TMJ Exercises for the Temporomandibular Joint (PowerPoint ...

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Dr. Tucker’s Self Help Guide to the Diagnosis & Treatment of Temporo-

mandibular Disorders

Jeffrey Tucker, DC, DACRB11600 Wilshire Blvd. #412

Los Angeles, CA 90025310-473-2911


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WHAT YOU CAN LEARN IN THIS SELF GUIDE:

• To identify problems of craniomandibular function and appropriate self care.

• To determine if your jaw muscles are overactive and learn a corrective exercise treatment.

• To screen yourself for problems related to activity limitations with chewing, swallowing, speaking, respiration, and emotional expression.

• Learn specific nutritional recommendations.


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DIAGNOSIS of Temporomandibular Disorders (TMD)

TMD is a collective term for a broad range of disorders displaying a variety of signs – radiating pain in the face, neck, or shoulders; limited movement or locking of the jaw; painful clicking or grating when opening or closing the mouth; and a significant change in the way the upper and lower teeth fit together. Other common symptoms include headaches, earaches, dizziness, hearing problems, and difficulty swallowing.


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The Jaw Symptom Questionnaire consists of the following questions:

Does it hurt when you open wide to yawn? Does it hurt when you chew or use the jaws? Does it hurt when you’re not chewing or using the jaws? Is your pain worse upon waking? Do you have pain in front of the ear, or earaches? Do you have jaw muscle or cheek pain? Do you have pain in the temples? Do you have pain or soreness in the teeth? Do your jaws make noise so that it bothers you or others? Do you find it difficult to open your mouth wide? Does your jaw ever get stuck/lock as you open it? Does your jaw ever lock open so that you cannot close it? Is your bite uncomfortable?


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Jaw Symptom Questionnaire

• In my experience if a patient answers more than three of the above questions they will benefit by education, an anti-inflammatory home care program including dietary changes, nutritional supplements, heat or ice applications, avoidance of mechanically stressful activities, and resting the jaw (practice the “lips apart and jaws relaxed” procedure).


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“Do I have a disorder of the mouth, face or Temporomandibular joints manifesting as neck

pain or headache?”Your Dentist can evaluate if you have the

following:• Disorders of the teethAtypical OdontalgiaSilent draining abscess• Oral lesionsCarcinomas of the oral cavity• Vascular lesions (see specific nutrition

recommendations next slide)Temporal arteritisFacial migraine


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General Nutrition for TM Disorders• EC Matrixx™ is a mechanism-specific formula designed to support healthy

connective tissues by supporting the extracellular matrix, a key structural component of connective tissues such as tendons, ligaments, and cartilage. Features berberine and tetrahydro iso-alpha acids (THIAA), which have been shown in laboratory research to influence MMP-13, an enzyme involved in the maintenance of connective tissue structure.

THIAA has also been shown to beneficially influence multiple cellular signaling processes related to connective tissue health.

Supports biochemical processes that influence the health of the extracellular matrix.

• Chondro-Relief Intensive Care — 3-6 capsules daily with food. Joint & soft tissue support with MSM, Green Lipped Mussel, Hyaluronic Acid and ASU.

• Inflavonoid Intensive Care — 3-9 tablets daily with meals. For relief of minor pain.

• E-Complex 1:1 — 2-4 softgels daily. 1:1 ratio of alpha and gamma tocopheryls.


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“Do I have a disorder of the mouth, face or Temporo-

mandibular joints manifesting as neck pain or headache?” • Your Dentist can evaluate if you have the following:• Disorders of the teeth• Atypical Odontalgia• Silent draining abscess• Oral lesions• Carcinomas of the oral cavity• Vascular lesions (see specific nutrition

recommendations next slide)• Temporal arteritis• Facial migraine


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Headache: Vascular / Migraine Nutrition

• In conjunction with UltraInflamX

• NOTE: in all forms of headaches, sensitivities to certain food or environmental factors can be a significant entity to address. If determined to be, add to the outlined protocols Perimine.


