Temporomandibular Disorders and

Physical Therapy Interventions

Brittany Annis, Physical Therapy Student
Ithaca College, February 2009
 Temporomandibular Disorders
(TMDs)
Different pathologies
affecting the masticatory
muscles, the
temporomandibular joint
(TMJ), and related
structures
Affects more than 25% of
the population
90% of those seeking
treatment are women
 Signs/Symptoms
Facial pains/Muscle spasms
Pain/tenderness in the
muscles of mastication and
joint
Joint sounds (popping,
clicking)
Limited jaw motion
Jaw locking open or closed
Headaches
Teeth grinding
Abnormal swallowing
Uncomfortable off bite
Inability to comfortably
open/close mouth
Dizziness/vertigo
Ringing in the ears
Visual disturbances
Insomnia
Tingling in hands/fingers
Deviation of jaw to one
side
 Additional Symptoms
People with temporomandibular
dysfunctions frequently report symptoms of
depression, affected sleep quality, and a
decrease in energy.
It may also interfere with personal
relationships and normal social activities.
 Causes
Trauma Bruxism
Excessive stress (teeth grinding)
Arthritis of the TMJ Unaligned teeth
Whiplash injury Congenital
Postural abnormality Jaw abnormalities
Ligamentous laxity Prolonged mouth
Psychosocial distress breathing
(stresses) Thumb sucking
 TMJ Anatomy
Osseous Anatomy
The articulation between the condyles of the mandible
and the temporal bone, which is part of the cranium.
The articular surface of the condyle is convex and the
articular eminence of the temporal bone is concave.
 TMJ Anatomy
Meniscal Anatomy
Oval-shaped fibrocartilaginous articular disk (meniscus) between
the osseous components of the joint.
The central, intermediate portion of the disk is thin while the
anterior and posterior aspects, or bands, are thicker.
The bilaminar zone attaches to the posterior disc assists the head
of the condyle in moving forward.

Ligaments
Temporomandibular ligament
Stylomandibular ligament
Sphenomandibular ligament
TMJ Musculature
Four muscles of
mastication that move
the mandible:
Masseter
Temporalis
Medial Pterygoid
Lateral Pterygoid
TMJ Biomechanics
Two motions:
First 20mm of motion is
rotation. The mandible and
meniscus move anteriorly
together beneath the
articular eminence while
opening or closing.

Second motion is
translation, which slides the
jaw further forward or from
side to side.
 Normal TMJ
The TMJ allows the jaw to open, close,
protrude, retract, and deviate laterally.
Mainly used for chewing and speaking
Normal opening 35-40
2 to 3 knuckles
 TMD Treatment
Working together:
Dentists
Orthodontists
Psychologists
Physical Therapists
Ear, Nose, Throat Doctor
Physicians
Alternative Medicine
 TMD Examination
MRI
X-Ray
Dental examination for bite alignment
Physical Therapy Treatment
Physical Therapy is an
important aspect in the
treatment for TMD to:
Relieve musculoskeletal
pain
Decrease inflammation
Restore normal
joint/muscular movements
for oral motor function
Correct poor posture
 TMJ Evaluation
History
Posture
Watch, feel, listen to jaw with AROM
Opening between 40-50mm
Protrusion/retraction between 8-10mm
Lateral deviation while opening (S or C curve)
Lateral excursion 8-10mm
Ligamentous Laxity testing
Transverse Ligament
Alar Ligament
Cervical ROM testing
Palpate joints/muscles for tenderness
Postural Examination
Forward head
Thoracic kyphosis
Soft tissue dysfunctions

ADLs/Occupational
activities
 Types of Treatment
Therapeutic Exercises
Manual Therapy
Modalities
Electromyographic
(EMG) Biofeedback
Dental Splint
 Therapeutic Exercise
Improve muscular Muscles of
coordination mastication
Increase muscular Cervical spine
strength muscles
Postural exercises General mobility
Active ROM exercises
 Techniques: Tongue
Proprioception and Control
Make a clicking sound Place tip of tongue on
with the tongue on the palate behind teeth and
roof of the mouth. This draw small circles.
slightly opens the jaw
with the tongue on the Place tip of tongue on
palate behind the front hard palate and blow air
teeth, which is the resting out, rolling the tongue, or
position of the jaw and the making a r r r r sound.
first portion of relaxation
exercises.
 Techniques: Control of
Jaw Muscles
Begin with proper resting position of the jaw. Teach the
patient control while elevating and depressing the
mandible throughout the first half of the ROM.
Keeping the tongue on the roof of the mouth, the patient
opens the mouth while trying to keep the chin in midline.
Use a mirror for visual reinforcement.
If the jaw deviates to one side, teach the patient to practice
lateral deviation to the opposite side without creating pain
or excessive motion.
 Strengthening Exercises
Periscapular mm
Trunk Extensors
Shoulder External Rotators
 Rocabados 6x6 Program
Six components
Repeat six times each
Perform six times/day

