Professional Papers

_______________________________________________________

Conservative management of
temporomandibular joint dys-
function
Franklin Schoenoltz, DC, DABCO
Arcadia, California

ACA Journal of Chiropractic /August 1978

Copyright American Equilibration Society 1980. Copyright Franklin Schoenholtz

“Authorization granted to the American Equilibration Society for reprint in their Compendium 15,
by the ACA Journal of Chiropractic.”
Temporomandibular joint (TMJ) pain is a condition which may need a multi-pro-
fessional approach for its successful resolution. Because of the unique problems it
presents, there is no place for intellectual isolationism in the total approach to the
diagnosis and treatment of this disorder.

The etiology of the TMJ pain dysfunction syndrome is the topic of much debate.
One group feels that occlusion is the major etiologic factor and the other group
feels that myofascial muscle spasm with psychological factors initiates the syn-
drome.

The controversy as to which comes first, the malocclusion or the muscle spasm
dictates, in fact, that the syndrome seems to be multifactorial and the treatment
should be directed to eliminate the multiple etiologic factors.

Examination

When examining the temporomandibular joint the clinician should remember how
the joint hinges with in the glenoid fossa and then glides forward to the eminentia
(see Figure 1).

The dual heads of each of the external Pterygoid muscles act asynchronously, with
one head pulling the meniscus forward as the second opens the joint (see Figure
2).

A technique of bony palpation of the temporomandibular joint is accomplished by
placing the index finger into the patient’s auditory canal and pressing anteriorly.
When the patient opens and closes his mouth the doctor may palpate the mandib-
ular condyle with his fingertip. (see Figure 3).

Soft tissue palpation of the external Pterygoid muscle is important clinically. Spasm
of this muscle will cause temporomandibular joint pain as well as asymmetrical,
lateral movement of the jaw. The technique for this examination is to place one’s
finger in the patient’s mouth between the buccal mucosa and superior gum and
direct the tip of one’s index finger posteriorly, past the last upper molar to the
neck of the mandible. The clinician should request the patient to open and close
his mouth in a slow, deliberate manner. As the mouth opens, the doctor will feel
the neck of the mandible swing forward and the external Pterygoid muscle tighten
against the tip of his finger (see Figure 4).
Figure 1. The meniscus divides the joint into an Figure 2. The two heads of the external Pterygoid
upper and lower portion with its hinge and glide ac- muscle act asynchronously to open the temporo-
tion. mandibular joint.

Figure 3. Palpation of the temporomandibular joint Figure 4. Palpation of the external pterygoid muscle
can be accomplished by placing the index finger in can be accomplished by placing the tip of the index
the auditory canal. finger posteriorly between the buccal mucosa and
the superior gum.
Normal range of motion is accomplished
by having the patient open his mouth as
wide as possible. The patient should be
able to insert his three fingers between
incisor teeth (See Figure 5).

Diagnosis

Frequently the patient will complain of

unilateral pain which may be intermit-
tent or constant in the area of the jaw,
but which may extend to the ear, head,
neck and shoulder. When requesting the
patient to open his mouth to the wid-
est extent, the mandible is usually seen
to deviate toward the painful side (see
Figure 6).

Figure 5. When the patient opens his mouth

One of the most common problems of
to a normal mouth span, he should be able to
the temporomandibular joint syndrome
insert three fingers between the incisor teeth.
is the limitation of the normal range of
mandibular movement. Subluxation may
cause acute instant pain and the patient
may feel that his teeth are no longer ar-
ticulating properly.

Palpation will usually elicit tenderness at

the temporomandibular joint. The patient
may also complain of a “clicking” on the
affected side. The use of a stethoscope
placed over the joint during mandibular
movement will often reveal this sound as
well as crepitus.

Figure 6. When the patient opens his mouth to

the widest possible extent, the mandible will
usually shift toward the painful side.
Pathophysiology

The combination of hypertonicity of the muscles of mastication, dental malocclusion

and emotional tension usually is the basis for most temporomandibular joint pain.

