Structural influences in temporomandibular joint pain and dysfunction

JAMES 0. ROYDER, Hutchins, Texas

FAAO

The role of the temporomandibular joint in baffling headaches often is overlooked by both physician and dentist, while the patient seeks help in vain. The syndrome will not be discovered unless the physician looks for it. Symptoms may involve the ears, eyes, and joints and may not be produced by the syndrome itself. Instead, they, may result from the mechanism that causes the syndrome. A holistic approach to treatment may involve nutritional guidance, dental equilibration, medication, and osteopathic manipulation directed toward the musculoskeletal component of the syndrome. Sometimes neurosurgery may be necessary.

Clinical evidence' has demonstrated that longstanding structural imbalances of the body produce fascial strains that can contribute directly to the production of the syndrome of temporomandibular joint (TMJ) pain and dysfunction. Strains due to structural imbalances are transmitted to the masticatory musculature (somatognathic system) and introduce neurogenic stress into the chewing mechanism. The resulting stress on the TMJ and the associated neuromusculature can be tolerated for long periods before pain becomes intolerable. Eventually, the unrelenting stress on this delicate mechanism can manifest itself in a myriad of bizarre pain symptoms which make up the TMJ pain-dysfunction syndrome. Mandibular dysfunction produced from dental disease, trauma, premature extractions, or joint disease can produce secondary fascial stress and referred pain that can affect virtually any related part of the body.2 Conversely, the fascial strains produced by structural imbalance, originating in the pelvis, lumbar spine, or thoracic spine can contribute directly to mandibular dysfunction that can

eventually develop into the painful complex." The whole body must be considered as a unit, since none of the parts functions independently. Therefore, the underlying cause of the syndrome may be in the mouth and project its deleterious influence caudad. Conversely, structural stress originating in the lower extremities, pelvis, or spine may exert noxious strain patterns cephalad.4 With either mechanism, mandibular imbalance can lead to the same stress in the neuromusculature of the chewing mechanism. Long-standing fascial strains, whether they come from above or below, soon become apparent throughout the entire body, and produce neural facilitation and somatic dysfunction.5 Therefore, malocclusion and mandibular dysfunction can be the result of somatic dysfunction resulting from structural imbalances in distant and seemingly unrelated parts of the body. Shores said it has been estimated that 20 percent of the population is afflicted with some form of TMJ dysfunction. Gelb and Tarte7 estimate that $500,000,000 per year is spent in the United States alone for the relief of headaches, often to no avail because the TMJ syndrome usually is not recognized or diagnosed. Patients may wander from specialist to specialist for from 10 to 20 years in the search for relief from persistent nagging and disabling pain. An alert physician can detect disharmony of mandibular function in only a few seconds. Once it is recognized, an appropriate treatment plan can be designed which will significantly improve the patient's quality of life. Orthodox medical education does not teach the physician to recognize or appreciate the clinical significance of mandibular dysfunction. Yet without this appreciation the physician fails to recognize or suspect the symptoms, despite the fact that TMJ dysfunction may be present in at least 20 percent of our patients.6 TMJ dysfunction has been recognized for thousands of years, according to Gelb?' In the fifth century B.C. Hippocrates described a method of reducing dislocations of the mandible much like the technique used at present, A similar technique was used by the ancient Egyptians even 2,500 years earlier. Over the past 40 years the TMJ syn-

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drome has been described extensively in both dental and medical literature, yet, according to Greene,' a considerable number of practitioners of dentistry and medicine do not even acknowledge the existence of the syndrome.
Symptoms

an astute physician can begin to piece together the clues to the development of a disabling disorder years before it actually fulminates. This certainly is an admirable goal in the practice of holistic preventive medicine.
Etiologic factors

