TMJ

SET TALK
By Don McCann, MA, LMT, LMHC
MA3267 MH705 MM3717

TMJ Syndrome

A topic that keeps coming up in my classes and lectures is (temporomandibular joint) TMJ Syndrome.  Over and over again massage therapists encounter this problem and tend to be intimidated or scared by it.  The flip side of the coin is that some therapists have taken a simple weekend course on treating TMJ Syndrome (hereafter referred to as TMJ) and feel they are experts, but in reality the basic cause of TMJ has not been resolved by their treatments.  There seems to be a lot of confusion among massage therapists about TMJ and the approaches for treating it.  In this installment I am going to discuss the basis of TMJ, and the necessary components of successfully applying massage techniques to treat this syndrome.

First the basis:  Those of you who have been reading this column know I often refer to the core distortion pattern found in everyone I have ever seen in over 25 years of practice.  This distortion includes rotated iliums and shoulders, and an imbalance of the cervical spine and cranium.  The entire body is involved in this core distortion.  However, for purposes of understanding TMJ, we will have a clearer picture if we look at the components of the core distortion pattern.

The cranium has bones that relate to the bones of the pelvis.  Of specific importance here are the sphenoid, occiput, temporals, zygomas, maxilla, palatines and palate.  There is a direct relationship between the iliums of the pelvis and the temporals and greater wings of the sphenoid – if the greater wings of the sphenoid and temporals are rotated anteriorly on one side, then the ilium on that same side will also be rotated anteriorly.  There is also a direct relationship between the occiput and sacrum – the direction in which the occiput is tipped is the same direction of tippage seen in the sacrum.  Key in cranial motion is a flexion/extension movement of the occiput and the sphenoid.  When the cranium moves evenly into flexion/extension without tippage or rotation, then the iliums and sacrum are level and offer a balanced support for the body.  When the flexion/extension motion of the sphenoid and occiput is torqued, an uneven movement of the cranium in flexion/extension is created, which results in a torquing of the ilium and sacrum mirroring what takes place in the cranium. While this is technical, it is important to recognize this since this is the primary torsion found in the core distortion pattern and in TMJ Syndrome.  Additionally, when this torsion exists between the sphenoid and occiput, the other facial bones involved with TMJ – the mandible, maxilla, palatines, palate and zygomas – are also in this torsion distortion.  Using kinesiology and a right arm for muscle testing, this can be verified by testing the client with the mouth open wide.  If TMJ is present, the muscle test will be weak, as will additional tests involving the structure of the pelvis.  Consequently, it is easy to see that the TMJ Syndrome is synonymous with the core distortion of the entire body, and that the pelvis and the cranium need to be brought back into balance in order to effectively treat TMJ.  Another consideration is the curvature of the neck, which is also a result of this distortion, and the imbalance found here helps support and lock up the dysfunctional TMJ pattern.  So the TMJ syndrome needs to be looked at as a structural balance problem with the TMJ being a distortion that is a result of the core distortion of the full body.  Now for the fun.

Treating TMJ Syndrome

As you can see from the discussion above, TMJ distortion stems from the imbalance of the pelvis, spine and cranium.  So when seeking long-term correction of TMJ problems, the massage therapist needs to treat this entire distortion pattern.  If massage and Cranial/Structural techniques (not to be confused with craniosacral techniques) are applied only to the cranium, then the distortion in the rest of the body will bring the distortion back into the cranium and the TMJ, and you’ll be back where you started.  If, however, there is a balancing of the pelvis, a reduction of the scoliotic curve caused by the imbalanced pelvis, a reduction of the reverse curvature of the neck, and a balancing of the cranium, then the positive changes to the TMJ will be able to be maintained long-term leading to happy clients.

Recently, when working with a dentist who had a severe TMJ problem complicated by extensive dental correction, the changes in the balancing of the jaw were so profound after the torsion in the cranium was released and the core distortion throughout her body had been released, that she had to go back into braces to bring her bite back into alignment.  However, her TMJ symptoms disappeared!

TMJ problems are often accompanied by many emotional blockages that have become chronic, and often manifest as a thickening and tightening of the soft tissue.  They can exist throughout the structure, but especially in the pelvis, abdomen, thorax, neck, and jaw.  These emotional blockages can, and often do, resist soft tissue changes that are necessary to balance the structure.  It is important for the client to be able to release the trapped emotional energy so the chronically tightened soft tissue can relax and release the old core distortion holding pattern.

When balancing the core distortion pattern and working with TMJ, I prefer to integrate a number of techniques.  First, I will initiate the torsion release throughout the core distortion pattern by using Cranial/Structural techniques.  Then, once the torsion is released from the cranium, the soft tissue of the entire body starts to unwind and release, which greatly facilitates the balancing of the structure.  There are usually many areas where this unwinding of the structure is limited due to the myofascial holding pattern, adhesions and scar tissue.  The proper application of the Three-step technique allows the therapist to effectively work deeply in the various layers of fascia to continue the unwinding process initiated by the Cranial/Structural work (see the Nov/Dec issue of Massage Message on Deep Tissue, or view that article on the website).

Releasing the torsion in the cranium allows a balancing of the bones in the cranium, and consequently a balancing in the TMJ.  I have found that in balancing the cranium using Cranial/Structural techniques, many of the TMJ problems will be profoundly minimized or disappear entirely with minimal work in the actual muscles that are directly related to the TMJ – i.e. masseter, pterygoid, temporalis.  However before I will work with the muscles of the TMJ, I am going to seek a balance between the pelvis and the cervical spine, and release the musculature of the neck and shoulder.  By doing this I will have maximum results in a minimum amount of time when actually working in the muscles of the TMJ.  This will usually take 3-4 sessions of balancing the structure, including the neck, before doing deep efficient work with the muscles associated to the bones of the TMJ.

When addressing the cervical spine, I would work to release the anterior muscles first, and then the posterior muscles, and concentrate more on the SCM and scalenes because they tend to hold the neck in a distorted curvature. Often much more work is necessary on the muscles of the anterior neck than the muscles connected to the bones of the TMJ, even though the pain is felt in the area of the muscles of the TMJ.

When working with the muscles directly associated with the TMJ, I will check the cranium first using kinesiology to be sure that optimum balance and mobilization of the cranial motion is present.  Then, after treating the anterior neck and posterior neck, I release the soft tissue over the scalp and face.  Now I will release the masseter and its attachments externally.  I will then work with the musculature inferior to the mandible, paying special attention to the tissue around the angle of the mandible, to where it attaches in the back of the TMJ.  After having released both sides of the mandible, I will now work intraorally on the masseter including the attachments on both sides.  At this point the pterygoids are about the only muscles affecting the TMJ that have not been addressed.  Since they are located at the back of the mandible, releasing them tends to be uncomfortable for many clients.  However, by releasing everything else first, there will be no resistance from the other musculature of the mandible that would diminish the release of the pterygoid.  Consequently, the amount of time and pressure necessary to fully mobilize and balance the TMJ by working on the pterygoids will be minimized.

It is important not to try to do too much in any one session when working with the TMJ because clients will have a significant shift throughout their structure, and we need to have that structural shift integrate as it balances.  Additionally, TMJ problems are often at the top of clients’ lists as far as being painful, so we need to remember to always work within client’s pain threshold.

The work mentioned above is very specific and advanced, and I would strongly suggest that you take a course in Cranial/Structural and specific related soft tissue protocols before treating TMJ problems in your clients.