TMJ Trauma and Its Rehabilitation
By R. C. Schafer, DC, PhD, FICC
Manuscript Prepublication Copyright 1997
Copied with permission from ACAPress
TEMPOROMANDIBULAR JOINT DYSFUNCTION
Proper treatment of TMJ dysfunction must be based on a thorough case
history, a complete physical workup, an evaluation of the cranial
respiratory impulse and craniosacral mechanisms, and a detailed
examination of the TMJ, cranium, and cervical spine.
Unfortunately, radiographs to determine abnormal joint space are
rarely successful unless over 30% of the bone has been
A blow to the jaw is easily transmitted to the temporal bones.
As mentioned previously, osteopathic research suggests that a
subluxated temporal bone is often the focal fault. This is
reported to be grossly indicated by flattening (temporal internal
rotation) or protrusion (temporal external rotation) of an ear
from the skull.
The major symptoms of TMJ dysfunction are masticator muscle fatigue and
pain, which are usually described as a severe, unilateral (rarely
bilateral), dull facial ache that is often fairly localized to an
area just anterior to the tragus of the ear. The onset of pain is
gradual, progressively increasing over several days or months. It
is aggravated by chewing and opening and closing the mouth.
Precipitation is often made by eating an apple, a wide yawn,
snorkeling, prolonged dental work, playing a wind instrument,
prolonged chewing, a bump or pressure on the mandible, sleeping
in the prone position, or a cervical whiplash.
Joint clicking, popping, or grinding are often felt and/or
heard with or without auscultation. The mandible deviates to one
side when opened, tenderness and muscle spasm are present, and a
nervous bruxism is usually in the history. There is pain on
opening and closing the mouth, or, sometimes, just by moving the
head on the neck. An associated referred earache is common, but
it should be noted that an ear disorder can sometimes refer pain
to the TMJ area.
Neurologic and Circulatory Effects. Nine of the 12
cranial nerves are in close relation to the temporal bones from
which the mandible is suspended; thus, universal effects may be
expressed. There is no doubt that TMJ dysfunction can have
far-reaching effects, even to the point of involving peripheral
circulation and paresthesias. S. D. Smith reported a case where
major improvement in leg circulation directly corresponded to
balancing a left TMJ compression through jaw repositioning.
Referred Pain. Within the immediate area of the TMJ are
found the chorda tympanum nerve and branches of the superficial
temporary artery, vein, and nerve wherein area irritation may
cause reflex pain in other areas. While pain is often referred
from the TMJ to the scalp, supraorbital area, ear, or neck, the
TMJ is rarely a site of referred pain except in cases of a tooth
abscess in the mandible or an inflamed upper or lower wisdom
Differentiation should first be made from angina or cardiac
infarction, both of which often refer pain, aching, or throbbing
to the angle and base of the mandible. Sinusitis usually refers
pain to the frontal area, but sometimes pain is referred to the
jaw. Temporal arteritis and glaucoma can also refer pain to the
jaw. Referred pain may also be due to dental pathology such as
dental caries, pulpitis, impaction, occlusal trauma, periapical
abscess, and cementitis. Referred pain from a lower molar is
carried by the trigeminal, which also supplies the external
Associated Spasticity. The location of associated
muscle spasm in TMJ dysfunction according to incidence is in the
external pterygoid, internal pterygoid, masseter, posterior
cervical, temporalis, sternomastoideus, trapezius, and mylohyoid.
Rhomboid and scalene attachments to the first rib are also
commonly tender and hypertonic.
Inspection and Palpation
Active joint motion is observed by having the patient open and close the
mouth, observing the movement of the mandible from the front and
sides. The rhythm should be smooth, the arc should be continuous
and unbroken, and the mandible should open and close in a
straight line symmetrically, with the teeth easily separating and
joining. An awkward arc, a restricted range of motion, and/or
lateral deviation during motion suggest an abnormality.
Bony Palpation. During the initial palpation of the
TMJs, the examiner sits in front of the patient, places his index
fingers in the patient's external auditory canals, and applies
pressure anteriorly while the patient opens and closes the mouth.
Motion of the mandibular condyles will be felt on the fingertips.
