Conservative Management Of Temporomandibular Joint Disfunction
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Professional Papers _______________________________________________________
Conservative management of temporomandibular joint dysfunction Franklin Schoenoltz, DC, DABCO Arcadia, California
ACA Journal of Chiropractic /August 1978 Copyright American Equilibration Society 1980. Copyright Franklin Schoenholtz “Authorization granted to the American Equilibration Society for reprint in their Compendium 15, by the ACA Journal of Chiropractic.”
Temporomandibular joint (TMJ) pain is a condition which may need a multi-professional approach for its successful resolution. Because of the unique problems it presents, there is no place for intellectual isolationism in the total approach to the diagnosis and treatment of this disorder. The etiology of the TMJ pain dysfunction syndrome is the topic of much debate. One group feels that occlusion is the major etiologic factor and the other group feels that myofascial muscle spasm with psychological factors initiates the syndrome. The controversy as to which comes first, the malocclusion or the muscle spasm dictates, in fact, that the syndrome seems to be multifactorial and the treatment should be directed to eliminate the multiple etiologic factors.
Examination When examining the temporomandibular joint the clinician should remember how the joint hinges with in the glenoid fossa and then glides forward to the eminentia (see Figure 1). The dual heads of each of the external Pterygoid muscles act asynchronously, with one head pulling the meniscus forward as the second opens the joint (see Figure 2). A technique of bony palpation of the temporomandibular joint is accomplished by placing the index finger into the patient’s auditory canal and pressing anteriorly. When the patient opens and closes his mouth the doctor may palpate the mandibular condyle with his fingertip. (see Figure 3). Soft tissue palpation of the external Pterygoid muscle is important clinically. Spasm of this muscle will cause temporomandibular joint pain as well as asymmetrical, lateral movement of the jaw. The technique for this examination is to place one’s finger in the patient’s mouth between the buccal mucosa and superior gum and direct the tip of one’s index finger posteriorly, past the last upper molar to the neck of the mandible. The clinician should request the patient to open and close his mouth in a slow, deliberate manner. As the mouth opens, the doctor will feel the neck of the mandible swing forward and the external Pterygoid muscle tighten against the tip of his finger (see Figure 4).
Figure 1. The meniscus divides the joint into an upper and lower portion with its hinge and glide action.
Figure 2. The two heads of the external Pterygoid muscle act asynchronously to open the temporomandibular joint.
Figure 3. Palpation of the temporomandibular joint can be accomplished by placing the index finger in
Figure 4. Palpation of the external pterygoid muscle can be accomplished by placing the tip of the index finger posteriorly between the buccal mucosa and the superior gum.
the auditory canal.
Normal range of motion is accomplished by having the patient open his mouth as wide as possible. The patient should be able to insert his three fingers between incisor teeth (See Figure 5).
Diagnosis Frequently the patient will complain of unilateral pain which may be intermittent or constant in the area of the jaw, but which may extend to the ear, head, neck and shoulder. When requesting the patient to open his mouth to the widest extent, the mandible is usually seen to deviate toward the painful side (see Figure 6). One of the most common problems of the temporomandibular joint syndrome is the limitation of the normal range of mandibular movement. Subluxation may cause acute instant pain and the patient may feel that his teeth are no longer articulating properly.
Figure 5. When the patient opens his mouth to a normal mouth span, he should be able to insert three fingers between the incisor teeth.
Palpation will usually elicit tenderness at the temporomandibular joint. The patient may also complain of a “clicking” on the affected side. The use of a stethoscope placed over the joint during mandibular movement will often reveal this sound as well as crepitus.
Figure 6. When the patient opens his mouth to the widest possible extent, the mandible will usually shift toward the painful side.
Pathophysiology The combination of hypertonicity of the muscles of mastication, dental malocclusion and emotional tension usually is the basis for most temporomandibular joint pain. Muscle tension is probably the major contributing cause of dysfunction of the muscles of mastication (Figure 7). Gnashing and grinding of the teeth when under stress is known as occlusal neurosis, if it becomes habitual it is known as bruxomania. This phenomenon implies a longstanding isometric muscle activity which leads to a hypertonicity within the masticatory muscles. The physiological act of occlusion of the teeth occurs every 50 to 70 seconds prior to deglutition. If the mandible cannot complete that act because of muscular dysfunction, struggling movements are initiated. The patient attempts to force the mandible through to a completed occlusion despite muscular restraints. X-ray evaluation of the temporomandibular joint is usually negative but is useful in excluding other causes of dysfunction such as congenital anomalies, trauma, neoplastic and general disorders of the bone (Figure 8).
