Cranial Made Clinical

Headache Symposium:Part 4:

Temporal Mandibular Joint (TMJ)

Kate Worden, DO, MS

Clinical Professor OMM

MWU AZCOM

AOMA Spring Convention

13 April 2019

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Disclosure

I have no financial or other disclosures

to make regarding this presentation

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Learning Objectives: Appreciate TMJ as a frequent cause of

Headache

Recognize TMJ key anatomical landmarks

ID the action of the TMJ on opening and closing

and its affect on the articular disc

Correlate the position of the Temporal bone with

that of the Mandible during the 2 phases of the

cranial mechanism (Fl/Ext)

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Learning Objectives:

ID TMJ Dysf as primarily a joint problem

that reciprocally influences the cranial

mechanism with secondary head, neck &

shoulder muscular dysfunction

ID the muscles of mastication as they

relate to TMJ dysf

Relate the constellation of clinical

symptoms that can occur with TMJ dysf

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Learning Objectives (LAB):

Be able to perform the following procedures:

Physical Exam to Evaluate TMJ

Muscle Energy for TMJ dysfunction

Strain Counterstrain (SCS) to

tenderpoints:

Medial Pterygoid muscle

Lateral Pterygoid muscle

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Trephination

Hot stone for TMJ

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Chinese herbs for TMJ

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Low level laser for TMJ

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Acupuncture for TMJ

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Biofeedback for TMJ

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Bite Splints for TMJ

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Osteopathic Manipulation for TMJ

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Cranial Osteopathy for TMJ

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Why so many different Txs for TMJ?

The higher the number of treatments,

the less likely that any one is fully

effective alone!

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Dental Hx:

1950-called TMD (TemporoMandibular

Dysfunction)- They thought that a

dental/teeth problem (Malocclusion)

caused a muscle imbalance problem-

became accepted norm within 12 mos

But inadequate to explain all findings-had

3 theories but no studies.

1979-introduced the concept of TMJ being

an Orthopedic (ie, Joint) Condition.

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Dental Hx:

2002-today most all agree it is primarily

an orthopedic problem, but they just

tx the secondary muscle problem

the same way they did before- but

now they call it “Orthopedics.”

Many DDS do Sx dept Dx & Tx, ie they

treat a syndrome not the pathology.

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*Signs & Symptoms of TMJ:

Pain with jaw

movement

Intermittent “locking”

Limited ROM

opening mouth

Facial pain & muscle

fatigue

Noises in Jt. with

movement

Ear pain w/o infection

Bruxism-

clenching/grinding

Ears feel “blocked”

Headache

Neck & Shoulder Pain

Dizziness

Sensitive Teeth

Tinnitus

Insomnia

2ary Depression18

Summary: Classic Triad-

Pain

Altered Function

Bruxism

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Cranial Motion and TMJ:

The Cranial Rhythmic Impulse (CRI) is

palpable in 2 phases:

Flexion-all bones move away from midline

single bonesFlexion

paired bonesExternal Rotation (ER)

Extension- bones move toward midline-

single bonesExtension

paired bonesInternal Rotation (IR)

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*Cranial Motion and TMJ:* Movement of Key bones drives motion of

others:

Occiput drives the Post Cranium

Temporals & Parietals

Sphenoid drives the Face esp Maxilla

Temporals drive the MandibleER and IR(Embryology: Mandible 2 parts-functions as paired bones)

Thus, the Maxilla may be in one phase

(Flexion with ER) while the Mandible may be

in the other phase (Extension with IR) leading

to Malocclusion (abnormal bite).

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*Cr Motion:Temporals & MandibleFlexion: Extension:

Jaw Retrudes-post

Crowds the airway

predisposing to

Obstructive Sleep

Apnea

Jaw Protrudes-ant

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TMJ & TEMPORAL ROTATION

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Class II: “Great American Bite”

I=Ideal II=overbite, III=underbite

overjet, retrude protrude

Cr Flexion Cr Extension

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So where do we start?

Anatomy, Anatomy, Anatomy!

