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Temporomandibular Joint Movements

Movements of the temporomandibular joint (TMJ) include depression of the mandible (i.e., opening the mouth), protrusion of the mandible (i.e., movement in a forward direction) retrusion of the mandible (i.e., movement in a posterior direction) and lateral motion of the mandible (i.e., side-to-side movements). Retrusion is very limited compared to protrusion.

Assessmentinterpretation

Unlike other joints of the body, there is rarely a singular mechanism of injury. Only occasionally does injury occur as one traumatic incident (i.e., a direct blow or whiplash). Usually there are multiple factors that cause low-grade microtrauma over a long period of time. The multiple causes of temporomandibular joint dysfunction are usually a combination of the following dental or oral habits (i.e., bruxism, clenching) partial or total absence of the temporomandibular joint

Job or Sportrelated Habits

In young children, the tongue must rest against the palate for normal palate development. Tongue position affects the equilibrium of the temporomandibular joint and its muscles. At rest, the tongue should lay against the back of the upper incisors, with the middle one third of the tongue resting on the roof of the mouth and the posterior one third of the tongue forming a 45 angle between the hard palate and the pharynx. During swallowing, the tongue should move up and back with the lips closed. If this tongue position or swallowing pattern is altered, the normal temporomandibular joint and cervical spine kinetic chain is altered, resulting in problems. Certain sports or occupations predispose the temporomandibular joint to extra stress Certain jaw and neck postures required for sports or occupations also stress the temporomandibular joint

Lateral View Head and Neck Position

The position of the head, cervical spine, and temporomandibular joint, and the occlusion of the teeth are all interrelated. A change in the head position changes the occlusion and temporomandibular joint position. A forward head or excessive cervical lordosis is common and leads to head, neck, and temporomandibular joint pain and dysfunction (Fig. 1-15, B).

Cranial Sacral Problem

Problems with the ear can be referred to the temporomandibular joint and vice versa because of their shared neural supply and close proximity. A viral infection (i.e., mumps, rheumatoid arthritis) can mimic temporomandibular joint problems. A systemic disease such as rheumatoid arthritis can also affect the TMJ, The family physician can rule out these systemic problems.

Passive Mandible Elevation and Depression

When the athlete taps his or her teeth together, all teeth should meet simultaneously. High cusps or fillings that contact first cause the jaw to rotate toward the opposite side, compressing the temporomandibular joint. This high spot may not be symptomatic unless the individual is overusing the masticatory muscles. A dentist should be consulted if there are any cusps or fillings that are meeting prematurely.

Passive Mandible Lateral Excursions Deviations

Range should be equal on each side in the normal temporomandibular joint. When the meniscus becomes dislocated anteriorly it jams the temporomandibular joint. Lateral excursion is limited to the opposite side. Therefore if the right meniscus is dislocated, lateral excursion is limited to the left.

Fibromyalgia Tired of Being Sick and Tired

Myalgia (muscle pain) characterizes this often-devastating chronic rheumatic pain disorder of unknown cause. The pain is usually described as achy but a few patients tell me they can also experience burning, throbbing, stabbing, or shooting pain. To make this dish sound even more appetizing, fibromyalgia is often accompanied by side orders of chronic headaches, strange skin sensations, temporomandibular joint pain (TMJ), insomnia, irritable bowel syndrome (IBS), anxiety, palpitations, fatigue, poor memory, painful menstruation, and depression.

Facial Bone Fractures

The bones of the face are traditionally divided into thirds. The upper third includes the frontal bone. The middle third or midface includes the maxilla, zygoma, lacrimal, nasal, palatine, inferior nasal concha, and vomer bones. The lower third includes the mandible with its temporomandibular joint.

Temporomandibular Disorder

Temporomandibular joint (TMJ) dysfunction is a fairly common problem. Patients may present with headache which is localized to the preauricular region, mandible, and TMJ region. In addition to frontotemporal headache, patients often complain of otalgia, tinnitus, and dizziness. Clinical history may elicit symptoms of bruxism during sleep and reported jaw locking or popping. Limited jaw opening and tenderness of the masticatory muscles may be noted during examination. TMJ dysfunction leads to myofascial pain contributing to the symptoms of headache. Symptoms are often self-limited but in persistent cases referral to a TMJ specialist may be required.

