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Craniomandibular Joint
O Synovial, condylar, modified hinge joint
O HAS FIBROCARTILAGINOUS articular disc;
O
O
Arthrokinematics
O Translation/Gliding - occurs at upper part of
cavity
O Rotation - occurs at lower part of cavity
O Distraction
Osteokinematics
O Protrusion = 7 mm
O Retrusion = 3 4 mm
O Lateral deviation = 10 15 mm
O Opposite condyle forward, down and toward the
motion side
O Condyle on same side = stationary and prominent
O Lateral deviation during protrusion: lateral
MUSCLES
OPENING OF MOUTH
O 23-35 mm Functional mouth
jt. space
O Late Phase
O Anterior translation (50-65),
inferior movement superior jt.
space
ACTIVE MOVEMENTS
NECK FLEXION
O Mandible moves up and forward
O Posterior structures tight
NECK EXTENSION
O Mandible moves down and back
O Anterior structures tight
ACTIVE MOVEMENTS
Opening and Closing of the Mouth
- Slowly
DEVIATIONS
Deviation towards L upon mouth opening
(a C-type curve) or to the right (a reverse Ctype curve),
(+) hypomobility is evident toward the side of
the deviation caused either by:
O a displaced disc without reduction or
O unilateral muscle hypomobility
PATIENT HISTORY
Extra-articular problem
O Pain in the fully opened position (e.g., pain
associated with opening to bite an apple,
yawning)
Intra-articular problem
O whereas pain associated with biting firm
objects (e.g., nuts, raw fruit and vegetables)
Limited opening may be due to:
O the disc displaced anteriorly,
O inert tissue tightness,
O muscle spasm
PATIENT HISTORY
O Early clicking - implies a developing dysfunction,
O Late clicking - is more likely to mean a chronic problem
PATIENT HISTORY
O There may be a partial anterior displacement (subluxation) or dislocation of
the disc, which the condyle must override to reach its normal position when
the mouth is fully open (Figure 4-8). This override may also cause a click.
PATIENT HISTORY
O If clicking occurs in both directions, it is called
reciprocal clicking
O The opening click occurs somewhere during the
opening or protrusive path, and the click indicates
the condyle is slipping over the thicker posterior
border of the disc to its position in the thinner
middle or intermediate zone.
O The closing (reciprocal) click occurs near the end of
the closing or retrusive path as the pull of the
superior lateral pterygoid muscle causes the disc to
slip more anteriorly and the condyle to move over its
posterior border.
RECIPROCAL CLICK
PATIENT HISTORY
O Clicks may also be caused by adhesions (Figure 4-10), especially in people
PATIENT HISTORY
O Soft or popping clicks that are sometimes heard in
PATIENT HISTORY
O Locked jaw
O Not full ROM (Open/Close)
O Preceded by reciprocal clicking
O often related to problems of the disc or joint degeneration.
O Locked jaw in closed position
O caused by a disc with the condyle being posterior or anteromedial
to the disc.
O Translation is blocked, mouth opening is 30 mm via rotation
O FUNCTIONAL DISLOCATION OF DISC WITH REDUCTION
O disc is usually positioned anteromedially, and opening is limited.
REDUCTION
O Results to: Closed lock implies there has been
anterior and/or medial displacement of the disc
so that the disc does not return to its normal
position during the entire movement of the
condyle.
O Opening: 25 mm, mandible deviates to
affected side, decreased ROM at C/L side
O If locking occurs in open position, it is caused
by: Posterior Disc displacement or joint
subluxation
the disc
O and then when it moves over the anterior rim of the
disc, and two clicks on closing.
O If, after the second click occurs on opening, the disc lies
posterior to the condyle, it may not allow the condyle to
slide back (Figure 4-12 - locking).
O If the condyle dislocates outside the fossa, it is a true
dislocation with open lock; the patient cannot close the
mouth, and the dislocation must be reduced.
OBSERVATION
TMJ
O Occlusion
O occurs when the teeth are in
normal occlusion.
O Class I occlusion
O normal anteroposterior relation of the maxillary teeth to mandibular
O
O
O
teeth.
Class I malocclusion.
O A slight modification with only the incisors affected and overjet slightly
larger
Class II malocclusion (overbite)
O Occurs when the mandibular teeth are positioned posterior to their
normal position relative to the maxillary teeth.
O This malocclusion deformity involves all the teeth, including the molars.
Class II Division 1 malocclusion (AKA large overjet or horizontal overlap)
O Indicates that the maxillary incisors demonstrate significant overjet.
Class II Division 2 malocclusion (AKA deep overbite or vertical overlap)
O implies that overjet is not significant but that there is overbite and
lateral flaring of the lateral maxillary incisors.
Class III malocclusion (i.e., underbite)
O occurs when the mandibular teeth are positioned anterior to their
normal position relative to the maxillary teeth.
O If maxillary and mandibular teeth are on the same vertical plane, a
Class III malocclusion would be present.
Crossbite
- With the teeth of the mandible are lateral to the
upper (maxillary) teeth on one side and medial on
the opposite side.
- There is abnormal interdigitation of the teeth.
- With anterior crossbite, the lower incisors are ahead
Underbite
- Teeth are unilaterally,
bilaterally, or in pairs
in buccoversion (i.e.,
they lie anterior to
the maxillary teeth
Overbite
- anterior maxillary incisors
extend below the anterior
mandibular incisors when
the jaw is in centric
occlusion.
- A small amount of overbite
(2 to 3 mm) anteriorly is the
most common position of
the teeth.
- This is because the
maxillary arch is slightly
longer than the mandibular
arch.
Facial Profile
O The orthognathic profile is the normal,
Tongue thrusting
O May be due to hyperactivity of the
masticatory muscles.
O When one swallows, the hyoid bone should
move up and down quickly.
O If it moves only upward and slowly, and the
suboccipital muscles posteriorly contract =
(+)
FUNCTIONAL ASSESSMENT
O Research Diagnostic Criteria for
O
O
O
O
SPECIAL TESTS
O Chvostek Test
AUSCULTATION
O listen to (auscultate) the
Temporomandibular
disorders (TMDs)
.
TMD
O Three cardinal features of TMD are:
O orofacial pain,
O restricted jaw motion,
O and joint noise
TABLE 4-2
Checklist of Psychological and Behavioral Factors*
1. Clinically significant anxiety or depression
2. Evidence of drug abuse
3. Repeated failures with conventional therapies
4. Evidence of secondary gain
5. Major life events; for example, new job, marriage or
divorce, death
6. Pain duration greater than 6 months
7. History of possible stress-related disorders
8. Inconsistency in response to drugs
9. Inconsistent, inappropriate, and vague reports of pain,
or both
10. Overdramatization of symptoms
11. Symptoms that vary with life events
TMJ CAPSULITIS
O (+) Pain upon mouth opening
O (+) LOM: Lateral deviation C/L
TMJ SYNOVITIS
O (+) PAIN UPON MOUTH OPENING
O LOM (I/L Lateral deviaiton)
O Swelling
TMJ HYPORMOBILITY
O (+) LOM towards mouth opening
O LOM: (C/L: Lateral deviation)
TMJ HYPERMOBILITY
O (+) Excessive mouth opening and C/L lateral
deviation
Stages Of Disc
Displacement
Bruxism
O Is the forced clenching and grinding of the