Guide to Temporomandibular Joint Disorder Manual Therapy by Osteopaths

What is a Temporomandibular Joint Disorder?

Temporomandibular joint disorder is a problem affecting the ‘chewing’ muscles and the joints between the lower jaw and the base of the skull. It is sometimes referred to as a “myofascial pain disorder”. It’s been estimated that up to 30% of adults will experience a temporomandibular joint (TMJ) disorder at some point in their lives.

The condition itself isn’t usually serious, and the symptoms it can cause – including pain, jaw joint clicking or popping, and difficulties eating – usually only last a few months before getting better. However, these symptoms can significantly lower quality of life, and specialist treatment might be required if they’re severe.

What are the symptoms?

Temporomandibular Joint Disorder can cause:
• clicking, popping or grating noises as you chew or move your mouth
• muscle pain around the jaw
• pain in front of the ear that may spread to the cheek, ear and temple
• difficulty opening the mouth – the jaw may feel tight, as if it is stuck, making eating difficult
• headache or migraine
• earache or a “buzzing” or blocked sensation in the ear
• pain in other areas of the body – such as neckache or backache
These symptoms may lead to related symptoms, such as disturbed sleep.

Possible causes of Temporomandibular Joint Disorder

• clenching your jaw or grinding your teeth during sleep (bruxism) – which overworks the jaw muscles and puts pressure on the joint (often caused by stress)
• wear and tear of the inside of the jaw joint – usually caused by osteoarthritis
• injury to the jaw joint – for example, after a blow to the face or surgery
• stress – some people may inherit increased sensitivity to pain or stress
• uneven bite – for example, when new fillings, dental crowns or dentures are fitted
• specific diseases – temporomandibular joint disorder may be associated with specific diseases such as rheumatoid arthritis, gout or fibromyalgia

The Dental Approach to a Temporomandibular Joint Disorder

Dentists may use occlusal splints to manage a temporomandibular joint disorder. These are known as nightguards, bruxism appliances, or orthotics.
Various kinds of splints are available and can be classified into 2 groups—anterior repositioning splints and autorepositional splints. Physiologic basis of the pain relief provided by splints is not well understood. Factors such as alteration of occlusal relationships, redistribution of occlusal forces of bite, and alteration of structural relationship and forces in the temporomandibular joint (TMJ) seem to play some role.

Also, Auto-repositional splints, also known as muscle splints, are used most frequently. Some sort of pain relief is seen in as many as 70-90% of patients using splints. In acute cases the splint may be worn 24 hours a day for several months and as the condition permits, worn at night only.

Manual Therapy for Temporomanibular Joint Disorder

Manual therapy has also been shown to be more cost effective and less prone to side effects than dental treatment (Martins et al. 2007).

Purpose of Temporomandibular Joint Manipulation

Temporomandibular manipulation is based on the premise that the curvilinear motion of the mandibular condyle can be interrupted should the articular disc be held anteriorly along the articular eminence through adhesions, myospasm or disc deformity. Since the TMJ is also capable of lateral glide, deviations and deflections also need to be addressed. Conditions are usually described as either acute or chronic and in terms of their functional capacity (open or closed lock, restricted range of motion) and tissue involvement (myogenous, arthrogenous, combined) (Kalamir et al. 2007).

Combined Osteopathic Manipulative Treatment and Osteopathy in the Cranial Field for Temporomandibular Joint Disorder

A pilot study demonstrated the reduction of pain, the improvement of temporomandibular joint dysfunction and the positive impact on quality of life after osteopathic manipulative treatment and osteopathy in the cranial field (Gesslbauer et al. 2016). However it is important to bear in mind that osteopathy in the cranial field has not been proven to effective for many musculoskeletal conditions.