General Considerations

Many physician visits for oral problems are associated with psychiatric disturbances. Psychosomatic disease symptoms often center on the mouth. Patients with psychosomatic disease may complain of ''burning'' or ''dryness'' of the mouth or tongue. Bruxism, or grinding of the teeth other than for chewing, occurs especially during sleep. This overuse of the muscles of mastication has often been interpreted as a manifestation of rage or aggression that is not overtly displayed it may also be an infantile response to reduce psychic tension. Bruxism can produce facial pain, which causes further spasm of the muscles and continued bruxism, resulting in a vicious circle. Individuals who habitually have something in their mouths, such as a pipe, a thumb, or a pencil, may cause damage to their oral cavities.

Choosing the Correct Restorative System

New developments in ceramic and composite systems have increased the choice of restoratives available for the dentist in treating noncarious tooth loss. It has often been stated that patients requiring a crown, but who have a history of bruxism, are best treated using the traditional metal-ceramic crown because only this restoration has sufficient strength. However, the most recent crown and bridge ceramic systems have outstanding strength. The latest addition to the all-ceramic family is a polycrystalline, zirconia-based Lava ceramic (3M ESPE), which has exceptional strength and can be used for anterior and posterior crowns and bridges. Anterior crown preparations are similar to those required for porcelain fused to metal restorations, and require a 1.0- to 1.5-mm labial and lingual reduction and a 1.5- to 2.0-mm incisal reduction. Posterior crown preparations require a 1- to 2-mm axial reduction and a 1.5- to 2.0-mm occlusal clearance. A chamfer margin and rounded internal...

Syndromes of Lesions Involving Peripheral Branches of Cranial Nerve V

The temporomandibular joint (TMJ) syndrome refers to recurrent pain in the region of the jaw, ear, occiput, and supraorbital regions, which is believed to result from degeneration or malocclusion of the TMJ. Erosion of the bony surfaces within the glenoid fossa may cause irritation of several adjacent nerves including the auriculotemporal and chorda tympani trigeminal nerves. Patients may report an increase in pain in the evening and pain referred to the oropharynx. Rarely, a

Clicking and Popping Rocabado M

Does the temporomandibular joint click or pop The muscles of mastication are innervated by the same nerves as the tensor tympani and tensor palatini. This may explain the ear symptoms caused by temporomandibular joint dysfunction. If the tensor muscles go into spasm, it may lead to tinnitus, hearing problems, and a sensation of ear stuffiness. There is also a reflex arc with sympathetic nerve fibers. The fibers originate in the temporomandibular joint and end up in the cochlea. This could also explain the dizziness and tinnitus.

Immediate extraction complications

Fracture of alveolar plate Fracture of mandible Soft tissue damage Involvement of maxillary antrum oroantral fistula fractured tuberosity loss of root (or tooth) Into antrum Loss of tooth or root into pharynx into soft tissues Damage to nerves or vessels Dislocation of temporomandibular joint Damage to adjacent teeth Dislocation of the temporomandibular joint should try, as quickly as possible, to reduce the dislocation by pushing the mandible downwards and backwards. If this is not done relatively quickly, muscle spasm of the powerful elevator muscles of the mandible will ensue and the patient will require sedation, or indeed even a general anaesthetic, to reduce the dislocation. When extracting teeth under general anaesthesia the mandible can dislocate due to the loss of muscular tone. It is important to ensure the mandible is repositioned before the patient recovers from the anaesthesia. Recurrent dislocation of the temporomandibular joint is discussed in Chapter 20.

Clinical Appearance of Attrition

Tooth Erosion Cupping

With attrition, the worn occlusal and incisal surfaces are flat and come into contact in lateral mandibular movements. A diagnosis of attrition therefore requires that the involved teeth contact in the intercuspal position or in lateral excursion. Erosion tends to accentuate any wear facets (Fig. 5.1), giving the false impression that the patient engages in bruxist activity. Bruxism is often associated with masseteric hypertrophy, temporomandibular joint dysfunction, ridging on the side of the tongue (lingual crenulation) and cervical abfraction lesions on the teeth.