Treatment The author’s treatment program consists of a supportive home exercise routine. The patient attempts to open his jaw against resistance for a period of five minutes, six times daily (Figure 9). The rationale of this therapy is to cause a pumping of the muscle by mechanical action. This promotes dissipation of metabolic waste products of the muscle group being treated, thus helping to restore a normal physiological state.
Figure 7. Anatomy of the masticatory muscles.
As a precursor to manipulation, a vapocoolant spray (Figure 10) or high-voltage galvanic current (Figure 11) is used to relive skeletal muscle spasm. The Spray should be applied in a slow, even, interrupted sweep, in one direction only. The skin should not be frosted. This process of intermittent spraying of a muscle group should last approximately one minute. The doctor should then request the patient to actively open and close the mouth in order to stretch the muscles for a period lasting 10 to 15 seconds. A prop, such as a cork, should be placed in between the teeth so that the jaw aperture becomes increased and then another application of the vapocoolant spray is once again instituted. This therapy is repeated with larger corks until the patient’s pain tolerance disallows the continuance of this procedure. When utilizing high-voltage galvanic therapy in the clinical management of the TMJ syndrome, this author’s technique is to place the electrode over the spastic temporal or masseter muscle for a period of 15 minutes. The clinician may vary the treatment application when indicated by placing the electrode inside the mouth without any discomfort of damage to the oral tissue.
Figure 8. Bony anatomy of the temporomandibular joint.
Figure 9. The patient attempts to open his jaw against resistance.
Excellent results are obtained by the use of this specialized galvanic current. This therapy relieves spasticity and painful muscle spasm while increasing local circulation and promoting muscle integrity in regaining joint control. The use of this recent development in electrical therapy has been reviewed extensively, and no deleterious effects or risks have been noted.
Manipulative Procedure This author has found the following technique to be most beneficial (Figure 12): 1. The patient lies in the supine position and opens his mouth as wide as possible. 2. The doctor winds a substantial length of ordinary bandage around his thumb for protection.
Figure 11. The therapist should place the electrode over the spastic temporal or masseter muscle. The large dispersive pad, 8”x10”, is strapped to the back to provide the return path of the current flow.
3. If the right temporomandibular articulation has suffered derangement, the doctor should stand on the patient’s left side. He then places his right hand on the patient’s forehead for counter-traction and his left thumb against the right lower back teeth, and, at the same time, grips the chin with the fingers of the left hand. By pressing downward on the molars, the mandible is then distracted from the temporal bone. 4. The object now is to gently disengage the fixation by taking the joint as far as it will comfortably go and then with a rocking movement mobilize the joint, similar to opening and closing of the mouth, for a period of 20 seconds.
Figure 12. The manipulative procedure should be preformed in a slow rhythmic action similar to opening and closing the mouth.
This manipulation may be repeated several times on a limited program and a recheck should be made for joint tenderness as well as movement range. Manipulation reduces the inflammation by mobilizing and dispersing the tissue-breakdown products. It aids in preventing fibrous arthrosis as well as separating articular structures, thus stretching contracted muscles. If primary dental malocclusion is suspected or the temporomandibular joint dysfunction assumes a chronic nature, consideration should be given to dental risers and splints and dental consultation should be sought. Figure 10. Technique for applying a vapocoolant spray for relief of masseter muscle spasm. The mouth is propped comfortably at its maximum opening. The eyes should be covered for protection. Each sweep follows the muscle lines and travels toward and over the related pain areas.
Dr Franklin Schoenholtz is a diplomate of the American Board of Chiropractic Orthopedists. He maintains a private practice at 226-228 East Foothill Blvd, in Arcadia, California. He has taught diversified technique and undergraduate orthopedics at the Los Angeles College of Chiropractic in Glendale, California from 19641976. Presently, Dr Schoenholtz is the secretary-treasure of the Board of Regents at LACC. HE has authored numerous articles including “Soft Tissue Pain Sites in the Low Back Area,” 1968; “A Guide to the Lectures in Chiropractic Orthopedics,” 1976; “A historical Review of Manipulative Therapy,” 1977; “The Diagnosis and Conservative Treatment of the Lumbar Disc Syndrome,” 1978, and “Manipulative Management of Tennis Elbow,” 1978.v
Figure 1. The meniscus divides the joint into an upper and lower portion with its hinge and glide action. Figure 2. The two heads of the external Pterygoid muscle act asynchronously to open the temporomandibular joint. Figure 3. Palpation of the temporomandibular joint can be accomplished by placing the index finger in the auditory canal. Figure 4. Palpation of the external pterygoid muscle can be accomplished by placing the tip of the index finger posteriorly between the buccal mucosa and the superior gum.