This motion is normally smooth and equal on both sides. Next, the
lateral aspects of the joints are palpated by placing the first
and second fingers just anterior to the patient's tragi. The
patient opens and closes the mouth, and any abnormalities are
noted. A palpable crepitus suggests traumatic synovial swelling
or meniscus damage, and a slight dislocation (painful) may be
felt when the patient widely opens the mouth. If there is any
doubt of the presence of crepitus, the joint is auscultated for
clicks or grating sounds.
Soft-Tissue Palpation. The middle fibers of the
temporalis muscles between the eye and the upper ear, the body
portion of the masseter muscles, and the external pterygoid
muscle are palpated after the patient has opened the mouth. A
gloved index finger is pointed posteriorly above the last molar,
between the gum and the buccal mucosa, on the mandibular neck.
The external pterygoid will normally be felt to tighten and relax
as the patient opens and closes the mouth. The patient will
report tenderness and pain on palpation if the muscle has been
strained or is in spasm. The internal pterygoid muscle is
palpated intra- and extra-orally simultaneously. The mylohyoid
muscle is palpated beneath the tongue. The examiner may wish to
test the jaw and Chvostek's reflexes at this time if they haven't
been checked previously. The posterior cervical,
sternocleidomastoideus, and trapezius muscles are palpated for
hypertonicity and tenderness.
Relationship to Cervical Motion. During examination,
the patient is asked to slowly tap their teeth together. The bite
is evaluated. Next, the relationship with cervical motion is
screened. The mandible normally moves backward during cervical
extension and forward in cervical flexion, producing poor
occlusion during extreme flexion-extension. Thus, a patient with
a cervical spine in a chronic state of fixed flexion or extension
in the resting position will exhibit a constant state of
malocclusion, which will lead to TMJ dysfunction.
strength is tested by placing one hand on the patient's occiput
to steady the patient and the other hand, palm up, under the
patient's jaw. The patient is asked to open the mouth while the
examiner applies resistance with his palm. The patient should
normally be able to open his mouth against the increasing
resistance of the examiner's palm. When the patient is unable to
close his mouth actively, an attempt should be made to can close
Range of Motion
range of mandibular motion is usually normal if (1) the examiner
is able to insert three finger widths between the incisor teeth
when the mouth is opened; (2) the patient is able to jut the jaw
forward and place the lower teeth in front of the upper teeth. If
deemed necessary, an accurate measurement of the interincisal
opening can be made using a Boley gauge.
Restricted joint motion can be the result of muscle spasm,
rheumatoid arthritis, osteoarthritis, joint ankylosis, scar
tissue, trismus from spasm of the elevating muscles of
mastication from hysteria, tetanus, congenital defect, or most
any type of local inflammation. If a patient with a subnormal
range of mandibular motion can suddenly open the mouth wider
after the TMJ area has been sprayed with a vapocoolant, muscle
hypertonicity should be suspected as an important ingredient in
APPLIED ANATOMY OF THE TMJ JOINT
Anatomy of the TMJ
The TMJ is a hinge and gliding joint and is the most constantly used joint in the body. The round upper end of the lower jaw, or the movable portion of the joint, is called the condyle; the socket is called the articular fossa. Between the condyle and the fossa is a disk made of cartilage that acts as a cushion to absorb stress and allows the condyle to move easily when the mouth opens and closes.
Thanks to AAOMS for the use of this table. Refer to their page for more sketches.
Function of the TMJ
Temporomandibular joint — Normal closed position. Jawbone is separated from skull by a soft disk that acts as a cushion when you chew, speak or swallow.
Temporomandibular joint — Noraml open position. Disk stays in place when jaw is in use.
Temporomandibular joint — Abnormal. Disk is pulled forward when jaw is in use, causing the bone structures to grind together.
Thanks again to AAOMS
The TMJ is the most active joint of the body, moving up to 2,000 times each
day during talking, chewing, swallowing, yawning, and snoring.
However, it has only been within the last decade or so that wide
recognition of the clinical importance of TMJ dysfunction on the
cervical spine and body as a whole has been achieved.