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Headache: Vascular / Migraine requires nutrition for Inflammation Management: Cleanse, Repair& Put Out

the Fire • A natural strategy should attempt to support the production of substances in the body that

protect tissue integrity and relieve pain and inflammation. This goal can be achieved by targeted nutritional support:

• Key anti-inflammatory nutrients, such as: – Ginger to inhibit pro-inflammatory prostaglandin and leukotriene production – Turmeric to scavenge nitric oxide production and inhibit pro-inflammatory prostaglandin production – Quercetin to inhibit lipoxygenase, tumor necrosis factor alpha, and nitric oxide

• Potent antioxidant nutrients, such as: – Mixed carotenoids, zinc, manganese, selenium, rutin, rosemary, and vitamins A, C & E to reduce free radical

generation • GI-supportive nutrients, such as:

– L-glutamine to protect the integrity of the gastrointestinal mucosa barrier – Vitamin B5 (along with zinc and quercetin) to promote GI healing – Rice bran fiber to promote the growth of beneficial GI bacteria; decrease betaglucuronidase, mucinase, and

nitroreductase activities; and increase bile excretion • Eicosanoid-balancing nutrients, such as:

– Magnesium, zinc, and vitamins C, B3 & B6 to support healthy essential fatty acid and eicosanoid metabolism • Citrus bioflavonoids, such as:

– Hesperidin to inhibit arachidonic acid metabolism and histamine release, thus resulting in analgesic and anti-inflammatory activities

• Detoxifying nutrients, such as: – N-acetylcysteine and sodium sulfate to promote sulfation in phase II detoxification activities (often compromised

in inflammatory conditions) – Limonene to induce glutathione conjugation and glucuronidation

– 2 scoops of UltraInflamX includes all of the above.


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Headache: Vascular / Migraine Nutrition

• In conjunction with UltraInflamX

• NOTE: in all forms of headaches, sensitivities to certain food or environmental factors can be a significant entity to address. If determined to be, add to the outlined protocols Perimine.


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Migraine Headache: Preventive Maintenance supplements

• Trancor — 4 capsules daily. Helps balance between the calming influence of GABA and the excitatory effects of glutamate.

• Somnolin — 4 capsules daily (2 in the AM and 2 in the PM). After headaches are under control for 4-6 weeks decrease by 1 pill per week until lowest dose is found that maintains the patient symptoms. Features a complementary blend of 5-HTP, theanine,and targeted B vitamins.

• EPA-DHA Extra Strength — 2 softgels 2-3 times daily with meals. Essential fatty acids from cold water fish. Natural anti-inflammatory documented to benefit migraine sufferers.


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Migraine HeadacheAt Onset:

• Trancor™ - 4 capsules daily.Trancor is formulated to support a sense of tranquility in those who may feel worried or nervous by beneficially modulating the balance between the calming influence of GABA and the excitatory effects of glutamate.


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pain or headache?”

Your Dentist or Chiropractor can evaluate you for the following:

• Neurological lesions

Atypical facial pain

Typical trigeminal neuralgia

Atypical trigeminal neuralgia

Pre-trigeminal neuralgia

Tic douloureux

See specific nutritional recommendations next slide


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Specific nutritional recommendations: Atypical facial pain, Typical trigeminal neuralgia, Atypical trigeminal neuralgia, Pre-trigeminal neuralgia, Tic douloureux

• Ceralin Forte® — Three capsules daily. Ceralin Forte is formulated to provide well-rounded support for brain and nerve protection, addressing multiple pathways involved in neurological health.

• Wellness Essentials™ For Men/Women formula — 2 packets daily. Key Vitamins & Minerals, Essential Fatty Acids, PLUS gender specific nutrition.


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pain or headache?”

Your Physician can evaluate you for the following:

• Disorders of the eyes

Eye strain

Acute glaucoma

• Disorders of the ears

Ear pain (otalgia) (specific nutrition recommendation)


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Ear pain of unknown origin. General Treatment Strategies:

• Assume problem has a dietary component until proven otherwise.• Eliminate all dairy products for at least three weeks.• Eliminate refined sugars and “junk food.”• Address food intolerance (begin with most simple and inexpensive).• eliminate foods that are on the “common offenders” list, or• perform elimination/provocation (E/P) testing• if E/P is unsuccessful you may wish to proceed to serum IgG, IgE or

IgM—invasive and costly but very useful.• Eliminate trans fatty acids from diet.• Decrease omega-6 intake while increasing omega-3 intake.• Reduce intake of meat and eggs unless person is malnourished.• Address biomechanical problems with Chiropractor i.e. TM

dysfunction.