Figure 5. When the patient opens his mouth to a normal mouth span, he should be able to insert three fingers between the incisor teeth. Figure 6. When the patient opens his mouth to the widest possible extent, the mandible will usually shift toward the painful side. Figure 7. Anatomy of the masticatory muscles. Figure 8. Bony anatomy of the temporomandibular joint. Figure 9. The patient attempts to open his jaw against resistance. Figure 10. Technique for applying a vapocoolant spray for relief of masseter muscle spasm. The mouth is propped comfortably at its maximum opening. The eyes should be covered for protection. Each sweep follows the muscle lines and travels toward and over the related pain areas. Figure 11. The therapist should place the electrode over the spastic temporal or masseter muscle. The large dispersive pad, 8”x10”, is strapped to the back to provide the return path of the current flow. Figure 12. The manipulative procedure should be preformed in a slow rhythmic action similar to opening and closing the mouth.
Sources Cyriax, Orthopaedic Medicine, Vol II, 1959. Downs, “Treating TMJ Dysfunction,” Osteopathic Physician, 1976. Finnerson, Diagnosis and Management of Pain Syndromes, 1963. Gelb, “TMJ Syndrome,” Dental Clinics of North America, 1970. Gelb, “Cranio-Mandibular Syndrome,” New York Journal of Dentistry, 1971. Gelb, Clinical Management of Head, Neck and TMJ Pain and Dysfunction, 1977. Hoppenfield, Physical Examination of the Spine and Extremities, 1976. Morgan, “The Great Imposter, Journal, California Dental Association,1974. Travell, “TMJ Dysfunction,” Journal of Prosthetic Dentistry, 1960.
Copyright American Equilibration Society Compendium 1980 Copyright Franklin Schoenholtz 2009 Volume 15 1980
Conservative management of temporomandibular joint dysfunction Franklin Schoenoltz, DC, DABCO Arcadia, California
ACA Journal of Chiropractic /August 1978 Copyright American Equilibration Society 1980. Copyright Franklin Schoenholtz “Authorization granted to the American Equilibration Society for reprint in their Compendium 15, by the ACA Journal of Chiropractic.”
Temporomandibular joint (TMJ) pain is a condition which may need a multi-professional approach for its successful resolution. Because of the unique problems it presents, there is no place for intellectual isolationism in the total approach to the diagnosis and treatment of this disorder. The etiology of the TMJ pain dysfunction syndrome is the topic of much debate. One group feels that occlusion is the major etiologic factor and the other group feels that myofascial muscle spasm with psychological factors initiates the syndrome. The controversy as to which comes first, the malocclusion or the muscle spasm dictates, in fact, that the syndrome seems to be multifactorial and the treatment should be directed to eliminate the multiple etiologic factors.
Examination When examining the temporomandibular joint the clinician should remember how the joint hinges with in the glenoid fossa and then glides forward to the eminentia (see Figure 1). The dual heads of each of the external Pterygoid muscles act asynchronously, with one head pulling the meniscus forward as the second opens the joint (see Figure 2). A technique of bony palpation of the temporomandibular joint is accomplished by placing the index finger into the patient’s auditory canal and pressing anteriorly. When the patient opens and closes his mouth the doctor may palpate the mandibular condyle with his fingertip. (see Figure 3). Soft tissue palpation of the external Pterygoid muscle is important clinically. Spasm of this muscle will cause temporomandibular joint pain as well as asymmetrical, lateral movement of the jaw. The technique for this examination is to place one’s finger in the patient’s mouth between the buccal mucosa and superior gum and direct the tip of one’s index finger posteriorly, past the last upper molar to the neck of the mandible. The clinician should request the patient to open and close his mouth in a slow, deliberate manner. As the mouth opens, the doctor will feel the neck of the mandible swing forward and the external Pterygoid muscle tighten against the tip of his finger (see Figure 4).
Figure 1. The meniscus divides the joint into an upper and lower portion with its hinge and glide action.