Like other synovial joints, the TMJ is lined with articular
cartilage, possesses an internal meniscus, and has a synovial
membrane. Because of the structural approximation and
neuromuscular relationship of the TMJ area and the
occipitoatlantal area, disorders of the TMJ can be referred
biomechanically and neurologically to the upper cervical spine in
particular. The reverse can be true in situations of
upper-cervical fixation/subluxation syndromes. TMJ meniscus
malposition frequently produces neck pain, suboccipital muscle
spasms, and headaches.
The TMJ articulation hinges within the glenoid fossa of the
mandible and glides anteriorly to the eminentia during normal
motion. The articular space contains a small amount of viscous
fluid for lubrication. The head of the condyle and the glenoid
fossa are covered with fibroid cartilage that serves as a shock
absorber. This cartilage tends to wear thin when subjected to
prolonged overstress because it contains no direct blood supply
that could assist in tissue regeneration. The blood supply to the
TMJ is from the superficial temporal branch of the external
carotid artery; the disc itself, however, is avascular.
The meniscus of the joint divides the joint cavity into two
divisions. The lower part of the joint cavity is used during
gliding motion, and the upper part is used for hinge movements.
This is accomplished primarily by one head of the external
pterygoid muscle pulling the meniscus forward while the second
head opens the joint. Secondary assistance is provided by the
mylohyoid, geniohyoid, and digastric muscles, and gravity is
helpful in lowering the mandible during the upright position.
Thus, the two heads of the pterygoid muscle, essentially, act
asynchronously to open the TMJ. In closing the jaw (approximating
the mandible and maxillae), the temporal, masseter, and internal
pterygoid muscles are activated. All muscles active during TMJ
function assist in maintaining the mandible in its resting
pterygoid muscle, the prime opener of the mouth, is supplied by
the pterygoid branch of the mandibular division of the trigeminal
nerve. Secondary force in opening is provided by the hyoid
muscles and gravity when upright. The masseter and temporalis
muscles, both supplied by the trigeminal nerve, are the primary
closers of the jaw, with secondary effort provided by the
internal pterygoid muscle. The capsule and structures of the TMJ
are innervated by branches of the articular temporal nerve,
filaments of the masseter nerve, and a sensory branch from the
TMJ nerves are not vulnerable to direct compression by the
condyle, but the joint's proprioceptive bed is abundant with
nerve endings. Thus, strain or subluxation, unilaterally or
bilaterally, may not only cause symptoms within the joint and
associated soft tissues but also by reflex action mirror
distorting effects within the musculature innervated by the gray
cell motor columns of the C1 C4 neuromeres. Reflex aberrant
stimulation transmitted downward via the tractus spinalis of the
5th cranial nerve, with attending atlanto-occipital jamming and
atlantoaxial and/or C3 rotational subluxation, may result in
suboccipital and cervical migraine (occipitofrontal neuralgia)
caused by asymmetrical spasm of the suboccipital muscles and the
upper extensions of the cervical multifidii.
TMJ CLINICAL MANAGEMENT ELECTIVES
1. Stage of Acute Inflammation and Active Congestion
The major goals are to control pain and reduce swelling by
vasoconstriction, compression, and elevation; to prevent further
irritation, inflammation, and secondary infection by
disinfection, protection, and rest; and to enhance healing
mechanisms. Common electives include:
Indirect therapy (reflex therapy)
Pulsed alternating current
Spondylotherapy (upper thoracic)
Rest (chin strap, liquid diet)
Nutritional supplementation to enhance connective tissue
Indirect articular therapy (reflex therapy)
2. Stage of Passive Congestion
goals are to control residual pain and swelling, provide rest and
protection, prevent stasis, disperse coagulates and gels, enhance
circulation and drainage, maintain muscle tone, and discourage
adhesion formation. Common electives include:
Alternating superficial heat and cold
Light nonpercussion vibrotherapy
Mild surging alternating current
Mild pulsed ultrasound
Cryokinetics (passive exercise)
Spondylotherapy (upper thoracic)
Rest (chin strap, soft diet)
Nutritional supplementation to enhance connective tissue
Mild articular adjustment technics, especially occipitocervical
3. Stage of Consolidation and/or Formation of Fibrinous Coagulant
The major goals
are the same as in Stage 2 plus enhancing muscle tone and
involved tissue integrity and stimulating healing processes.