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Key Landmarks:

Temporal Bone

External Acoustic Meatus (EAM)

Mastoid Process

Occipital Mastoid Suture (OM)

Parietal Notch (PN)

Spheno Squamous Pivot (SSP)

Zygomatic Process

Mandib (Glenoid) Fossa & Artic. Eminence

Petrous Pyramid/ Eustachian Tube

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Key Landmarks:

Mandible:

Ramus

Angle

Body

Mental Protruberance

Condylar Process

Articular Cartilage (Disc)

Coranoid Process

Medial & Lateral

Collateral Ligaments

Stylomandib Lig.

Sphenomand Lig.

BiLaminar Zone-

Post: Fascia w.

Neurovascular Bundle

incl. Temporal a.

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FIGURE #2

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TMJ

1. Mandibular condyle

2. Articular disk

3. Superior joint cavity

4. Articular eminence

5. External ear

TMJ Sagittal View (like MRI view)

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TMJ- Gross Sagittal Section

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“Bow tie” Disc

EAM

Condyle

Bilaminar

Zone

Glenoid

Fossa

TMJ Features:

Synovial Jt.-Med. & Lat Disc attached to Condyle by Med. & Lat. Collateral Ligaments

Ant. Disc attached to Jt. Capsule & fascia of Sup. Head of Lat. Pterygoid M.

Post Disc attached to Bilaminar Zone (Neurovascular Bundle btwn loose areolar fascia)-subject to compression with TMJ Dysfunction.

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Jaw Full Open- disc forms “bowtie”

35Jaw Full Closed-HyperExtension leads to grinding

Key Ligaments of the TMJ:

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Stylomandibular-styloid process Temporal to medial angle of Mandible

Sphenomandibular –spine of Sphenoid to medial ramus of Mandible

Joint capsule w Medial & Lateral Collateral Ligaments

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TMJ Troublemakers

Muscles of Mastication (CN V-Trigeminal):

Temporalis m

Masseter m

Lateral Pterygoid m

Medial Pterygoid m

Also:

Sternocleidomastoid (SCM) m (CN XI-Spinal

Accessory)

Omohyoid & Digastric mm

Suboccipital mm

Occipital-Mastoid Suture Compression 39

TEMPORALIS MUSCLE:

O: Temporal Fossa (formed by Frontal & Parietal bones)

I: medial aspect of the Ramus & the Coronoid Process of the Mandible

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MASSETER MUSCLE:

O: Zygomatic Arch & Maxilla

I: post-lateral aspect of Angle of Mandible

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LATERAL PTERYGOID MUSCLE:

Superior Head: O: inf-lat Greater Wing of Sphenoid

I: investing fascia which then attaches to the Disc & Joint Capsule

Inferior Head: O: lat. aspect Lat. Pterygoid Plate of Sphenoid

I: ant-lat Condylar Process of Mandible42

MEDIAL PTERYGOID MUSCLE:

O: med. aspect of Lateral Pterygoid Plate of Sphenoid

I: med. aspect of Angle of the Mandible43

Motions of the TMJ:

Opening (depression) ( Dental Flexion)– Hinge Motion: sl open (jaw drop) ~20mm

Glide Motion: full open ~30mm

Total ~50mm in the adult-3 knuckles of dom. hand

Closing (elevation) (Dental Extension)

Protrusion (forward)- esp w/ Cranial Extension

Retrusion (backward) – esp w/ Cranial Flexion

Lateral Motion – Usu 12-16mm from the midline –reflects tightness of Lat Pterygoid m/Stab: M&L Col L

Chewing –combo of all 4 M. of Mastication

Dental Terms:

Extension = Mouth Closed

Flexion = Mouth Fully Open

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NORMAL TMJ FUNCTION

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So. . .what can go wrong?

Internal Joint Derangement- via prolonged microtrauma from shearing forces with Hyperextension on closing

Anterior displacement of the Disc

Reversible

Irreversible

Muscle Imbalance- esp with head forward posture so common today, whiplash

Acute Lock- Open or Closed

Arthritis: Rheumatoid or Osteoarthritis

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O’Donahue’s Terrible Triad –

Knee

Medial Collateral

Ligament

Medial Meniscus

Ant. Cruciate Ligament

TMJ

Medial Collateral Ligament

Articular Disc

Lateral Collateral Ligament

NO Cruciate Ligaments

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TMJ Jt. analogous to Knee Jt.:

