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MORE DETAILS ABOUT TEMPOROMANDIBULAR JOINT DYSFUNCTION (TMJD) AND TREATMENT

These muscles of mastication are the masseter, the temporalis and the lateral pterygoid.

The masseters cover the jawbone as it descends from the TMJs and then angles to jut forward where it holds the teeth. It has been said to affect about 50% of the other muscles in the body. The power of its contraction is felt by placing your fingers along the back of your jaw and clenching. Fiber for fiber, it is the strongest muscle in the body.

The temporalis , as its name suggests, covers much of the temporal bone on the side of the skull largely above the ear. As I stated previously, temporalis contraction can be palpated as you clench. The quality of its cranial rhythm is among the most important. In fact, it is the bone for emergency jump-start if the rhythm stops, as I performed on Esther Sutton. It is reported that the emergency procedure has also restarted respiration.

The over-contraction of this muscle is one of the major causes of headaches, including migraine. Dr. Boyd reports that “”60%” of patients with migraine headache have been substantially relieved by his device.

The third muscle, the lateral pterygoid , is an internal muscle. It originates from deep in the recess of the oral cavity, from a downward extension of the sphenoid bone, so named because of its wing-like structure. The sphenoid is arguably the most important single bone in the cranial mechanism, and a downward extension is called the lateral pterygoid plate. It resembles the landing gear on an aircraft, and from that origin, the muscle goes dorsally (backward) and outwards to attach to the jaw close by the TMJ.

Whereas the first two cause closure of the jaw, the lateral pterygoid moves it forward when both contract, or to the opposite side when one does. The lateral pterygoid is not as easy to palpate, and only a portion of it can be by a skilled examiner.

A little finger is placed on the chewing surfaces of the back upper molars, right hand to right side and then rotated outwards to enter the space of the cheek outside the teeth just under the zygoma, the cheek bone. Then slowly, very slowly, allowing the tissues to accommodate, the finger is allowed to advance dorsally as if aiming for the ear canal.

A therapeutic technique is specific for releasing abnormal tension and scarring in each of the three muscles.

The TMJ related structures are intimately related to the ear mechanism and its functions. Important among them is the anatomy and physiology of the eustachian tube, which runs from the inner ear - inside the tympanic membrane, the eardrum - to open at the back of the mouth above the tonsils.

Air must be able to pass freely through the tube at all times to balance the air pressure, whatever it is, on both sides of the eardrum, so its delicate membrane can mechanically respond to sound waves and transmit them through fluid to be picked up and become electrical impulses that you hear as sound. The intricacy of it is exquisitely unimaginable, and whenever I need a good laugh I think of the “scientists” who declare it all happened during a long evolutionary crapshoot.

If the pressure is not equalized, then the movement of the eardrum is impaired, and earache, acute and chronic, loss of hearing, problems with balance, tinnitus (ringing in the ears) and other conditions can result. The TMJ is so close to the ear that it is palpable by placing the little fingers in the ear canals and palpating on its anterior surface as the mouth is opened and closed.

Some of the tiniest, hardly visible of muscles - with most impressive names – the tensor veli palatini and pharyngopalatinus control the eustachian tube's cartilaginous orifice, the torus tubarius, at its oral end.

Because the Fifth Cranial Nerve innervates them and the muscles of mastication, problems in one can influence the other however its influence may hide in the relatively unrealized relationship: within that complex and intimate binding, what may go wrong in the mouth can affect the ear, and visa versa - from the purely physical, like malocclusion, to the clenching that expresses stresses of the mind.

The muscles can lock, contracture, scar and become caught in a degenerative cascade the same as the tissues about the spine, and the soundest way to approach them is through orthopaedic medical techniques.

Many alleged TMJ conditions originate from problems here. Commonly the ears “pop” or give the sense of an unpredictably bothersome fullness. It all can frequently be relieved by an easily performed “sweeping” maneuver across the eustachial orifice. A (gloved) finger goes far back into the mouth beyond the soft palate to the eustachial orifice where it massages and stretches the tissues, breaking down adhesions and relieving edema that may cause sufficient stasis to “close the area.” The procedure takes only a few seconds.

A highbrow name was coined - Trigeminal Pharyngoplasty - for many reasons, particularly to facilitate big billing as a technical procedure. An old osteopath first showed it to me maybe thirty years ago when it was an incidental office treatment for post-pharyngeal congestion.