Common electives include:
Moist superficial heat
Cryokinetics (active exercise)
Moderate active range-of-motion exercises
Mild transverse friction massage
Mild proprioceptive neuromuscular facilitation techniques
Nutritional supplementation to enhance connective tissue
4. Stage of Fibroblastic Activity and Potential Fibrosis
At this stage,
causes for pain should be corrected but some local tenderness
likely exists. The major goals are to defeat any tendency for the
formation of adhesions, taut scar tissue, and area fibrosis and
to prevent atrophy. Common electives are:
Articular adjustment technics, especially occipitocervical
Spondylotherapy (upper thoracic)
Local vigorous vibromassage
Transverse friction massage
Mild active range-of-motion exercises
Sinusoidal and pulsed muscle stimulation
Proprioceptive neuromuscular facilitation techniques
Nutritional supplementation to enhance connective tissue
articular therapy for chronic fixations
5. Stage of Reconditioning
Progressive remedial exercise may be helpful, but it should be
that the TMJ is normally the most exercised joint in the
Nutritional supplementation to enhance connective tissue
symptoms to not fade after a logical trial of chiropractic
treatment, consultation with a dentist experienced in the care of
TMJ syndromes should be made. Intraprofessional cooperation is
frequently necessary for efficient patient care.
Mechanically, two major forms of TMJ malposition occur. They
arise from either partial displacement or complete dislocation of
the articular disc and occur in 10% 12% of the population. In
partial anterior displacements, condyle translation is not
blocked. That is, when the patient moves the closed jaw forward
and/or toward the contralateral side, the condyle will snap
forward (opening click) into its normal position so that the
mouth can be fully opened. However, Farrar/McCarty state that
when the jaw is retruded, the disc will displace with a snap
In complete dislocation, the disc is usually dislodged
anteriorly toward the front of the condyle so its translation is
restricted when the mouth is opened. This increases the joint
space. Persistent condyle motion on a dislocated disc encourages
irregular adaptive remodeling and osteoarthritis to develop
within the joint because the dislocated disc can no longer
cushion the articular surfaces. Crepitus arises if bone-on-bone
articulation occurs. In time, the collateral ligaments may
perforate or tear and be drawn into the articular space and
osteoarthritis will develop.
Several papers by osteopaths have proposed that TMJ
dysfunction is essentially caused by stress factors that distort
position of the temporal bone. For example, Magoun found that the
temporal bone usually rotates externally-internally on an axis
that extends from the petrous apex to the jugular surface,
depending on the stress pattern present.
The temporomandibular fossa moves posteromedially during
temporal external rotation (temporal protrusion) and
anterolaterally during temporal internal rotation (temporal
flattening), with the position of the mandible moving to
correspond to the positions of the temporomandibular fossae.
Thus, the mandible protrudes if both temporals are fixed in
external rotation, and retrudes if both temporals are fixed in
internal rotation. Hruby reports that it is more common to find
one temporal bone in internal rotation and one in external
rotation, thus producing mandibular misalignment.
TMJ Subluxation Fixations
As with most
subluxation complexes, the TMJ entity may be a cause or an
effect. If primary, its effects may express itself through the
whole functional-structural complex of the body. If secondary,
its cause may be found as remote as the feet.
Lay explains that the actions of muscles, ligaments, and
fasciae throughout the body, from head to foot, coordinate it as
a functioning unit. Thus, a functional or anatomical short leg,
sacroiliac fixation, lumbar subluxation complex, rib-cage
distortion (especially with scalene shortening), thoracic or
cervical subluxations, or occipital malalignment may be a cause
or contributor to or an effect of TMJ dysfunction.
Teeth grinding, jaw clenching, and the jaw tension associated
with anxiety or depression may be important psychologic or
somatopsychic considerations. The major features of TMJ
dysfunction are shown in Table 1.
Table 1. Major Signs and Symptoms of TMJ Dysfunction
Mandible deviates to one side when opened
Tenderness of posterior cervical muscles, usually unilateral|
Joint click (palpable and/or audible) in displacement but not in dislocation
Pain radiates from TMJ area superiorly to temporoparietal region and/or inferiorly into the neck
Severe, unilateral, dull facial pain, aggravated by chewing, opening and closing the mouth
Crepitus of involved joint (sometimes)
Muscle spasm:Posterior cervicals
Tenderness at proximal mandible,
|Muscle spasm:Pterygoids (internal and external)
Postural distortion (anywhere from the occiput to the internal pterygoids
Rib cage, spinal, and lower extremity sites of fixation and trigger points
Peripheral circulation disorders
ADJUSTIVE AND MANIPULATIVE APPROACHES
This article is provided for doctors as reference material, with the expectation that they are already skilled in assessment / diagnosis, in palpation, manipulative skills and in critical thinking.
