S.C. Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com
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I. The exercises should not produce nor increase pain. 2. The patient should be taught the exercises gradually, one to two per session. 3. The exercises should not take more than a few minutes to perform. 4. The performance of the exercises should be performed regularly and often so they become a routine act that contributes to the consistent compliance of the patient to the program. 5. The exercise performance should be spaced through the day (every 2-3 hours). 6. Performance expectations should not exceed the what a patient can truly accomplish between work and home responsibilities. 7. Visual cues wilt help patients remember to perform the exercises, i.e., sticky note on computer, phone, desk, mirror in bathroom, a timer or any helpful reminder. The 6 x 6 program is not meant to be a time consuming regime. These exercises should be able to be performed in any position and not last more than a few minutes. The program is termed "6 x6” because: 1. There should be no more than six instructions, 2. They should be repeated six times each, and 3. They should be performed six times a day. Although each exercise program should be individually designed to the patient's complaints, there are six fundamental exercises commonly used in the treatment of head-neck-mandibular dysfunction for these patients. These components are as noted below. 1. Rest position of the tongue: To establish a correct position of the tongue during rest, it is necessary to teach the patient the correct position of the tongue against the hard palate. The practitioner asks the patient to place their tongue against the hard palate (never directly behind the upper incisors) and make a "cluck-like” sound, or say the word “no” or “never”. This action will position the tip of the tongue in the same position that it assumes during swallowing and the correct mandibular rest position. After identifying this position, the patient attempts to maintain the anterior one-third of their tongue against the palate with a slight pressure, key word is slight. This position will contribute to the creation of negative pressure in Donder's space to hold the tongue with little or no muscle action against the hard palate, the normal rest position of the tongue. With the tongue in this position, the patient should attempt to breathe through their nose and use the diaphragm muscles for respiration rather than the accessory respiratory muscle (i.e. pectoralis, scalenes, scm, and intercostals). The use of the accessory muscles promotes abnormal forward head and rounded shoulder posture and could lead to a host of other musculoskeletal problems.
© 2015 Freedom Physical Therapy Services S.C. Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com
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2. Control temporomandibular or joint rotation: The temporomandibular joint rotation exercise limits early translation of the temporomandibular joint and promotes the normal repositioning of the mandibular head in the fossa. Rotation also allows the disc to maintain a healthy position over the mandibular head, rotating anteriorly or posteriorly during opening and closing of the mandible. During the phase of rotation in opening, the upper head of the lateral pterygoid is relaxed and the lower head is contracted. This creates a pumping effect of the intracapsular musculature, which is necessary to maintain a healthy synovial joint. The practitioner instructs the patient to place and hold the anterior one-third of their tongue flat against the palate as the patient opens their mouth. This tongue position limits the range of opening to rotation and reduces the patient's tendency to protrude the mandible. In addition, this exercise will minimize joint sounds, and therefore reduce the abnormal wear on the structures of the temporomandibular joint. This can be done by the patient monitoring joint rotation by placing his/her finger over the temporomandibular joint, the anterior lateral capsule. After the patient is able to perform this exercise adequately, they should attempt to chew with limited translation. This amount of opening with minimal to no pain can also help limit or determine the bite size of food they are allowed to chew. The patient can more easily control translation if he practices chewing in front of a mirror while palpating the temporomandibular joint. The major emphasis of treatment of the hypermobile joints are to limit translation of the mandibular head, control rotation, stabilize and realign the connective tissue, ligaments, capsule and joint, and maintain the orthostatic head , neck, and shoulder girdle positions. As the patient learns to control temporomandibular rotation and implement rhythmic stabilization techniques, they will be treating the hypermobility of the TM joints.
© 2015 Freedom Physical Therapy Services S.C. Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com
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3. Mandibular rhythmic stabilization technique (RST) : This technique is adapted from proprioceptive neuromuscular facilitation techniques. It attempts to increase the individual's muscular control by stimulating the proprioceptive capabilities of the neuromuscular system. RST is a series of isometric contractions of the muscles of mastication to resist opening, closing, and lateral excursion - the three planes of motion. The patient should begin with their mandible in its rest position. They should not permit movement of the temporomandibular joint in response to the resistance applied. Excessive forces should not be used because only the force of one or two fingers is required to stimulate the muscles of mastication. Initially, the patient may palpate the specific muscle of mastication being stimulated to provide feedback that the exercise is being done correctly. Excessive force may induce mandibular motion and potentially damage or irritate the joint. These exercises re-educate the patient's neuromuscular system to avoid unconscious abnormal positioning or posturing of the structures of the maxillofacial region, while maintaining an orthostatic posture.
