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This is the first of a three-part series exploring principles and concepts in intra-oral applications treating TMJ dysfunction. Developing mastery in intra-oral techniques is highly applicable to many of our clients, quite easy on the therapist, and can establish a niche among an ever expanding community of RMTs. It is a complex area of the body to understand and is therefore extremely interesting. This is the first of a three-part series exploring principles and concepts in intra-oral applications treating TMJ dysfunction. Developing mastery in intra-oral techniques is highly applicable to many of our clients, quite easy on the therapist, and can establish a niche among an ever expanding community of RMTs. It is a complex area of the body to understand and is therefore extremely interesting.

Developing Mastery
Mastery is a lifelong process in which focus is given to a specific subject, while acknowledging broad influences, in order to cultivate expertise. Ironically, the process is often humbling as each revelation leads to many more inquiries.

This series is not intended as a definitive, fully evidenced-based research paper, nor could it provide all the skills and concepts of a hands-on instructional course. It presents a working set of ideas and principles that might initiate new possibilities into a massage therapist’s repertoire. Observation of a great majority of our MT clients will show asymmetrical TMJ function. Asymmetrical hypertonicity of the muscles of mastication is so universal that it is postulated that it would be a challenge for an MT to find a client without it!

While hypertonicity is often portrayed by researchers to be a subjective issue, our palpation skills as MT’s have long been used to validate our clients’ reports. TMJ dysfunction is often an expression of, or a silent contributor to headache, MVA, Scoliosis, neck and head postural issues, especially hyperkyphosis and shoulder protraction. TMJ work is applicable for singers, actors and broadcasters, and musicians, especially brass and woodwind players.

TMJ issues can be found in clients who present with SI dysfunction, history of orthodontic applications, trauma, sport injuries, and RSI. There can be psychogenic components as it is the area through which we express ourselves and can therefore be a manifestation of mental/emotional “busy-mindedness.”

Busy-minded teeth clenching is common and often overlooked by practitioners. For one week in March 2007, 11 practitioners including two Speech-Language Pathologists in London, Ontario asked their clients, “Whether at night or day, during stress or pain, or part of concentration, etc, do you clench your teeth?” Of 180 respondents, 73 per cent said “yes,” 23 per cent said “no” and 5 per cent said they were “not sure.” 1 

Most clients don’t know that when the jaw is at rest the teeth are supposed to be apart according to the phrase, “lips closed, teeth open.” Is there space between your teeth right now?

After clenching patterns have been establish some of our population progress to grinding their teeth at night (Bruxism), which many researchers suggest occurs in 5 to 20 per cent of the population, and qualify that it is difficult to make accurate conclusions.2 For some, Bruxism was a childhood occurrence that gave way in adulthood. As MTs we are focused on when the masticatory system is over-employed, therefore the load on the joints as a result of clenching is enough of an issue to call upon our intervention. For many people in our society the TMJ is rarely unemployed. 

Given this prevalence, effective intra-oral work can be an important modality in an MT’s toolbox. Yet, after their introduction to intra-oral work in Ontario’s 2200-hour curriculum, many MTs profess a lack of confidence in accessing the muscles of mastication. Even after confident palpation is acquired, effective treatment is frequently still elusive given the common assessment point-of-reference of “tracking the wobbles.”

page-22.jpgAssessment Principles
Before any client can receive treatment, their particular presenting issues must be recorded and assessed to establish a baseline. Inquire about pain locations and character, about any teeth that are sore, and can the person open their mouth adequately with or without pain. Do they have a history of orthodontic applications, clicking or popping sounds or any events of locking? 

While the TMJ is acknowledged as a very complex system and often related to other issues, there is a way of assessing the joints to determine  a point-of-reference that acts as an “adjustable wrench” for de-mystifying many TMJ presentations. Perfect TM joints would have symmetrical condylar movement.

While performing an active motion-palpation of the joints, the practitioner asks themselves “Where is the delay?” Once the condyle with the delay is identified an effective treatment protocol can be created and monitored according to some principles of TMJ treatment.

Like the SI joint, the TM joints are measured according to symmetrical function. The dental profession believes that how well the teeth fit together (occlusion) will determine the symmetry of the TM joints. They see this as predominantly a one-way street. While this is true in many observed cases, there also exist those clients that present with mal-occlusion as a function of asymmetrical TM joint movement – suggesting the issue may work in both directions. 

One example is a case of a 22-year-old client who had her teeth ground to restore proper occlusion, and yet her TM joints remained asymmetrical, often progressively painful, and still presenting with noisy movement indicating disc displacements. In her case, receiving TMJ work had the positive potential of helping her pain and possibly restoring her joint/articular disc function, but had the negative potential of re-arranging the newly manipulated occlusion.