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“Do I have a disorder of the mouth, face or Temporomandibular joints manifesting as a

disorder of the nose and throat?” Chronic nasal airway obstruction (CNAO) or Sinusitis - Signs and Symptoms Tenderness to palpation, swelling, redness, and opaque trans-

illumination of involved sinuses Fever, chills: suggest expansion of the infection beyond the sinuses Nasal congestion and serous or mucopurulent discharge (usually

yellow or green) Malaise Headache and/or dizziness that changes with position and is worse

lying down or bending over History of upper respiratory infections, dental problems, nasal

allergies, or injury to the area Nasal mucosa is red and swollen, and the exudate may be seen in

the turbinates corresponding to the infected sinus(es)


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Sinusitis Acute Nutrition Management

• Sinuplex - Features a unique, ephedra-free blend of vitamin C, quercetin, nettle root extract, bromelain, and N-acetylcysteine. Supports healthy sinus, nasal, lung, and respiratory function. May help support healthy eicosanoid synthesis.

• Ingredients are carefully selected and manufactured with advanced processing technologies to preserve the potency and stability of delicate components such as bromelain.

• NOTE: If patient has a history of antibiotic use, add UltraFlora Plus to the protocol. Advanced Probiotic Nutrition with Immunoglobulins


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Chronic Sinus Condition Management

• Perimine — 1-2 tablets twice daily with food. Patented, Flavonoid-Rich Perilla Seed Extract. Perimine features a patented extract of Perilla seed (Perilla frutescens), a unique herb that supports a healthy immune response in individuals who may be sensitive to certain food or environment factors. Dried Perilla seed and leaves have both historical and modern applications in Traditional Chinese Medicine to alleviate chest fullness, support healthy mucus secretion, and promote healthy breathing.

• Sinuplex — 2-4 tablets daily as needed. Healthy sinus and lung support.

• Nazanol—1-2 tablets 2-3 times daily (based on severity of condition) on empty stomach. Natural, stimulant-free herbal support for healthy sinus, nasal and lung function.


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“Do I have a disorder of the cervical spine (neck) or headache manifesting as pain in the orofacial

or TM apparatus area?”

Ask your Doctor to rule out:• Vascular lesionCarotidyniaThomboangiitis obliterans (Buerger’s disease)• Neurological lesionsNeck-tongue syndrome• Arthritic DiseaseRA, SLE, AS, Psoriatic arthritis (see nutritional

recommendations)


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Core Nutritional Support Protocol for RA, SLE, AS, Psoriatic arthritis

• UltraInflamX® Plus 360 — 2 scoops twice daily. Multi-mechanistic support with key nutrients, phytonutrients, and selective kinase response modulators (SKRMs) to address underlying inflammation.

• Follow either the Modified Elimination Diet or the Anti-Inflammatory Diet• LactoFlamX™ — 1 capsule daily LactoFlamX features L. plantarum 299V

— a strain-identified probiotic that has been specifically shown to support the integrity and healthy function of the muscosal lining.

• EPA-DHA 6:1™ Enteric Coated — 2 softgels three times daily. EPA-DHA 6:1 Enteric Coated omega 3 fatty acids providing a ratio appropriate for patients with chronic inflammatory conditions.

• Iso D3™ — 1 tablet three times daily. Vitamin D3 with Isoflavones. Iso D3 is designed to support optimal metabolism of vitamin D to its active

form.If there is a soy sensitivity use:• D3 1000™ — 2 microtablets three times daily. High potency vitamin D3 —

the most bioactive form of supplemental vitamin D.


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“I have been diagnosed with a Temporal muscle tendinitis”

• Perform corrective exercise stretches in this presentation.

• Nutrition: EC Matrixx™ is a mechanism-specific formula designed to support healthy connective tissues by supporting the extracellular matrix, a key structural component of connective tissues such as tendons, ligaments, and cartilage.

Features berberine and tetrahydro iso-alpha acids (THIAA), which have been shown in laboratory research to influence MMP-13, an enzyme involved in the maintenance of connective tissue structure.