Massage Around The Tempormandibular Joint

Massage of the lateral pterygoid muscle according to Cyriax’s principles is a simple and efficient method that can be recommended for patients presenting with temporomandibular joint dysfunction syndrome (Barriere et al. 2009)

Effectiveness of Manipulative Techniques for Temporomandibular Joint Disorder

Musculoskeletal manipulations approaches are effective for the treatment of temporomandibular joint disorders. In short term, there is a larger effect for musculoskeletal manual approached manipulations compared to other conservative treatments for temporomandibular joint disorder (Martins et al. 2016).

Additionally, there is a fair level of evidence for the Manual and Manipulative treatment (MMT) of the temporomandibular joint disorder in the short term (≤3-6 months) using: MMT to the jaw joint, cervical spine, myofascial structures and/or combined with exercise, multimodal therapy and/or interdisciplinary care (Brantingham et al. 2013).

Effectiveness of Neck Joint Mobilization and Muscle Stretching for Temporomanibular Joint Disorder

The cervical spine therapy approach using neck joint mobilization, muscle stretching, and stretching stabilization seems to cause significant improvement in pain-free maximum mouth opening, self-reported pain, and mandibular functionality in subjects with myofascial pain or mixed Temporomandibular Joint Disorders (Calixtre et al. 2016).

Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Joint Disorder

Exercises and Manual Therapy are safe and simple interventions that could potentially be beneficial for patients with Temporomandibular Joint Disorders. Active and passive exercise for the jaw, postural exercises, and neck exercises appear to have favorable effects for patients with Temporomandibular Joint Disorders. Manual therapy alone or in combination with exercises shows promising effects. Exercises did not show clear superiority over other conservative treatments for Temporomandibular Joint Disorders (Armijo-Olivo et al. 2016).

Which Techniques work best to treat a Temporomandibular Joint Disorder?

The most effective techniques to improve clinical outcomes (pain and range of movement of the TMJ) include combined articular (e.g. mandibular distraction mobilization, mandibular translation mobilization, mandibular accessory movements, cervical mobilization, cranio-cervical thrust) and extraarticular (e.g. myofascial release in jaw elevator muscle, general myofascial release, muscle energy, balance membrane tension, cranial-sacral therapy, tender-trigger point, muscle stretching, soft tissue cervical and TMJ mobilization) techniques (Martin et al. 2016).

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Reference List

Armijo-Olivo S, Pitance L, Singh V, Neto F, Thie N, Michelotti A (2016). Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders: Systematic Review and Meta-Analysis. . Jan; 96(1): 9–25

Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A (2009). [Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome]. Rev Stomatol Chir Maxillofac. Apr; 110(2):77-80.

Brantingham JW, Cassa TK, Bonnefin D, Pribicevic M, Robb A, Pollard H, Tong V, Korporaal C (2013). Manipulative and multimodal therapy for upper extremity and temporomandibular disorders: a systematic review. J Manipulative Physiol Ther. Mar-Apr; 36 (3):143-201.

Calixtre LB, Grüninger BL, Haik MN, Alburquerque-Sendín F, Oliveira AB (2016). Effects of cervical mobilization and exercise on pain, movement and function in subjects with temporomandibular disorders: a single group pre-post test. J Appl Oral Sci. May-Jun;24(3):188-97

Gesslbauer C, Vavti N, Keilani M, Mickel M, Crevenna R (2016). Effectiveness of osteopathic manipulative treatment versus osteopathy in the cranial field in temporomandibular disorders – a pilot study. Disabil Rehabil. Dec 28:1-6.

Kalamir A, Pollard H, Vitiello AL, Bonello R (2007). Manual therapy for temporomandibular disorders: A review of the literature. Journal of Bodywork and Movement Therapies. 11, 84–90

Martins WR, Blasczyk JC, Aparecida Furlan de Oliveira M, Lagôa Gonçalves KF, Bonini-Rocha AC, Dugailly PM, de Oliveira RJ (2016). Efficacy of musculoskeletal manual approach in the treatment of temporomandibular joint disorder: A systematic review with meta-analysis. Man Ther. Feb; 21:10-7.

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