!"#$%&'(%)*+,'-.(/0,&! BY TIL LUCHAU & BETHANY WARD
Image 1: The medial pterygoids (purple) along with the masseters (orange) form left and right "slings" that support, close, and help align the mandible. Also shown are the lower head of the lateral pterygoids (green) and the articular surfaces of the TMJ (yellow). Source images courtesy of Primal Pictures, used with permission. !"#$%$"&'()*+,'-./)0*0*123+45" " 6)1,"#" WORKING WITH THE MEDIAL AND LATERAL PTERYGOIDS
Where would we be without jaws? In the evolutionary version of our creation story, there was a long period when no animals had them. Ancient animals such as amphioxus had a mouth, but not a mandiblei. Once jaws appeared, however, they proved extremely popular, as now all vertebrates (except for lampreys and hagfish) have mandibles. As useful as jaws aie, they uo come with complications. In mouein humans, piimaiy among these aie Tempoiomanuibulai }oint anu Nuscle Bisoiueis (TN}NB oi TNB), oi Tempoiomanuibulai }oint synuiome. These umbiella teims uesciibe conuitions chaiacteiizeu by biting uiscomfoit, jaw clicking, facial anu jaw pain, eaiaches, heauaches, gastiic uistuibance, anu iestiicteu jaw motion, among othei symptoms. Although estimates of TNB pievalence iange fiom 4.6% ii to 17.9% iii of the populations stuuieu, the numbei of people who expeiience TNB-like symptoms at some point is piobably even highei. Foitunately, theie aie effective ways that hanus-on woik can help ielieve anu pievent the symptoms associateu with TNB. In this article, well discuss myofascial techniques for two of the most valuable players in TMD: the medial and lateral pterygoids. Although often overlooked, in our clinical experience, direct, sensitive work with these important structures is often the key to alleviating TMJ symptoms, and a part of shifting the usage patterns that contribute to continued misalignment and joint irritation. Since the pterygoids are deep muscles, they will not usually be the first structures you choose to address. Necessary preparation would include work with larger head/neck/shoulder patterns, and with outer layers such as the masters, temporalis, and digastrics. In our next article, well describe ways to work with these supporting players. In the meantime, we will assume that readers are familiar with other methods for preparing the surrounding structures before working the pterygoids. For inspiration, you may want to check out Advanced-Trainings.coms Anterior Neck/Shoulder Differentiation Technique on YouTube, which addresses the superficial cervical fascia and its effect on jaw alignment and mobility. Speaking, swallowing, and mastication all require three-dimensional movement of the mandible. But with this high degree of mobility comes greater susceptibility to jaw misalignment. Restricted soft tissues, imbalanced movement patterns, and fascial strain from elsewhere in the body can disrupt the delicate balance of the TMJs. The effects of jaw misalignment are compounded by the powerful forces of bite compression, which can squeeze or bind the articular disks and surrounding tissues. The result is tissue irritation, pain, and if uncorrected, possible joint degeneration and damage over time. Although paits of the pteiygoius can be accesseu extia-oially, in oui expeiience, woiking insiue the mouth (when agieeable to the client) is the most effective way to auuiess these stiuctuies. Befoie woiking intiaoially, be suie to explain the puipose anu intention of the woik, anu obtain explicit peimission fiom youi client to woik within his oi hei mouth. Nost clients aie veiy ieceptive to intiaoial woik when they unueistanu what it entails anu why it's being consiueieu. MEDIAL PTERYGOIDS Fiom a myo-stiuctuial point of view, many (if not most) TN} symptoms aie ielateu to joint compiession anu misalignment. Because the meuial pteiygoius play a key iole in both factois, woiking these stiuctuies is inuicateu whenevei you see symptoms of TN}. It is useful to think of the meuial pteiygoius as the "insiue masseteis" of the mouth. Like the masseteis, meuial pteiygoius aie stiong jaw-closeis. Togethei, the meuial pteiygoius anu masseteis cieate two v-shapeu slings (Image 1) that suppoit anu elevate the jaw. Babitual tension oi imbalance !"