TMJ: Osteopathic Techniques for the Office

Jesus Sanchez, Jr. , D.O

AAO Convocation 2019

March 16, 2019

Epidemiology

Most common non-dental orofacial pain condition in primary care (Foundations of Osteopathic Medicine - FOM 4)

Multifactorial: Trauma (micro/macro), malocclusion, bruxism, psychological, metabolic/inflammatory and genetic

Prevalence: 5-12% of the population (NIH)

Age: 20 – 60 years old (30 – 40)

Gender: Women = Men (affects both)

Younger patients Myofascial pain

Older patients – Arthritis related Pain

Hruby, RJ. The total body approach to the osteopathic management of temporalmandibular joint dysfunction. JAOA. 1985;85 (8):502-510

Physiology

Stress-Strain

http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=3023

http://www.msdlatinamerica.com/ebooks/HandSurgery/sid125381.html

http://www.psychometric-success.com/aptitude-tests/mechanical-reasoning-tests-springs.htm

Ligament Crimp

http://ajs.sagepub.com/content/32/4/870/F9.expansion

Ligaments

Cuccia A. Manual Therapy of the Mandibular Accessory Ligaments for the Management of Temporomandibular Joint Disorders J Am Osteopath Assoc.2011;111(2):102-112

• Stabilize joints and help guide them through the normal ROM

• Dense bands of connective tissue containing fibroblasts, collagen and elastic fibers

• Inherent collagen elasticity is neutralized by the crisscrossed layers of their fibers

• White elastin between each layer of the ligament allows some movement between the layers

• More efficient than muscles as they use no energy and are more reliable because they can be stretched without damage

• Contain mechanoreceptors which provide sensory feedback for muscular coordination

Evaluation

• Cranial Vault – Temporal Bones

• Observation

• Decreased ROM

• Chin Deviation off midline - alignment

• Palpation of Condyles

• Crepitus

• Click/Pop

• Tenderness

• Oral Cavity Aperture

• Knuckle/Finger Test -3

• Measure

Balancing the Temporal Bones

Temporal Bone Evaluation

• Contact the temporal bone with 5th and ring fingers on the mastoid process, middle finger in the external auditory meatus, index finger and thumb grasping the zygomatic arch (Temporal Hold)

• The other hand contacts the infracostal margin on the same side of the palpated temporal bone (reach across thorax)

• Ask patient to take deep inhalation• Note thoracic diaphragm motion – should descend• Note temporal bone motion – should externally rotate

• Always check both sides!

Balancing the Temporal Bones

Treatment of Internally Rotated Temporal Bone

• Using Temporal Hold

• Ask patient to take a deep inhalation then follow temporal bone into internal rotation and hold

• Ask the patient to exhale and maintain exhalation as long as possible

• Spontaneous release and restoration of physiologic movement of the temporal bone into external rotation on inhalation should occur

• Recheck with deep inhalation and monitoring of temporal bone

• Repeat as needed

BLTCardinal

Principles of Treatment

Disengagement of the dysfunctional area (de/compression)

Exaggeration of the dysfunctional pattern (returning to the original position of injury)

Balanced tension of ligaments (maintained until release)

Technique can be done direct, indirect or both

Therapeutic Process of BLT

• Diagnosis the region of somatic dysfunction

• Select a direct, indirect or combined approach based on clinical presentation and response of the tissues to the procedure

• As tissue responds to extrinsic force the physician follows the release

• Work at “Tissue Speed”

• Retest the region for release of the somatic dysfunction

Cautions

• Physicians must NOT put too much pressure into this technique

• Tissue must not be taken beyond its elastic limits

• Physician must NOT produce discomfort to a level that causes patient guarding

• This treatment should be tolerable to the patient

Sphenomandibular Ligament Release

• Patient Supine

• Stand opposite of side being treated

• Physician knee on table to support head and prevent too much pressure

• Contact greater wing of sphenoid with one hand over forehead

• Place cotted thumb on occlusal surface of last molar on side of mouth being treated and wrap remaining fingers over ramus of the mandible

• Exert slight pressure to move mandible inferiorly to test: (+) look for greater wing to move superiorly (extension) or decreased tissue compliance

• Treat by monitoring the sphenoid while maintaining inferior pressure on mandible all at tissue speed until tension is released and physiologic motion is restored

• Advanced: encouraging sphenoid motion into flexion

Stylomandibular Ligament Release

• Patient Supine

• Stand opposite of side being treated

• Physician knee on table to support head and prevent too much pressure

• Contact temporal bone using temporal hold

• Place cotted thumb on occlusal surface of last molar on side of mouth being treated and wrap remaining fingers over ramus of the mandible

• Exert slight traction to move mandible inferior, lateral and anterior to test: (+) look for temporal bone to internally rotate (flexion phase) or decreased tissue compliance

• Treat by monitoring temporal bone motion while maintaining inferior, lateral and anterior pressure on mandible all at tissue speed until tension is released and physiologic motion is restored

• Advanced: encouraging temporal motion into external rotation

TMJ Decompression

• Patient Supine

• Stand opposite of side being treated

• Physician knee on table to support head and prevent too much pressure

• Contact temporal bone using temporal hold

• Place gloved thumb on occlusal surface of last molar on side of mouth being treated and wrap remaining fingers over ramus of the mandible

• Direct - Exert slight traction to move mandible inferior and anterior to distract head of mandible from glenoid fossa until spontaneous compression is felt

• Indirect – apply gentle compression of head of mandible into the glenoid fossa until spontaneous decompression occurs.

Practice and Explore

Questions?jsanchez@westernu.edu

References

• Hruby, RJ. The total body approach to the osteopathic management of temporalmandibular joint dysfunction. JAOA. 1985;85 (8):502-510

• Seffinger MA, executive ed. Foundations of Osteopathic Medicine: Philosophy, Science, Clinical Application and Research 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2018. Chp 48:1399 - 1403

• Department of Neuromusculoskeletal Medicine/ Osteopathic Manipulative Medicine at Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. The Expanding Osteopathic Concept. Pomona, CA: 2014:pp. 170 172

• Cuccia A. Manual Therapy of the Mandibular Accessory Ligaments for the Management of Temporomandibular Joint Disorders J Am Osteopath Assoc.2011;111(2):102-112