These muscles of mastication are the masseter, the temporalis and the lateral pterygoid.

A little finger is placed on the chewing surfaces of the back upper molars, right hand to right side, and then rotated outwards to enter the space of the cheek outside the teeth just under the zygoma, the cheek bone. Then slowly, very slowly, allowing the tissues to accommodate, the finger is allowed to advance dorsally as if aiming for the ear canal.

A therapeutic technique is specific for releasing abnormal tension and scarring in each of the three muscles.

All those structures and more can become sources of “TMJ” pain. With the blending of the orthopaedic medical approaches into the dental foundations of TMJD treatment, a major contribution to the healing arts is in he offing.

There are no boundaries. There are no boundaries!

SYNOVIAL ENTRAPMENT

This is specially prepared for those who saw my presentation at the Israeli Medical Association Meeting December 15-16, 2005.

The cases are excerpts from Release From Pain.

A NEW AC DIAGNOSIS

Pat Hansen's case is unique. If you want an approximation of her suffering, bite the inside of your cheek and hold it - for fifteen months! It was early 1974. Pat had been serially recycled through the departments at the University of California , Davis/Sacramento Medical Center since her injury. This time, she returned to Occupational Therapy with a plaintive Rx from orthopedic surgery. “Teach this woman to use her right arm!”

I first saw Pat from her back. She was sitting at the conference table in the clinic. Despite all the therapies, excruciating pain unremittingly drove her to the ground every time she attempted to move her right shoulder at all. Dr. Mel Sterling, one of the professors asked me if I thought I might be able to help her.

Her history was so unusual, it taunted diagnosis, and the totality of it was baffling until the very end. Pat had been involved in a very minor auto accident. She had been seen in the emergency room where she was fitted with a firm cervical collar and told to return home and rest for a few days. Everything was reasonable and well documented.

She was lying on her right side reading for a few hours, when suddenly she felt as if she'd sunk deeper into the bed. Within minutes, pain was intensifying at the top of her right shoulder and radiating through her thoracic spine and right scapula areas. In a short time, she was totally disabled by severe pain with no position of relief.

As I approached her, immediately obvious to me was a puffy edema in the skin overlying her right scapula. Just running my fingers gently over it markedly intensified her pain, and when I attempted to barely mobilize her AC joint, she turned a gray ashen, groaned and almost fainted.

I admitted Pat to the hospital. I told her that although I had no idea what was producing her symptoms, I was certain where a significant part of her pain was coming from. That, itself, was therapeutic for her. She was resented because she'd failed to respond for so long as reflected in the orthopedic surgical Rx.

Palpating her thoracic spine revealed a remarkable loss of the resilience that normally is sensed as a moderately firm spring under the gentle but firm pressure of the examiner's hand as the patient lies prone. Hers was "locked" and exquisitely tender, as well. Skin rolling the area or trying to mobilize her scapula was impossibly painful, and there was also a minor dysfunction in her neck. Neurologically, she was normal.

I completed my examination on the ward that evening and explained my thinking. After fifteen months, many adaptive abnormal tissue changes had occurred from the prolonged spasm and tissue contracture. We could work a few weeks to try to soften them, or I could immediately manipulate the rigidity of her thoracic spine, which I hesitated recommending. Manipulation shouldn't be painful. This one would likely be, and it could cause complications. Whatever I preferred, Pat didn't hesitate to interrupt me. She told me emphatically that she had been in such severe pain for so long, she didn't think it could get worse. “Do it!”

I needed a firm surface to manipulate her on, and rather than reopen the clinic several floors down, I cleared the ping-pong table in the recreation room. With her lying supine, the relieving manipulation to her neck went easily and happily relieved that minor aspect of her case.

Then, I placed my right arm around and under her, my closed hand placed carefully under the most obviously restricted segments of her thoracic spine. I folded her arms over her chest arms uncrossed and moved my chest close against her elbows. I put my left hand under her head and flexed her neck sufficiently to focus my intended force through my chest at my hand and further facilitated the maneuver by Pat's pushing her head back slightly into my hand.

. Pat relaxed as best she could. The manipulation is performed by “taking up the slack” and then thrusting down with my chest while “moving towards the upward.”

It was the shot heard round the ward! It was the loudest single manipulative release of my life, as if a pistol had been fired, so alarming, the nurses ran in from down the hall. At the " craaack," Pat's mouth opened to scream, but it stopped in her throat as she looked at me wide-eyed, "My God, most of the pain is gone!"

