1.     Stage of Acute Inflammation and Active Congestion

The major goals are to control pain and reduce swelling by vasoconstriction, compression, and elevation; to prevent further irritation, inflammation, and secondary infection by disinfection, protection, and rest; and to enhance healing mechanisms. Common electives include:

Cryotherapy
Cold packs
Ice massage
Vapocoolant spray
Compression
Pressure bandage
Protection (padding)
Indirect therapy (reflex therapy)
Pulsed alternating current
Iontophoresis/phonophoresis
Auriculotherapy
Meridian therapy
Spondylotherapy (upper thoracic)
Rest (chin strap, liquid diet)
Nutritional supplementation to enhance connective tissue integrity.

2.     Stage of Passive Congestion

The major goals are to control residual pain and swelling, provide rest and protection, prevent stasis, disperse coagulates and gels, enhance circulation and drainage, maintain muscle tone, and discourage adhesion formation. Common electives include:

Indirect articular therapy (reflex therapy)
Alternating superficial heat and cold
Pressure bandage
Light nonpercussion vibrotherapy
Mild surging alternating current
Mild pulsed ultrasound
Cryokinetics (passive exercise)
Meridian therapy
Spondylotherapy (upper thoracic)
Rest (chin strap, soft diet)
Nutritional supplementation to enhance connective tissue integrity.

3.     Stage of Consolidation and/or Formation of Fibrinous Coagulant

The major goals are the same as in Stage 2 plus enhancing muscle tone and involved tissue integrity and stimulating healing processes. Common electives include:

Mild articular adjustment technics, especially occipitocervical
Moist superficial heat
Thermowraps
Spray-and-stretch
Cryokinetics (active exercise)
Moderate active range-of-motion exercises
Meridian therapy
Alternating traction
Sinusoidal current
Ultrasound
Microwave
Vibromassage
High-volt therapy
Interferential current
Spondylotherapy
Mild transverse friction massage
Mild proprioceptive neuromuscular facilitation techniques
Rest
Diet modification
Nutritional supplementation to enhance connective tissue integrity.

4.     Stage of Fibroblastic Activity and Potential Fibrosis

At this stage, causes for pain should be corrected but some local tenderness likely exists. The major goals are to defeat any tendency for the formation of adhesions, taut scar tissue, and area fibrosis and to prevent atrophy. Common electives are:

Deep heat
Articular adjustment technics, especially occipitocervical
Spondylotherapy (upper thoracic)
Local vigorous vibromassage
Transverse friction massage
Spray-and-stretch
Mild active range-of-motion exercises
Negative galvanism
Ultrasound, continuous
Sinusoidal and pulsed muscle stimulation
Microwave
High-volt therapy
Interferential current
Meridian therapy
Proprioceptive neuromuscular facilitation techniques
Nutritional supplementation to enhance connective tissue integrity.

5.     Stage of Reconditioning

Direct articular therapy for chronic fixations
Progressive remedial exercise may be helpful, but it should be noted
that the TMJ is normally the most exercised joint in the body.
Nutritional supplementation to enhance connective tissue integrity.

Dear Reader(s), This article is provided for doctors as reference material, with the expectation that they are already skilled in assessment / diagnosis, in palpation, manipulative skills and in critical thinking. It is certainly NOT intended for ANY person to use for self-diagnosis or self-treatment purposes. The biomedical literature is filled with reports of self-manipulation gone wrong. If you have a TMJ problem, seek competent care from a licensed health care provider, with a specialty knowledge level, and a strong track record in successful TMJ management.

If a site of soft-tissue hypertension is found in one or both TMJs, gentle but firm passive pressure against resistance until the tissues release is usually all that is necessary. This will be indicated when free mobility is restored. The same technique can be applied if abnormal tension is found in sphenomandibular and stylomandibular area soft tissues, as determined by exerting pressure on the angle of the mandible caudally and then cephally, and comparing the resistance found bilaterally.

When TMJ compression is a factor, and it often is, physical correction can be aided by the doctor inserting gloved thumbs against the patient's lower molars, with the fingers wrapped around the jaw, and applying pressure to bring the mandible down and forward and then down and backward several times to open the joint space.

Invariably, motion palpation of the pubic and/or sacroiliac joints will reveal a fixation when TMJ dysfunction is present. When this is found, the fixation should be mobilized unless contraindications for adjustive therapy are found.


Mild Mobility Restriction (Fixation) Release

The basic condyle motions of the TMJ essentially include rotation with and without a lateral shift; rotation with backward, upward, and lateral motion; and rotation with forward, downward, and lateral motion. Functional restriction may be the common result of muscle hypertonicity or ligamentous shortening.