#$%$"&'()*+,'-./)0*0*123+45" " 6)1,"7" heie will exeit inappiopiiate foice on the TN}, contiibuting to iiiitation anu uysfunction. The meuial uppeimost attachments on the sphenoiu bone aie high anu ueep in the soft palate, anu aie piobably impossible to palpate uiiectly. Bowevei, the belly of the muscle is easily accessible wheie it lines the insiue of the jaw, in a miiioi image of the massetei on the outsiue. The lowei inseitions aie accessible just meuial to the angle of the manuible. To woik the meuial pteiygoius, gently palpate them on the meuial aspect of the jaw, simultaneously fiom both insiue anu outsiue the mouth (Images S anu 4). Feel foi aieas of highei tonus in the muscle belly, while using caie not to mistake the glanus anu othei uelicate stiuctuies heie foi aieas of tension (Image 2). Some clients can have a milu gag ieflex in this aiea, so woik slowly anu cautiously. Ask youi client to make small, slow jaw movements to help you uistinguish the infeiioi attachments just insiue the manuible's angle, as this is wheie uolgi tenuon oigans aie most concentiateu; steauy piessuie heie influences the postuial ieflexes that govein the iesting tone of the entiie muscle gioup iv . 0ui intention is ielease; so encouiage youi client to ielax his oi hei jaw anu to bieathe, while you keep youi piessuie steauy, slow, anu ieceptive. The mouth, inciuentally, has even moie of the biain's sensoiy coitex ueuicateu to it, than oui hanus uo. Thus, the mouth may be the only place we woik wheie youi client feels youi touch moie acutely than you feel theii tissue. Be extiemely sensitive anu patient when woiking intiaoially. Tiy it on youiself fiist to get a sense of the kinu of touch neeueu, anu the feeling of ielease afteiwaius.
Images 3 and 4: To work the medial pterygoids, gently press into their lower attachments on the medial aspect of the jaw from both inside and outside the mouth simultaneously. Ask your client to make small, slow jaw movements to help you locate the attachments and encourage release Image 2: When working the medial pterygoid (purple), keep in mind that they lie close the salivary and parotid glands, nerves, and delicate mucous membranes under the tongue. Image courtesy of Primal Pictures, used with permission. !"#$%$"&'()*+,'-./)0*0*123+45" " 6)1,"8" LATERAL PTERYGOIDS The lateial pteiygoiu muscles affect TN} health in at least two impoitant ways. Fiist, they initiate jaw opening. Since theii lowei heaus inseit on the manuibulai conuyle (Image S), they pull the jaw anteiioily in oiuei to begin the movement of jaw uepiession. If one siue's lateial pteiygoiu is tightei than the othei's, this will misalign the jaw's movement. The lateral pterygoid affects the TMJ in a second way. As you open and close your mouth, the TMJ's articular disk is positioned by its suspensory membrane, which is attached directly to the upper head of the lateral pterygoid (Image 6). In a healthy joint, this helps keep disk in position to cushion the contact point between the mandibular condyle and the temporal bone during opening and closing. However, excessive tension in the lateral pterygoids can contribute to anterior displacement of the articular disk. When this happens, or when there is excessive compression on the disk, the condyle can slide on and off the disk during jaw movement, producing the pop or click often associated with TMD. In more severe cases, the disk remains anterior to the condyle; the telltale popping sound is absent, but jaw opening is painful and limited.