Within minutes, the resilience in her spine was improved, and within a few days, with directed physical therapy, all her skin and soft tissues pain had cleared. Her skin rolling was normal, and I was able to painlessly mobilize her scapula. The prompt change was remarkable. The body's ability to heal when an impediment is removed can seem miraculous.

But at that same moment, despite the reasons to rejoice, Pat's AC joint was obviously the same. Any movement of her arm away from her body still drove her instantly to the ground. I anesthetized the joint with an injection, and, for about an hour, Pat was totally pain free for the first time in about four hundred days and able to fully range her shoulder, but she commented that she still felt " As if there's something in it, like a piece of rubber."

The next morning, I performed arthrograms on both ACs. I could find no reference for normalcy. AC arthrograms hadn't been reported. I studied the left side first and assumed it was normal, so it became my standard.

The dye pattern looked like an inverted T ( ^ ) with an abundant inferior reservoir and thick vertical column in the joint space. Pat's right, symptomatic, side also showed a similar inferior recess, but as I watched the dye enter on the intensifier screen, the verticality was a bare hairline. Clearly, most of the joint was filled with something.

From that point, I believed Pat's condition required surgery. I spoke with the chief of orthopedic surgery. His reflex response was that they'd first do their own arthrogram. Pat disagreed. She reminded them what she had gone through and how many chances they'd had at her. If they wouldn't explore her AC on my diagnosis, she'd go elsewhere. They accepted but refused to just explore the joint. The C hief's condition was that they would perform only the standard surgery - the excision of the end of her clavicle - or nothing, thus taking care of the problem by obliterating the entire joint. That's the way things were done. They would not consent to see what was there and then decide. The idea that Pat's total shoulder pathology – that they had not diagnosed - was from unheard of soft-tissue entrapment did not please them. Pat agreed to the surgery.

The C hief did agree, however, that as soon as the joint was entered, he would step back and allow me to examine and photograph it. I stood behind him in the operating room with all my equipment set up. The C hief incised the capsule then in a sudden blur he picked up a sponge with a clamp and thrust it forcefully into the joint, in and out, again and again, as I watched in anguished, sickening surprise. What had been trapped was gone. Finally the C hief turned his head to me, his eyes slits above his surgical mask, as he said acidly, “Look for yourself. There's nothing in there.”

Pat had been cured, but I still didn't understand how the accident had happened.

I studied fifty fresh post-mortem AC joints, from infancy through the tenth decades. What was immediately clear was that Pat had congenital anomalies in both joints. I didn't find a single joint with a " ^ " on the arthrograms. In all fifty cases, the ligaments under the joints were completely intact and fully supported them. Not one had any recess at all. The consensus normal arthrographic appearance was discoid.

That last residency year in Northern California , I was away from my family for two or three weeks at a time. It was agreed I could “moonlight,” so long as I didn't work in hospitals around Sacramento . I'd fly back to Los Angeles on a Friday and go straight to my small office, see patients, get a little sleep, fly my Cessna 310 to El Centro early the next morning, see patients, fly back, see patients again on Sunday in Los Angeles and race for the last PSA flight back to Sacramento. One evening, I returned home after traveling somewhere, exhausted and desperate for sleep. Doing something I'd never before done in my life, I crawled into bed and almost begged the mattress to close over me. Lying on my side, I kept pushing myself into the mattress harder and harder trying to literally bury myself into it.

Suddenly, my mind exploded in the purest of Archimedes E ureka experiences! It was among the rarest of human events that, if it happens once in a life, is worthy of a lifetime's celebration. I knew ! Amazingly, I was instantly totally refreshed, shouting, jumping up and down on the bed. (I have had one other somewhat similar experience, an incredible illustration of the incalculable power of the mind.)

Pat had been on her side reading for hours. Her persistent weight on the mattress slowly stretched her shoulder muscles sufficiently so her humerus moved down slightly from its position directly under her AC. Under ordinary circumstances, it would have made no difference at all, but Pat's underside ligaments are defective though she'd lived her whole life till then with no problem. Anatomically, all the restraining ligaments about the AC joint keep the clavicle from moving up. None of them keep it from moving down! Pat was wearing a hard cervical collar that kept exerting a downward pressure onto her clavicle. At the fateful instant, the forces converged, and the joint collapsed. The clavicle dislocated inferiorly, trapped synovium and, as suddenly, realigned itself while capturing the soft tissue in a vicious vise.