Focusing on finding the delay in condylar movement will initiate the practitioner’s quest to restore both joint symmetry and joint space. It is the assertion of this practitioner that because the mandible is suspended by soft tissue3, it is therefore primarily affected by soft tissue injury or dysfunction. The components shown below are often present in a vicious cycle of TMJ dysfunction: The compressive forces that accumulate in the joint structures combine with asymmetrical hypertonic muscle function, and occasionally joint capsular adhesion to form a vicious cycle of signs and symptoms.

If the joint is noisy most often the discal ligaments have been compromised setting in motion a progressive scenario of disc displacement. This issue will be addressed in Part 3.

The intent is to intervene on the cycle and improve or resolve enough of the components so that the overall sum of the problem will diminish to either manageable levels, or be resolved entirely. The question remains from case to case: “How many components can be resolved?”

Treatment Protocol & Principles
The first approach in many TMJ dysfunction cases often addresses pain and stiffness. Many times there will be a contra-lateral presentation where the client will report pain and stiffness on one side and the condylar delay will be on the other side. Often both condyles are delayed but one is predominantly so.

The treatment begins with the goal to decrease hypertonicity in the masticatory muscles as a way toward symmetrical condylar movement, and revealing other causal factors.

Each TMJ case arrives with a different combination of signs and symptoms, and while there is never a recipe for massage therapy treatments there are principles that provide a foundation to critical thinking.

A principle is defined as a law of action or a general guideline. Shown in the box on the right are some of the principles of TMJ treatment that offer guidance toward the initial goal of decreasing hypertonicity.

Principles Of TMJ Treatment:

Begin treatment of the muscles of mastication
in the following sequence:
  1. Temporalis m.
  2. Masseter m.
  3. Medial Pterygoid m.
  4. Lateral Pterygoid m.
  5. suprahyoid ms. – sometimes
Exit your treatment in the reverse order. Effective treatment is achieved through short duration intra-oral applications, repeated back and forth – 10 to 30 seconds at a time. Effectiveness is acquired through repetition, not duration! Joint asymmetry often leads to contra-lateral patterns of adaptation and then possibly progressing to Articular Disc displacement and/or degeneration.

temporalis-muscle.jpgTreatment Applications
Effectively decreasing hypertonicity of the Temporalis and Masseter muscles often yields an initial steep curve in diminished pain, especially where headaches are presented in combination with TMJ dysfunction. 

The Crown Jewel in TMJ treatment, and the issue most often avoided by practitioners, is the access and treatment of the Pterygoid group. Therefore, much of Part 2 of this series will be devoted to Medial and Lateral Pterygoid muscles.

All good massage therapy treatments are an integration of many modalities applied to primary, secondary, and compensatory issues. In a TMJ treatment, the client is supine where work is initiated at the neck and shoulders.

The practitioners’ mechanics are very well-served if they are seated on an adjustable-height stool with wheels, and their client is well-served if their table has stages of incline to elevate the client’s upper body and head. If not, an incline wedge can be purchased from medical supply to position clients higher during Pterygoid muscle access as salivation can increase as an autonomic referral of Myofascial Trigger Points.

It is especially useful to pursue a sub-occipital release with TMJ clients as there is often interplay between these regions. Scalene group and SCM are also valuable structures to release as part of TMJ work.

Now is the time to assess for joint symmetry. Palpation of the TM joints is done by placing the finger pads directly in front of the external auditory meatus. Gentle pressure yields more sensitivity than overt force. Instruct the client by saying: “Once I say ‘go,’ open and close your mouth to comfortable maximum a few times.” Watch for those clients who want to pause at full opening.

When palpating the joints in motion asking yourself, “Which side is delayed?” It is not necessary to watch the client’s mouth as they move; in fact it is better to be in your head visualizing the condyles as they hinge and glide, so don’t look! Palpation is a visualization skill, not a sight skill. This is not CSI!
Now you know that there is a delay on one side, even if you do not know why. Likely that delayed condyle is the one that has accumulated more compressive forces in the course of this clients’ life of clenching. Begin the quest of decreasing hypertonicity according to the Principles of TMJ Treatment and more will be revealed as you go.

The Temporalis muscle, inserting as it does on the coronoid process of the mandible, assists closure, and can harbour Myofascial Trigger Points whose referral pain patterns occur at the upper molars, sometimes mimicking tooth ache. This structure often requires no-lotion style fascial release and very often clients will report not only how surprised they are at how much tightness and tenderness resides there, but also how much relief they feel once hypertonicity, trigger points and fascial limitations are treated.

Many people sense a restoration of their powers of concentration, memory, and sleep-depth once the sub-occipital and Temporalis muscle releases are delivered over a few treatments. Clients talk about “having been in a fog.”