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SELF TEST: MANDIBULAR FUNCTION MOVEMENT

PATTERN• Seated or standing in front of a mirror.

1. Slowly open & close mandible.

2. Qualification: Pass/fail

You fail if your mandible (lower jaw) protrudes on initial phase of opening.

Follow the exercises in this presentation.


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Normal Opening

Three fingers width


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General Signs & Symptoms of TMD

Pain on opening Trismus (limitation of mouth opening) or deviated jaw mobility Joint noises (clicking, popping, grinding) Pain on chewing Tenderness or pain felt in the jaw joint or muscles, or both Pain felt in the area of the ear, temples, or cheeks General Signs & Symptoms of TMD, con’t Ear “fullness” Subjective hearing loss Change in occlusion Abnormal wear of the teeth Headache (most common presentation are frontotemporal & suboccipital) Muscle hypertonicity Hypertrophy of the jaw muscles Tinnitis Dizziness Neck pain Upper trapezial pain Upper extremity pain & paresthesia Difficulty swallowingSteigerwald, D.P., Whiplash and Temporomandibular Disorders: An Interdisiplinary Approach to Case

Management. Keiser Publishing, San Diego, CA., 1992


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Major Categories of TMDS• Muscle Disorders (treat with corrective exercises & nutrition)Muscle painProtective muscle splinting (trismus, bracing, guarding)MyospasmMyositisMyofascial pain (trigger point activity)ContractureHypertrophyDyskinesia (muscle incoordination)DstoniaBruxismThese disorders are treated by a Rehabilitation Chiropractor or

physical therapist. Warm laser, as used by Dr. Tucker is an excellent pain-less non-surgical treatment for the above symptoms.


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Nutrition for Muscle Disorders• EC Matrixx™ is a mechanism-specific formula designed to support healthy

connective tissues by supporting the extracellular matrix, a key structural component of connective tissues such as tendons, ligaments, and cartilage. Features berberine and tetrahydro iso-alpha acids (THIAA), which have been shown in laboratory research to influence MMP-13, an enzyme involved in the maintenance of connective tissue structure.


Supports biochemical processes that influence the health of the extracellular matrix• Muscle Spasm Remedy is a high quality, handmade homeopathic remedy designed

to relieve muscle aches, spasms, or pain.• Chondro Relief Intensive Care — 3-6 capsules daily with meals. Comprehensive

joint & soft tissue support, with MSM, Green Lipped Mussel, Hyaluronic Acid, and ASU.

• E-Complex 1:1 — 1 softgel 2 times daily with food. E Complex-1:1 is a unique, natural vitamin E supplement that features a 1:1 ratio of alpha- to gamma-tocopherol; this ratio more closely resembles the tocopherol profile found naturally in vitamin E-rich plants.

• Avoid caffeine, menthols.• Dietary Suggestions: Anti-Inflammatory Diet


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Major Categories of TMDS• Ask your Doctor which Temporomandibular joint disorders do

you have: Disc displacement or internal derangement Arthralgia Capsulitis or synovitis Arthritis disease (systemic) Degenerative disease (osteoarthritis) Traumatic articular disease (sprain or strain, fracture) Disc displacement without reduction (closed lock) Disc displacement with reduction Subluxation of the condyle Dislocation of the condyleThese disorders are treated by a Rehabilitation Chiropractor or

physical therapist. Warm laser, as used by Dr. Tucker is an excellent pain-less non-surgical treatment for the above symptoms.


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General Nutrition for TM Disorders • EC Matrixx™ is a mechanism-specific formula designed to support

healthy connective tissues by supporting the extracellular matrix, a key structural component of connective tissues such as tendons, ligaments, and cartilage. Features berberine and tetrahydro iso-alpha acids (THIAA), which have been shown in laboratory research to influence MMP-13, an enzyme involved in the maintenance of connective tissue structure.



• Chondro-Relief Intensive Care — 3-6 capsules daily with food. Joint & soft tissue support with MSM, Green Lipped Mussel, Hyaluronic Acid and ASU.

• Inflavonoid Intensive Care — 3-9 tablets daily with meals. For relief of minor pain.