Many complex, perplexing, and disabling pain syndromes have been found to be the direct result of long-standing, unrecognized and undiagnosed TMJ dysfunction. Complaints described by various authors include: 7, 8, 11.12 head and neck pain, face pain, swallowing difficulties, tinnitus, digestive disorders, herpes, iritis, backache, mouth dryness, TMJ noise and popping, speech difficulties, mental aberrations, nervousness, hyperactivity, dyslexia, bruxism, sleep disorders, snoring, lowered resistance to infection, acceleration of aging, and chronic fatigue. Ear symptoms include some types of conductive hearing loss, earache, tinnitus, buzzing or hissing in the ears, a stuffy sensation in the ears, dizziness, loss of balance, itching in the ears, herpes of the external ear canal, pressure, and fullness. Among eye symptoms are nystagmus, tearing, twitching of the eyelids, blurring of vision, double vision, and iritis. Joint symptoms include clicking, crepitus, popping, limitation of mandibular motion, poor occlusal contact, and pain. Among painful manifestations are headaches of all varieties, pain around the ears, a burning sensation in the tongue, throat, or side of the nose, pain in the neck, shoulder, arms and fingers, or the upper part of the back, atypical facial pain mimicking tic douloureaux and temporal arteritis, sinusitis, muscle tenderness, and trigeminal neuralgia. Miscellaneous symptoms include dryness of the mouth, nervousness, herpes of the buccal mucosa, difficulty in swallowing, fatigue, dyslexia, speech difficulties, mental illness, hyperactivity, Parkinson's disease, bruxism and clicking of teeth, acceleration of aging, sleep disorders, periodontal disease of neurogenic origin, choking, digestive disorders, and snoring. These perplexing symptoms represent the end product of long-standing somatic dysfunction operative in fascial and neuromuscular stress associated with TMJ dysfunction. The symptoms may not be produced directly by TMJ dysfunction itself, but may be the product of the mechanism that produces the TMJ dysfunction. This becomes evident when one realizes that the full-blown syndrome does not appear overnight, but develops insidiously over several years. By understanding the sequential development of the symptom complex,

The search for the various contributing etiologic factors is demanding. No investigator ever has attributed TMJ dysfunction to only one etiologic factor. Dysfunction and imbalance of the chewing mechanism usually are present for many years before there is enough discomfort to lead the patient to seek professional help. The pathologic impulses emanating from mandibular imbalance often are of low intensity and remain below the level of consciousness for years. They may never progress to frank TMJ pain. When other stressful factors are layered on top of TMJ imbalance, the intensity of the pathologic neural impulses from the TMJ dysfunction increases substantially, and the antagonizing symptoms of the syndrome begin to fulminate." Agerberg and Carlsson" recently stated: "The etiology of functional disturbances of the masticatory system is heterogenous and often involves disturbances in general health, psychoemotional status, and occlusal stability and function." If the disturbance persists, the symptoms will continue to increase in magnitude until the patient experiences severe pain. Many etiologic factors arising in the oral cavity and the TMJ contribute significantly to development of the syndrome. Among the dental factors is premature extraction of premolars, which allows adjacent teeth to drift into the gap, changing the angle of the teeth so there is significant change in or loss of occlusal contact. This prevents proper spacing of teeth which erupt later. Other factors are dental caries; periodontal and other dental disease; the application of excessive force in dental extractions, which can produce jamming and restriction of the temporal bone and thereby disturb the harmonious function of the cranial mechanism; malocclusion which allows deviation of sliding and centric stopping of the mandible; and inflammatory diseases of the TMJ. Among types of inflammatory disease are developmental and infectious arthritis of the TMJ; degenerative osteoarthritis of the TMJ; myositis of the somatognathic system; mandibular fracture; recurrent dislocation of the TMJ; and facial fractures causing architectural malalignment. The mandibular musculature is an intricately balanced functioning unit, which is harmonized, correlated, and coordinated by a delicate feedback mechanism. The regulating reflexes originate in

