by Ross Turchaninov, MD, Ali A Bipar, DDS, MS



This is the final part of the article on TMJ dysfunction, and it is dedicated to the MEDICAL MASSAGE PROTOCOL. We would like to start Part III by addressing the modern treatment options.

First of all the diagnosis of TMJ dysfunction must be correctly established (see part II of this article in the previous issue of JMS).

The patient who suffers from TMJ dysfunction has very limited treatment options: various stretchings, physical therapy exercises, night guards for those who had bruxism, and surgery (Wright et al, 1995). Usually, the patients go through the set of conservative treatments quickly, and very early they realize these treatments don’t work in many cases.

The widely popularized by the chiropractors cervical adjustments to relieve TMJ dysfunction have low clinical effectiveness when they are used alone (Bronfort, et al. 2010). This treatment is valuable only as integrative part of somatic rehabilitation in combination with MEDICAL MASSAGE PROTOCOL.

The surgical procedures, like arthrosporic surgery, articular disk replacement, osteotomy, etc. should be considered only if every conservative option failed and the patient still in severe pain. The low clinical effectiveness of surgical interventions is well documented fact.

Hodges (2000) conducted a clinical study on 448 patients with TMJ dysfunction. The author compared the clinical effect of conservative management of TMJ dysfunction with the outcome of arthrosporic surgical intervention. One of the key elements of conservative therapy was regular application of self-massage by previously trained patients. The success rate in the group with conservative management of TMJ dysfunction was 75% compared to 64% in the group with surgical disk replacement.

According to De Bar et al., (2003) the majority of American patients with TMJ dysfunction consider regular massage the most valuable method of therapy and it is the most frequently used (66% of respondents). The evaluation of the outcomes of various treatments offered to the patients with TMJ dysfunction has allowed authors to conclude that there is “a failure of conventional treatments to relieve symptoms (of TMJ, by JMS)”.

The frequently used treatment option is day or/and night guards which are custom made for the patients, especially those who suffer from bruxism which is night grinding and clenching of the teeth. There is a significant problem with this treatment as well. Let’s briefly discuss how this treatment is usually conducted.

The patient experiences pain in the TMJ as a result of bruxism. He or she is consulted by dentist or oral surgeon and advised to wear a custom made night guard to prevent teeth grinding at night. To do so the dentist makes an impression of the patient’s bite and sends it to the dental technician who makes a night guard from acrylic.

This guard reflects the patient’s individual bite and is supposed to be used during sleep. This sounds very logical, however in many cases it doesn’t work and frequently it makes the clinical picture worse. The patient spends money on several guards before completely abandon this idea. Frequently dentists don’t even know that their treatment didn’t work because the patient has stopped visits and they consider that the problem was solved.

What is the reason for the failure of a completely legitimate and correctly prescribed treatment? The problem is that original impression of the bite the dentist made was incorrect and this fact compromised the entire treatment. If the patient has correctly diagnosed TMJ dysfunction his or her bite will be pathologically changed in 100% of cases. In such a case impression of the pathologically changed bite becomes the matrix for manufacturing the night guard which enforces the incorrect bite, instead of restoring and maintaining the normal bite.

There is only one solution for this problem – the normal bite must be restored before impression was made. In such a case a custom made guard will support normal bite and work for the patient instead of against him or her. The restoration of physiological bite can be done by MEDICAL MASSAGE PROTOCOL only. There is no other clinically effective modality which will be able in a short time to relieve tension in the TMJ, restore anatomical length of masticatory muscles, adjust the position of the lower jaw, and restore normal bite.

Usually the course of medical massage consists of 5-7 sessions. These treatments should be separated by one day and by two days between the first and second sessions. This is why the first session is better conducted on Friday (if the patient has following two days off). Before each new session the practitioner must repeat examination tests especially the Three Knuckles Test to evaluate progress of the treatment. As soon as the practitioner sees that the patient is able to fit three knuckles into his or her mouth he or she must schedule an appointment with a dentist for an impression to be taken. The final session of medical massage must be conducted on the same day 1-5 hours before the dentist’s appointment. This will guarantee a correctly made bite impression.

Below you will find MEDICAL MASSAGE PROTOCOL addressing TMJ dysfunction. We consider this protocol as the most comprehensive treatment, because it covers all aspects of TMJ dysfunction except intraoral treatment. However, other massage protocols can be used as long as they address all aspects TMJ dysfunction.

A couple of words about the intraoral treatment. This is a very helpful tool and practitioners may add this treatment to the protocol presented below and use it if they have proper training and signed permission from the client. However, we would like to recommend that practitioners review local or state rules and regulations in regard to massage therapy profession. Commonly, massage inside of any cavity of the human body can be conducted only in the medical office under the direct supervision of a physician, dentist or physical therapist. The great thing about the MEDICAL MASSAGE PROTOCOL presented below that it gives exactly the same clinical outcomes without the necessity of application of intraoral treatment.