• E-Complex 1:1 — 2-4 softgels daily. 1:1 ratio of alpha and gamma tocopheryls.


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Major Categories of TMDS: Inflammatory disorders

Continuous pain that is increased with function

Core Nutritional Support Protocol• UltraInflamX® Plus 360 — 2 scoops twice daily. Multi-mechanistic support with key

nutrients, phytonutrients, and selective kinase response modulators (SKRMs) to address underlying inflammation.

• Follow either the Modified Elimination Diet or the Anti-Inflammatory Diet• Kaprex® — 2 tablets twice daily. Non-responders by day 5 move to 3 tablets 2-3 times

daily. Time to benefit: Immediate to 10 days. Kaprex is a clinically tested herbal dietary supplement that provides natural joint relief that is

easy on the gastrointestinal (GI) tract. It works by interfering with signals in the body that initiate the production of damaging compounds that cause minor pain and negatively impact cartilage and other joint tissues

• EPA-DHA 6:1™ Enteric Coated — 2 softgels three times daily. EPA-DHA 6:1 Enteric Coated omega 3 fatty acids providing a ratio appropriate for patients with chronic inflammatory conditions.

• Iso D3™ — 1 tablet three times daily. Vitamin D3 with Isoflavones. Iso D3 is designed to support optimal metabolism of vitamin D to its active form.

• If there is a soy sensitivity use:• D3 1000™ — 2 microtablets three times daily. High potency vitamin D3 — the most

bioactive form of supplemental vitamin D.


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Anti-Inflammatory Diet


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Major Categories of TMDS• Disorders of mandibular mobility (hyper- or

hypo-mobility)HypermobilityAdhesionAnkylosisCoronoid process elongationFibrosis of muscle (contracture) These disorders are treated by a Rehabilitation

Chiropractor or physical therapist. Warm laser, as used by Dr. Tucker is an excellent pain-less non-surgical treatment for the above symptoms.


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Major Categories of TMDS

• Growth disorders

Hypoplasias

Hyperplasias

Neoplasias

These conditions require co-management of multiple doctors.


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OROFACIAL DISORDERSFUNCTIONAL ANATOMY

Primary Functions of the Masticatory System:

MasticationSwallowingSpeechSecondary Functions:RespirationEmotional expression


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MANDIBULAR POSTURAL REST POSITION (MPRP)

The normal MPRP is in equilibrium between the downward pull of gravity and the myotatic reflex contraction of the mandibular elevators. MPRP depends on muscle tonus of the anterior and posterior cervical muscles, head posture, and the inherent elasticity of muscles.


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• Normally there is no occlusal (tooth-to-tooth) contact during MPRP. This interoccclusal space is termed freeway space and is usually 3-5 mm when measured from MPRP to full occlusal contact. This dimension is increased in mouth breathers and is decreased in people who brux or clench.

• Significance of MPRP is that, under normal conditions, it is a time for rest and repair of the TMJ system.

• Head posture is probably the single most important factor governing MPRP. A Chiropractor is the most skilled practitioner to evaluate your head posture.


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• Significance of MPRP is that, under normal conditions, it is a time for rest and repair of the TMJ system.


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MUSCLES OF MASTICATION

• Elevators (jaw closing) of the mandible: (these are commonly overactive)

1. Masseter

2. Medial pterygoid

3. Temporalis muscles


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• The posterior fibers of the temporalis can retract the mandible and maintain the condyles posteriorly. The superficial fibers of the masseter protrude the jaw. The deep fibers act as a retruder. The medial pterygoid can protrude and lateral deviate it to the opposite side.


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• Depressors (jaw opening) of the mandible:

Digastrics

• Protrusion (jaw jutting forward) of the mandible:

Inferior lateral pterygoid


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MASSETER MUSCLE

• Actions: Elevate the mandible and close the jaw. Deep fibers also retrude the mandible.

• Synergist: Temporalis, medial pterygoid

• Antagonist: Digastric, inferior lateral pterygoid

• It is frequently overactive and can become tight.


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Masseter muscle nutrition

• Fibroplex® Plus provides targeted nutritional support for soft tissues in those with muscle tenderness and discomfort. Featuring a blend of specific vitamins, minerals, and amino acids in an easy-to-use delivery form, this specialized formula works by supporting cellular energy production and muscular and nervous system function.

