Unformatted text preview: Chapter 9 – The spinal column and thorax Chapter 9 – The spinal column and thorax Cervical Spine
Cervical Spine Curves of the Spine: Normal Postureplumb line
7 Cervical vertebrae and 8 discs C1C2: Atypical joints: OA (occiput and atlas or atlantooccipital joint) and the AA or atlantoaxial joint. C3C7 are more similar in structure
Lordosis is assisted by wedge shaped discs, like lumbar discs, which are larger anteriorly ANATOMY
ANATOMY VERTEBRAL BODY
FACET JOINTS
NEURAL FORAMINA
TRANSVERSE PROCESS
SPINOUS PROCESS
UNCINATE PROCESS OAA joints make up 40% of cervical flexion and OAA joints make up 40% of cervical flexion and 60% cervical rotation
Atlas has concave masses that join with convex occipital condyles: Flexion and Extension; Concave and Convex Rule
AA or C1C2: mostly Rotation
No discs between OAA joints
Stability in cervical spine especially within OAA complex is articulation and ligamentous DISC
DISC NUCLEUS PULPOSUS
ANNULUS FIBROSIS Discs: Contribute to 1/3 height of Discs: Contribute to 1/3 height of spine
Viscoelastic material allowing it to sustain great loads when they are rapidly applied Vertebrae
Vertebrae
Compression strength increases from the Cervical to the Lumbar direction
Bending moments occur in the vertebral bodies during movements
Flexion causes tensile forces posteriorly and compressive forces anteriorly SPINAL CANAL AND NEURAL SPINAL CANAL AND NEURAL FORAMINA WHAT HAPPENS TO THE NEURAL FORAMINA, SPINAL CANAL AND ALSO TO THE SPINOUS PROCESSES WITH FLEXION?
WHAT HAPPENS WITH EXTENSION? Range of Motion of Mid to Lower Range of Motion of Mid to Lower Cervical Spine: Rotation, Sidebending, Flexion and Extension
Range of Motion to Upper Cervical Spine: lateral tilting and nodding
During normal activities:Tying shoes Backing up a car Washing Angle of Facets or Zygoapophyseal Angle of Facets or Zygoapophyseal Joints What is the angle?
Class example
What motions will be limited with this angle? Combination movements:
Combination movements:
Retraction: what happens with upper cervical and lower cervical
Protraction: what happens with upper cervical and lower cervical? SUBAXIAL SPINE
SUBAXIAL SPINE Rotation of head one way causes SP to move in the same or opposite direction
Direction of rotation based upon vertebral body or spinous process? Suboccipital spine
Suboccipital spine Convex occipital condyles moving on concave atlas
Lateral tilt to right will have right occipital condyle moving anterior and left occipital condyle moving posterior and vise versa Spinal Stability Spinal Stability OAA Complex: Transverse Ligament disruption from the following:RA and Down’s Syndrome
Subaxial Cervical Spine
Muscles and discs provide the most stability
Supraspinous and interspinous and Ligaments that are important for attachment Ligaments that are important for attachment of the Dens from C2 to Anterior Arch of C1
Transverse Ligament
Alar Ligaments
Apical Ligaments
Accessory Ligaments
C3C7:Spinous Process
Transverse Process
Lamina Facet joints
Uncinate Process: arise from the lateral margins of the superior end plates of the vertebral body MYOTOMES AND DERMATOMES MYOTOMES AND DERMATOMES OF THE CERVICAL SPINE AND ASSOCIATED NERVE ROOTS WITH BRACHIAL PLEXUS STRETCHING
STRETCHING UPPER TRAPEZIUS
LEVATOR SCAPULAE
SCALENES
SCM
PECTORALS PATHOLOGY
PATHOLOGY CERVICAL SPRAIN AND STRAIN
CERVICAL DDD/HNP/OA (PROBLEMS WITH PERIPHERAL NERVES AND VERTEBRAL ARTERY)
CERVICAL STENOSIS
CERVICAL RADICULOPATHY
WHIPLASH
OSTEOPOROSIS’ EFFECT ON CERVICAL SPINE
CERVICAL FUSION: MIDLEVEL AND LOWER LEVEL, SURGICAL APPROACH TMJ
TMJ Temporomandibular Joint
TMJ is not the name of the disorder it is the name of the joint; the name of the disorder is Temporomandibular Dysfunction or Disorder
Anatomy Review Osseous
Muscular
Articular Dentists and Physical Therapists
Dentists and Physical Therapists Dentists starting to realize the craniocervical part of TMD
Physical therapists can assist dentists with their patients because of our knowledge of the TMJ and concurrent effects with the cervical spine Basic Features
Basic Features Compound synovial joint between the mandible and cranium
Articulating surfaces are covered by avascular fibrocartilage which can withstand large amounts of compressive and shearing forces
The active joint surface is from the superior part of the fossa to the anterior / inferior slope of the eminence all the way to the apex of the eminence Basic Features
Basic Features The articular disc divides the TMJ into an upper and lower compartment
Innervated by the mandibular division of the trigeminal nerve Basic Features
Basic Features In the sagittal plane, The convex condyle does not articulate with the concave temporal or mandibular fossa but against the convex slope and apex Basic Features
Basic Features In the Horizontal Plane, the direction of the temporal joint is in an oblique and sagittal direction
This orientation causes the condyles to translate laterally as we open our mouths as the condyles slide forward
Palpation of this movement Articular Disc