© 2015 Freedom Physical Therapy Services S.C. Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com
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4. Cervical joint liberation: This technique creates a distraction force on the upper cervical vertebrae and relieves mechanical compression by elongating the posterior and suboccipital cervical muscles. In the patient with maxillo-oral facial pain mechanical compressions occur between the occiput-atlas, atlas axis, and axis-C3 joints. The patient can distract their craniovertebral joints by holding both hands with fingers interlaced behind their neck to stabilize the C-2. to C-7 region. Then the patient nods their head forward six times while stabilizing the cervical spine in only 15 degrees of anterior cranial rotation. This controlled flexion relieves neurovascular compression in the upper cervical region. The application of this technique distracts the occiput from the atlas to counteract the dysfunctional effect of extension of the cervical spine produced by a forward head posture. The patient should recognize that this exercise does not include flexion of the neck but flexion of the head on the cervical spine.
Stabilize C2
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5. Axial extension of the cervical spine: This exercise improves the functional and mechanical relationship of the head to the cervical spine. Before learning axial extension, the patient must learn toposition their head forward to the level of the sternum, aligning the malar bone. The patient creates a distraction force on the cervical vertebrae as he combines flexion of the occiput on the upper cervical spine and extension of the lower cervical spine, relative to the thoracic region. These movements position the head in an ideal orthostatic position. In this ideal position the scm muscle shifts from its vertical relationship in the dysfunctional posture to its normal posterior angulation in a posterior direction in axial extension. The realignment of the scm limits the unnecessary cervical muscle activity required to maintain the abnormal forward head posture; the levator scapulae and trapezius relaxes by shortening. The practitioner may remind the patient that the muscles of the posterior cervical spine must work twice as hard 10 hold the head upright in the forward head posture than in the more normal head on neck posture.
Start with back of head and spine against corner of wall
--Nod your chin down about 15 degrees --The back of your head should remain in contact with the wall --Your eyes should remain level-imagine a string at the top of your head pulling up © 2015 Freedom Physical Therapy Services S.C. Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com
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6. Shoulder girdle retraction: These exercises restore the shoulder girdle to a more ideal and stable postural relationship of the head-neck- shoulder complex. The therapist instructs the patient to retract and depress the shoulder girdle relative to the rib cage. These actions correct the abnormal scapular abduction, reduce tension in the acromioclavicular joint, relieve compression in the sternoclavicular joint, and promote elevation of the sternum. The therapist, in time, must instruct the patient in exercises to strengthen the upper larger back muscles, i.e., rhomboids, mid trapezius and the inferior trapezius, to maintain the shoulder girdle in this corrected position and prevent postural relapse (Antoniotti and Rocabado).
Perform chin nod and roll shoulders back and downward
© 2015 Freedom Physical Therapy Services S.C. Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com
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Additional Scapular exercise per Rocabado:
Reference: Musculoskeletal Approach to Maxillofacial Pain, by Rocabado and Iglarsh,1991
© 2015 Freedom Physical Therapy Services S.C. Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com
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HYPERBOLOID EXERCISES
Move hyperboloid for 2 minutes from molar to molar 1 to 2 x a day
Laterally deviate your mandible right 10 reps 2 to 3 times a day
Laterally deviate your mandible left 10 reps 2 to 3 times a day
Protrude Mandible forward teeth to teeth 10 reps 2 to 3 times a day
© 2015 Freedom Physical Therapy Services S.C. Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com
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Guidelines To Minimize TMJ Pain In general, avoid: Large bites, “big” food Repetitive chewing Forceful bites Using tongue to remove food from teeth Specifically, avoid these foods: Gum Jaw breakers Popcorn Caramel Steak Pizza Bagels Chips Nuts Ice Beef jerky Crunchy fruits and vegetables French bread Hard cereal Lettuce Other things to avoid: Resting chin on hand Holding phone with shoulder Sleeping on stomach “Big” yawns Singing Yelling Nail biting Chewing on inside of cheek Biting lip
© 2015 Freedom Physical Therapy Services S.C. Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com
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