O’Donahue’s Terrible Triad –

Lateral Collateral Ligament fails first->Disc begins

to deviate medially->Med.Col. Lig fails

Cartilage Disc is displaced Anterior by the

forward motion of the Condyle (but NOT actively

pulled by any muscle contraction)

Disc can get caught ant. & won’t reduce back up

on the Condyle

Spheno/Stylomandib Ligs-check ligs. to prevent

HyperFlex (opening)

*No Cruciate Lig. to prevent HyperExt* (closing)

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TMJ Model:

On Full Opening (Flexion) “classic

bowtie appearance” on MRI- ie, Disc

should be seated mid-Condyle

On Closing (Extension)

By convention, as a frame of reference,

the midpoint of the Condyle acts as mid pt.

of a clock

Post aspect of Disc should line up at

EXACTLY 12 o’clock to prevent Hyper Ext

Bite splint acts to prevent/correct Hyper Ext

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Perfect closure (TMJ Ext) @ 12:00

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12

Perfect Open (TMJ Flex) “Bow-Tie”

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ABN Closure (HyperExt) @ 10:00

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1210

Closure corrected w/ Bite splint to 12:00

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Summary:

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Jaw Click

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Internal Jt. Derangement can produce “click” Displacement/distortion of the disc

Catching of torn ligaments/disc in Jt.

Remodeling of the articular surfaces

Joint ligamentous hypermobility

The Disc is displaced anterior to the Condyle.

“Click” occurs as the Disc attempts to locate itself on the Condyle.

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Acute Closed Lock-Emergent

Must be reduced within short window (~4-6 wks)

Once reduced DON’T CLOSE MOUTH till sees dentist-place bite block/ bite guard to prevent another ant. displacement

If Dx missed, will have Hinge motion only- lose Glide Motion- so can only open mouth 20mm

Forces the neurovascular rich bilaminar zone to now act as disc—Exquisitely Painful!

Leads to DJD-thereafter followed by CT scan until pt. is a candidate for TMJ joint remodeling surgery

NO longer do TMJ joint replacement-off market

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Inflam cyst

Irregular condyle

Ant displaced disc

The Condyle is prevented from translating

at all due to the Disc being unable to

locate itself on the Condyle.

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Causes of TMJ

Joint Pathology- analogous to the Knee

Trauma

Macro- a blow, accel/decel or inertial injuries

Repetitive Micro- clenching, grinding with

malocclusion and/or emotional stress.

Frequently with chronic severe headache

Prior Dental extractions

Posture-can lead to Myofascial Imbalances

Functional or Anatomic Short leg, Scoliosis61

Nociception via Trigeminal from the Teeth leads to Tension in Muscles of Mastication

A Viscero-Somatic Reflex

NMM/OMM Specialist: if you recognize

problems but it is beyond your OMT skills

TMJ Specialist (DDS):

When you suspect internal derangement

or degenerative joint disease which does

not respond to OMT. May be a painful or

painless click or limited opening.

Urgent : Acute Closed Lock: Jaw fails to

open due to the Condyle being unable to

capture the Disc with opening. Must be

treated promptly to avoid sequela

When to Refer?

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Osteopathic treatment can be considered

when the problems appear to be

A. Muscular in origin: This includes the

major muscles for chewing, cervical,

sternocleidomastoid, trapezius, and

levator scapulae muscles.

B. Articular (Jt) in origin: the cranium, upper

cervicals, ribs, upper thoracics & sacrum

are also important to examine.

Where do you focus the OMT?

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TMJ Tomogram X-rays

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MRI

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CT scan with sagittal views:

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Ant disc

TMJ & Sleep Apnea

If you have mild to moderate obstructive sleep apnea

and can't tolerate or haven't been helped by CPAP,

oral appliances may be an effective treatment option.

These devices, which must be fitted by a dentist or

orthodontist, and worn in the mouth at night include:

Mandibular advancement device (MAD). The most widely

used mouth device for sleep apnea, MADs look much like a

mouth guard used in sports. The devices snap over the

upper and lower dental arches and have metal hinges that

make it possible for the lower jaw to be eased forward.

Some, such as the Thornton Adjustable Positioner (TAP),

allow you to control the degree of advancement.