Articular Disc Plays a central role in the stability of the TMJ by making up for the congruency problem between the two joint surfaces
The disc is biconcave and oval in shape
This orientation presents the disc to be thinner in the central portion and thicker in the peripheral portions; self seating capacity of the disc
Excellent shock absorber
Laterally and medially the disc is stabilized by collateral ligaments Articular Disc
Articular Disc The superior disc surface contacts the middle onethird of the articular eminence
The inferior disc surface articulates with the convex joint surfaces of the mandibular head
The disc divides the joint into two compartments
Rotation takes place in the inferior compartment Translation takes place in the superior compartment Muscles of mastication
Muscles of mastication Temporalis: Muscle fibers in antero and postero inferior directions
Origin: entire temporal fossa
Insertion: coronoid process and anterior border of the ramus and some fibers to the skeletal orbit of the eye
Function: Bilateral contraction closes the mandible
Unilaterally deviates the mandible to same side
Posterior fibers minimally retract the mandible from rest position
All fibers retract mandible if it is fully protruded; helped by suprahyoid
Guides biting motion Muscles of mastication
Muscles of mastication Lateral pterygoid Prime mover of TMJ and guides disc both during eccentric and concentric contractions
Two bellies: superior and inferior
Origin: superior: sphenoid bone; inferior: lateral surface of lateral pterygoid plate
Insertion: superior: condylar head and disc; inferior: neck of the condyle
Function: two heads are antagonistic Inferior: mandibular depression as it pulls the condyle and disc forward and protrudes the mandible
Superior: stabilizes the mandibular head and disc against the articular eminence as the mandible closes
Assist in the deceleration of the posterior movement of the condyle during closing as well as stabilizing the anterior and medial joint capsule during closure preventing nipping of the capsule Muscles of mastication
Muscles of mastication Medial pterygoid Similar to the masseter but smaller
Origin: palatine bone and tuberosity of maxilla
Insertion: medial surface of ramus and mandibular angle
Function: elevates the mandible; if mandible is depressed, this muscle will limit protrusion; unilaterally deviates mandible toward opposite side; participates in chewing motion
Decelerates the posterior movement of the condyle with closing Muscles of mastication
Muscles of mastication Masseter: Origin: superficial and deep; superficial: anterior and inferior part of zygomatic arch and maxillary process; deep: deep side of zygomatic arch
Insertion: superficial: angle and lateral ramus of mandible; deep: superior half of the ramus and lateral surface of coronoid process
Function: initiates elevation of mandible
adds force to closure
Contributes to clenching and grinding Muscles of mastication
Muscles of mastication Digastric: anterior and posterior bellies and a central tendinous portion connected to the hyoid bone via a fibrous loop
Origin: anterior: digastric fossa of the mandible along the lower border lateral to the inner surface of the mandibular symphysis; posterior: mastoid notch medial to the mastoid process
Insertion: anteriorintermediate tendon connects the anterior and posterior bellies, splints the stylohyoid muscle, and is attached to the hyoid bone by a fibrous bone by a fibrous ring which acts like a pulley forming an obtuse angle
Function: if the hyoid bone is fixed by the action of the stylohyoid and infrahyoid muscles, the digastric muscle pulls the mandible back and down and functions during retrusive and opening movements of the mandible; during opening the digastric forms a force couple with the lateral pterygoid muscle Muscles of mastication
Muscles of mastication Stylohyoid: fiber direction similar to that of the posterior belly of the digastric and also assists in jaw opening through its action on the hyoid bone
Origin: styloid process of the temporal bone
Insertion: hyoid bone
Function: initiates jaw opening and draws hyoid up and back Muscles of mastication
Muscles of mastication Geniohyoid: Mylohyoid: Function: determines the length of the floor of the mouth; pulls mandible back and down Function: forms the floor of the mouth; elevates the floor of the mouth when the hyoid is fixed Infrahyoid muscles: Includes: sternohyoid, thyrohyoid, omohyoid
Function: depress the hyoid bone and stabilizes it for th action of the suprahyoid muscles Biomechanics of the TMJ
Biomechanics of the TMJ Functional unit Craniocervical joint posteriorly
Craniomandibular joint anteriorly TMJ problem, check the cervical spine and vice versa Biomechanics of the TMJ
Biomechanics of the TMJ Complex synovial joint: moves in three planes
4:1:1 ratio between opening, lateral excursion, and protrusion
For 40 mm if opening, there is 10 mm of lateral excursion and 10 mm of protrusion