• Provides targeted nutrition for soft tissue in those with muscle tenderness and discomfort.

• Provides targeted support for energy metabolism and neuromuscular function.

• Supports cellular energy production and mitochondrial function.

• Provides magnesium in the form of an amino acid chelate designed to be easily absorbed


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Tinnitis caused by the Masseter Muscle

• Unilateral tinnitus may be associated with trigger points in the upper posterior portion of the deep layer of the masseter muscle. Unilateral tinnitus also may arise from TMJ intracapsular disease. If the tinnitus is bilateral, one should suspect a systemic, rather than a myofascial cause (Travell).

• Vitamin-deficiency of niacinamide and thiamine may be related to tinnitus. (see next slide for nutrition)


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Tinnitis: Nutrition• Appropriate Wellness Essentials™ formula — 1-2 packets daily. Key

Vitamins & Minerals, Essential Fatty Acids, PLUS gender specific nutrition.• CoQ10 ST 100 — 1 softgel three times daily. Stabilized, Highly Absorbable

Coenzyme Q10 with Natural Vitamin E. According to a German study published in Otolaryngol Head Neck Surg. 2007 Jan; 136(1):72-7, “For a Subgroup of people CoQ10 may provide relief from the symptoms of tinnitus.” The test group was administered 100mg. of CoQ10 three times daily for 12 weeks.

• If a history of antibiotic use:• Ultra Flora IB — 1 capsule daily with food. (minimum of 2 bottles). Ultra

Flora IB is an enhanced potency probiotic formula designed to help relieve bowel irritation and related functional discomforts by promoting a healthy balance of intestinal microflora.

• If on prescription diuretics:• MG/K Aspartate — 2 tablets daily with food. Magnesium and Potassium

combination designed to optimally replace lost potassium levels.


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MASSETER MUSCLE Exercise

1) Passive Mandibular Self-stretch2) Three-step resistive exercise: 1. resistance held

for 10 sec as the patient actively, gently tries to close the mouth while it is held wide open. 1a. Relax. 2. patient tries to open the mouth as wide as possible with gentle assistance from the hand, slightly increasing the range of motion. 3. active opening effort of the patient is resisted by the hand. Repeat 3X. The patient then opens and closes the mouth through the maximal active range of motion several times without resistance.


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TEMPORALIS MUSCLE

• Actions: Elevation (closure) of the mandible. The posterior fibers, in addition, are important for retrusion and lateral deviation of the mandible to the same side.

• Synergists: ipsilateral: masseter, superior lateral pterygoid, medial pterygoid.

contralaterally: same plus temporalis.

• Antagonist: inferior lateral pterygoid, anterior digastric, omohyoid, mylohyoid.


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TEMPORALIS MUSCLE

• Trigger points may be activated: by bruxism & clenching; direct trauma i.e. fall on the head, impact from a ball, auto accident; prolonged jaw immobilization; cervical traction; excessive gum chewing.

• Self Treatment: Massage the muscle and rub out the tender points found.


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TEMPORALIS MUSCLE

• Usually, about 2 ½ knuckles of jaw opening is reached if the temporalis, but not the masseter, muscle is involved. Masseter tension restricts opening more severely.

• Giant Cell Arteritis (Temporal arteritis): headache, fever, consequent blindness, respond to corticosteroid therapy.

• Exercise: Mandibular Self-stretchThe patient is encouraged to induce a wide-

open yawn as a regular exercise.


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MEDIAL (INTERNAL) PTERYGOID• Actions: Bilaterally, elevates the mandible:

Unilaterally, deviates the mandible to the opposite side; it also can assist protrusion.

• Symptoms caused by active trigger points are difficulty in swallowing & painful, moderately restricted, jaw opening. Stuffiness of the ear may be a symptom of trigger points.


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MEDIAL (INTERNAL) PTERYGOID

• Patient examination usually reveals contralateral deviation of the incisal path as the jaws are opened and closed, with restriction of opening.

• Activation: sucking of thumb, excessive gum chewing, occlusal interference, bruxism (lateral grinding of the teeth), clenching, anxiety and emotional tension.