Tongue retaining device. Used less commonly than MAD,

this device is a splint that holds the tongue in place to keep

the airway open. 70

LAB

Evaluate the Bite for TMJ

Muscle Energy TMJ

SCS Medial & Lateral Pterygoid muscles

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Headache: TMJ

PERFORM A PHYSICAL EXAM

Sit or stand facing your patient1) Observe for:

• facial asymmetries• head tilt (tight SCM on side of tilt)

2) Observe for restriction in the 2 actions on opening of the joint:• hinge• glide

3) Observe for restriction of:• Protrusion (jaw forward)• Retrusion (jaw backward)• Lateral Deviation (L & R)

• less motion available to side that jaw is dysfunctionallydeviated toward

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PERFORM A PHYSICAL EXAM

4) Have them smile or otherwise show their teeth• Observe the mid-incisor line: Do the top & bottom line up:

• Open (flexed) position• Closed (extended) position

• Observe the other teeth in a closed position:• Do the front teeth meet in front?

• Closed Bite: the front teeth meet but the back teeth do not• Do the back teeth meet when the front teeth meet?

• Open Bite: the back teeth meet but the front teeth do not• Are the upper teeth just anterior to the bottom teeth all the way

around? • Cross bite--on one side the bottom teeth will be anterior to the top

teeth.• Class II (“Great American”) bite (overbite, overjet=buck teeth) is

when the lower teeth slide further superior and posterior to the upper teeth

Headache: TMJ

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PERFORM A PHYSICAL EXAM

5) Place 5th finger pads on anterior aspect of patients EAC.• Palpate for asymmetry and tenderness. • Motion Test: With opening and closing of the jaw:

palpate again for tenderness and for an opening clickor closing click or other crepitus such as clunking.

6) Palpate for muscle tension• Make note of any SCS points, see table below.

Headache: TMJ

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Muscles of mastication Occipital Mastoid Suture

Suboccipital muscles Neck Muscles related to forward head posture.

Temporalis Rectus capitis posterior major SCM

Masseter Rectus capitis posterior minor Scalenes

Lateral pterygoid Obliquus capitis Trapezius

Medial pterygoid Levator scapulae

PERFORM A PHYSICAL EXAM

7) Determine the TMJ Deviation pattern of the patient:• C-shaped deviation: jaw deviates to one side

• Always deviates to the side of the dysfunctional joint• Dysfunctional side will stop first upon opening –the other

side opens further & deviates to the dysfunctional side

• S-shaped deviation: jaw deviates from midline in one direction until half-way through the range then deviates the other direction. • Indicates dysfunctional movement of the Disc from

ligamentous instability involving BOTH the Left & Right Condyles.

Headache: TMJ

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Principle of Muscle Energy

Direct technique (take toward the restrictive

barrier)

Activating force: Pt.’s own muscle force

pushing away from the barrier.

Doc give equal counterforce x 3-5 sec.

Relax.

Wait 1-2 sec for the Post Isometric

Contraction Relaxation Phase.

Take up slack to the next barrier.

Repeat 2-5 x. Retest.76

Headache: TMJ

Treatment of TMJ Dysfunction

Muscle Energy TMJ:

Diagnose:• Using the pads of your 5th fingers, palpate the anterior

external auditory meatus. • Determine which side the mandible deviates while the

mouth opens. This is the “dysfunctional” side!• Is there associated crepitus, muscle tightness, and/or

tenderness of the anterior EAM?• Is it a C or S deviation?

Finger alignment for DX of TMJ Dysfunction

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Headache: TMJ

Treatment of TMJ Dysfunction

Muscle Energy TMJ:

Technique:Patient: SupinePhysician: Seated at head of patient1. Hold the temporal bone on the “dysfunctional” side to stabilize the head.

With your other hand cup the chin as shown on the “good” side. 2. Have the patient relax their jaw (use instructions like drop or sag the jaw). 3. Have the patient contract their jaw isometrically against your hand for 3-5

seconds (they will be firing the muscles of the “good side” to push their jaw away from the “dysfunctional side).

4. Patient relaxes for 2 seconds. 5. You take up the slack by medial translation of the jaw into the new barrier. 6. Repeat the muscle energy cycle 3 times. 7. At the end of each muscle energy cycle, have the patient slightly open their

jaw further while you hold it at the barrier (the last time they open the jaw fully).