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the proprioceptive nerve endings in the muscles, the articulatory capsule, and the periodontal ligaments. Any disturbance of the proprioceptive signals may lead to overexcitation of the mandibular musculature, trismus, and bruxism. Such disturbances are self-perpetuating and self-aggravating. Overclosure, premature contacts, and mental tension are the most frequent causes of proprioceptive imbalance. Local TMJ pain is caused by pressure of the condyle on the loose connective tissue behind the disk. Pain in the surrounding region is due primarily to muscle spasm. Fascial strain patterns that disturb the head in space become disruptive to the anatomic position of the mandible and will disturb the intricately balanced feedback of the chewing mechanism. Fasciae of the head and neck are intimately related to dental lesions and changes in TMJ articulation.2 Cathie2 listed the fasciae with direct and indirect anatomic relations to the osseous structures lodging on the dental arches, as follows: the superficial layer of deep cervical fascia, pretracheal fascia, prevertebral fascia, buccopharyngeal fascia, pharyngobasilar fascia, pterygoid fascia, lateral pterygoid fascia, interpterygoid fascia, stylomandibular ligament, sphenomandibular ligament, capsule of the parotid gland, capsule of the submaxillary gland, and carotid sheath. To appreciate fully the clinical importance of these structures, one must consider the strength of the masticatory musculature, the thickness of the specialized fasciae, their interrelations, and the manner in which the fasciae insert into the periosteum at the site of bony attaclunent.'2. The fasciae thus become an integral part of the bony architecture of the skull and other bony insertions throughout the body. To appreciate fully the fascial influences throughout the body, one must consider the manner in which the fascia of one region or muscle group becomes contiguous with and confluent with the fascia of its adjacent member. Anteriorly the aponeurosis of the skull is intimately attached to the temporal fascia. The fascial plane continues caudad, inserting into the fascia of the facial, anterior cervical, scalene, and sternocleidomastoid muscles, and platysma. Both the deep and superficial fascial planes of the cervical region positively connect the skull and cervical vertebrae to the shoulders, upper ribs, and thorax. This fascia is contiguous with the fascia of the pectoralis major, serratus anterior, anterior rectus sheath, and fascia of the obliquus abdominis externus and attaches securely to the crest of the ilium and inguinal ligament. Posteriorly, the aponeurosis of the skull connects with the trapezius and posterior cervical muscula-

ture and proceeds caudad to insert into the latissimus dorsi fascia. These cervical and thoracic fasciae insert into the posterior spinal ligaments and lumbodorsal fascia and posterior sacroiliac fascia and attach firmly to the pelvic brim and vertebral column. The fascia of the pelvis becomes contiguous with the fascia of the gluteus maximus, which blends with the deep fasciae of the lower extremities. These posterior fasciae progress caudad to blend into the sacrotuberous ligament. The sacrotuberous ligament becomes a part of the biceps femoris fascia where it attaches to the fibular head. The fascia then blends with the fascia of the tibialis anterior muscle, which in turn attaches firmly to the cuboid bone and base of the foot. The fasciae encasing the muscle groups of the lower extremities, tendons, ligaments, and neurovascular bundles are closely associated with and integrated with one another. Each firmly attaches to the periosteum at its insertion and actually becomes a functional part of the bony architecture at that point. Each time the fascia is pulled or moves, the bone at the site of insertion moves accordingly. Centrally, the anterior longitudinal ligament, the posterior longitudinal ligament, and the multitude of ligaments of the spinal column attach the vertebral column firmly together. The dura mater encases the brain and spinal cord and attaches firmly at the foramen magnum and second and third cervical vertebrae but is free of other attachments in the spinal canal until it reaches the second sacral segment, where it is anchored. This again attaches the cranium firmly to the sacrum. The falx cerebri and the tentorium cerebelli are strong ligamentous structures of the dura mater that attach firmly to the inner table of the cranium. As the spinal nerves exit from the spinal canal, they are encased in specialized fasciae from the dura mater called perineural sheaths. These sheaths enclose the nerves from the spinal cord until their final destination. Here they anchor the nerve fibrils and become contiguous with and connect to collagen fibrils. As the deep fasciae of the cervical region attach to the thorax (Fig. 1), the internal fascia of the thoracic cage becomes the parietal pleura and the anterior diaphragmatic pleura. The fasciae investing the trachea and esophagus become contiguous with the mediastinum and visceral pleura. In the abdominal and pelvic cavities, the fasciae of the neurovascular bundles and mesenteries become contiguous with the visceral and parietal peritoneum. Virtually no cell in the living body lies outside the sphere of influence of the fascia. Fasciae intimately and positively connect and interconnect

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Mardi 15814eureal d AOAMIL 1101as.