Image 6: As the jaw depresses, membranes contiguous with the TMJ capsule and the upper head of the lateral pterygoid ("LP") suspend the articular disk within the joint (in green). When there is tension, misalignment, or excessive compression, the disk can be displaced (most often anteriorly). Note also that the anterior tissue of the external acoustic meatus (marked e) forms the posterior side of the TMJ joint capsule. Source image courtesy of Primal Pictures, used with permission. Image 5: The lateral pterygoid is in a unique position to both pull the jaw forward, and to influence the position of the TMJ's articular disk, as the superior head attaches to the TMJ capsule (yellow) and to the articular disk within. The zygomatic arch and the coronoid process of the mandible have been removed in this view to better show the lateral pterygoid. Image courtesy of Primal Pictures, used with permission. !"#$%$"&'()*+,'-./)0*0*123+45" " 6)1,"9" LATERAL PTERYGOID ASSESSMENT Since the anterior wall of the ear canal is contiguous with the posterior side of the TMJ capsule (Image 7), we can easily assess the amount of anterior mandibular condyle movement here. Position the tip of your little finger just inside each ear passage (Images 8 and 9). With your finger pads, feel for the mandibular condyles, which are palpable on the anterior wall of the canal. Ask your client to slowly begin to open his or her jaw, and you'll feel the condyles glide anteriorly. As the jaw begins to open, which condyle glides anteriorly (away from your finger pad) first? The lateral pterygoid on that side is likely tighter, so work that side as described below and recheck.
Image 7 (right): The anterior wall of the external acoustic meatus (purple) is the posterior side of the TMJ capsule (yellow). Palpating the movement of the condyle just inside the ear canal is an effective way to assess lateral pterygoid tension and balanced function. Source image courtesy of Primal Pictures, used with permission.
Images 8 (left) and 9 (right): To assess left-right balance of the lateral pterygoids, use your finger pads to palpate the anterior wall of the external acoustic meatus. Feel for any left/right differences in the anterior movement of the mandibular condyles as the jaw begins to open. The tighter lateral pterygoid will usually be on the side that moves earlier or more. !"#$%$"&'()*+,'-./)0*0*123+45" " 6)1,":" LATERAL PTERYGOID RELEASE TECHNIQUE Because the lateial pteiygoius can be uifficult to locate v , exploie this aiea in youi own mouth befoie woiking with a client. 0sing youi little fingei, sliue along the outsiue of youi uppei teeth until you come to the back euge of the last molai. Lateially, feel the insiue of youi cheek foi a veitical bony fin this is the coianoiu piocess of the manuible, anu the stiong tempoialis tenuon. You can confiim you'ie on the coianoiu piocess by opening anu closing youi jaw slightly; the piocess will cleaily move. Now shift youi jaw to the same-siue (Image 1u) to open up moie space between the coianoiu piocess anu the teeth. Notice that a pocket opens up behinu the last molai (Image 11). You may have to open youi mouth a bit moie to feel this, but only uo so enough to accommouate youi fingei as you move it fuithei posteiioily anu slightly meuially. The tip of youi fingei will now be on the lateial pteiygoiu; confiim anu iefine youi location by opening youi jaw slightly anu feeling the muscle contiact. 0se the same appioach with youi clients, being veiy gentle, patient, anu specific. Auuiess the tightei siue fiist, baseu on youi assessment of conuyle movement as uesciibeu above. Apply steauy, slow, ieceptive piessuie to the lateial pteiygoiu while asking foi small opening anu closing movements to facilitate its ielease. Reassess to see if the left anu iight manuibulai conuyles' anteiioi gliue is moie cooiuinateu, anu check in with youi client about any changes in pain level oi theii own peiception of movement. You may neeu to woik back anu foith between the lateial pteiygoius to achieve moie balanceu movement anu gieatei comfoit.