It is certainly NOT intended for ANY person to use for self-diagnosis or self-treatment purposes. The biomedical literature is filled with reports of self-manipulation gone wrong. If you have a TMJ problem, seek competent care from a licensed health care provider, with a specialty knowledge level, and a strong track record in successful TMJ management.
If a site of soft-tissue
hypertension is found in one or both TMJs, gentle but firm
passive pressure against resistance until the tissues release is
usually all that is necessary. This will be indicated when free
mobility is restored. The same technique can be applied if
abnormal tension is found in sphenomandibular and stylomandibular
area soft tissues, as determined by exerting pressure on the
angle of the mandible caudally and then cephally, and comparing
the resistance found bilaterally.
When TMJ compression is a factor, and it often is, physical
correction can be aided by the doctor inserting gloved thumbs
against the patient's lower molars, with the fingers wrapped
around the jaw, and applying pressure to bring the mandible down
and forward and then down and backward several times to open the
Invariably, motion palpation of the pubic and/or sacroiliac
joints will reveal a fixation when TMJ dysfunction is present.
When this is found, the fixation should be mobilized unless
contraindications for adjustive therapy are found.
Mild Mobility Restriction (Fixation) Release
The basic condyle motions of
the TMJ essentially include rotation with and without a lateral
shift; rotation with backward, upward, and lateral motion; and
rotation with forward, downward, and lateral motion. Functional
restriction may be the common result of muscle hypertonicity or
Passive Stretching. When jaw opening is restricted,
sustained passive stretching can be administered by most any type
of padded appliance (eg, a surgical mouth prop with a spring or
ratchet). Slowly inserting layers of tongue blades or a tapered
cork (15 30 mm) between the molars are sometimes substituted
during home treatments. Regardless of what appliance is used,
this technique is best conducted with the patient in the relaxed
nonweight-bearing supine position at first and then in the
sitting position as improvement is achieved. Special care must be
used to avoid too vigorous application. Preadjustment moist heat
application to the involved TMJ(s) and cervical spine for
15 to 20 minutes is beneficial.
Active Stretching. The supine patient slowly and
progressively opens his mouth to a larger and larger degree but
not to the degree of pain. During this exercise, the patient is
asked to place the tongue against the hard palate as this will
keep the motions essentially rotary and minimize protrusion.
After the initial warm-up, the patient holds the full-open
position for several seconds and follows this with complete jaw
relaxation for several seconds in a hold-relax fashion.
Kessler/Hertling state that ultrasound may be beneficial during
Reflex Relaxation. This is done by applying slow
reducing resistance as the patient attempts to open the closed
mouth. After several seconds of relaxation, active jaw motion
(stretching) without resistance should be conducted for several
seconds. A reverse technique is then used by applying slow
reducing resistance as the patient attempts to close the opened
mouth. These action-rest procedures should be repeated several
times until function improves.
Mobilization Technics for Moderate Fixations
Caudal Traction. The
patient is placed in a relaxed full-supine or semi-supine
position and the doctor stands to the side of the involved joint
facing the patient. The doctor's cephalad stabilizing hand is
placed against the patient's forehead and scalp, and the thumbpad
of his caudad hand is placed against the patient's rear molars
with the doctor's fingers cupping the patient's chin. Traction is
applied caudad and the patient is asked to swallow. Pressure is
held several seconds, and then a similar period for relaxation is
Mobilizing Restricted Anterior Glide. After caudal
traction is administered several times, anterior glide
(protraction) and posterior glide (retraction) is included in the
procedure. This is best accomplished by standing on the opposite
side and grasping the angle of the mandible externally with the
active hand's 1st and 2nd fingers with the thumb wrapped around
the chin. Sustained anterior traction is applied, and the patient
is asked to swallow. After a period of relaxation and holding the
same contact, sustained posterior pressure is applied and the
patient is again asked to swallow. These action-rest modes are
done several times until function of anterior glide improves.