Ruptur Thympanic Membran Cruris

Vibratori Coppia Gif

Figure 20-35 Technique for evaluating the temporomandibular joint. Figure 20-35 Technique for evaluating the temporomandibular joint. Temporomandibular Joint Symptoms A patient with temporomandibular joint problems may complain of unilateral or bilateral jaw pain. The pain is worse in the morning and after chewing or eating. The patient may also complain of ''clicking'' of the jaw.

Cervical Spine Assessment

Examining the cervical spine requires a thorough neurological and a rthrological scan of the spine and entire upper quadrant. The temporomandibular joint, upper thoracic spine, costovertebral joints, costotransverse joints, first rib, rib cage, and shoulder complex also have a large influence on the cervical spine and should be ruled out when assessing cervical pathologic conditions. Because of the frequent occurrence of motor vehicle accidents, the athlete must always be questioned regarding a previous accident or whiplash injury. If there has been a previous whiplash to the cervical spine, there is usually scar tissue and dysfunction that will affect the testing. It is also important to determine the emotional status of the athlete in the general history because stress or increased muscle tension can make testing more difficult and may alter the results. Temporomandibular joint injury or faulty mechanics can lead to myofascial trigger points and referred pain into the neck...

Temporomandibular Overload

Are the temporomandibular joints Overload problems are usually related to emotional stress, overloaded Stress leads to excessive musculature activity the lateral ptery- Bruxism (grinding the teeth) for a long period of time will overstrengthen the jaw elevators. Repeated overload leads to microtrauma and an inflammation reaction in the capsule, the loose peripheral parts of the disc, and the lateral pterygoid insertion. The overfatigued lateral pterygoid's ability to move the disc harmoniously during jaw movements can be upset and result in disc displacement. Repeated inflammation results from microtrauma with the condyle in a forward and downward displaced position, resulting in further joint dysfunction. If the temporomandibular joint is overloaded when malocclusion exists, joint dysfunction occurs more readily. There is usually an interplay of several factors, including

Temporomandibular Assessment

The temporomandibular joint can not be viewed in isolation. Temporomandibular joint problems often coexist with upper cervical joint dysfunction and shoulder girdle postural problems (Grieve G). Temporomandibular joint (TMJ) dysfunction can cause a variety of symptoms in the cervical region, cranium, dentition, face, throat, and even ears. Because of these symptoms, it is very difficult to determine the exact site of the problem. Therefore other head, neck, and shoulder problems may need to be ruled out. To rule out other pathologic conditions, it may be necessary to consult a dentist, physician, otolaryngologist, or orthopedic surgeon before a final diagnosis can be determined. The temporomandibular joint is the articulation between the mandibular condylar process, the mandibular fossa, and the articular eminence of the cranium bilaterally. The temporal articular surface is usually less than 2.5 cm long. In the horizontal plane, the condyles are on an oblique axis with the disc...

Rheumatoid Arthritis

The disease affects the cervical spine in up to 80 of patients. About a quarter of these have instability or subluxation, with a risk of dislocation. Neck movements, particularly those likely to be required during tracheal intubation and positioning, should be assessed. Recent X-rays of the neck in flexion and extension (with 'through the mouth' views) or magnetic resonance images should be examined for evidence of separation of the odontoid peg from the atlas, or subluxation of any cervical vertebrae. These images are not easy to interpret a radiologist should advise (Fig. 45.1). Patients with an unstable neck should be managed by an experienced anaesthetist, especially if tracheal intubation is planned. Tracheal intubation is even more difficult if movement of the temporomandibular joint is restricted. The need for tracheal intubation should be considered. For many procedures, the use of a laryngeal mask airway is a suitable and potentially less traumatic alternative. If tracheal...

Ophthalmic Nerve And Orbit Anatomy

Superior Oblique Muscle Too Tight Defect

The mandibular division is the largest division of the trigeminal nerve and is a mixed sensory and motor nerve. It exits the cranium through the foramen ovale, just posterior to the lateral pterygoid muscle. The nerve divides into anterior and posterior branches. The anterior branch supplies motor fibers to the muscles of mastication and only supplies sensation to the lateral face and underlying mucosa via the buccal nerve. The posterior nerve, which is the auriculotemporal nerve, emerges from behind the temporomandibular joint to supply sensation to the external auditory meatus and temple. The inferior dental nerve enters the foramen on the medial side of the ramus of the mandible to run through the bone and emerge at the mental foramen as the mental nerve. The lingual nerve runs

