Medical Management

TRYING TO RESTORE PROPER TONGUE POSTURE is a favorite technique of some physical therapists (the Rocabado school) and some orthodontists (Orthotropics), because they believe that many TMJ disorders are due to low tongue posture. The tongue should rest up high in the palate with its tip up against the front of the palate just behind the upper front teeth; however, in many people it rests too far down and back. Myofunctional therapists try to teach people to use this ideal tongue posture, but the tongue cannot be simply retrained to stay in a space where there is no room for it. The teeth are in the way, so the tongue must rest below them.   

SURGERY

Open surgery is rarely necessary and can lead to problems that persist long after the injured TMJ would have healed naturally. Arthroscopy and arthrocentesis are closed surgeries that don’t involve the same risk of failure. Instead of cutting the joint open, the surgeon inserts two little tubes to irrigate the TMJ. Arthrocentesis employs tubes that are just large enough to flush out the waste products and inflammatory mediators. Arthroscopy employs slightly larger tubes that can incorporate a fiberoptic cable for visualization and small instruments such as miniature cutters to remove scar tissue. These closed surgeries usually provide quick short-term relief by flushing waste products out of the joint; however, if they are not combined with some orthopedic or behavioral changes that address the cause of the problem, the symptoms are likely to recur. In the near future, mini implants in the condyle will probably enable surgeons to reposition dislocated TMJ disks, but not yet.

 

CONTINUOUS PASSIVE MOTION

Animal experiments have shown that continuous passive motion can dramatically reduce healing time in synovial joints. Joint surfaces get their circulation from the rubbing of the cartilage, which drives out fluids from areas under compression, and then allows new fluids in to replace them, when the compression moves on to a different area. This functionally generated circulation process, known as weeping circulation, was discovered when a researcher put rabbits with injured hip joints on a machine that slowly and continuously moved their legs and found that they healed twice as fast as normal. To try and mimic that success, some companies have tried to design machines that similarly provide continuous passive motion for simple joints like knees and elbows; but the machines are expensive and lack the variable range of motion that most joints require. A simple way to provide functionally generated circulation for most joints at home is by using rubber straps like bicycle inner tubes to create continuous almost-passive motion. For the TMJs, you can lie face down on a massage table with your jaw hanging freely in the hole and use your hand to move your jaw around passively.

 

TREATING THE MUSCLES - can provide quick relief of symptoms if neither TMJ is inflamed. Typically the jaw muscles become chronically sore and painful, because waste products build up in the capillary beds. These capillary beds function like big sponges. The heart can easily pump new blood into them, but it cannot so easily suck the old blood and waste products out of them. In most areas of the body, that drainage is assisted by functional forces, which alternately compress and release the veins, which have one-way valves that turn the alternating compression and release into a pump. However, chewing no longer provides sufficient functional circulation to keep our jaw muscles healthy, so jaw muscle health relies on good resting circulation, which requires low muscle tonus. Normal muscle tonus is about one percent of maximal voluntary contractile force. When it increases, it can compress the capillary beds enough to interfere with the drainage of waste products. For short term relief, they need stretching to restore their resting lengths and/or lowering of their resting tonus to create conditions in which their waste products drain naturally. For lasting relief, the teeth should provide a stable bite platform just above the mandible's ideal postural position, so the jaw muscles can maintain mandibular posture with minimal muscle tonus.  

 

POSTURAL MUSCLES - Treating the jaw muscles must include the neck muscles, because these muscles don't function separately. Chewing involves your neck muscles, and moving your head involves your jaw muscles. Treating the postural muscles requires improving your body posture by shifting your resting weight-bearing stance to one that is easily maintained by low tonus in your postural muscles, stretching out the fascia and muscles that held the old weight-bearing stance, and strengthening the muscles that are needed to hold the new weight-bearing stance. All the body’s postural muscles are involved, because the jaw and neck muscles are connected with the other postural muscles in long myofascial chains running up and down the length of the body. A change in the resting length of one muscle affects all the muscles in the chain, and a change in the resting length of a chain induces a change in the resting length of the opposing chain. The mandible and the jaw muscles are members of the anterior kinetic chain holding the front of the head down onto the front of the body.  

 

TRIGGER POINTS - are probably small pools of waste products that have accumulated in a muscle with inadequate resting circulation. They are commonly described as pea shaped nodes that are exquisitely sensitive to manual pressure, and they can cause pain at distant locations in typical "pain referral" patterns, which can be evoked and also treated by forceful compression of the site using a finger, knuckle, or elbow. The greater the force used, the more sustained the relief. Many dentists and doctors inject trigger points with novocaine or saline. The immediate pain is intense, but the relief can last a long time. Vibrating massagers can also flush waste products from pockets where they have accumulated.

CONTRACTURE - When muscle tightness persists for long enough, the muscle fibers shorten anatomically in a process called contracture. They lose some of their resting length. If your jaw muscles are relaxed when you fall asleep in a chair, your jaw will hang open. However, if your jaw muscles are contracted and you fall asleep in a chair, your jaw will not hang open. 

