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TMJ Manipulation/Mobilization

I'll do my best here to describe the TMJ manipulation/mobilization technique I have used to treat thousands of TMD patients in both conservative and surgical cases, however the technique is best learned by observation. As I can't actively lecture anymore I have recorded demonstrations of the technique on the TMD Training System along with demonstrations of all of the examination procedures necessary for an accurate diagnosis. Distraction manipulation of the temporomandibular joints is a gentle, painless, simultaneous distraction of both joints combined with guided translation movements. Manipulative thrusts to the mandible, especially A-P or lateral thrusts, should be avoided at all times and the temporomanidublar joints should not be manipulated in any fashion if the joints demonstrate signs of substantial acute inflammation.

The objectives of temporomandibular joint manipulation include:

  1. Cavitate the joints
  2. Adhesion release
  3. Capsular stretch and capsular adhesion release
  4. Disc "recapture", that is, allowing the anterior displaced disc to re-seat itself on top of the mandibular condyle.

When distractive temporomandibular joint manipulation is combined with guided translatory movement and proprioceptive neuromuscular facilitation techniques for the external ptyerygoid musculature, it can:

  1. Reestablish pterygoid synergy
  2. Strengthen and stretch pterygoid musculature
  3. Help guide connective tissue matrix formation

Technique:

Temporomandibular joint distraction manipulation is performed with the patient supine to eliminate the effects of gravity on the neuromuscular tone of the masticatory elevator muscles . This is a bimanual, bilateral distraction to avoid distracting one joint only to overload the contralateral joint. The temporomandibular joints should, in fact, be viewed as two halves of one joint and incapable of independent movement. The patient is instructed to lie supine and a cervical support pillow is placed under the head and cervical spine. The patient's head is placed in a neutral or slightly flexed posture. The patient is instructed to open the mouth just enough to allow the practitioner to place the thumb pads over the first and second mandibular molars bilaterally. If these teeth are missing, an oral orthotic, dentures, or bridge needs to be in place for support/leverage. The practitioner then flexes the thumbs approximately 5 to 10 degrees forming a slight fulcrum and places the remaining fingers of each hand under the bottom of the mandible with the fifth digits under the chin. The patient is the instructed to slowly bite down. This biting action will initiate distraction of the joints. The practitioner immediately begins to apply gradual distractive pressure by pressing down on the molars while pulling up under the chin with the second through fifth digits of each hand. This rotates the joint, effectively distracting it without trauma. The patient is then instructed to relax the bite while the practitioner maintains and slightly increases the distractive pressure. The practitioner then moves the condyles in a slow, gentle figure-8 movement within the confines of the joint capsule for approximately 5 seconds. While continuing to maintain distraction, the practitioner then instructs the patient to allow the mandible to drop back (retrusion) and then subsequently the patient is instructed to protrude the mandible. Distractive force is maintained during these movements while the practitioner guides parallel joint movement. The patient is then instructed to move the mandible to one side and then the other (laterotrusive movement) while the practitioner increases distraction the contralateral side while maintaining distraction on the ipsilateral side. Distraction is maintained while the patient allows the mandible to fall back into a neutral position. This completes the manipulation/mobilization procedure. This entire process should take less than 30 seconds and need not be repeated more than two times per session. This manipulative procedure is best applied in the subacute and chronic stages of temporomanidular dysfunction and is essential for the effective management of post surgical cases. In the post whiplash scenario, manipulation should enter the treatment protocol as signs of acute joint inflammation begin to subside and continued throughout the protocol until acceptable range of motion is achieved and maintained, adhesion formation is no longer considered an active process and optimum external pterygoid function is restored. In a variation on this maneuver the inferior heads of the external pterygoids can be treated with properioceptive neuromuscular techniques. To accomplish this, have the patient protrude the mandible while you resist mandibular movement for two or three seconds. Next, instruct the patient to allow the mandible to passively drop back (retrusion). Repeat this procedure one more time. Follow this immediately with guided protrusion avoiding deviation or deflection from a straight protrusive path.

Physiotherapy application pre and post manipulation:

  1. If muscular trigger points prevent manipulation by causing muscle stretch pain the trigger points can be treated with micro-current, ultrasound, ultrasound/electrical combinations, massage and/or appropriate lazer applications before manipulation.

  2. If temporomandibular joint pain occurs when manipulation is attempted, yet signs of inflammation have been decreasing over the course of treatment, application of pulsed ultrasound, galvanic current, ionto- or phono-phoresis, lazer and/or pulsed diathermy can be delivered to the joint proper before manipulation. If pain during manipulation continues to be present after physiotherapy it should be discontinued for one to two sessions before it is attempted again.

  3. If manipulation is accomplished successfully it is frequently beneficial to place two lightly moistened cotton rolls between the upper and lower molar and pre-molar dentition, one on each side of the mouth, immediately following the manipulation. This will maintain a slightly open joint space and avoid engaging occlusal proprioception while physiotherapy is provided to the temproromandibular joints, masticatory and cervico-trapezial musculature. This technique can be used even if an oral orthotic is in place.

Questions?
Email Dr. Steigerwald at: info@whiplashandtmj.com or call 631-749-1534 (NY)

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