Muscle tension is probably the major contributing cause of dysfunction of the mus-
cles of mastication (Figure 7).

Gnashing and grinding of the teeth when under stress is known as occlusal neu-
rosis, if it becomes habitual it is known as bruxomania. This phenomenon implies
a longstanding isometric muscle activity which leads to a hypertonicity within the
masticatory muscles.

The physiological act of occlusion of the teeth occurs every 50 to 70 seconds prior
to deglutition. If the mandible cannot complete that act because of muscular dys-
function, struggling movements are initiated. The patient attempts to force the
mandible through to a completed occlusion despite muscular restraints.

X-ray evaluation of the temporomandibular joint is usually negative but is useful in

excluding other causes of dysfunction such as congenital anomalies, trauma, neo-
plastic and general disorders of the bone (Figure 8).

Treatment

The author’s treatment program consists of a

supportive home exercise routine. The patient
attempts to open his jaw against resistance for
a period of five minutes, six times daily (Figure
9).

The rationale of this therapy is to cause a

pumping of the muscle by mechanical action.
This promotes dissipation of metabolic waste
products of the muscle group being treated,
thus helping to restore a normal physiological
Figure 7. Anatomy of the masticatory
state. muscles.
As a precursor to manipulation, a vapocoolant spray (Figure 10) or high-voltage
galvanic current (Figure 11) is used to relive skeletal muscle spasm.

The Spray should be applied in a slow, even, interrupted sweep, in one direction
only. The skin should not be frosted. This process of intermittent spraying of a
muscle group should last approximately one minute. The doctor should then re-
quest the patient to actively open and close the mouth in order to stretch the mus-
cles for a period lasting 10 to 15 seconds.

A prop, such as a cork, should be placed in between the teeth so that the jaw ap-
erture becomes increased and then another application of the vapocoolant spray is
once again instituted. This therapy is repeated with larger corks until the patient’s
pain tolerance disallows the continuance of this procedure.

When utilizing high-voltage galvanic therapy in the clinical management of the TMJ
syndrome, this author’s technique is to place the electrode over the spastic tempo-
ral or masseter muscle for a period of 15 minutes. The clinician may vary the treat-
ment application when indicated by placing the electrode inside the mouth without
any discomfort of damage to the oral tissue.

Figure 8. Bony anatomy of the temporomandibular Figure 9. The patient attempts to open his jaw
joint. against resistance.
Excellent results are obtained by the use of
this specialized galvanic current. This ther-
apy relieves spasticity and painful muscle
spasm while increasing local circulation and
promoting muscle integrity in regaining joint
control.

The use of this recent development in elec-

trical therapy has been reviewed extensively,
and no deleterious effects or risks have been
noted.

Manipulative Procedure
This author has found the following tech-
nique to be most beneficial (Figure 12):

1. The patient lies in the supine position

Figure 11. The therapist should place the electrode
and opens his mouth as wide as possible. over the spastic temporal or masseter muscle. The
large dispersive pad, 8”x10”, is strapped to the back
to provide the return path of the current flow.
2. The doctor winds a substantial length
of ordinary bandage around his thumb for
protection.

3. If the right temporomandibular articu-

lation has suffered derangement, the doctor
should stand on the patient’s left side. He
then places his right hand on the patient’s
forehead for counter-traction and his left
thumb against the right lower back teeth,
and, at the same time, grips the chin with
the fingers of the left hand. By pressing
downward on the molars, the mandible is
then distracted from the temporal bone.

4. The object now is to gently disengage

the fixation by taking the joint as far as it
will comfortably go and then with a rock- Figure 12. The manipulative procedure should
be preformed in a slow rhythmic action similar to
ing movement mobilize the joint, similar
opening and closing the mouth.
to opening and closing of the mouth, for a
period of 20 seconds.
 This manipulation may be repeated several
times on a limited program and a recheck
should be made for joint tenderness as well
as movement range.