Prevertabral fascia RatroPharVngsal apace scare! fascia Skin Enveloping taw Hyoid bone Superficial fascia Enveloping fascia layer Infrahyold muscle Pretracheal fascia Suprastemal space Esophagus Trachea

Brachiocephalic vein /fi ll Aorta Pericardium

"

VN

11,411
)

Fig. 1. Fascial planes of cervical region.

every part of the body from the cranium to the sacrum and on to the arches of the feet and out to the toes. Fasciae encase the muscles, blood vessels, lymphatic channels, and nerves. Inappropriate strains in the fascia associated with these neurovascular lymphatic bundles can alter significantly the function and economy of the organs or the structures that are served and supported by them. A clear example of fascial influences on the body function occurs in sacral base unleveling (SBU). This produces a compensatory rotoscoliosis of the lumbar, thoracic, and cervical spine. Often TMJ pain and dysfunction can be traced back to SBU' through the fascial influences on cranial and mandibular function.2.3.7." Fascial strain produces an effect on the body similar to that conveyed through the superstructure of a skyscraper when an earthquake causes a shift of its foundation. As the foundation is shifted, the structural strain and distortion are transmitted all the way up to the penthouse through the twisting steel superstructure. The displacement of the foundation produces strains, pulls, and torsions that are positively and directly transmitted throughout the entire length and width of the structure, from top to bottom. The same is true with SBU, no matter what the etiologic mech.

anism may be. An unlevel sacral base produces a similar distortion all the way up to and including the cranium. Conversely, a torsion of the sphenobasilar symphysis will produce a torsion from the cranium caudad to the sacrum and on to the feet. Fascial strains follow the anatomic pathways previously outlined. Such a torsional strain pattern will be present throughout the entire body and can be detected and identified by an astute examiner. Asymmetric fascial tension anywhere in the body can produce a dynamic physiologic effect on the entire body. This may explain why an occasional patient who receives craniosacral therapy may experience reduction of fallen arches or tibial torsion when the fascial strain pattern is released. It is not uncommon after craniosacral treatment for a patient to experience some aching and discomfort in distant untreated areas when a significant fascial release has been accomplished. This demonstrates the dynamic effect that fascial relief can have throughout the body. In the holistic approach to a patient with any chronic disabling or degenerative disease, the physician must consider every etiologic factor that contributes to or detracts from his status of health and increases his susceptibility to disease. General health factors dictate how the body will respond to or give in to the incessant barrage of stress. If it gives in or the immune system gives out, a disease state begins. The factors that must be considered are tissue texture, muscle tone, nutritional status, emotional health and stability, anxiety stress level in the patient's life, ability of the patient to cope with the stress of daily living, fatigue factors, sleep patterns, ability to relax, use and abuse of tobacco, drugs, and alcohol, overindulgence in food and overweight, postural habits, and exercise pattern, as well as miscellaneous factors that may affect health. Arlen 15 recently added considerably to understanding of the integral relation between disorders of the jaw and ear pain. He said that the trigeminal nerve innervates the muscles of mastication, the temporal, masseter, both pterygoid and mylohyoid muscles, and the anterior belly of the digastric muscle. He also pointed out that two other muscles which are embryologically rudimentary jaw muscles also are innervated by this nerve. They are the tensor tympani and the tensor veli palatini. Embryologically, the same bud cell gives off the internal pterygoid and the tensor tympani muscle. In addition, the same nerve that comes off the mandibular branch of the trigeminal nerve goes to both muscles. The integrated relation between dysfunc-