Tension Type Headaches

Tension-type headaches into those with and without pericranial tenderness (Sarchielli, 2004). Headaches can be classified by cause, such as temporomandibular joint dysfunction, psychosocial stress, and analgesic overuse. Tension-type headaches require a comprehensive assessment to determine whether any comorbid conditions exacerbate the headache. The diagnostic criteria for episodic tension-type headaches include at least 10 previous headache episodes fulfilling the following criteria

Surgery On The Upper Third Of The Face

Parts The Kidney Labeled

The trigeminal nerve is the largest of the cranial nerves. It contains both sensory and motor fibers ( Fig. 24-13 ). General somatic afferent fibers convey both exteroceptive and proprioceptive impluses ( Fig. 24-14 ). Somatic exteroceptive impulses carried by the trigeminal nerve include touch, pain, and thermal senses. These impulses are transmitted from the skin of the face and forehead, the mucous membranes of the nasal surfaces and oral cavity, the teeth, the anterior two thirds of the tongue, and the anterior portions of the cranial dura. Proprioceptive impulses are conveyed from the teeth, the periodontium, the hard palate, and the temporomandibular joint. The trigeminal nerve is involved in carrying afferent impulses from stretch receptors in the muscles of mastication. Additionally, visceral efferent fibers innervate the muscles of mastication, the tensor tympani and tensor veli palatini muscles, the muscles of the eye, and the facial muscles.

Surgery On The Lower Third Of The Face

The posterior division comprises the auriculotemporal nerve, the lingual nerve, and the inferior alveolar nerve. The auriculotemporal nerve is a sensory nerve to the zygomatic, buccal, and mandibular areas over the skin, which are also supplied by branches of the facial (seventh cranial) nerve the parotid gland by means of the parotid branch temporomandibular joint skin and scalp over the upper part of the external ear and side of the head up to the vertex of the skull. The lingual nerve carries sensory input from the mucous membrane covering the anterior two thirds of the tongue and the floor of the mouth, the lingual side of the mandibular gingivae, and the submandibular and sublingual glands. The inferior alveolar nerve carries sensory input from all the lower molar and bicuspid mandibular teeth and their periodontal membranes. The anterior portions of this nerve are called the mental and

Temporal Mandibular Joint Dislocation Clinical Summary

Temporal mandibular joint (TMJ) dislocation generally occurs in predisposed individuals after a vigorous yawn or seizure, or less commonly from direct trauma to the chin while the mouth is open. Acute dislocation occurs when the mandibular condyles displace forward and become locked anterior to the articular eminence. Masseter muscle spasm contributes to prevention of spontaneous relocation. Weakness of the temporomandibular ligament, an overstretched joint capsule, and a shallow articular eminence are predisposing factors. Patients usually present with an inability to close an open mouth. Other associated symptoms include pain, discomfort, and facial swelling near the temporomandibular joint. Difficulty speaking and swallowing is common. Anterior dislocations are most common however, posterior dislocation may occur with significant trauma, often in association with a basilar skull fracture. Unilateral dislocation results in deviation of the mandible to the unaffected side. TMJ...

Condylar Reconstruction

Relocating Dislocated Jaw

When condyle transplantation is oncologically unsafe, the proximal end of the reconstructed mandible can be shaped and rounded to mimic a condyle (with fascia used as a spacer), or a 1 cm gap can simply be left in the temporomandibular joint. The potential for ankylosis or some dislocation of the jaw to the side of the defect is higher with this type of reconstruction, but most patients function remarkably well with only one intact tem-poromandibular joint. This is essentially the equivalent of a condylar resection for a shattered condyle after trauma. Although prosthetic condylar implants have been used, potential extrusion or erosion of these implants into the temporal fossa is a serious complication that should be avoided if at all possible. Thus we do not advocate the use of these prostheses.