Figure 2. The two heads of the external Pterygoid muscle act asynchronously to open the temporomandibular joint.
Figure 3. Palpation of the temporomandibular joint can be accomplished by placing the index finger in
Figure 4. Palpation of the external pterygoid muscle can be accomplished by placing the tip of the index finger posteriorly between the buccal mucosa and the superior gum.
the auditory canal.
Normal range of motion is accomplished by having the patient open his mouth as wide as possible. The patient should be able to insert his three fingers between incisor teeth (See Figure 5).
Diagnosis Frequently the patient will complain of unilateral pain which may be intermittent or constant in the area of the jaw, but which may extend to the ear, head, neck and shoulder. When requesting the patient to open his mouth to the widest extent, the mandible is usually seen to deviate toward the painful side (see Figure 6). One of the most common problems of the temporomandibular joint syndrome is the limitation of the normal range of mandibular movement. Subluxation may cause acute instant pain and the patient may feel that his teeth are no longer articulating properly.
Figure 5. When the patient opens his mouth to a normal mouth span, he should be able to insert three fingers between the incisor teeth.
Palpation will usually elicit tenderness at the temporomandibular joint. The patient may also complain of a “clicking” on the affected side. The use of a stethoscope placed over the joint during mandibular movement will often reveal this sound as well as crepitus.
Figure 6. When the patient opens his mouth to the widest possible extent, the mandible will usually shift toward the painful side.
Pathophysiology The combination of hypertonicity of the muscles of mastication, dental malocclusion and emotional tension usually is the basis for most temporomandibular joint pain. Muscle tension is probably the major contributing cause of dysfunction of the muscles of mastication (Figure 7). Gnashing and grinding of the teeth when under stress is known as occlusal neurosis, if it becomes habitual it is known as bruxomania. This phenomenon implies a longstanding isometric muscle activity which leads to a hypertonicity within the masticatory muscles. The physiological act of occlusion of the teeth occurs every 50 to 70 seconds prior to deglutition. If the mandible cannot complete that act because of muscular dysfunction, struggling movements are initiated. The patient attempts to force the mandible through to a completed occlusion despite muscular restraints. X-ray evaluation of the temporomandibular joint is usually negative but is useful in excluding other causes of dysfunction such as congenital anomalies, trauma, neoplastic and general disorders of the bone (Figure 8).
Treatment The author’s treatment program consists of a supportive home exercise routine. The patient attempts to open his jaw against resistance for a period of five minutes, six times daily (Figure 9). The rationale of this therapy is to cause a pumping of the muscle by mechanical action. This promotes dissipation of metabolic waste products of the muscle group being treated, thus helping to restore a normal physiological state.
Figure 7. Anatomy of the masticatory muscles.
As a precursor to manipulation, a vapocoolant spray (Figure 10) or high-voltage galvanic current (Figure 11) is used to relive skeletal muscle spasm. The Spray should be applied in a slow, even, interrupted sweep, in one direction only. The skin should not be frosted. This process of intermittent spraying of a muscle group should last approximately one minute. The doctor should then request the patient to actively open and close the mouth in order to stretch the muscles for a period lasting 10 to 15 seconds. A prop, such as a cork, should be placed in between the teeth so that the jaw aperture becomes increased and then another application of the vapocoolant spray is once again instituted. This therapy is repeated with larger corks until the patient’s pain tolerance disallows the continuance of this procedure. When utilizing high-voltage galvanic therapy in the clinical management of the TMJ syndrome, this author’s technique is to place the electrode over the spastic temporal or masseter muscle for a period of 15 minutes. The clinician may vary the treatment application when indicated by placing the electrode inside the mouth without any discomfort of damage to the oral tissue.
Figure 8. Bony anatomy of the temporomandibular joint.
Figure 9. The patient attempts to open his jaw against resistance.
Excellent results are obtained by the use of this specialized galvanic current. This therapy relieves spasticity and painful muscle spasm while increasing local circulation and promoting muscle integrity in regaining joint control. The use of this recent development in electrical therapy has been reviewed extensively, and no deleterious effects or risks have been noted.
Manipulative Procedure This author has found the following technique to be most beneficial (Figure 12): 1. The patient lies in the supine position and opens his mouth as wide as possible. 2. The doctor winds a substantial length of ordinary bandage around his thumb for protection.