tion of the mandible and of the ear is understand-

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able, especially when one considers that the tensor veli palatini is innervated by the same mandibular branch. Since the function of this muscle is to open the eustachian tube, it is clear why symptoms such as high frequency hissing sounds, fullness of the ears, pressure in the ears, and hearing loss often accompany mandibular dysfunction. Thus, any cranial dysfunction or restriction that might embrace or impinge on the trigeminal nerve could alter the transneural axionic flow of cerebrospinal fluid with its specific nucleoproteins and nutrients to the structures it serves and reduce their function. In the progressive development of the TMJ syndrome, the structural imbalance produces fascia! strain patterns that affect the entire soma. If the fascial strains are sustained for some time, mandibular imbalance can be produced. With sustained neurogenic stress, symptoms of mandibular dysfunction so produced will begin to plague the patient insidiously. As the mandibular dysfunction persists, the symptoms progress over months or years until the disabling, excruciating TMJ symptom complex develops. The primary etiologic factor may be from either a variety of oral disorders or a structural dysfunction. The ever-present structural-fascial-cranial component may be produced secondarily to the myofascial strains in the chewing mechanism or may be the primary initiating factor in this pain syndrome. Its influence is transmitted directly through the fascia and the cranial mechanism as already described. The structural side effects enter into the cycle of pain, spasm, and pain that progressively and incessantly builds up. The structural component not only contributes to but aggravates the entire pain complex in a reduplicating fashion. Adept osteopathic manipulative management can begin to break down this cyclic phenomenon by resolving the myofascitis in the mandibular, cervical, thoracic, and lumbar regions. Cranial osteopathy will direct the cranial mechanism toward more appropriate function and considerably facilitate resolution. Examination Physical examination l". 17 should not be considered complete until the patient is checked for mandibular imbalance. Unfortunately, this seldom is searched for in the average physician's office because the clinical significance of TMJ dysfunction is not widely recognized or understood and the physician is not trained to include it in differential diagnosis. As Sir William Osler said, "In order to treat something, we must first learn to recognize t." No specialized equipment and only a few seconds

of time are necessary for a physician to identify mandibular imbalance that can produce stress in

the somatognathic system (chewing mechanism). However, Greene' stated:

Many physicians and dentists are either uninformed about the syndrome or they are following outdated concepts of diagnosis and treatment for TMJ problems. In fact, a substantial number of practitioners in both professions did not even acknowledge the existence of a TMJ pain-dysfunction syndrome.

Many excellent articles in the recent literature have described the different methods of diagnosis and treatment of this problem, but only the basic ones will be considered here. An investment of just a few seconds for careful examination of the mouth and cranium will demonstrate dysfunction of the TMJ years before pain in this joint begins to radiate into the face, neck, and head. Serious stress loads that the patient would experience in the years to come might be eliminated or prevented easily long before the syndrome fulminates. In cranial examination for the TMJ syndrome' s one should begin with facial and cranial contour. Several facial characteristics already mentioned here can be clues to cranial distortions associated with mandibular dysfunction. The most important points to observe are facial and cranial contour, position of the mandible, gravitational position of the head on the shoulders, angle of the mouth, angle of the orbits, and position and flare of the ears. The key lesions of the cranial mechanism are occipital and temporal restrictions with secondary sphenobasilar torsion patterns. "' t IS Such cranial distortions can be secondary to long-standing fascial strains, birth trauma, facial or cranial trauma, malnutrition, heredity, and various pathologic processes. On dental examination, the physician should observe occlusal balance, molar contact, absence of teeth, periodontal disease, angle of molars, and evidence of bruxism. Inside the mouth he should note bite marks on the tongue and cheek. Difficulty in swallowing rapidly three times without pausing also is worth observing. The lateral pterygoid muscles should be palpated for tenderness. The mandible should be observed for symmetry of swing during opening and closing, distance the mandible can open without pain, and symmetry of the upper and lower incisal lines on first occlusal contact versus final stance after the mandible has shifted to its final stop position. Noise produced in the TMJ should be noted by palpation and auscultation. Crepitation of the TMJ can be palpated through the external auditory canal. Protrusion, retrusion, and lateral excursion should be tested. The face should be observed for tenderness at the insertion of the masseter over the coronoid process, asymmetry of

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.LEFT SIDE Vordeel dimension of tape Mee thin on right angle low Inge
Ear

low and fired

Mouth angle high Mandible Weft to left Muscles fight and lender Shoulder high

right.