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INFERIOR LATERAL PTERYGOID

• Attaches, in front, to the lateral pterygoid plate and, behind, to the neck of the mandible.

• Action: Bilateral=its primary role is protrusion (jaw jutting forward)

Unilateral=lateral movement to opposite sideWith depressors=pulls the condylar head

forward and down so that the condyle can translate over the posterior surface of the eminence, (essential for full opening)


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• Examination: Slight decrease in jaw opening; lateral excursion of the mandible is reduced toward the opposite side, away from the involved muscle; midline incisal path deviates, usually away from the affected side.


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• Lateral pterygoid function is practically eliminated by having the patient slide the tip of the tongue backward along the roof of the mouth to the posterior border of the hard palate, which stops translation of the condyles across the eminentia. If the incisal path straightens out when the mouth is opened in this way, it is chiefly lateral pterygoid dysfunction that is causing the muscular imbalance; if the incisal path still zigzags, other muscles and/or a TMJ derangement are responsible (Travell p.264)


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INFERIOR LATERAL PTERYGOIDExercise #1

• Both divisions are passively stretched by maximal retrusion of the mandible. Patient supine. Practitioner places his thumbs on the mandible from above; the patient is told to press chin gently forward against his thumbs, while breathing in; the patient then exhales, the Dr. pushes the mandible backwards with the teeth separated by only a few millimeters. Follow this up with full active ROM by maximally protruding & retruding the mandible, without manual resistance.


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• Rhythmic stabilization self stretch: patient grasping the mandible by the fingers & thumb, inside & outside the mouth, then slowly & smoothly, but firmly, pulling it forward until the muscles feel tight. Alternate, rhythmic protrusion and retrusion efforts by the hand.


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• Active resistive exercise (strength): patient protrudes the mandible against resistance, and then moves the mandible to each side also against resistance.


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SUPERIOR LATERAL PTERYGOID

• Originates from the infratemporal surface of the greater wing of the sphenoid bone and, attaches to the disc and capsule (40 percent) and condyle (60 percent).

• Action: Pulls the articular disc forward & checkreins its backward movement, thus assisting mandibular elevation. Overactivity or TrP shortening, displaces the articular disc forward & impedes its return to its normal position on closure of the jaws.


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SUPERIOIR LATERAL PTERYGOID

• Patient examination: slight restriction of jaw opening, a distorted incisal path, and often occlusal abnormality.

• Travell “Trigger point’s in this muscle are the chief myofascial source of referred pain felt in the TMJ area.” P.260

• Activation of trigger points: Satellites from the SCM (short leg), malocclusion, bruxism, gum chewing, playing an instrument.


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DIGASTRIC causes difficulty swallowing

• Referred pain and tenderness from trigger points in the posterior belly are projected to the upper part of the sternocleidomastoid muscle.

• Symptoms include difficulty swallowing.


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DIGASTRIC

• Action: Assist depression & retrusion (pulls the mandible back & down).

• When the hyoid is fixed by the suprahyoid & infrahyoid muscles, the digastics (left & right) can depress the mandible & bring the teeth apart.

• When the mandible is stabilized, the digastric muscles, with the suprahyoid & infrahyoid muscles, elevate the hyoid bone, which is a necessary function for swallowing.


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DIGASTRIC

• Omohyoid & sternothyroid are both muscles involved in proximal stabilization for speaking and swallowing function of the mandible.

Zang, B.A. The effect of the occlusal splint on the biomechanics of the cranium, cervical spine, mandible and the hyoid region. Orthodontic Review, Jan/Feb., 1988.

• Synergist: Inferior lateral pterygoid

• Exercise: patient should do a self-stretch, jaw protruding passive exercise, lying supine.


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DIGASTRICSKILL TECHNIQUE

• Hyoid restriction is most often associated with unilateral increased tension of the digastrics. This is evaluated by softly shifting the hyoid from side to side. Deviation of the cartilage can usually be seen on the side of increased tension.


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DIGASTRICSKILL TECHNIQUE

• Post-isometric Release (PIR) is performed with the patient supine; one hand of the practitioner resists the opening of the mouth while the thumb or finger of the other hand exerts minimal force on the hyoid on the side of increased tension or deviation. The patient is instructed to open their mouth gently, and breath in; to hold their breath, and then to breath out and relax. During relaxation, resistance in the digastrics will give under the practitioner’s thumb.