Mobilizing Restricted Medial-Lateral Glide. The doctor
stands behind the relaxed supine patient and cups his active hand
around the patient's chin, while supporting the patient's head
with the stabilizing hand. With his active hand, the doctor
slowly applies lateral traction, holding it for several seconds.
The patient is then asked to swallow and then allow several
seconds for relaxation. The procedure is then reversed by
applying medial pressure, holding it for several seconds, asking
the patient to swallow, and then allowing several seconds for
relaxation. These procedures are repeated several times until
function of medial-lateral glide improves.
Note: Lateral mandibular movements are the most
restricted jaw motions in bilateral TMJ capsule restrictions (eg,
contractures, spasm, adhesions). Contralateral anterior-posterior
gliding movements are the most restricted jaw motions in
unilateral capsule restrictions, and the mandible will deviate
toward the restricted side when the mouth is opened widely.
Unilateral TMJ Inferior Subluxation Technic
A TMJ may become abnormally
separated and fixed in a straight inferior position with the
contralateral side normal. Before correction, the patient is
placed in the sitting position facing forward. The doctor stands
behind the patient, slightly to the side of the lesion. If the
lesion is of the patient's left TMJ, contact is made on the
medial aspect of the mandible under the angle with the fingertips
of the doctor's left hand. His right stabilizing hand should be
cupped under the patient's right mandibular ramus. The patient is
asked to stabilize the back of his head against the doctor's
chest. The adjustment is made by asking the patient to force the
mouth open while the doctor applies pressure directed from the
inferior to the superior.
Unilateral TMJ Anterior-Inferior Subluxation Technic
A fixated anterior-inferior
misalignment of the TMJ may be found on one side with the other
side normal. To correct this subluxation, the patient is placed
in the sitting position facing forward. The doctor stands behind
the patient and cups the patient's chin within clasped fingers.
The patient is asked to stabilize the occiput against the
doctor's chest. The adjustment is made from the anterior-inferior
to the posterior-superior. The thrust should be short, rapid,
well controlled, and in accord with normalizing the anatomical
Associated Medial Malposition. There may also be a
degree of associated medial misalignment. If this occurs, the
line of correction should be diagonal toward the patient's eye on
the side of misalignment rather than directly posterior-superior
(ie, posterior-superior-lateral). This will requires the doctor
to slightly rotate his shoulder anteriorly on the side
contralateral to the lesion.
Unilateral TMJ Lateral Subluxation Technic
A TMJ joint
may articulate in an abnormal lateral position. This misalignment
is usually accompanied by some degree of superior jamming. Before
correction, the patient is placed in the sitting position facing
forward. The doctor stands behind the patient, slightly to the
side of the lesion. If the lesion is of the patient's right TMJ,
the doctor places his right palm on the right side of the TMJ so
his thenar eminence is directly over the head of the affected
condyle and the ramus of the mandible above the angle. The
doctor's left stabilizing hand is placed in a like position on
the patient's left mandible. The doctor leans slightly forward so
his head is over the patient's head. In this position, his elbows
will be bent and his wrists extended. The adjustment is made from
the superior-lateral to the inferior-medial against the doctor's
Uncomplicated Dislocation Reduction
dislocation is invariably anterior displacement of the mandibular
condyle from its temporal articulation into the infratemporal
fossa anterior to the articular eminences. It may involve either
or both joints. The chin is displaced toward the uninjured side
in unilateral dislocation and displaced forward in bilateral
dislocation. The patient presents with anxiety, helplessness,
aching and spastic temporal and masseter muscles, and the classic
"mouth-agape." The mouth cannot be closed. Dislocation is often
caused by a blow to a lax joint or simply by a wide yawn,
laughing, or eating an apple.
During reduction of uncomplicated luxation confirmed by x-ray,
the patient should be placed supine. The doctor's thumbpads are
firmed against the last molars, with his remaining fingers
extended around the patient's jaw. A diagonal
inferior-posteriorly thrust is made against the molars with the
thumbs while the doctor's fingers tilt (lift) the mandible
superior-anteriorly upward with a rotatory motion. The downward
pressure is to overcome the associated muscle spasm, and the
rotation of the chin upward is to reposition the condyle(s)
posteriorly to the articular eminences. If only one side is
involved, only one contact thumb is used within the mouth. The
doctor's other hand is applied against the patient's forehead for
counterpressure. After successful reduction, the chin is mildly
mobilized for several seconds, a cold pack is applied, and chin
support is provided for 1 to 3 days.