Fig. 2. Typical structural pattern with TMJ syndrome on the

the face, mandibular position, angle of the mouth, size of the orbits, and vertical dimension of the face. The cranium should be observed also for evidence of warping of the skull, sphenobasilar torsion, temporal restrictions or malpositions, and occipital restrictions. Morn' described a practical and simple method for use of dental wax in testing and demonstrating the extent of distress attributable to mandibular imbalance. Two 3/4-inch strips of Yale dental base plate wax are warmed under tap water until they are softened and then are folded over three times and placed over the lower first molars bilaterally. Then the patient is instructed to close his mouth, but not bite down, and then swallow. This will bring the mandible into comfortable resting position in the soft, warm wax. The patient then is told to relax for a few seconds while he is observed for subtle changes in facial characteristics. Color change often will be observed almost immediately in the face, ears, and neck. Wrinkle lines will seem to soften and diminish. A look of obvious comfort will come over the patient's face. The patient should continue to relax for from 10 to 20 minutes before the wax is removed. If mandibular imbalance is producing stress, the patient will experience a feeling of comfort with the wax in place as described. With removal of the wax, the patient will feel the loss of stability and security instantly. Structural examination of the patient with TMJ dysfunction and chronic fascial strain often will reveal a characteristic pattern. An example of one such pattern (Fig. 2) includes elevation of the left

iliac crest; unleveling of the sacral base, high on the left; compensatory rotoscoliosis of the spine with the lumbar spine convex to the right, thoracic scoliosis convex to the left, and cervical convexity to the right; elevation of the left shoulder; tightening and tenderness of the left cervical musculature; vertical shortening of the left side of the face; elevation of the angle of the mouth on the left; enlargement of the right orbit and right nostril; prominence of the right frontal bone and right maxilla; and crepitus of the right TMJ. Various combinations of these structural observations may be present in patients with the TMJ syndrome. Compensatory rotoscoliosis extending to the cervical spine will tighten the left cervical musculature on the concave side of the cervical component. The flexible spinal mechanism allows the adjustment of the gravitational position of the head so that the eyes and the labyrinthine mechanism can remain level and stable. These postural adjustments are necessary for proper vision and balance. The fascial strain pattern in Figure 2, if allowed to become chronic, will produce long-standing structural imbalance, which often is a significant factor in the development of TMJ dysfunction. Such structural changes can reflect their influence either in a caudad direction, from the head down to the sacrum and pelvis, or in a cephalad direction, from the sacral base up to the base of the cranium. In either case, stress is placed on the cranial mechanism and has a deleterious effect on the patient's homeostasis and health. As demonstrated in Figure 2, the continuous cervical myofascial strain on the occiput, a caudad traction on the left side of the occiput, forces the left side of the occiput inferiorly and anteriorly (held in a position of flexion). The chronic myofascial strain of the sternocleidomastoid muscle on the left mastoid process of the left temporal bone exerts continual downward traction on the mastoid. This type of downward traction pulls the mastoid process inferiorly, anteriorly, and medially. As the entire temporal bone is thus pivoted, the TMJ condyle is displaced medially, anteriorly, and superiorly. After months of this continual pull, the temporal bone is found to be chronically restricted in this position. (The left temporal bone is held in a position of external rotation and is restricted from normal internal rotation.) These strains do not stop exerting their influence at this point, but are projected further into the cranial mechanism, where they dynamically affect the sphenobasilar symphysis, frontal bone, and facial bones. With the left temporal bone held in a position of external rotation, a chronic right tentorial strain is placed on the right anterior clinoid