TMJ treatment begins with Temporalis Muscle release. Once the Temporalis muscle is treated some, it is time to move to the Masseter muscle. The Temporalis work becomes the “resting stroke” as one returns again and again while moving from one side to the next – remember treatment effectiveness is by repetition, not duration.

Some external work of the Masseter muscle is helpful to increase circulation, to palpate for hypertonicity, and to ask about pain and tenderness. This is the “Power Chewer” of the masticatory system and participates in the “Mandibular Sling” which governs much of the symmetry and joint space issues.

page-25.jpgThe Mandibular Sling
The length and strength of two inter-related muscles make up a large part of the overall function of the masticatory system; it is known as the Mandibular Sling. Each angle of the mandible is wrapped by the continuity of the Masseter muscle on the lateral side, and the Medial Pterygoid on the medial side (although its name is derived because it is medial to its mate – the Lateral Pterygoid). Understanding this relationship goes a long way in knowing why we, as soft tissue manipulators can have a direct influence on the pattern of movement, and the overall compressive forces within the joint.

The diagram at the right shows the two muscles from the unique perspective of below the skull.  Take note regarding the origin of the Medial Pterygoid muscle on the sphenoid bone. Craniosacral Therapists may report greater results by addressing this length/strength asymmetry of the Mandibular Sling.

TMJ-figure-4.jpg
Masseter Muscle Access: Keep your elbows high to avoid undue wrist flexion, and avoid pulling the clients cheek laterally. Not a fish on a hook!
Accessing The Masseter Muscle
Effective treatment of the Masseter muscle cannot begin until successful access is attained. Accessing the Masseter muscle can be accomplished using the pad of the gloved thumb, to the contra-lateral side of the therapist, as shown in Fig 4. 

TMJ-figure-5.jpg
Accessing the Masseter muscle with the thumb contra-laterally allows excellent play with the muscle and fascial interrelationship.
It would be timely to acknowledge that lightly powdered Nitrile gloves are chosen because they are non-latex and offer excellent dexterity.
The presence of lotion on MT’s hands necessitates the lightly powdered version; the powder-free gloves bring tremendous struggle.

Prepare the client by telling them:
  • That this work does not require them to keep their mouth open as in dentistry. Once you have accessed the vestibule of their cheek with your thumb they may close their mouth, remembering to have a tiny space between their teeth – you want all their muscles unemployed! 
  • That you need their coaching regarding pain/tenderness intensity. They are the boss!
  • Set their expectations that you will be inside for only up to 20 to 30 seconds at a time.
Gathering the Masseter muscle between thumb and finger and outer fingers allows you to search superiorly and inferiorly, palpating the micro world of Trigger Points and distinct boundaries of fascial layers. 

Picking-up the whole structure explores the macro world of how the fascial compartment may be tethered to many bony prominences and how it can relate to inner ear fascial continuity. How much can you get behind the fascial compartment?

After no more than 30 seconds retreat and hold both Masseter muscles bilaterally; this grounds the client and gives an opportunity to sooth the tenderness just engaged. Remove the glove and return to the Temporalis muscle for more release. Another glove is dawned and you are ready to explore the other side.
 
As the client gets more accustomed to receiving this intra-oral work you can explore the duration of Ischemic Compression on some Masseter muscle Trigger Points. Many clients will declare feeling a difference in the space inside and an ease of movement after only a few intra-oral increments. This responsiveness should be noted, and celebrated. However, encourage the client to be aware how long this lasts, as this is the ultimate criteria for success!

Treatment Soreness
The Temporalis and Masseter muscles present a large factor in many clients’ TMJ dysfunction and as such there is a high potential for stirring up the hive.
 This is especially true when combined with a history of headache.

It is essential that pain/tenderness levels be managed so that at all times the client is thinking, “That hurts some, but feels good at the same time.” Often the “scale of 1 to 10” game can be used, where 7 or less is safe. It cannot be stressed enough that the trust relationship is paramount in intra-oral work. Inform clients that there may be some treatment soreness afterward, but do so within the delicate balance of not paying so much attention to it as to
create a prediction to fulfill! 

The incremental nature of 30-second intervals intra-orally, as well as finishing with flushing neck and shoulder work help to manage such a possibility.
Encourage the client to drink plenty of water, get a good night sleep and consider the modified Epsom salts application below.

Epsom Salts Compress: Before Bedtime
• Pour 1.5 cups of Epsom salts into a bathroom sink of hot water.
• Immerse 2 face cloths to absorb salts.
• Wring out and apply to each cheek until the heat is neutralized, repeat.
• Go to bed repeating over and over “Is there space between my teeth?”.