When we measure left lateral excursion, we are measuring the function of theright TMJ Biomechanics of the TMJ
Biomechanics of the TMJ Joint surfaces and the articular disc Stability based upon on the shape and relationship of the joint surfaces
TMJ is unstable
The anterior slope of the temporal surface is convex and the condyle is convex: so convex on convex relationship: not stable
Not a problem with rolling but a problem with sliding: grinding and instability
Disc solves this problem by being biconcave and creates two compartments Biomechanics of the TMJ
Biomechanics of the TMJ The 2 departments of the TMJ Disccondylar (inferior) and disctemporal/eminence (superior) joints
Inferior department: rotation
Superior department: translation
Disc will follow the condyle as long as there is apposition of the two joint surfaces and there is no subluxation
Centric relation: term that refers to the most congruent contact between disc/eminence and disc/condyle with the disc interposed TMJ Movements
TMJ Movements Mandibular depression (opening) and elevation
Osteokinematics: mandible moves back and down; center of rotation moves from behind and inferior to a position anterior and below the joint Arthrokinematics: ½ half of opening is rotational or rollgliding of the condyle/disc in the inferior joint space; at the beginning of movement the condyle glides anteriorly and the disc posteriorly relative to each other; as the temporomandibular ligament tightens rotation will end and translation begins; condyle and disc will move together in translatory movement, down and forward on the articular eminence TMJ Movements
TMJ Movements Elevation: reverse of depression Protrusion: Symmetrical anterior translation of both condyle/disc complexes on the articular eminence The motion occurs in superior joint space Lateral Excursion: The condyle and disc of the joint contralateral to the direction of movement are pulled forward, downward, and medially along the articular eminence
The condyle of the ipsilateral side only minimal movement takes place, rotation around a vertical axis and a lateral shift; these motions take place in the upper joint space
Left lateral excursion: left mid and posterior temporalis is active; inferior fibers of both lateral pterygoids are active; the right medial pterygoid is active; force couple of left lateral pterygoid and left temporalis Other biomechanical Other biomechanical considerations Closed position: Orthostatic position: teeth are slightly apart, normal freeway space, tongue placed on the palate
Freeway space: separation between the central incisors; referred as interocclusal space
Point of reference for mandibular movements
Centric relation most stable position of the joint in which the condyles are in the unstrained position in the fossa in which the condyles are in a superoanterior position in the fossa against the slope of the eminence
Centric occlusion: teeth are in max intercuspation Other biomechanical Other biomechanical considerations The role of the tongue: Position of the tongue is important in that it can determine dentition an shape of maxillary bones
Connects to the hyoid bone which affects muscle balance in the craniomandibular system
Normal resting positon: tongue against the palate with the tip slightly behind the posterior side of the upper central incisors
Functional role: swallowing; normal swallowing, teeth must be together; abnormal swallowing can disrupt the teeth
Three forces: Anterior force: opposed by teeth and orbicularis oris
Transverse force: opposed by teeth and buccinator
Anteriorsuperior force:against the palate Other biomechanical Other biomechanical considerations Postural considerations: Movement or position of the head can challenge the normal rest positon
Muscle hyperactivity: can lead to a deep overbite
Forward head: the lowered mandible/tongue position facilitates eruption of the posterior teeth
Loss of tongue position against the palate can lead to constriction of the maxilla and narrowing in of the upper teeth
Respiratory difficulties: long face syndrome, leading to lowered mandible and tongue position and greater disruption of posterior teeth Postural and functional Postural and functional relationships Normal breathing: through the nose
What happens with mouth breathing: Affects dentition and facial development
Lowers the mandible
Results in backward rotation of the cranium
Stretches the inframandibular musculature
Contact between the tongue and upper maxilla/teeth is lost and maxillary arch collapses
Increased use of accessory respiratory muscles, such as scalenei and sternomastoid, decrease in diaphragmatic breathing Postural and functional Postural and functional relationships Mouth breathing leads to forward head posture which causes the following: Spondylosis
Disc pathologies
Facet joint pathologies
Loss of cervical lordosis
Narrow subcranial space
Complaint of HA, itching scalp, sensations in the eye or fullness in the ear Assessment of the TMJ
Assessment of the TMJ History: macro or microtrauma Macro: hit on the mandible via punch or fall