Manipulation reduces the inflammation by

mobilizing and dispersing the tissue-break-
down products. It aids in preventing fibrous
arthrosis as well as separating articular
structures, thus stretching contracted mus-
cles.

If primary dental malocclusion is suspected

or the temporomandibular joint dysfunction
assumes a chronic nature, consideration
should be given to dental risers and splints
and dental consultation should be sought.
Figure 10. Technique for applying a vapocoolant spray for
relief of masseter muscle spasm. The mouth is propped
comfortably at its maximum opening. The eyes should be
covered for protection. Each sweep follows the muscle
lines and travels toward and over the related pain areas.

Dr Franklin Schoenholtz is a diplomate of the American Board of Chiropractic Orthopedists. He maintains a

private practice at 226-228 East Foothill Blvd, in Arcadia, California. He has taught diversified technique and
undergraduate orthopedics at the Los Angeles College of Chiropractic in Glendale, California from 1964-
1976. Presently, Dr Schoenholtz is the secretary-treasure of the Board of Regents at LACC. HE has authored
numerous articles including “Soft Tissue Pain Sites in the Low Back Area,” 1968; “A Guide to the Lectures
in Chiropractic Orthopedics,” 1976; “A historical Review of Manipulative Therapy,” 1977; “The Diagnosis
and Conservative Treatment of the Lumbar Disc Syndrome,” 1978, and “Manipulative Management of Tennis
Elbow,” 1978.v

Figure 1. The meniscus divides the joint into an upper and lower portion with its
hinge and glide action.

Figure 2. The two heads of the external Pterygoid muscle act asynchronously to open
the temporomandibular joint.

Figure 3. Palpation of the temporomandibular joint can be accomplished by placing

the index finger in the auditory canal.

Figure 4. Palpation of the external pterygoid muscle can be accomplished by placing

the tip of the index finger posteriorly between the buccal mucosa and the superior
gum.
Figure 5. When the patient opens his mouth to a normal mouth span, he should be
able to insert three fingers between the incisor teeth.

Figure 6. When the patient opens his mouth to the widest possible extent, the man-
dible will usually shift toward the painful side.

Figure 7. Anatomy of the masticatory muscles.

Figure 8. Bony anatomy of the temporomandibular joint.

Figure 9. The patient attempts to open his jaw against resistance.

Figure 10. Technique for applying a vapocoolant spray for relief of masseter muscle
spasm. The mouth is propped comfortably at its maximum opening. The eyes should
be covered for protection. Each sweep follows the muscle lines and travels toward and
over the related pain areas.

Figure 11. The therapist should place the electrode over the spastic temporal or
masseter muscle. The large dispersive pad, 8”x10”, is strapped to the back to provide
the return path of the current flow.

Figure 12. The manipulative procedure should be preformed in a slow rhythmic action
similar to opening and closing the mouth.

Sources

Cyriax, Orthopaedic Medicine, Vol II, 1959.

Downs, “Treating TMJ Dysfunction,” Osteopathic Physician, 1976.
Finnerson, Diagnosis and Management of Pain Syndromes, 1963.
Gelb, “TMJ Syndrome,” Dental Clinics of North America, 1970.
Gelb, “Cranio-Mandibular Syndrome,” New York Journal of Dentistry, 1971.
Gelb, Clinical Management of Head, Neck and TMJ Pain and Dysfunction, 1977.
Hoppenfield, Physical Examination of the Spine and Extremities, 1976.
Morgan, “The Great Imposter, Journal, California Dental Association,1974.
Travell, “TMJ Dysfunction,” Journal of Prosthetic Dentistry, 1960.

Copyright American Equilibration Society Compendium 1980

Copyright Franklin Schoenholtz 2009

Volume 15 1980