Passive Stretching.   When jaw opening is restricted, sustained passive stretching can be administered by most any type of padded appliance (eg, a surgical mouth prop with a spring or ratchet). Slowly inserting layers of tongue blades or a tapered cork (15 30 mm) between the molars are sometimes substituted during home treatments. Regardless of what appliance is used, this technique is best conducted with the patient in the relaxed nonweight-bearing supine position at first and then in the sitting position as improvement is achieved. Special care must be used to avoid too vigorous application. Preadjustment moist heat application to the involved TMJ(s) and cervical spine for 15 to 20 minutes is beneficial.

Active Stretching.   The supine patient slowly and progressively opens his mouth to a larger and larger degree but not to the degree of pain. During this exercise, the patient is asked to place the tongue against the hard palate as this will keep the motions essentially rotary and minimize protrusion. After the initial warm-up, the patient holds the full-open position for several seconds and follows this with complete jaw relaxation for several seconds in a hold-relax fashion. Kessler/Hertling state that ultrasound may be beneficial during this exercise.

Reflex Relaxation.   This is done by applying slow reducing resistance as the patient attempts to open the closed mouth. After several seconds of relaxation, active jaw motion (stretching) without resistance should be conducted for several seconds. A reverse technique is then used by applying slow reducing resistance as the patient attempts to close the opened mouth. These action-rest procedures should be repeated several times until function improves.

Mobilization Technics for Moderate Fixations

Caudal Traction.   The patient is placed in a relaxed full-supine or semi-supine position and the doctor stands to the side of the involved joint facing the patient. The doctor's cephalad stabilizing hand is placed against the patient's forehead and scalp, and the thumbpad of his caudad hand is placed against the patient's rear molars with the doctor's fingers cupping the patient's chin. Traction is applied caudad and the patient is asked to swallow. Pressure is held several seconds, and then a similar period for relaxation is allowed.

Mobilizing Restricted Anterior Glide.   After caudal traction is administered several times, anterior glide (protraction) and posterior glide (retraction) is included in the procedure. This is best accomplished by standing on the opposite side and grasping the angle of the mandible externally with the active hand's 1st and 2nd fingers with the thumb wrapped around the chin. Sustained anterior traction is applied, and the patient is asked to swallow. After a period of relaxation and holding the same contact, sustained posterior pressure is applied and the patient is again asked to swallow. These action-rest modes are done several times until function of anterior glide improves.

Mobilizing Restricted Medial-Lateral Glide.   The doctor stands behind the relaxed supine patient and cups his active hand around the patient's chin, while supporting the patient's head with the stabilizing hand. With his active hand, the doctor slowly applies lateral traction, holding it for several seconds. The patient is then asked to swallow and then allow several seconds for relaxation. The procedure is then reversed by applying medial pressure, holding it for several seconds, asking the patient to swallow, and then allowing several seconds for relaxation. These procedures are repeated several times until function of medial-lateral glide improves.

Note:   Lateral mandibular movements are the most restricted jaw motions in bilateral TMJ capsule restrictions (eg, contractures, spasm, adhesions). Contralateral anterior-posterior gliding movements are the most restricted jaw motions in unilateral capsule restrictions, and the mandible will deviate toward the restricted side when the mouth is opened widely.

Unilateral TMJ Inferior Subluxation Technic

A TMJ may become abnormally separated and fixed in a straight inferior position with the contralateral side normal. Before correction, the patient is placed in the sitting position facing forward. The doctor stands behind the patient, slightly to the side of the lesion. If the lesion is of the patient's left TMJ, contact is made on the medial aspect of the mandible under the angle with the fingertips of the doctor's left hand. His right stabilizing hand should be cupped under the patient's right mandibular ramus. The patient is asked to stabilize the back of his head against the doctor's chest. The adjustment is made by asking the patient to force the mouth open while the doctor applies pressure directed from the inferior to the superior.


Unilateral TMJ Anterior-Inferior Subluxation Technic

A fixated anterior-inferior misalignment of the TMJ may be found on one side with the other side normal. To correct this subluxation, the patient is placed in the sitting position facing forward. The doctor stands behind the patient and cups the patient's chin within clasped fingers. The patient is asked to stabilize the occiput against the doctor's chest. The adjustment is made from the anterior-inferior to the posterior-superior. The thrust should be short, rapid, well controlled, and in accord with normalizing the anatomical disrelationship.