Entering Pterygold Country

Rarely, if ever, is the Pterygoid muscle access pursued during the first visit of a TMJ client. As soon as the client is accustomed to Masseter muscle access introduce the idea that there is a partner to that muscle on the inside of the jaw bone. 

Some clients may never be able to open wide enough for Pterygoid muscle access as was the case of a client with Rheumatoid Arthritis. For most clients access is possible, and indeed essential, if mandibular sling re-patterning is to be successful.

However, Pterygoid access is the entrée of TMJ work and, as such, Part Two of this series is devoted to exploring those applications.

The nearly universal hypertonicity of the mandibular sling, once reduced, can begin to reduce the compressive forces within the TM joints, restoring the disc space leading to more symmetrical joint movement and the possibility of managing the displaced disc.

Combine the muscle work with fascial release and decompression mobilizations and the treatment now offers a taming of the mandibular sling that is unique to our scope of practice. 

A Series Of Series

Often, TMJ dysfunction is reported to have started long before the MT meets the client. Some will report entertaining their friends as adolescents with clicking or clunking jaw joints. When clients present with decades of accumulated issues re-patterning TMJ movement has tenuous possibilities at best. 
Often, our duty is to create an improved situation and then establish ourselves as a management resource, always fighting complacency by looking for plateau-busting opportunities.

TMJ clients will require continuity from one treatment to the next therefore; suggest a series of three to eight weekly treatments. The hope is by that time the client is “fixed” and does not need you anymore.

However, the reality is that many cases will stump you, and fall into the “improved, but not resolved” category. In this case, a series of two or three treatments every so often, perhaps every other season, will maintain their improved status, and may prevent further joint degeneration. 

Be sure to contact and refer to other practitioners as the combination of modalities often yields synergistic results. Networking with MDs, dentists, chiropractors, physiotherapists, acupuncturists, and speech-language pathologists has proven successful.

TMJ-part-2-image.jpgTMJ Mastery: Part Two – Pterygoid Syndrome
• Part Two will highlight the Pterygoid group and, while technique is never acquired from text in Massage Therapy, we will continue to explore principles and applications that make gaining access and treating the Pterygoid group possible.
• Part Two will also introduce Pterygoid Syndrome, and explore the different functions of the superior and inferior divisions of the Lateral Pterygoid muscle.

TMJ-part-3-picture.jpgTMJ Mastery: Part Three – Displaced Articular Disc
• In Part Three will look at decompression mobilization, the continuum of disc displacement, and whether we have any positive influence over such disc displacements.

References

1. Jaw Survey; “Whether at night or day, during stress or pain, or part of concentration, etc, do you clench your teeth?” March 2007.
2. Lobbezoo, Lavigne: Do Bruxism and Temporomandibular Disorders Have a Cause-and-Effect Relationship?: Journal of Orofacial Pain, Vol. 11, Issue 1, 1997
3. Okeson, Jeffrey P: Management of Temporomandibular Disorders and Occlusion, 5th Edition: Lexington, Kentucky, 2003. P 106

Bibliography

• Clemente Carmine D., Anatomy; A Regional Atlas of the Human Body, 5th Edition, New York, 2003
• Dorland’s Illustrated Medical Dictionary, 29th Edition: 2000
• Kessler Randolph M, Hertling Darlene: Management of Common Musculoskeletal Disorders, Physical Therapy Principles and Methods Philadelphia, 1990
• Okeson, Jeffrey P: Management of Temporomandibular Disorders and Occlusion, 5th Edition:
    Lexington, Kentucky, 2003
• Still A.T.: Osteopathy Research & Practice, Kirksville, Missouri, 1910.
• Upledger, John: TMJ; Primary Problem or Tip of The Iceberg, Massage Today, August 2002, Vol. 2, Issue 8.

John-Corry---Head-Shot.jpg
John w. Corry, rmt

Biography
John Corry graduated in 1989 from Sutherland-Chan School and Teaching Clinic in Toronto. He has been a Treatments & Techniques instructor in London’s massage therapy school, D’Arcy Lane Institute, has presented at workshops and international fitness conferences, and has been a career-long member of the Ontario Massage Therapists Association, twice being a local chapter president. He pursues a level of excellence in innovative applications, and started focusing on TMJ cases in 1992. He facilitates a three-day instructional workshop called TMJ Mastery and works at Wholisitc Body & Baby in the core of London, Ontario. You can contact John Corry at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it





COMMENTS

This e-mail address is being protected from spam bots, you need JavaScript enabled to view it
Written by sadun on 2014-04-07 08:36:29
Hi ,I have slipped TMJ disc,it can be put it back to its original location without surgery? 
Thank you

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