Targets the craniocervical and

craniomandibular systems
Educate/instruct patient during treatment,
then issue for HEP
 Rocabados Program
1) Tongue Rest Position
Lips together, teeth slightly apart. Anterior 1/3 of tongue against roof
of mouth with slight pressure.
Breathe through nostrils, and use diaphragm for deep breathing.
2) Control TMJ Rotation
While opening jaw, keep anterior 1/3 of tongue on roof of mouth to
limit movement to rotation only, no protrusion.
Instruct patient to chew in this manner- without translation/protrusion.
3) Rhythmic Stabilization Technique
Lightly resisted motions: opening, closing, lateral deviations
 Rocabados Program
4) Cervical Joint Liberation
Distract the upper cervical vertebrae by clasping hands behind neck to
stablize C2-C7, and flex head 15 degrees for distraction.
Not neck flexion exercise, but flexion of the head on the cervical
spine.
5) Axial Extension of Cervical Spine
Push posteriorly on the upper jaw into lower cervical spine extension
and slight flexion of the occiput.
This reduces unnecessary cervical mm. activity and improves the
functional relationship between the head and cervical spine.
6) Shoulder Girdle Retraction
Draw shoulders back and down.
Restores shoulders to normal postural position to reduce tension and increase
stability.
 Manual Therapy
Massage Reduce pain
Joint Mobilizations Increase mobility
Muscle stretching (passive Restore oral range of motion
and active)
Myofascial Release
Manual Traction
Trigger Points
Relaxation techniques
 Massage
Masseter mm
Thumb inside mouth, fingers on cheek- sweeping motion to angle
of jaw
Cross-friction massage parallel to inner and outer fibers of mm.
If trigger point, focus there
Temporalis
Circular motions
Sternocleidomastoid
Corn Cob technique
Postural mm.
Face, shoulders, back of neck
Pressure on sensitive points, massage with hard, slow, short strokes
 Stretching Tissues
If the jaw is restricted from opening,
determine if the cause is:
A dislocated meniscus, which can be
repositioned by joint mobilizations, or
Hypomobile tissues, which can be passively
lengthened with stretching as well as joint
mobilizations.
 Stretching
Passively increase jaw Also focus on:
opening by placing Upper and Lower Trapezius
Sternocleidomastoid
thumbs on last molars
Masseter
of lower jaw and Temporalis
adding slight caudal Suboccipital/Posterior
pressure until the Cervical mm
patient can insert the Scalenes
Rotator Cuff mm.
knuckles of the index
Pectorals
and middle fingers.
 Resisted Stretching
Mandibular Opening Lateral Mandibular
Open to widest point Movement
Place both thumbs Mouth slightly open
inside mouth on molar Move mandible
surface laterally
Resist light closure for Resist medial
6 seconds movement for 6
Relax 6 seconds seconds
Relax 6 seconds
Open further, repeat 3-
5x Laterally deviate
further, repeat 3-5x
 Joint Mobilizations
Long Axis Distraction: Anterior Glide
Sitting/Supine
Same hand placement
PT positioned opposite of
affected side Slightly distract using
Use hand opposite of DIP of thumb while
affected jt. side
gliding anteriorly
Thumb in mouth on last
molar Oscillate for 30
Apply gentle downward seconds
pressure with thumb
Hold for ~30 seconds 2-
3x/session
Bilaterally
 Joint Mobilizations
Lateral Glide
Thumb on tongue side of last molar
Use whole hand to oscillate laterally
Medial Glide
Stand on affected side
Thumb on lateral side of last molar
Glide medially
 Electrophysical Modalities
Increase blood flow to Moist Hot Pack
the area Cold Pack
Relax tense muscles Ultrasound
Reduce inflammation Transcutaneous
Reduce pain Electrical Nerve
Stimulation (TENS)
Increase range of
Laser
motion for joint
Shortwave Diathermy
opening and lateral
deviation
 Preventing TMD
Avoid: Relaxation techniques
Large bites to reduce
Excessive chewing
stress/muscle tension
Removing food from teeth
with tongue Maintain good posture
Gum chewing
Chewy foods: bagels,
sandwiches, steak, ice,
crunchy fruits/vegetables,
caramel, nuts etc.
 Bibliography
McNeely, Margeret L., Susan Armijo Olivo, and David J. Magee. "A Systematic Review of the
Effectiveness of Physical Therapy Interventions for Temporomandibular Disorders." PT Journal 86 (May
2006): 710-25. Physical Therapy. 27 Jan. 2009 <http://www.ptjournal.org/cgi/content/full/86/5/710?
maxtoshow=&HITS=10&hits=10&RESULTFORMAT=1&title=temporomandibular&andorexacttitle=an
d&andorexacttitleabs=and&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance
&resourcetype=HWCIT>.

Medlicott, Marega S., and Susan R. Harris. "A Systematic Review of the Effectiveness of Exercise,
Manual Therapy, Electrotherapy, Relaxation, and Biofeedback in the Management of Temporomandibular
Disorder." PT Journal 86 (July 2006): 955-73. Physical Therapy. 27 Jan. 2009
<http://www.ptjournal.org/cgi/content/full/86/7/955#T3>.
Kisner, Carolyn; Lynn Allen Colby. Therapeutic Exercise, Foundations and Techniques. 2002

http://www.nismat.org/ptcor/tmj
http://uwmsk.org/tmj/anatomy.html
http://www.nlm.nih.gov/medlineplus/ency/article/001227.htm
http://udel.edu/~spetter/TMJWebsite/anatomy.htm