MEDICAL MASSAGE PROTOCOL IN CASES OF TEMPOROMANDIBULAR JOINT DYSFUNCTION

The duration of the treatment is approximately 30-40 minutes. There is a two day break between the first and second sessions, and after that the treatments should be conducted with a one day break until the pain is eliminated and the patient is able to correctly execute the Three Knuckles Test (see Part II of the article in the previous issue of JMS). Usually it takes 5-7 sessions to restore normal bite, eliminate tension and spasm in the masticatory muscles and restore normal biomechanical relations between both TMJs. If a night or day guard is needed the last session must be conducted hours before impression of the bite is made.

Quick and stable clinical results can be achieved only with the patient’s participation in the treatment. He or she must use self-stretching at home between sessions. We will discuss this important issue below in the special section after the MEDICAL MASSAGE PROTOCOL.



Step 1. Work on the temporalis muscle with mouth closed
a. Effleurage and friction along the temporalis muscle 



Duration: 2 min
Pressure: below the pain threshold

Start with superficial effleurage along the temporalis muscle. Spread your fingers, and using only your fingertips apply light circular effleurage strokes along the fibers of the temporalis muscle. Be careful not to pull the hair. To avoid this, place the fingers right against the scalp and between the hair. Pay attention to the direction of the strokes.

For the next part, increase the pressure and compress the temporalis muscle against the temporal bone, without activating the pain analyzing system. Apply friction along, and after this across, the fibers of the temporalis muscle. During the effleurage strokes the practitioner’s fingers actively move along the temporalis muscle, whereas during the application of friction the fingertips (brought together) stay in the same area. In other words, the practitioner uses the scalp elasticity to apply back-and-forth friction along or across the fibers of the temporalis muscle without sliding along the skin surface.


b. Friction at the insertion of the temporalis muscle 



Duration: 3 min
Pressure: at the level of the pain threshold (first sensation of discomfort)

Anatomical landmarks: the dashed line indicates the upper edge of the zygomatic bone; the solid line indicates the lower edge of the zygomatic bone; the waved lines indicate the anterior and posterior edges of the masseter muscle; the dotted line is the lower edge of the mandible.

Apply cross-fiber friction at the origin of the temporalis muscle, in the temporal fossa. Follow this by the application of cross-fiber friction along the upper edge of the zygomatic bone. Pay attention to the position of the thumb.


Step 2. Work on the temporalis muscle
a. Repeat Step 1 with the mouth open
Duration: 1 min
Pressure: below the pain threshold

Repeat the techniques of Step 1, this time asking the patient to keep his or her mouth open. Make this treatment shorter.


b. Trigger Point Therapy of the temporalis muscle 



Duration: 3 min
Pressure: at the level of the pain threshold (first sensation of discomfort)

The video shows the location of trigger points in the temporalis muscle. To review the applicable scientifically based trigger point therapy protocol, click here.

There is only one exception to be observed in this protocol: do not apply electric vibration as a component of trigger point therapy here; rather, substitute electric vibration by manual vibration in the area of the trigger point.


Step 3. Work on the masseter muscle with the mouth closed
a. Effleurage and kneading



Duration: 3 min
Pressure: below the pain threshold

Start with superficial effleurage in the direction of drainage. Because of the size of the masseter muscle, use both thumbs. Begin strokes below the lower edge of the zygomatic bone, and end them on the lower edge of the mandible. Follow this by kneading of the masseter muscle. Notice that both index fingers are placed on the anterior edge of the masseter muscle.


b. Friction 



Duration: 2 min
Pressure: at the level of the pain threshold (first sensation of discomfort) 

Start with friction along the belly of the masseter muscle. After this, apply cross-fiber friction at the insertion of the masseter muscle into the lower edge of the mandible, and at its origin on the zygomatic bone. Pay attention to the correct position of the thumb during the application of friction in both these areas.


Step 4. Work on the masseter muscle
a. Repeat Step 3 with the mouth open
Duration: 2 min
Pressure: below the pain threshold

Repeat the techniques of Step 3 while the patient keeps his or her mouth open. Make this treatment shorter.


b. Trigger Point Therapy for the masseter muscle 



Duration: 2 min
Pressure: at the level of the pain threshold (first sensation of discomfort)

Anatomical landmarks: the dashed line indicates the upper edge of the zygomatic bone; the solid line indicates the lower edge of the zygomatic bone; the waved lines indicate the anterior and posterior edges of the masseter muscle; the dotted line is the lower edge of the mandible; the black dots indicate trigger points in the masseter muscle.

The video shows the location of the trigger point in the masseter muscle. To review the applicable scientifically based trigger point therapy protocol, click here.


Step 5. Work on the digastric muscle 



Duration: 1 min
Pressure: below the pain threshold

Apply circular effleurage, friction and repetitive compressions along both digastric muscles in the areas just below the chin.


Step 6. Work on the lateral pterygoid muscle (LPM) 



Duration: 1 min
Pressure: at the level of the pain threshold (first sensation of discomfort)

Apply a combination of circular friction and compression onto the small area in which the LPM is directly assessable. This area is restricted by the lower edge of the zygomatic bone (dashed line) from above and by the anterior edge of the mandible (solid line) from behind. Be sure that the patient completely relaxes the lower jaw.