8. Have the patient fully close jaw while you hold the jaw at the barrier. 9. Switch hands and repeat steps 1-8 for the “dysfunctional” side. 10. Reassess by reinserting your 5th digits in the ear canals & have the patient

slowly fully open & close

**At the final open & close by the patient, there is often a palpable clunk in the TMJ as the disc reseats on the mandible.

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Headache: TMJ

Treatment of TMJ Dysfunction

Muscle Energy: TMJ:

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Cup the Jaw Patient Sags the jaw, counterforce is applied Patient relaxes, Slack is taken up

Cup the Jaw Patient Sags the jaw, counterforce is applied Patient relaxes, Slack is taken up

Principles of Strain Counterstrain (SCS):

Find a tenderpoint with testing pressure

Put the associated muscle, fascia, etc. in its most

relaxed position, wrapping around the opp. side and

hold for 90 sec

3 phases of release:

Nerve phase: pain diminishes- then use monitoring

pressure (less)

Circulatory phase: as fascia relaxes, the relatively ischemic

area allows fresh blood to enter-feel a pulse

Lymphatic phase: as fluid passes through the capillary, the

lymphatics drain-feel a softening

Slowly, passively return body to a neutral position

Retest. Goal is 70+% improvement

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PTERYGOID MUSCLES

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Medial Pterygoid (MPT)

Location of

Tender Point

Posterior surface

of ascending

ramus of

mandible

Approx 2 cm

above

mandibular angle

Press anteriorly

Medial Pterygoid (MPT)

Treatment Position–

Pt. supine

Push slightly open

jaw laterally away

from TP side

Apply stabilizing

force on opposite

side of forehead

w/ forearm

PTERYGOID MUSCLES

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Lateral Pterygoid (LPT)

Location of

Tender Point(s)

1) Below the

zygomatic arch

(cheek bone),

1 cm anterior to

neck of the

condyle

Press medial

and posterior

Treatment Position

Pt. supine

Pt protrudes (juts)

jaw forward

Push open jaw

laterally away from

TP side

Pt. relaxes.

Apply stabilizing

force w/ forearm of

motion hand

Lateral Pterygoid (LPT)

References:

Chila, A, Foundations of Osteopathic

Medicine, 3rd ed by Lippincott, Williams &

Wilkins, 2011, Ch.37: Head and Suboccipital

Region by Heinking, KP, Kappler, RE and

Ramey, KA, 510-511.

Meyers, HL, et al, Clinical Application of

Counterstrain, TOMF Osteopathic Press,

compendium ed, 2012, Treatment of

Headache, Neck Pain, and TMJ Dysfunction

with Counterstrain.

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References:

DiGiovanna, EL and Schiowitz, S, The

Temporomandibular Joint by Donald Phykitt, in An

Osteopathic Approach to Diagnosis and Treatment,

Lippincott Williams & Wilkins, 3rd ed, 607-611.

Magoun, HI, Temporomandibular Lesions, in Osteopathy

in the Cranial Field, 1976, 3rd ed, The Journal Printing

Company, Kirksville MO, 155,162-163, 201-202.

Upledger, JE and Vredevoogd, JD, TemporoMandibular

Joint Evaluation and Treatment in CranioSacral

Therapy,1983, Eastland Press, 199-202.

Seffinger, M and Hruby, R, Evidence Based Manual

Medicine,Saunders Elsevier, 2007,129-187 (Mechanical

Neck Pain), 189-205 (Cervicogenic HA), 207-220 (TMJ).

88

References Greenman, PE,Craniosacral manipulation in

Phys Med Rehab Clin N Am, 1996, 7: 877-896.

Gehin, A, Atlas of manipulative techniques for

the cranium and face, 1985, Eastland Press.

Rimon, A, et al, Review for the Generalist:

Temporomandibular joint pain in pediatrics: the

clinical approach and differential diagnosis:

http://www.pedrheumonlinejournal.org/may-

june05/TMJ-Pain.htm

Eraso, F, TMJ Imaging: What should be the

Standard of Care?, Winter 2006 AADMRT

Newsletter,http://www.aadmrt.com/currents/eras

o_winter_06_print.htm