Micro: bad oral habits; leaning forward to read or watch tv
612% of the population
Women out number men 2:1
Mean age is 32
2540% have clicking sounds Areas of pain
Areas of pain Pain to the muscles of mastication
Neurological cause: unilateral
Pain reference from neck and shoulder muscles
Tension HA in 50% of the patients
Chronic pain with clenching Symptoms
Symptoms Neurological pain is sharp
Muscular pain is dull and aching
Trigeminal pain: severe facial pain
Pain usually low grade and intermittent but can become constant over time
Painful restriction of range of motion
Cold weather causes increased pain
Salivation, rhinorrhea, lacrimation, photophobia, nausea, tinnitus and stuffiness Onset of symptoms
Onset of symptoms 75% unknown cause
History of tooth extractions
History of clenching and grinding
Orthodontic care Clicking, grating or locking
Clicking, grating or locking Associated with disc displacement
Associated with degenerative changes or disc perforation
Disc derangement causing locking Precipitating factors
Precipitating factors Lifestyle, occupations or habits can contribute Parafunctions: (nail biting, clenching, grinding)
Smoke a pipe
Playing a wind instrument or the violin Psychological factors
Psychological factors Tension, fear, and certain personalities
Depression Facial symmetry
Facial symmetry Vertical dimension of the face Lower 1/3 is the most important for PT
Vertical dimension of occlusion is controlled by dentist but may be altered by fillings, bridges, and implants
Altered height of the lower 1/3 can result from biting, temporal HA, cervical muscle tightness/discomfort, increased muscle activitation Occlusion classes
Occlusion classes Straight profile: neutral occlusion: class 1 type
Retroinclined profile: dorsal occlusion: class 2 type
Anteroinclined profile: ventral occlusion: class 3 type
Clapping of the teeth: Put finger on front of teeth and clap teeth lightly
No bouncing or vibration in the upper anterior 6 teeth only neat clack
Vibration means mandible hitting on the upper front teeth and bounding back
No contact between lower/upper front teeth in maximum intercuspation, only between molars and premolars Observing parafunction
Observing parafunction Biting nails: repeated sliding of the mandible in the same direction
Increased action of masticatory muscles
Negative effect of posterior neck muscles
Increase subcranial sidebending Lip closure
Lip closure Shortness of the upper lip Lead to increased activity of the muscles of mastication Normally: the upper lip should cover ¾ of the upper teeth
Too short: mentalis muscle will have to raise the lower lip the distance needed to close the lips and cause muscle hypertrophy; this activates the masseter leading to clenching; posterior rotation of the head when trying to close the lips; interocclusal appliance makes this worse: how?
Treatment: firm rubber to stretch the lip or stretches: can take 6 months Active movements
Active movements Opening and closing: check deviations and measure vertical distance between upper and lower central incisors
Lateral deviation: measure deviation of the mandible using the space between the lower central incisors as a reference and marking its terminal locations during lateral deviation
Protrusion and retrusion: measure horizontal distance between upper and lower central incisors Basic concepts in TMD Basic concepts in TMD management Exercises for the rest position of the tongue: correct breathing in this position
Exercises to control TMJ rotation: 1. rest position 2. chew in limited motion in front of mirror 3. this limits early translation and maintains optimal position of the disc Basic concepts in TMD Basic concepts in TMD management Mandibular rhythmic stabilization First in resting position
Pressure in different directions Basic concepts in TMD Basic concepts in TMD management Upper cervical distraction: interlace fingers between C2C7 and then forward bends the head Axial extension of the cervical spine: Retraction Exercises for shoulder girdle retraction: shoulders back and down; strengthen the low traps and rhomboids Patient Education
Patient Education Explain structure and function of TMJ
Explain causes
Make patient aware of parafunctions
Do not sleep on stomach
Avoid biting off large pieces
Refrain from habitual protrusion of the mandible
Eat soft food
If hypermobile: limit excessive movements like yawning Management of inflammation
Management of inflammation Education, avoid excessive loading, stop parafunctional activities, soft diet, exercises such as correct tongue position and rest position, move mandible side to side with tongue in correct position, teach to breath and swallow in this position, nasal breathing promotes relaxation Management of hypermobility
Management of hypermobility Do not open mouth wide
Excessive mouth opening...
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- Fall '11
- ChrisD’Andrea
- muscles, Cervical vertebrae, cervical spine, TMJ
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