Step 7. Work on the temporomandibular (TM) joint with the mouth closed 



Duration: 2 min
Pressure: at the level of the pain threshold (first sensation of discomfort)

Apply intense circular friction and manual vibration in the very small area restricted superiorly by the lower edge of the zygomatic bone, inferiorly and anteriorly by the mandible, and posteriorly by the ear canal. The thumb, or part of the thumb, can fit there.

At the end of this step, apply electric vibration in the permanent fixed mode to the same area. To minimize uncomfortable sensations, apply the vibration through a towel.


Step 8. Work on the TM joint with the mouth open 
Duration: 1 min
Pressure: at the level of the pain threshold (first sensation of discomfort)

Repeat Step 5 while the patient keeps his or her mouth open. Apply the same combination of techniques, but for a shorter time.


Step 9. Postisometric Muscular Relaxation (PIR)
Masseter and Temporalis muscle 



Duration: 3 min
Pressure: below the pain threshold

Ask the patient to relax the masticatory muscles. The mouth will slightly open. Place both thumbs on the chin and ask the patient to close the mouth while you provide resistance. The white arrows indicate the direction of the muscle contraction.

For the second level of PIR, open the patient’s mouth wide and again ask him or her to close it against your resistance.

After each level, apply three passive stretches by passively opening the patient’s mouth. Be sure that the patient does not participate actively in the opening of the mouth. Also, stop the passive stretch as soon as the patient feels pain in the area of the TM joint.


Lateral pterygoid muscle

The lateral pterygoid muscle is responsible for two movements in the TM joint: pushing the lower jaw to the side (lateral movement), and pushing it forward (jaw protrusion)


a. Lateral movement 



Duration: 3 min
Pressure: below the pain threshold

From the same initial position, ask the patient to push the lower jaw to the side against your resistance. The white arrows indicate the direction of the muscle contraction.

For the second level of the PIR, move the patient’s jaw to the side and ask him or her to push it back against your resistance.

After each level, apply three passive stretches by passively opening the patient’s mouth.


b. Jaw protrusion 



Duration: 2 min
Pressure: below the pain threshold

From the initial position, ask the patient to push the lower jaw forward against your resistance. Apply the PIR only on one level and employ three passive stretches after it. The white arrows indicate the direction of the muscle contraction.



PROTOCOL OF HOME SELF-STRETCHING

The critical component for successful treatment of TMJ dysfunction is the necessity of the patient’s participation in treatment, at home, between the sessions. It helps to cut the number of sessions while providing stable clinical results.

Before and after each meal as well as 4-5 times per day the patient must repeat a simple set of stretchings of the lower jaw. The videos below shows first part of this set which targets masseter and temporalis muscles.

The correct execution of this stretch is a very important factor. At the beginning the patient must relax all masticatory muscles and drop the lower jaw. Next he or she places the 3rd-4th fingers on the lower teeth and pulls the lower jaw down during prolonged exhalation. The patient must stop further pull as soon as he or she reaches the pain threshold. However, obtained level of stretch must be maintained until the end of complete exhalation.

The critical point is the correct position of the upper extremity the patient uses during the stretch. The video below shows both the correct and incorrect ways of stretching.

The first part of the video shows the position of the right upper extremity when stretching is conducted correctly. Notice the position of the elbow, which is placed in front of the body by moving the shoulder forward. This position allows the patient to stretch the masticatory muscles and TMJ on both sides equally by pulling the lower jaw strictly down.

The second part of the video shows the most common mistake. As you can see an incorrectly placed upper extremity will pull the lower jaw to the side instead of pulling it straight down. Such an unequal stretch will reinforce the imbalance between the right and left TMJ.

The final stretch is directed laterally as it is shown in the video below. Notice that before the passive self-stretch the patient must completely relax the masitcatory muscles and drop the lower jaw. Each stretch must fit one prolonged exhalation. The patient must repeat the right and left lateral stretch five times. Be sure that the patient stretches the lower jaw until he or she feels the first uncomfortable sensations.

After the end of the treatment the patient must apply these simple stretches in the mornings daily and every time he or she feels pressure building up in the area of TMJ. It will let the patient control the intensity of the tension around the affected joint.

REFERENCES
De Bar, L.L., Vuckovic, N,. Scneider, J., Ritenbaugh, C. Use Complimentary and Alternative Medicine for Temporomandibular Disorders. Nurs. Times, 91(25), 42-43, 1995.
Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of Manual Therapies: the UK Evidence Report. Chiropr Osteopat, Feb 25;18:3, 2010.
Hodjes J.M. Managing Temporomadibular Joint Syndrome. Laryngoscope, 100 January 60-66, 2000.
Wright E.F. Schiffman, E.L. Treatment Alternatives For Patients With Masticatory Myofascial Pain. JADA, Vol. 126 1030, July 1995.


Category: Medical Massage

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