Prior to reduction, special care must be taken to adequately
pad the thumbs before placing them firmly on the molar and
premolar surfaces. This is for the doctor's protection not the
patient's benefit. Thumb padding is essential during this
leverage maneuver because reduction is usually followed
immediately by an involuntary contraction of the masseter and
temporal muscles in unison, causing the jaws to clamp shut
ASSOCIATED TMJ JOINT STRAINS AND SPRAINS
Poor occlusion leads to a chronic strain or sprain as does bruxism
(teeth grinding). Bruxism is commonly increased in anxiety
states, thus TMJ dysfunction is often related to various
Strains. The major muscles to be considered are the
medial and lateral pterygoid, masseter, and temporalis. Strain of
the suprahyoid muscles (digastric, stylohyoid, mylohyoid, and
geniohyoid) and infrahyoid muscles (thyrohyoid, omohyoid, and
sternohyoid) should also be considered as contributing factors.
Overworked and overstretched temporalis and pterygoid muscles can
become chronically spastic and produce localized pain at muscle
attachments or refer pain and/or paresthesias to one or both
ears, the face, the temples, or the forehead.
Overstretch causes an asymmetrical lateral motion of the jaw
and malocclusion. There is usually joint clicking and transient
locking, and, if not properly treated, a subluxation-fixation may
result. Such strains are sometimes seen after activities where
the teeth must be tightly clenched for a prolonged period (eg,
underwater swimmers who clench their teeth tightly on a
Sprains. The straps to be considered are the articular
capsule and the lateral (temporomandibular), sphenomandibular,
and stylomandibular ligaments. TMJ sprain is usually the result
of malocclusion, acute or chronic subluxation, or spontaneously
reduced dislocation from trauma (eg, whiplash, eating an apple,
traction). Related muscle strain and spasm, tissue ruptures, and
soft-tissue swelling may be involved depending on the extent of
The correction of structural disrelationships and fixations by
chiropractic techniques coupled with referral for appropriate
orthodontic and prosthodontic appliances (which are often
necessary), provides the most practical approach to the treatment
of TMJ function. According to several observations, the
therapeutic approach is recommended to be structurally holistic
because TMJ dysfunction can affect any part or the whole of the
skeleton or vice versa. In other words, sites of fixation should
be sought in the feet, ankles, knees, hips, pubes, sacroiliacs,
spine, rib cage, and skull, and mobilized if found. Obviously, if
muscle groups are weak, spastic, or shortened, therapy should be
applied to restore their normal state.
Trigger Points and Spasm: Vapocoolant Technique. Many
trigger points have been isolated that frequently refer pain and
deep tenderness to the TMJ. The most common points are within the
masseter, temporalis, and internal and external pterygoid
muscles. Before correcting isolated subluxations, it is helpful
to spray the located trigger areas with a vapocoolant. The
patient's mouth is comfortably propped open with a roll of gauze,
his eyes and nose are draped, and his neck is laterally flexed
away from the involved side. A few slow, even, interrupted sweeps
of the spray in one direction only from jaw angle to temple
should reduce any spasm and referred pain present. The skin
should not be frosted. Two or three applications a few days apart
are usually sufficient. High-voltage galvanic current over
spastic masseter or temporal muscles for 15 minutes is an
Adjunctive Procedures. Just about any therapy whose
objective is to reduce pain and spasm is indicated. During the
acute stage for example, cryotherapy, acupuncture, trigger-point
therapy, and high-volt or interferential therapy or microcurrents
are frequently recommended. After the acute stage, the common
modalities used include moist heat over spastic areas, TENS, and
ultrasound. Biofeedback has been reported effective in some
stubborn cases. Nutritional muscle relaxants and
anti-inflammatory agents are frequently recommended when pain and
swelling are major factors.