TEAM PLAYERS Although the meuial anu lateial pteiygoius aie often the "most valuable playeis" when woiking with TNB, they aie by no means the entiie team. Like stai playeis, theii key iole can oveishauow the impoitance of othei stiuctuies anu ielationships. If you ignoie the iest of the team, youi ability to help clients with TN} uisoiueis will be limiteu. As mentioneu, in the seconu pait of this aiticle, we'll piesent techniques foi auuiessing some of these othei impoitant team membeis. To maximize youi effectiveness, iemembei to attenu to both local factois (such as jaw tension anu alignment, bite occlusion, anu heau position), as well as global, whole-bouy patteins, since issues such as pelvis muscle tension vi , pelvic angle vii , anu spinal cuives viii have all been shown to coiielate with jaw function. As myofascial theiapists, oui intent is to ielease any soft tissue iestiictions anu movement patteins which inteifeie with alignment anu pain-fiee function. This appioach can be a veiy effective compliment to othei methous, such as stabilisation exeicises, postuial woik, etc. Since theie aie many appioaches to TN} anu no single methou woiks with all clients, uon't hesitate to use a vaiiety of appioaches oi to iefei clients to otheis as you tiack the iesults of youi woik. Images 10 and 11: To access the lateral pterygoid, ask your client to shift their jaw towards the side you're working, and slide your finger posteriorly and slightly medially. Because the lateral pterygoid inserts on the TMJ capsule and the suspensory membrane of the articular disk, work here can reduce tensions that cause the anterior disk displacement characteristic of TMD. !"#$%$"&'()*+,'-./)0*0*123+45" " 6)1,";"
Til Luchau is a lead instructor at Advanced-Trainings.com Inc., which offers continuing education DVDs and seminars throughout the United States and abroad. Til is a Certified Advanced Rolfer and on the faculty of the Rolf Institute of Structural Integration. Bethany Ward is certified in Advanced Myofascial Techniques. She is also a Certified Advanced Rolfer and Rolf Movement Practitioner, and a Rolf Institute faculty member. She and lead instructor, Larry Koliha, will be teaching Advanced-Trainings.com workshops in Australia throughout October 2012. Contact them at info@advanced-trainings.com or on Advanced-Trainings.com's Facebook page.
i Though still existent, amphioxus are thought to be an evolutionary predecessor to the modern vertebrates they resemble. ii Isong U, Gansky SA, Plesh O. Temporomandibular joint and muscle disorder-type pain in U.S. adults: the National Health Interview Survey. J Orofac Pain. 2008 Fall;22(4):317-22. iii Deng YM, Fu MK, Hgg U. Prevalence of temporomandibular joint dysfunction (TMJD) in Chinese children and adolescents. A cross-sectional epidemiological study. Eur J Orthod. 1995 Aug;17(4):305-9. Review. PubMed PMID: 8521924. iv Schleip, R. Fascial plasticity a new neurobiological explanation: Part I. Journal of Bodywork and Movement Therapies (2003) 7(1), 11-19 v Due to their location, there has been some debate about whether or not the lateral pterygoids can be palpated intraorally. (See: Tuerp JC, Minagi S. Palpation of the lateral pterygoid region in TMD--where is the evidence?, J Dent. 2001 Sep; 29(7):475-83, and Stratmann U, Mokrys K, Meyer U, et. al. Clinical anatomy and palpability of the inferior lateral pterygoid muscle, J Prosthet Dent. 2000 May;83(5):548-54). A more recent study (Stelzenmller W, Weber N-I, zkan V et al. Is the lateral pterygoid muscle palpable? A pilot study for determining the possibilities of palpating the lateral pterygoid muscle. International Poster, Journal of Dentistry and Oral Medicine 2006; 8(1):Poster 301), employing MRI and electromyogram verification, concluded that the lateral pterygoid's "muscle structure and pain sensation can be determined by digital palpation and subsequently treated by functional massage...". This outcome is consistant with our clinical experience that addressing this area is an effective approach to alleviating TMD symptoms. (Thanks to Dr. Leon Chaitow.) vi Lippold C, Danesh G, Schilgen M, Derup B Hackenberg L. Relationship between thoracic, lordotic, and pelvic inclination and craniofacial morphology in adults. Angle Orthod. 2006;76:779-85. vii Rocabado Seaton, Mariano & Iglarsh, Z. Annette. The Musculoskeletal Approach to Maxillofacial Pain. NY: Lippincott Williams & Wilkins, 1990 viii Cuccia A, Caradonna C. The relationship between the stomatognathic system and body posture. Clinics 2009;64(1):61-6.
Interactions between the Craniomandibular System and Cervical Spine: The influence of an unilateral change of occlusion on the upper cervical range of motion