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process, which holds the sphenoid bone in this position. Tentorial strains affect the entire cranial mechanism.11.18.19 Treatment Once the diagnosis of TMJ pain-dysfunction syndrome is established, treatment must be directed to relief of pain and discomfort as rapidly as possible. The multiprofessional approach is appropriate. There is no place for professional isolationism in the total approach to this syndrome! The cooperation of a physician skilled in the management of musculoskeletal pain, structural components, and cranial osteopathy working in concert with a dentist skilled in pivotal mandibular equilibration will provide the most satisfactory synergistic approach. It is absolutely necessary for the patient to understand and appreciate the complexity of the treatment. His enthusiastic cooperation is a keystone in satisfactory resolution of this disorder. The dentist and physician must counsel the patient carefully and patiently as to the responsibility he must assume in the overall treatment plan. Without his wholehearted cooperation, the most skilled professional team will not succeed. Several modalities of physical therapy are of immediate benefit in relieving the musculoskeletal component of this complex. These include moist heat, vapocoolant sprays, ultrasound, and electrotherapy. W 21 Osteopathic manipulative counterstrain therapy, indirect functional balancing, muscle energy therapy, myofunctional therapy, fasciae release, heel-lift therapy, and cranial therapy will offer substantial immediate and prolonged benefits. Trigger point injection, acupuncture, and auriculotherapy may be helpful. Careful and accurate evaluation of occlusal function by a dentist may indicate that only a simple occlusal adjustment is required. Sometimes in patients showing dental neglect a more complex full-mouth restoration is necessary. Initially the dentist may need to prepare a precisely fitting adjustable acrylic splint (anterior gig) 22 or lower mandibular splint." As a result of the combined efforts of the professional team the chewing mechanism will shift toward normal. As the mandible shifts, the muscles of mastication begin to relax and approach normal functional length and posture. These changes require frequent and meticulous readjustments of the splint. Osteopathic manipulative therapy is of considerable value in the resolution of the musculoskeletal component of the syndrome. Initially, pain relief is the paramount aim. Counterstrain therapy, indirect functional balancing therapy, cranial therapy, muscle energy technique, and myo-

functional therapy will relieve the muscle spasms, myositis, and pain. These procedures will begin to interrupt the cycle of pain, spasm, and pain and provide prompt relief. As the spasm and myofascial component begin to resolve, the mandible will continue to shift toward its normal functional anatomic position. Whether structural influences are the primary etiologic factor or are produced secondarily, structural balancing is necessary to eliminate the fascial drag on the cranium that tends to perpetuate the lesion. For example, a short leg, sacral torsion, or ilial malposition can produce sacral base unleveling. Heel-lift therapy or muscle energy therapy to balance the pelvis is necessary to remove this portion of the pelvic somatic dysfunction. Likewise, an unrecognized fallen arch may introduce deleterious fascial strain that is projected cephalad. A common denominator in the TMJ syndrome consists of anxiety and emotional stress. This may become the most disabling and disconcerting element. Hypnotherapy, biofeedback training, relaxation training, behavioral modification, and counseling are beneficial in assisting the patient to adjust. Emotional support and empathetic understanding on the part of the physician and dentist are essential. Efforts must be made to improve the patient's general state of health. He should be counseled to avoid refined sugar, carbohydrates, and wheat products, alcohol, tobacco, drugs, coffee, cola drinks, and carbonated beverages and encouraged to eat fresh, raw, organically grown fruits and vegetables. The use of organically produced meats, poultry, and eggs and fresh fish and of pure water should be encouraged. Assisting the patient to reach and attain optimal weight also is important. An essential part of any plan designed to restore optimal health is exercise. The concerned physician should design an appropriate exercise program which will be acceptable, practical, and graduated. This will improve tissue texture and assist the patient in building stamina and muscle tone and achieving an inner feeling of confidence and well-being.. The sleep pattern often is disturbed with the syndrome. The continual shifting of the mandible during the night, grinding, and gnashing introduce a continual irritant that interferes with a patient's sleep. A chronic inability to sleep and rest contributes to the total fatigue that every patient with the syndrome experiences. The restoration of a normal circadian rhythm will benefit the patient substantially by interrupting this common energy drain.

