FUNCTIONAL MANIPULATION OF MUSCLES OF MASTICATION FOR TMD (Temporomandibular Joint disorders) By Dr Maryam Malik
Most valuable aspects of diagnostic assessment of Temporomandibular Joint disorders are through history and physical examination.
Complaint by patient:
- Limited function of lower jaw
- Limited range of movement in all direction
- Difficulty in eating , speech
- Most common complaint is pain.
Question to ask when evaluating a patient for TMD:
- Do you have pain in face in front of ear and temple area?
- Do you get headaches, earaches cheek pain?
- When the pain at its worst?
- Do you feel pain while opening wide, yawning, chewing, speaking or swallowing?
- Do you experience joint noises when moving jaws or when chewing?
- Do you experience pain in the teeth?
- Have you had any jaw injury?
- Does your bite feel uncomfortable?
- Does your jaw motion feel restricted?
Factor kept in mind during examination:
- Range of motion measured prior to palpating (may aggravates masticatory muscle) à decrease patients range of motion
- Consider Minimum of normal range of motion ( 40 mm opening, 7 mm right and left lateral & 6mm protrusive movements)
- For Odontogenic pain contributing to patient’s TMD pain àbilateral painà check anterior teeth (canine-canine)
- For Odontogenic pain contributing to patient’s TMD pain àIpsilateral painà check premolar to molar teeth (canine-canine)
Pattern of abnormalities may suggest source of a problem and possible diagnosis
A widely accepted digital examination is palpation
Masticatory muscle tenderness on palpation is most consistent examination feature in cases of TMD
Muscles impossible to palpate
- Inferior Lateral pterygoid
- Superior Lateral pterygoid
- Medial pterygoid
*Method of evaluating symptoms in medial pteryoid. Superior and inferior Lateral pterygoid is functional manipulation.
*Functional manipulation developed on principle that as muscle becomes fatigue and symptomatic further function elicits pain.
* Functional manipulation of muscles that are impossible to palpate can give accurate information regarding source of masticatory pain
*Functional manipulation is done by instructing patient to:
- Open mouth wide
- Protrude Jaw against resistance
- Clench teeth together
- Bite on separator between posterior teeth
Inferior Lateral Pterygoid Muscle:
ORIGIN: inferior head on the lateral surface of the lateral pterygoid plate.
INSERTION: Inferior head inserts onto the neck of condyloid process of the mandible.
Inferior Lateral Pterygoid Contraction à mandible protruded/mouth open
Inferior Lateral Pterygoid Stretchedà when teeth in maximum intercuspation
Functional Manipulation of Inferior Lateral Pterygoid Muscle:
1)Patient is asked to protrude Jaw against resistance(by dentist) à Increase pain à Source is Inferior Lateral Pterygoid Muscle(contracts)
2) Patient is asked to clench teethà Increase painà Source is Inferior Lateral Pterygoid Muscle (stretch)
Superior Lateral Pterygoid Muscle:
ORIGIN: superior head originates Infratemporal crest of the greater wing of the sphenoid bone
Active with muscle of closure –> aids in stabilization of condyle during power stroke
Functional Manipulation of Superior Lateral Pterygoid Muscle:
Patient is instructed to bite on tongue blade bilaterally on posterior teeth à clenching increase pain –> Superior Lateral Pterygoid Muscle stretch & contraction same time
Patient is instructed to open wide –> Increase pain –> Elevators( temporalis, masseter and medial pterygoid) contraction
Medial Pterygoid Muscle:
Origin: medial surface of lateral pterygoid plate, pyramidal process of palatine bone & Maxillary tuberosity
Insertion: medial surface of ramus & angle of mandible
–> Elevation of the mandible,
–> Protrusion of the mandible
–> Lateral movement of the mandible with unilateral activation
Functional Manipulation of Medial Pterygoid Muscle:
1)Patient is asked to clench teeth together –> increase pain –> Medial Pterygoid Muscle contraction
2)Patient is asked to clench teeth together against tongue blade b/w posterior teeth à Medial Pterygoid Muscle contraction
3)Patient is instructed to open wide –> Increase pain –> medial pterygoid stretches
Dr MaryamMalik 🙂