TMJ Update

Click below for the TMJ update post!

There were several presenters in addition to Dr. Mariano Rocabado.

Eva Caput

epidemology of ID (internal derangement)
40-75% of population at least 1 sign of TMD
33% report at least 1 Sx
4.6% of 31,000 had TMJ +muscle disorder type pain
5.3 million americans sought care for $2 billion cost
prevalence of ID in patients with craniomandibular disorders 78%
32% dysfunction found in asymptomatic

as Rocabado would say, it's not no pain, no problem
a clicking, non painful joint should still be treated

systematic review and meta-analysis
Physiotherapy Canada Jjournal

Jan 94-Oct 09
4000+ articles, only 8 met criteria
ID without reduction
usually important +ve test
deflection
creptitation

The best predictors were a combination of

crepitation
deflection
pain/limited mouth opening
ruled in with a positive LR between 5 and 10

usually important negative tests

click/deviation/pain
mod probability to rule out, LR 0.1 and 0.2

no one single test including click or cluster of tests was found predictive

Dr. Harry von Piekartz

Integrating US for TMD

He stated in regard to using US for dianostics, when compared to pregnancy, it can tell if you are pregnant or not, but not for who are you pregnant for..

quality of movement, parameters, pain, resistance
should be taken into account in addition to US findings
we need better tests
tomography gold standard, can't assess, reassess, static and supine

US advantages

quick
short time
no radiation
relatively cheap
comfortable
use in different functional positions

How reliable? comopared with tomography

systematic review Chunjie et al 2012 in Anaesthesia/Facial Pain

They found US is acceptable, however

13/16 done in supine
15/16 studies mouth closed
15/16 studied longitudinal measurement
These are not necessarily how we would as PTs measure function

UE vs CT in physiotherapeutic setting

PT was a young clinician, female 26 yo trained for the study

results

good correlation between MRI and US
PT can diagnose after 6-8 hours
however, high false positives - due to the lack of clinical expertise lacking in this study

proposed uses of US for TMD

can use as a functional diagnosis
calibration during exercises
diff Dx of ID versus capsular dysfunction
transverse measurement - horizontal plane
assess in functional positions (upright, mouth open, closed, during mastication)
perform dynamic assessment
pt education - show them different views in different postures, or before and after Tx

condyle position tomography vs sonography - 2010 study

validated Prof Rocabado's research using x-rays in 90s
US to assess/reassess
disc reduced and moving on condyle after manual treatment
US good to mod reliability compared to tomography when used by PT

The man, the myth, the legend, Rocabado

dividing the cranium into proportions
PT looks at posterior 50%
dentist looks at anterior 50%
both areas have in common the cranium with TMJ positions

The temporal fossa congruency depends on the occiput position horizontal

CR (centric relation) determinues the stability of joints with two convexities
the dense portion of the disc must be on sup covexity of the temporal bone
if the distance increases, (condyle moves posterior or anterior) the dense portion slips
50/50 relationship causes changes of the mandible condyle in fossa and the temporal position
this faciliates luxation of disc in fossa leading to ID
this may happen at any age without pain, and is mostly undiagnosed

A clinician should look at symmetry and proportions in different planes
50% craniomand 50% craniovert - transverse
50% left 50% right in coronal
determined by position of C2

if C2 is rotated, C1 rotates in the opposite direction also having a positional fault in the coronal plane
this causes cranial SB
moving the temporal bone
and the condyle in the fossa
the short side (concave) side of the face is often the dysfunctional side

the first occlusal contact in the short or more superior side, moves the condyle out of the fossa as mandible slides forward to get the rest of teeth occluding

this is from a fulcrumming effect

Chantal Lafreniere, DO and physio

don't forget about the teeth or temporal bone
temp can be corrected just as well as mand or condyle

temp bone trauma

fall on back of head
ear surgeries
dental procedures
temp fixations from SCM, collar bone, IX cranial
mandible trauma
C2-3 SB rot, opp rot of C0-1

SCM can influence temp bone rotation causing posterior rotation (how much? She didn't say)
bruxism rotates temp bone anteriorly
axis of rot through ear canal

temporal bone IR is associated with

anterior position of the condyle
early and increased ant glide during mandible depression
hypermobile disc unit
lateral ligamentous laxity or pain
FHP, increased vertical dimension of the condyle rest measurement
contralateral side often has ER of the temporal bone
cranial trauma and dental Tx will rotate the temporal bone
50% ER on one side will have IR on other, both can click

The last presentation is obviously from an osteopathic standpoint, she also spoke of CS fluid dysfunction, and had treatments for cranial mobilization. The IR and ER of the temporal bone may be worth a try with either light mobilizations or isometric (MET) mobilization.

All in all a great presentation!