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Pharmacologic management may be necessary, especially in the initial phase of treatment. Ataractic or sedative medication may be helpful. Muscle relaxants and analgesics assist in managing the pain. Anti-inflammatory agents will be helpful for myositis and joint inflammation. Such medication will elevate the pain threshold, reduce the muscle spasm, and resolve inflammation. If all conservative measures fail, surgical intervention may be necessary. High intracapsular condylectomy19 may be necessary for degenerative TMJ disease. Rhizotomy that destroys the sensory nerve tract of the trigeminal nerve from the muscles of mastication and TMJ may be elected.

Osteopath News, Apr 65 2. Cathie, A.: Fascia of the head and neck as it applies to dental lesions. A preliminary consideration. JAOA 51:260-1, Jan 52; AAO Yearbook, 1974, pp. 173-5 3. Downs, J.R.: Treating TMJ dysfunction. Osteopath Physician 43:106-13, Mar 76 4. Becker, R.F.: The meaning of fascia and fascial continuity. Osteopath Ann 3:8-32, Feb 75 5. Korr, I.M.: The neural basis of the osteopathic lesion. JAOA 47:191-8, Dec 47 6. Shore, NA: What every dentist should know about TMJ dysfunction. Dent Survey 46:36-7, Oct 70 7. Gelb, H., and Tarte, J.: A two-year clinical dental evaluation of 200 cases of chronic headache. The craniocervical-mandibular syndrome. J Am Dent Assoc 91:1230-6, Dec 75 8. Gelb, H.: The temporomandibular joint syndrome. Patient communication and motivation. Dent Clin North Am 14:287-307, Apr 70 9. Cathie, A.: Considerations of fascia and its relation to disease of the musculoskeletal system. AAO Yearbook, 1974, pp. 85-8

I. Strachan, F., and Robinson, M.J.: Short leg linked to malocclusion,

10. Greene, C.S.: The temporomandibular syndrome. JAMA 224:622, 30 Apr 73 11. Magoun, RI.: Osteopathic approach to dental enigmas. JAOA 62:110-8, Oct 62 12. May, W.B.: Reduction of stress in the chewing mechanism. Unpublished manuscript 13. Agerberg, G., and Carlsson, G.E.: Symptoms of functional disturbances of the masticatory system. A comparison of frequencies in a population sample and in a group of patients. Acta Odontol Scand 33:183-90, 1975 14. Lockhart, RD.: Myology. In Cunningham's text-book of anatomy, edited by J.C. Brash. Ed. 9. Oxford University Press, London, 1951 15. Arlen, H.: The otomandibular syndrome. A new concept. Ear Nose Throat J 56:60-2, Feb 77 16. Hoppenfeld, S.: Physical examination of the spine and extremities. Appleton-Century-Crofts, New York, 1976 17. Schwartz, L.: Disorders of the temporomandibular joint. Diagnosis, management, relation to occlusion of teeth. W.B. Saunders Co., Philadelphia, 1959 18. Magoun, H.I.: Osteopathy in the cranial field. Ed. 2. Journal Printing Co., Kirksville, 1966 19. Magoun, H.I.: Dental equilibration and osteopathy. JAOA 74:98191, Jun 75 20. Kreutziger, K.L., and Mahan, P.E.: Temporomandibular degenerative joint disease. II. Diagnostic procedure and comprehensive management. Oral Surg 40:297-319, Sep 75 21. Zohn, D.A., and Mennell, J.M.: Diagnosis and physical treatment. Musculoskeletal pain. Little, Brown & Co., Boston, 1976 22. Weinberg, L.A.: Posterior bilateral condylar displacement. Its diagnosis and treatment. J Prosthet Dent 36:426-40, Oct 76

Accepted for publication in April 1979. Updating, as necessary, has been done by the author. This paper was prepared in partial fulfillment of the requirements for fellowship in the American Academy of Osteopathy. Dr. Royder, who is in general practice, is an associate clinical professor of osteopathic principles and practice, Texas College of Osteopathic Medicine, Fort Worth. Dr. Royder, 1111 Lancaster Hutchins Road, Hutchins. Texas 75141.

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