Sitting

Compression of the temporomandibular joint Compression of the temporomandibular joint When the head is held in a relaxed upright posture, the opposing teeth do not contact each other (interocclusal clearance). This mandibular resting position should have no muscle contractions and the temporomandibular joint is in equilibrium between the tonus of the muscles and gravity. This relaxed position allows the muscles and joint structures to rest and, if necessary, repair themselves. If the interocclusal clearance is decreased or nonexistent, there is constant muscular tension and temporomandibular joint compression. Altered head or neck positions affect this occlusion (Fig. 1-12). For example, if the neck is sidebent to the left, maximal occlusion occurs on the right with more temporomandibular joint compression on this side. If the neck is sidebent and rotated to the same side, maximal occlusion occurs on this side. Jaw Position and Temporomandibular Joint Symmetry If the ramus is tilted...

Internally

And temporomandibular joint patients, 1982. Babcock JK Sheridan College Medical Lecture Series Dental and Temporomandibular Joint Injuries April 1986,1987. Heiland MM Anatomy and function of the temporomandibular joint, J Orthop Sports Phys Ther 145,1980. Kraus SL (ed.) TMJ disorders management of the cra-niomandibular complex, New York, 1988, Churchill Livingstone. Rocabado M Arthrokinematics of the temporomandibular joints (article and seminar), Nov 26-27,1989. Solberg WK and Clark GT Temporomandibular joint problems, Chicago, 1980, Quintessence Publishing Co, Inc. Trott PH Examination of the temporomandibular joint. In Grieve G Modern manual therapy of the vertebral column, New York, Churchill Livingstone, pg 691, 1986.

Vertigo Tinnitus

Vertigo and tinnitus can originate from the upper cervical region (CI, C2 dysfunction) or from an obstruction of the vertebral arteries (secondary to a dens defect or cervical osteophytes). It develops from prolonged cervical back bending (i.e., painting a ceiling), a postural forward head carriage, repeated cervical rotation, or rising from a supine to a sitting position or vice versa. This sensation can also be referred from inner ear (vestibular apparatus in semicircular canals) or temporomandibular joint problems.

Clinical

The first step in treatment planning must be the correct diagnosis of the deformities present and the associated dental problems. Measurements of the face need to be taken from both full face and profile views followed by an oral examination and assessment of nasal and temporomandibular joint function. This will need to be evaluated radiographically, photographically and with dental casts. Additional investigations such as computerised tomography (CT) scanning, full speech assessment and in some cases a full ophthalmic and neurological assessment will be needed where changes to the jaws also involve the upper midface.

Thoracic Spine

Any decrease in range or signs of pain or clicking during the opening or closing of the mouth can demonstrate temporomandibular pathologic conditions. Any lateral deviation of the mandible during opening indicates temporomandibular joint dysfunction or muscle imbalance. If TMJ dysfunction exists, the resulting forward head posture and myofascial syndromes can cause adaptive shoulder problems.

Cocaine

Clinical Features and Associated Findings. Cocaine produces a brief rush, which peaks at 1 to 2 minutes. This rush is followed by euphoria, excitability, and hypervigilance. The acute administration of cocaine causes both psychiatric and neurological symptoms. Acute psychiatric symptoms include anxiety, insomnia, paranoia, agitation, and psychosis. Neurological symptoms include stereotypy, bruxism, chorea, dystonia, myoclonus, seizures, lethargy, strokes, and coma. In addition, high doses of cocaine cause tachycardia, tachypnea, and hypertension. Parenteral cocaine users are also at risk for stroke related to infection, such as endocarditis and the acquired immune deficiency syndrome (AIDS).

Amphetamine Analogs

Tourette's syndrome can be exacerbated and precipitated by amphetamine, methylphenidate, and pemoline it sometimes clears with discontinuation of the drug but occasionally persists. y , y The bruxism and choreiform movements that develop with chronic amphetamine use may also persist after the drug has been discontinued.

Biological Dentistry

This alternative form of acupuncture is much like oral acupuncture, but without the injections. It involves the use of a laser light beam aimed at an acupoint. Proponents claim that cold laser therapy kills bacteria associated with dental work, aids in wound healing, and reduces swelling. It is also applied to treat TMJ (temporomandibular joint syndrome).

Whiplash Injuries

Eighty percent of patients with whiplash-type injuries complain of headaches during the first 4 weeks after the accident. The headaches are usually of the muscle contraction type and are often associated with greater occipital neuralgia. Whiplash trauma can also injure the temporomandibular joint and can cause jaw pain often associated with headache. Headache may be referred from the C2-C3 facet joint that is innervated by the third occipital nerve, which is third occipital headache. Occasionally, whiplash injuries can precipitate recurring common, classic, and basilar migraines de novo.