STRETCHING - is especially important for people with strong muscles. To be effective, it should include the tough sheets of fascial webbing that bind all the muscles together into long functional units (AKA myofascial release). Stretching can also be accomplished by icing muscles while they are held elongated. You can ice the jaw muscles by holding ice packs or bags of frozen vegetables on your cheeks and temples while propping your jaw fairly open with a block like a piece of wood, a stack of post-its, or a wine cork held vertically between your front teeth. The icing with stretch is maintained until it becomes uncomfortable. Then the block is removed, the mouth is closed, and the ice is replaced by a hot wet towel (microwaved). The heat will feel good and bring in fresh blood after the ice, and the ice will feel good after the heat; so you can go back and forth from ice with stretch to heat with relaxing many times while watching a movie.  

STRESS - can worsen a muscle related condition in any part of the body by increasing resting muscle tonus all over the body. When a muscle has  been operating at borderline resting circulatory levels due to chronic tightness from an inflamed TMJ or an unstable bite; even a slight increase in resting muscle tonus due to increased central nervous system stress can result in accumulation of waste products, which causes pain. For that reason, a period of increased central nervous system stress often precedes the onset of postural muscle symptoms, and relief can usually be obtained from stress lowering measures like relaxation, meditation, humor, spiritual inspiration, or feeling loved.

ATTITUDE influences posture by selectively altering resting muscle tonus. The motor end plates, where the electrical signals from the brain reach the muscles, are anatomically extensions of the brain, so the state of the brain determines which muscles are held tightly and which are held loosely. Feeling sad alters resting tonus to make the chest sink inward, the head hang downward, and the shoulders slump. It can make the mandible move so far backward that it impinges on the airway passage, which triggers a protective response that pulls the hyoid bone forward, producing the classic lump in the throat that often accompanies grief. Conversely, feeling proud, angry, or determined alters resting tonus to cause thrusting of the chest, standing tall, and jutting the mandible.

PASSIVE PHYSICAL SUPPORT realigns your body for long enough to impact the shapes of your bones and your weight-bearing postural stance. Most seats on planes, trains, and buses have head rests that force the head forward. Sleeping on your back on a soft mattress such as a waterbed, an air mattress, or memory foam also forces your head forward, because it allows your body to sink down at its center of mass (usually at the hips or abdomen). A firm mattress or a futon can improve your body posture by constantly pushing your spine towards a straight axial alignment that supports your legs and head in the same plane as your abdomen, hips, and shoulders.

Pillows influence your posture by the way they align your head. They should allow the back of your head to rest in contact with your mattress. Pillows that hold your head above your mattress when back sleeping reinforce forward head posture. Contoured pillows allow your head to rest closer to your mattress, but they still hold it forward. The necessary support can be provided by a U shaped pillow (such as a travel pillow), a pillow with a hole in the middle, or a rolled-up towel under your neck combined with a pillow on each side of your head so that you can easily roll onto either side where the support from the pillow is roughly as thick as the distance between your ear and your shoulder.

ACTIVE PHYSICAL SUPPORT - uses your muscles to improve your skeletal alignment by holding yourself as tall as possible. Both the anterior shifting of the head and the increased thoracic and lumbar curvatures that accompany it cause loss of vertical height, and restoring some of that height can reverse some of the pathologies that led to the loss of height and restore some of the lost spinal support; however, you can't just hold an ideal alignment, or your muscles will rapidly become exhausted. They need rhythmic exercises that pump blood. You can selectively strengthen the muscles that you need to improve your posture by making an exercise of repeatedly allowing yourself to slouch and then pulling yourself back up into ideal posture. Also, you can selectively strengthen the neck muscles that you will need to reverse forward head posture by repeatedly working your head back against resistance, like a head rest in a car or your hands held behind your head. Incorporating movement, such as simultaneously rotating your head slowly from side to side, adds the benefits of weeping circulation at the joint surfaces. Strengthening the jaw and neck muscles requires also strengthening the muscles of the shoulders and back, which form their base of operation.

Exercises used to rehabilitate muscles for health are designed to build blood supply rather than maximal strength. They should be repeated in rhythmically alternating contractions of about a second each to mimic functional activities such as chewing, walking, climbing, hitting, shaking, etc; in which opposing muscle groups alternate firing and relaxing in a way that pumps circulation. Guarding behavior in muscles, which is reflexively triggered to protect inflamed joints or unstable bites, interferes with this circulation by overlapping the firings of antagonistic muscles (co-contraction) to hold the bones more tightly.

COMBINING stretching and strengthening of muscles can be accomplished by exercises such as Yoga, Tai Chi, or pulling yourself upward using overhead bars in a technique I call variable rhythmic distraction. Even if you don't pull yourself off the ground, applying some traction to your spine by pulling upward with your arms serves to distract the compressed vertebral segments, doing it rhythmically provides accessory circulation at the joint surfaces, and doing it in a variety of positions and directions extends that circulation all around the joint surfaces. In this manner, you can exercise your arms while using your arm strength to decompress your spine in a way that enhances circulation to your intervertebral joints.