Associated Medial Malposition.   There may also be a degree of associated medial misalignment. If this occurs, the line of correction should be diagonal toward the patient's eye on the side of misalignment rather than directly posterior-superior (ie, posterior-superior-lateral). This will requires the doctor to slightly rotate his shoulder anteriorly on the side contralateral to the lesion.

Poor occlusion leads to a chronic strain or sprain as does bruxism (teeth grinding). Bruxism is commonly increased in anxiety states, thus TMJ dysfunction is often related to various psychoneuroses.

Strains.   The major muscles to be considered are the medial and lateral pterygoid, masseter, and temporalis. Strain of the suprahyoid muscles (digastric, stylohyoid, mylohyoid, and geniohyoid) and infrahyoid muscles (thyrohyoid, omohyoid, and sternohyoid) should also be considered as contributing factors. Overworked and overstretched temporalis and pterygoid muscles can become chronically spastic and produce localized pain at muscle attachments or refer pain and/or paresthesias to one or both ears, the face, the temples, or the forehead.

Overstretch causes an asymmetrical lateral motion of the jaw and malocclusion. There is usually joint clicking and transient locking, and, if not properly treated, a subluxation-fixation may result. Such strains are sometimes seen after activities where the teeth must be tightly clenched for a prolonged period (eg, underwater swimmers who clench their teeth tightly on a mouthpiece).

Sprains.   The straps to be considered are the articular capsule and the lateral (temporomandibular), sphenomandibular, and stylomandibular ligaments. TMJ sprain is usually the result of malocclusion, acute or chronic subluxation, or spontaneously reduced dislocation from trauma (eg, whiplash, eating an apple, traction). Related muscle strain and spasm, tissue ruptures, and soft-tissue swelling may be involved depending on the extent of injury.

The correction of structural disrelationships and fixations by chiropractic techniques coupled with referral for appropriate orthodontic and prosthodontic appliances (which are often necessary), provides the most practical approach to the treatment of TMJ function. According to several observations, the therapeutic approach is recommended to be structurally holistic because TMJ dysfunction can affect any part or the whole of the skeleton or vice versa. In other words, sites of fixation should be sought in the feet, ankles, knees, hips, pubes, sacroiliacs, spine, rib cage, and skull, and mobilized if found. Obviously, if muscle groups are weak, spastic, or shortened, therapy should be applied to restore their normal state.

Trigger Points and Spasm: Vapocoolant Technique.   Many trigger points have been isolated that frequently refer pain and deep tenderness to the TMJ. The most common points are within the masseter, temporalis, and internal and external pterygoid muscles. Before correcting isolated subluxations, it is helpful to spray the located trigger areas with a vapocoolant. The patient's mouth is comfortably propped open with a roll of gauze, his eyes and nose are draped, and his neck is laterally flexed away from the involved side. A few slow, even, interrupted sweeps of the spray in one direction only from jaw angle to temple should reduce any spasm and referred pain present. The skin should not be frosted. Two or three applications a few days apart are usually sufficient. High-voltage galvanic current over spastic masseter or temporal muscles for 15 minutes is an alternative approach.

Adjunctive Procedures.   Just about any therapy whose objective is to reduce pain and spasm is indicated. During the acute stage for example, cryotherapy, acupuncture, trigger-point therapy, and high-volt or interferential therapy or microcurrents are frequently recommended. After the acute stage, the common modalities used include moist heat over spastic areas, TENS, and ultrasound. Biofeedback has been reported effective in some stubborn cases. Nutritional muscle relaxants and anti-inflammatory agents are frequently recommended when pain and swelling are major factors.

Diet.   During the acute stage, the diet should restrict difficult-to-chew foods (eg, steak, nuts, raw vegetables) or those that require wide opening of the mouth (eg, thick sandwiches, apples) to avoid masticatory overstretch and articular displacement.

Habits.   The patient should be alerted to relax the jaw whenever muscle tension, jaw clenching, or teeth grinding are noticed. "Lips together, teeth apart" is the normal position of relaxation. Pipe smoking and sleeping on the stomach should be discontinued. Sleeping with an orthopedic pillow to maintain good cervical posture is often beneficial.

Remedial Exercises.   Exercise against resistance is often helpful to relax cramped muscles and strengthen antagonists. The patient should be taught to slowly open the mouth as wide as possible without discomfort several times and continued this exercise until, in time, the knuckles of the index and middle finger can be easily inserted between the front teeth. This exercise should be followed by holding the chin between the index finger and thumb and resisting opening and closing the mouth. Next, resisted lateral movements of the jaw against the palm of the hand should be made, first on one side and then the other. Each exercise should be conducted about 10 times in 3-5 bouts daily.