What is whiplash

The possible pathological events during this occurrence are numerous and include damage to a range of soft tissues, the intervertebral disc, zygapophyseal joints, the odontoid process, the temporomandibular joint and other structures, even including the brain (Bogduk 1986). The pathophysiology of whiplash is discussed in detail elsewhere (Barnsley et al. 1994a Bogduk 1986 Barnsley et al. 2002). The most likely structures to be injured are the zygapophyseal joints, the intervertebral discs and the upper cervical ligaments (Barnsley et al 2002). In a systematic review of autopsy studies of the cervical spine of road traffic fatalities, pathoanatomical lesions were found in the cervical discs, endplates and zygapophyseal joints (Uhrenholt et al 2002). These were generally of a subtle nature that would not be detected by imaging studies, especially radiography

Lower Face

The mandible is a U-shaped bone, composed of the body, two rami, and their articulating temporomandibular joints. It is the only mobile bone of the facial skeleton, and proper motion is essential for adequate mastication. The temporomandibular joint (TMJ) is a freely movable synovial joint located between the glenoid fossa of the temporal bone and the head of the mandibular condyle below. The articular surfaces of the joint and the condyle are covered by avascular fibrocartilage and are unlike most joint surfaces, which are covered by hyaline cartilage. A fibrocartilaginous disc is interposed between the joint surfaces. Temporomandibular joint dislocation is caused by lateral forces. It may be unilateral or bilateral. Joint reduction can often be accomplished shortly after the injury without sedation, before severe facial edema and muscle spasm develop. With the patient sitting, the physician stands in front of the patient and places thumbs inside the mouth, lateral to the teeth, and...

Pain following TBI

Numerous possible conditions can contribute to the emergence of headache in the period following trauma (as of course do those occurring in the absence of such an event) and these include a variety of musculoskeletal and neuropathic causes. The former category includes such entities as temporomandibular joint dysfunction and myofascial pain syndrome. Also depression, level of activity, life stressor, caffeine, hormonal factors, diet, sleep and exercise ability (Ivanhoe & Hartman, 2004, p. 34) could each alone or in concert contribute to the problem.

Clinical History

Obtaining a detailed clinical history is especially important when diagnosing a sleep disturbance because routine physical examination is often not revealing during the waking hours. From the history, age of onset, duration and progression of the sleep complaint, and the general classification of the type of sleep disturbance is usually obtained. The International Classification of Sleep Disorders categorizes sleep disturbances as (1) dyssomnias or disorders that result in insomnia or excessive sleepiness (2) parasomnias or disorders of arousal, partial arousal, or sleep stage transition and (3) sleep disorders associated with medical or psychiatric disorders. The dyssomnias include the intrinsic sleep disorders arising from bodily malfunctions such as psychophysiological insomnia, obstructive and central sleep apnea, restless legs syndrome (RLS), and periodic limb movement disorder (PLMD). Examples of parasomnias include sleep walking, sleep terrors, sleep talking, nightmares, REM...

Local Pain

Horrific Tmj Pain

Any traumatic, degenerative, mechanical derangement or inflammatory lesion can contribute to or cause the temporomandibular pain. Specific local pain at the temporomandibular joint is not always present, although on palpation there is usually point tenderness on the lateral or posterior part of the joint. Because there is so much referred pain, the athlete may seek medical help for head, cervical, shoulder, ear, or dental problems. 1. Retro-orbital, temporal, and occipital headache pain are the most common complaints of temporomandibular joint sufferers. There may be local pain right over the joint but this is not as frequent as retro-orbital discomfort.

Shoulder Assessment

For several reasons the shoulder girdle is a difficult area to examine it has many movements, many components, many conditions, and there is a good chance of the existence of multiple lesions at this site. Also pain that manifests in the shoulder area is seldom caused by a shoulder joint problem. Pain can be referred to the shoulder from the cervical spine, the thoracic spine, the first costovertebral joint, the first costosternal joint, the temporomandibular joint, the elbow joint, and the viscera. Therefore these joints and structures may need to be ruled out before examining the shoulder joint. temporomandibular joint problems TMJ degeneration or effusion, which can refer pain through the neck region and into the shoulder

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