TMJ: Osteopathic Techniques for the...
Transcript of TMJ: Osteopathic Techniques for the...
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TMJ: Osteopathic Techniques for the Office
Jesus Sanchez, Jr. , D.O
AAO Convocation 2019
March 16, 2019
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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
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Hruby, RJ. The total body approach to the osteopathic management of temporalmandibular joint dysfunction. JAOA. 1985;85 (8):502-510
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Physiology
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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
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Ligament Crimp
http://ajs.sagepub.com/content/32/4/870/F9.expansion
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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
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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
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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!
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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
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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
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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
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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
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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
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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
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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.
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Practice and Explore
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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