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
Excessive stress
Arthritis of the TMJ
Whiplash injury
Postural abnormality
Ligamentous laxity
Psychosocial distress
(stresses)

Bruxism
(teeth grinding)
Unaligned teeth
Congenital
Jaw abnormalities
Prolonged mouth
breathing
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
coordination
Increase muscular
strength
Postural exercises
Active ROM exercises

Muscles of
mastication
Cervical spine
muscles
General mobility

Techniques: Tongue
Proprioception and Control
Make a clicking sound
with the tongue on the
roof of the mouth. This
slightly opens the jaw
with the tongue on the
palate behind the front
teeth, which is the resting
position of the jaw and the
first portion of relaxation
exercises.

Place tip of tongue on

palate behind teeth and
draw small circles.
Place tip of tongue on
hard palate and blow air
out, rolling the tongue, or
making a r r r r sound.

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
Joint Mobilizations
Muscle stretching (passive
and active)
Myofascial Release
Manual Traction
Trigger Points
Relaxation techniques

Reduce pain
Increase mobility
Restore oral range of motion

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
opening by placing
thumbs on last molars
of lower jaw and
adding slight caudal
pressure until the
patient can insert the
knuckles of the index
and middle fingers.

Also focus on:

Upper and Lower Trapezius

Sternocleidomastoid
Masseter
Temporalis
Suboccipital/Posterior
Cervical mm
Scalenes
Rotator Cuff mm.
Pectorals

Resisted Stretching
Mandibular Opening
Open to widest point
Place both thumbs
inside mouth on molar
surface
Resist light closure for
6 seconds
Relax 6 seconds
Open further, repeat 35x

Lateral Mandibular
Movement
Mouth slightly open
Move mandible
laterally
Resist medial
movement for 6
seconds
Relax 6 seconds
Laterally deviate
further, repeat 3-5x

Joint Mobilizations
Long Axis Distraction:
Sitting/Supine
PT positioned opposite of
affected side
Use hand opposite of
affected jt. side
Thumb in mouth on last
molar
Apply gentle downward
pressure with thumb
Hold for ~30 seconds 23x/session
Bilaterally

Anterior Glide
Same hand placement
Slightly distract using
DIP of thumb while
gliding anteriorly
Oscillate for 30
seconds

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
the area
Relax tense muscles
Reduce inflammation
Reduce pain
Increase range of
motion for joint
opening and lateral
deviation

Moist Hot Pack

Cold Pack
Ultrasound
Transcutaneous
Electrical Nerve
Stimulation (TENS)
Laser
Shortwave Diathermy

Preventing TMD
Avoid:
Large bites
Excessive chewing
Removing food from teeth
with tongue
Gum chewing
Chewy foods: bagels,
sandwiches, steak, ice,
crunchy fruits/vegetables,
caramel, nuts etc.

Relaxation techniques
to reduce
stress/muscle tension
Maintain good posture

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