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TMJ Update

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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

  • 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!

On the streets of Quebec City

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