TMJ Classification/Diagnoses

Question 1

ADD Definition

Answer 1

• Articular Disc Displacement

- alteration in normal mechanics due to hypermobility can lead to internal derangement of the disc (4 phases)

Question 2

ADD: Phase 1

Answer 2

• Lateral and medial ligs slightly elongated from repeated microtrauma
• Disc slides medially during opening and reduces laterally when condyle moves back during closing
• No joint sounds; pain free

Question 3

ADD: Phase 2

Answer 3

• Lateral and medial lig elongation progressis and bilaminar tissues lengthen
• disc migrates medially and anteriorly (stays there at rest when mouth is closed or when the freeway space is maintained)
• During opening: condyle rides over post disc producing EARLY OPENING CLICK and reducing the condyle onto the disc
• During Closing: condyle will luxate off the disc and LATE CLOSING CLICK will occur

Question 4

ADD: Phase 3

Answer 4

• Significant overstretching of post and lat lig
• disc deformed (more convex) and no longer sits on top of condyle
• condyle rests on post, sup, lat position which retracts the lat and med capsules (causes shortening of capsule)
• Lateral pterygoid shortens and becomes inactive
• LATE OPENING CLICK
• EARLY CLOSING CLICK

Question 5

ADD: Phase 4

Answer 5

• No joint sounds
• post lig completely stretched
• condyle no longer on disc
• mandibular head deformed from bone on bone
• condyle rests in most sup, post position of mandibular fossa
• Entrapment neuropathy (post lig can perforate)

Question 6

Systemic Inflammatory conditions

Answer 6

• RA, gout, psoriatic arthritis, SLE, ankylosing spondylitis

- chronic inflam of capsule can–>adhesions & fibrosis–>limited/painful opening and lat deviation and facial deformity

Question 7

Capsular Fibrosis

Answer 7

• unresolved local inflamm due to micro/macro trauma
• chronic inflam–>shortening and fibrosis of capsule
• limited opening and reduced lateral deviation to opposite side

Question 8

Potential Sources of TMJ Pain

Answer 8

UCS, C3, neuralgia, Arteritis, Dental problems, Sinusitis, Tumor

Question 9

Referred, Non-radicular Pain

Answer 9

UCS, Teeth, Muscles (temporalis, masseter, pterygoids

Question 10

Neurogenic Pain (referred radicular)

Answer 10

• Trigeminal N
• Geniculate N
• Glossopharyngeal N
• Tumor compressing cord, meninges, spinal nerve, nerve root, peripheral entrapment, neuritis

Question 11

Viscerogenic Referral

Answer 11

-Heart

Question 12

Vasculogenic

Answer 12

• venous congestion or arterial deprivation to MS areas

- Arteritis (carotidynia, temporal arteritis)

Question 13

S/Sx Associated with TMJ

Answer 13

• Chronic HA
• Teeth clenching/grinding
• Ringing/throbing/swishing ears/earaches
• clicking/popping jaw while eating/talk/sing/yawn
• pain/difficulty opening mouth very wide
• shoulder pn/stiffness
• face/neck pain
• tooth pain with no apparent cause
• Jaws lock in open or closed
• sensitive hearing/hearing loss

Question 14

Body Chart:

ADD

Answer 14

• Joint noises in early phases progressing to difficulty opening and pain by phase 3 (crepitus at phase 4)
• Phase 1: no sounds
• Phase 2: early opening/late closing click
• Phase 3: late opening/early closing click
• Phase 4: no joint sounds (or crepitus)

Question 15

Body Chart:

Systemic Inflammatory Conditions

Answer 15

• Pn in periauricular area
• increased or decreased with functional or parafunctional activities
• better with rest

Question 16

Parafunctional Activities

Answer 16

thumb sucking, lip chewing, nail biting, chewing ice/hard candy, gum chewing, bruxing, abnormal tongue pressure, clenching, resting jaw in hand

Question 17

Body Chart:

Capsular Fibrosis

Answer 17

Stiffness (may have pain)

Question 18

Body Chart:

Joint Hypermobility

Answer 18

Feeling of jaw going out of place

Question 19

Body Chart:

Dislocations

Answer 19

• Inability to close mouth

- may or may not have pain

Question 20

Body Chart:

Degenerative conditions

Answer 20

• primary complaint is joint noises

- Joint noise/crepitus at same points in ROM

Question 21

History:

ADD

Answer 21

• initial trauma

- gradual onset that progresses to noises or intermittent locking

Question 22

History:

Systemic Inflammatory Conditions

Answer 22

Gradual/acute exacerbation of chronic condition

Question 23

History:

Capsular Fibrosis

Answer 23

follows history of prolonged capsulitis, prolonged immobilization or mandibular restriction, trauma, repetitive microtrauma or arthritis

Question 24

History:

Joint Hypermobility

Answer 24

may report catching when mouth opened making closing difficult

Question 25

History: | dislocation

Answer 25

may report catching or feeling jaw is going out of place due to trauma or over opening

Question 26

History: | Degenerative Conditions

Answer 26

End result of OA

Question 27

9 Points of Hypermobility

Answer 27

``` 1/2: pinky extension >90* 3/4: Thumb to forearm 5/6: elbow hyperextension >10* 7/8: Knee hyperextension 9: palms flat on floor with knees extended ```

Question 28

Objective Tests: | ADD

Answer 28

- Clicking over lateral poles with opening/closing - Limited depression with deviation to ipsilateral side - protrusion limited with deviation to ipsilateral side - Lateral deviation limited to contralateral side - Palpable crepitus Stage 1: non/min pn with #1, 2, &3 synovials Stage 2: pn with #1, 2, 3 synovials Stage 3: pn with #3, 5, 6 synovials (#4 variable), stiff inferior glide Stage 4: pn with #3, 5, 6 synovials; pn with #7, 8 provocation tests (#4 variable); stiff inferior glide

Question 29

Objective Tests: | Systemic Inflammatory Conditions

Answer 29

- Unable to fully open or fully close (due to pn) - pn with TMJ palpation with mouth closed and opened - (+) forced biting - (+) retrusive overpressure

Question 30

Objective Tests: | Capsular Fibrosis

Answer 30

- decreased mandibular mobility and deflection from midline - decreased translation - restricted inferior and lateral glides

Question 31

Objective Tests: | Joint Hypermobility

Answer 31

- large indentation palpable post to condyle when mouth opened - deviation of mandible to contralateral side at end opening - Depression >40mm - Provocation test #4 increase movement

Question 32

Objective Test: | Dislocations

Answer 32

- mouth locked in opening and deviated to contralat side with unilat dislocations - no deviations with bilateral deviations

Question 33

Objective Test: | Degenerative Conditions

Answer 33

- global limitations in movement but not function - close to functional depression and protrusion with slight deviation toward involved side at end range - close to functional lateral deviation to opposite side - X-ray (+) for structural changes