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A PROPER TM CLINICAL EXAMINATION INCLUDES

1. History

2. ROM

3. Mandibular tracking

4. Auscultation

5. Palpation

6. Provocations (joint/muscle challenges)


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Motor Vehicle Accidents & TMD History Questions

1. Have you noticed any clicking, popping or other noise in the temporomandibular (jaw) joints occurring with mouth movement which have arisen (or have increased) following the accident?

Yes___ No___2. Since the accident have you noticed any inability to fully open or fully close the mouth without strain/pain?Yes___ No___. 3. Since the accident have you noticed any sense of an altered bite or altered jaw posture or altered jaw function

during chewing, speech or other mouth movements?Yes___ No___ 4. Have you noticed any symptoms associated with your ears since the accident, specifically: A sense of diminished hearingRinging in the earsA sense of pressure in the earsPain in the ears5. Since the accident have you experienced headaches, neck or shoulder pain?Yes___ No___6. Have you noticed any tendency to clench your teeth since the accident?Yes___ No___7. Have you experienced any of these symptoms before the accident?Yes___ No___If yes, which ones?If yes, when was the last time you had this/these symptom(s) before the accident?If yes, describe the difference, if any, between the symptom before and after the accident?


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TM Diagnostic Aides

• Typical arthrogenous (joint) pain improves as the day progresses, especially if the jaw is active.

• Masticatory myofascial pain is typically worse upon awakening if bruxism (grinding) is present. However, inflamed joints can be aggravated by bruxism as well and hurt upon awakening as well.


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Whiplash/TMD Unique Factors

1. The onset of local signs and symptoms of TMD may be delayed by weeks to months.

2. Peripheral symptoms of TMJ inflammation such as headaches and neck pain will surface within hours to days. These symptoms may continue to be the dominant complaint indefinitely.


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Causes of pain in the Region of the Temporomandibular Joint Differential

Diagnosis • Inflammation of the preauricular lymph nodes• Otitis media or extrena• Referred pain from a trigger point• Tenosynovitis of the temporalis tendon as it

passes behind the zygomatic arch• Trigeminal neuralgia• Dental caries• Bony tumors, both benign & malignant (primary &

metastatic)• Inflammatory arthritides (i.e., ankylosing

spondylitis, rheumatoid arthritis, juvenile arthrits, psoriatic arthritis, etc.)


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DR. TUCKER’S INITIAL MANAGEMENT & TREATMENT

• I want to reassure you that you can get better and have many treatment options.

• Continue to become educated:

a) Anti-inflammatory diet is very valuable.

b) Self care includes the use of heat or ice.

c) Avoid mechanically stressful activities, soft diet, avoid exhaustive chewing (chewing gum, eating caramels, biting a pen or pencil, chewing tough meat, bagels, pizza, cracking nuts or ice with teeth), avoid sleeping on stomach.


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INITIAL MANAGEMENT & TREATMENT

• Rest the jaw. That means minimal talking & chewing.

• Maintain good posture. Get evaluated by a Chiropractor and learn how to enhance your posture.

• Avoid clenching.

• Practice the “lips apart & jaws relaxed” procedure.


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INITIAL MANAGEMENT & TREATMENT

• Approximately 10 to 30 days are usually required for chiropractic & home therapy to exert some effect.

• Pain Control: Meditation, vitamins/herbs, NSAID’s, muscle relaxant, antidepressants.

• Physiotherapy: Laser, Stretch-and-spray, ice packs, heat packs, diathermy, EMS, US, anesthetic injections, soft tissue mobilization & manipulation.


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THANK YOU!

• I appreciate that we could spend time together.

• My email is [email protected]

• To order vitamins/minerals please go to my website www.DrJeffreyTucker.com and click on the Metagenics link.

mailto:[email protected]

http://www.drjeffreytucker.com/

TMJ Exercises for the Temporomandibular Joint (PowerPoint ...

Health & Medicine

Transcript of TMJ Exercises for the Temporomandibular Joint (PowerPoint ...