Figure 11. The therapist should place the electrode over the spastic temporal or masseter muscle. The large dispersive pad, 8”x10”, is strapped to the back to provide the return path of the current flow.
3. If the right temporomandibular articulation has suffered derangement, the doctor should stand on the patient’s left side. He then places his right hand on the patient’s forehead for counter-traction and his left thumb against the right lower back teeth, and, at the same time, grips the chin with the fingers of the left hand. By pressing downward on the molars, the mandible is then distracted from the temporal bone. 4. The object now is to gently disengage the fixation by taking the joint as far as it will comfortably go and then with a rocking movement mobilize the joint, similar to opening and closing of the mouth, for a period of 20 seconds.
Figure 12. The manipulative procedure should be preformed in a slow rhythmic action similar to opening and closing the mouth.
This manipulation may be repeated several times on a limited program and a recheck should be made for joint tenderness as well as movement range. Manipulation reduces the inflammation by mobilizing and dispersing the tissue-breakdown products. It aids in preventing fibrous arthrosis as well as separating articular structures, thus stretching contracted muscles. If primary dental malocclusion is suspected or the temporomandibular joint dysfunction assumes a chronic nature, consideration should be given to dental risers and splints and dental consultation should be sought. Figure 10. Technique for applying a vapocoolant spray for relief of masseter muscle spasm. The mouth is propped comfortably at its maximum opening. The eyes should be covered for protection. Each sweep follows the muscle lines and travels toward and over the related pain areas.
Dr Franklin Schoenholtz is a diplomate of the American Board of Chiropractic Orthopedists. He maintains a private practice at 226-228 East Foothill Blvd, in Arcadia, California. He has taught diversified technique and undergraduate orthopedics at the Los Angeles College of Chiropractic in Glendale, California from 19641976. Presently, Dr Schoenholtz is the secretary-treasure of the Board of Regents at LACC. HE has authored numerous articles including “Soft Tissue Pain Sites in the Low Back Area,” 1968; “A Guide to the Lectures in Chiropractic Orthopedics,” 1976; “A historical Review of Manipulative Therapy,” 1977; “The Diagnosis and Conservative Treatment of the Lumbar Disc Syndrome,” 1978, and “Manipulative Management of Tennis Elbow,” 1978.v
Figure 1. The meniscus divides the joint into an upper and lower portion with its hinge and glide action. Figure 2. The two heads of the external Pterygoid muscle act asynchronously to open the temporomandibular joint. Figure 3. Palpation of the temporomandibular joint can be accomplished by placing the index finger in the auditory canal. Figure 4. Palpation of the external pterygoid muscle can be accomplished by placing the tip of the index finger posteriorly between the buccal mucosa and the superior gum.
Figure 5. When the patient opens his mouth to a normal mouth span, he should be able to insert three fingers between the incisor teeth. Figure 6. When the patient opens his mouth to the widest possible extent, the mandible will usually shift toward the painful side. Figure 7. Anatomy of the masticatory muscles. Figure 8. Bony anatomy of the temporomandibular joint. Figure 9. The patient attempts to open his jaw against resistance. Figure 10. Technique for applying a vapocoolant spray for relief of masseter muscle spasm. The mouth is propped comfortably at its maximum opening. The eyes should be covered for protection. Each sweep follows the muscle lines and travels toward and over the related pain areas. Figure 11. The therapist should place the electrode over the spastic temporal or masseter muscle. The large dispersive pad, 8”x10”, is strapped to the back to provide the return path of the current flow. Figure 12. The manipulative procedure should be preformed in a slow rhythmic action similar to opening and closing the mouth.
Sources Cyriax, Orthopaedic Medicine, Vol II, 1959. Downs, “Treating TMJ Dysfunction,” Osteopathic Physician, 1976. Finnerson, Diagnosis and Management of Pain Syndromes, 1963. Gelb, “TMJ Syndrome,” Dental Clinics of North America, 1970. Gelb, “Cranio-Mandibular Syndrome,” New York Journal of Dentistry, 1971. Gelb, Clinical Management of Head, Neck and TMJ Pain and Dysfunction, 1977. Hoppenfield, Physical Examination of the Spine and Extremities, 1976. Morgan, “The Great Imposter, Journal, California Dental Association,1974. Travell, “TMJ Dysfunction,” Journal of Prosthetic Dentistry, 1960.
Copyright American Equilibration Society Compendium 1980 Copyright Franklin Schoenholtz 2009 Volume 15 1980
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