Pat did suddenly sink into the bed! Lying on her side, her vertical clavicle became a major strut supporting her horizontal spine. As it unexpectedly "kicked out," in that instant, her spine reflexively buckled in a totally unnatural manner. As the mid thoracic joints suddenly “sprung” and gapped, they jammed and locked, also possibly entrapping their own synovium along the linkage.

A new hip diagnosis:

Concerning synovial entrapment in the hip, it was 1972. I was then “Co-Chairman of Acupuncture Research” at USC, and it was my task to decide which pain patients would be studied.

Lisa was a delicate 12 -year-old girl with a touch of intestinal flu who had only a little fever and diarrhea as she went to the potty to pee. She stood up. She screamed in agony and fell to the floor. For the next six months, she couldn't bear any weight on her left leg, or sit, without immediately experiencing intense pain. During that time, she had been seen by many orthopedic surgeons, including at Orthopaedic Hospital , in Los Angeles , without success. As a last resort, Lisa's mother had brought her to the clinic, but one glance at that gentle gazelle and I knew she would never tolerate the needles.

Yu Wing Choi, a Chinese physician who had recently escaped from Red China, was teaching us and wanted to try. I smiled as he entered her room, from which almost immediately there screeched the most piercing screams followed by a fast exiting, very pale and sweating Yu Wing, who, in his inimitable accent, pleaded, “ You twy!”

Lisa's findings were fascinating. As she lay on the table looking up at me, her left leg was 15 ° more outwardly rotated than her right, and testing demonstrated that it internally rotated less than the right by the same amount, i.e. the entire range of her left hip had been precisely shifted. Trying to move her left hip joint through its natural range of motion by raising her leg was immediately prohibitively painful, but she was able to tolerate its passive motion in a different way, with my hands close about the hip joint. I performed a “short fulcrum” mobilization rotating the head of the femur within in the acetabulum. The maneuver was pain free by, in retrospect, having avoided the stresses that the long leverage had provoked. Otherwise, her examination was remarkably normal except for a little irritability in her low back.

Lisa's mother brought her back the next day and told me optimistically that, for the first time, she had been able to sit for fifteen minutes before the pain recurred, so I repeated the procedures.

I didn't know what Lisa had, or how it had happened, but I suspected that something was caught in her hip joint, abnormally displacing it, and that the pain resulted from this something being pinched whenever she tried to bear weight. Such a condition had never been visualized.

Freddie Kaltenborn, a Norwegian physical therapist who had taught me the mobilization techniques along with much else, had told us about a fatigued hiker who had fallen on a slippery switchback and injured his hip. He hadn't been able to relieve him until he performed an “axial traction manipulation.” He didn't know why it had helped. I wondered if there might be a relationship.

I went to the radiology department and asked who might perform a cinearthrogram , an x-ray movie of the hip and was directed to Dr. Frank Turner, then Professor of Radiology. Frank became one of the great compatabilities of my life, a man of unabashed enthusiasm who wasn't threatened by someone else's ideas and who loved a new search. I was amazed at what his gifted eyes could see on an x-ray. He is a great teacher who loves what he does. He could quote from 10,000 papers he'd read. He'd performed over 5000 hip arthrograms. Frank listened and simply said, "Let's do it."

I sedated Lisa, secured a strap around her ankle and around my back and, as we watched on the image intensifier, I leaned back and gently eased her femur from the acetabulum. Frank was astonished. He'd never seen that done before.

Comparing the findings with her right side, there indeed was a difference in the shape of the joint space as I continued to move Lisa's femur in and out. The haze of a soft tissue mass was clearly visible in the inferior aspect of the joint. First, I performed the axial traction manipulation, a sudden additional thrust at the end of the range, and followed it with an arthrogram. In Lisa's case, I added to the procedure by maximally filling the joint under pressure to "push out" anything entrapped, as may be done with barium to reduce an intussusception. When Lisa awakened, she was cured.

December 3, 06 Technical difficulties with the hip entrapment video were discovered after a hacker attempted to sabotage the website. It should be corrected within the next few days.

Click here to see the slide show.

Broadband Users- Click here to view the Cinearthrogram.

Non-Broadband Users- Right click here and then select 'Save Target As' to download the Cine.