Diet. During the acute stage, the diet should restrict
difficult-to-chew foods (eg, steak, nuts, raw vegetables) or
those that require wide opening of the mouth (eg, thick
sandwiches, apples) to avoid masticatory overstretch and
Habits. The patient should be alerted to relax the jaw
whenever muscle tension, jaw clenching, or teeth grinding are
noticed. "Lips together, teeth apart" is the normal position of
relaxation. Pipe smoking and sleeping on the stomach should be
discontinued. Sleeping with an orthopedic pillow to maintain good
cervical posture is often beneficial.
Remedial Exercises. Exercise against resistance is often
helpful to relax cramped muscles and strengthen antagonists. The
patient should be taught to slowly open the mouth as wide as
possible without discomfort several times and continued this
exercise until, in time, the knuckles of the index and middle
finger can be easily inserted between the front teeth. This
exercise should be followed by holding the chin between the index
finger and thumb and resisting opening and closing the mouth.
Next, resisted lateral movements of the jaw against the palm of
the hand should be made, first on one side and then the other.
Each exercise should be conducted about 10 times in 3-5 bouts
REFERENCES AND BIBLIOGRAPHY:
The Troublesome TMJ. ACA Journal of Chiropractic, June
Common Sense Management for TMJ Troubles. Patient Care,
pp 129-157, January 15, 1984.
"Doctor, My Jaw Hurts." Patient Care, pp 108-136,
December 15, 1983.
Farrar WB, McCarty WL Jr: A Clinical Outline of
Temporomandibular Joint Diagnosis and Treatment. Montgomery,
AL, Normandie Publications, 1982.
Farrar WB: Dysfunctional Centric Relation of the Jaw
Associated with Dislocation and Displacement of the Disc.
Compendium of the American Equilibrium Society, 13:63-67,
Gelb H (ed): Clinical Management of Head, Neck and TMJ Pain
and Dysfunction. Philadelphia, W.B. Saunders, 1977.
Hruby RJ: The Total Body Approach to the Osteopathic
Management of Temporomandibular Joint Dysfunction. Journal of
the American Osteopathic Association, 85(8):502-509.
Kessler RM, Hertling D (eds): Management of Common
Musculoskeletal Disorders. Philadelphia, Harper & Row,
1983, pp 233-271, 533-537.
Larsen NJ: Osteopathic Manipulative Contribution to Treatment
of TMJ Syndrome. Osteopathic Medicine, 3:15-27, August
Lay EM: The Osteopathic Management of Temporomandibular Joint
Dysfunction. In Gelb H (ed): Clinical Management of Head, Neck
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Magoun HI Sr: Dental Equilibrium and Osteopathy. Journal of
the American Osteopathic Association, 75:981-991, June
Mahan PE: Temporomandibular Joint Dysfunction: Physiological
and Clinical Aspects. In Rowe NH (ed): Occlusion: Research in
Form and Function. Proceedings of Symposium. East Lansing,
MI, University of Michigan, 1975, p 112.
Royder JO: Structural Influences in Temporomandibular Joint
Pain and Dysfunction. Journal of the American Osteopathic
Association, 80:460-467, March 1981.
Schafer RC: Chiropractic Management of Extraspinal
Articular Disorders. Arlington, Virginia, American
Chiropractic Association, 1989.
Schafer RC: Chiropractic Management of Sports and
Recreational Injuries, ed 2. Baltimore, Williams &
Schafer RC: Chiropractic Physical and Spinal Diagnosis.
Oklahoma City, Associated Chiropractic Academic Press, 1980.
Schafer RC (ed): Basic Chiropractic Procedural Manual,
ed 4. Des Moines, Iowa, Ameri?can Chiropractic Association, 1980.
Schafer RC: Clinical Biomechanics: Musculoskeletal Actions
and Reactions, ed 2. Baltimore, Williams & Wilkins.
Schafer RC: Physical Diagnosis. Arlington, Virginia,
American Chiropractic Association, 1988.
Shapiro BL: Changing Views About Temporomandibular
Pain-Dysfunction. Northwest Dentistry, 60:6, 1981.
Shore NA: Occlusal Equilibration and Temporomandibular
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Smith SD: Vascular Analysis in Temporomandibular Orthopedics:
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Osteopathic Medicine, pp 29-32, 35-41, 71, October
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