Soft Tissue Review Summer 2008
Innervation of mastication muscles: anterior trunk of mandibular
nerve of CNV3
Muscles involved with CLOSING
-temporalis
-masseter
-medial pterygoid
Muscles involved with OPENING
-diagastric
-suprahyoid
Lateral pterygoid- pulls open jaw, protrudes mandible, lateral
movement, pulls condyle forward and disc anterior
Anatomy
Temporalisorigin- triangular muscle with broad attachment to the
floor of temporal fossa and deep surface of temporal
fascia
Insertion- narrow attachment to tip and medial surface of
coronoid process and anterior border of ramus of
mandible
Masseter Origin- quadrate muscle attaching to the inferior border
And medial surface of maxillary process of zygomatic bone
and the zygomatic arch
insertion- angle of lateral surface of ramus and mandible
Susanne’s notes summer 2008
Medial pterygoid
Origin- quadrangular 2 headed muscle from medial
surface of the lateral pterygoid plate and pyramidal
process of the palatine bone and tuberosity of maxilla
Insertion- medial surface of ramus of the mandible,
inferior to mandibular foramen; in essence, a “mirror
image” of the ipsilateral masseter, the two muscles
flanking the ramus
Lateral pterygoidOrigin- triangular two-headed muscle from infratemporal
surface and crest of greater wing of sphenoid and lateral
surface of lateral pterygoid plate
insertion- superior head attaches primarily to joint
capsule and articular disk of TMJ; inferior head attaches
primarily to pterygoid fovea on anteromedial aspect of
neck of condyloid process of mandible.
Digastric (a suprahyoid muscle)
Origin- anterior belly: digastric fossa of mandible
Posterior belly: mastoid notch of temporal
bone
Insertion- intermediate tendon to body and greater horn
of hyoid
innervation: anterior belly: nerve to mylohyoid, a branch of
inferior alveolar nerve
posterior belly: digastric belly: digastric branch
of the facial nerve, CN VII
TMD Innervation
Trigeminal
-post deep temporal & massenteric nerve: supplies medial and
anterior portions of the joint
Susanne’s notes summer 2008
-auriculotemporal nerve: supplies post & lateral regions
(capsule) AND branch to tympanic membrane (ext. auditory
meatus)
TMD - Etiology
Etiology of pain is multicausal – 5 factors
1. neurological
2. vascular
3. joint diease (infection, disc derangement, condylar displacement,
microtrauma, trauma)
4. muscular
5. hysterical
Differential DX
Capsulitis-(stretch) - distraction type
Synovitis- (compression) posterior/ superior pressure (affects
retrodiscal area
Myofascial (contraction) – resisted ROM
Difference between intraarticular and extraarticular TMJ
conditions
Intraarticular- synovitis and capsulitis with a focus on articular disc
(often displace or degenerated)
Extraarticular: ranger from cervical spine involvement (myofascial,
postural, subluxaiton-related dys), to dental abnormalities and/ or
pathologies
Pathological tonic neck reflex- and its effect on cervical spine
and posture
Aberrant impulses from subluxation may result in pathological TNR
causing dysfunctional head posture.
Susanne’s notes summer 2008
Studies have shown that changes in head posture will affect the
position of the mandible.
TMD and breastfeeding difficulties
Most common cause of breastfeeding difficulties. 800/1000 newborns
birth induced TMJ dysfunction was found to be the cause. Babies
were teated with chiropractic cranial and spinal adjustments, with
excellent results in 99% of the cases.
Management of TMD: chiropractic adjustment and rehab
exercises
If joint inflamed- don’t do diversified
If joint has adhesions then do diversified
Joint gapping with gloves may use either unilateral or bilateral
variation
Look at posture
Pelvis/ SI joint
Spinal curves
Anterior weightbearing
Cervical subluxation
Hypertonic muscles may lead to dysfunction of TMJ
-temporalis – may pull condyle posterior
-lateral pterygoid muscle: may pull disk anterior
-masster muscles
TMJ exercises
Relax “tight” jaw or TMJ muscles or Bruxism
-open mouth until your mouth until jaw muscles feel some
stretching which about 75%
-hold your mouth open for 20 seconds then close slowly until
your lips touch.
-open slowly and repeat 5x for about 2 minutes. Perform 4x/
day and whenever your teeth are touching or clenching
Susanne’s notes summer 2008
Strengthen Jaw/ TMJ’s Opening Muscles
Performed after above exercise
-Rest the “tip” of your jaw between the middle and index finger
of a closed fist with your forearm against your chest. Hold
gentle pressure against your chin while slowly opening an
closing. Your head stays in one place during exercise
-
try to keep the muscle under the chin tense while opening
and closing using the pressure of the arm to slose the mouth
until the lips tough
repeat 20x or until the muscles fatigue
Prevent side to side jaw “Overmotion”
-place the tip of your tongue a little behind the top teeth on the
side away from the “popping” side or the side that moves too
much
keeping the tongue in contact with the roof of the mouth open
and close slowly. 20 times 4x/day. Watch in a mirror to self
correct yourself in order to open and close your mouth evenly
Prevent Jaw Jutting Forward (protruding) or opening
-place the tip of your tongue near the back (soft) part of the roof
of the mouth
-maintain your tongue contact while you open and close your
mouth 20x 4x/day. Watch in a mirror to self correct and open
and close your mouth evenly
Foreman and Croft “Whiplash Injuries”
?????
TMJ Evaluation
Mandibular gait pattern/tracking
Susanne’s notes summer 2008
Inspection:
Opening (52 mm)
Closing
Protrusion (12mm)
Lateraltrusion (8mm)
Auscultation:
Clicking over the TMJ during opening and closing
Palpation:
Pain with static palpation
-lateral condlyle
-superior joint space
-posterior joint space
-angle of mandible
-coronoid process
Pain with palpation during active ROM
- contact on coronoid process
- finger in the ear
- mandibular test/stylomandibular ligament/ pterygoid
Trigger Points
-temporalis
-masseter
-medial pterygoid (internal)
-lateral ptyergoid (external)
-diagastic
-sternocleidomastoid
-trapezius
-posterior cervicals
Susanne’s notes summer 2008
Provocative maneuvers
Mandibular resisted ROM- induces myofascial pain during contraction
-opening (diagastric and suprahyoid)
-closing (temporalis, masseter, and medial pterygoid)
Mandibular Stretch – jaw distraction
-pain over the TMJ indicative of capsulitis
Mandibular Compression- posterior superior pressure
-pain is indicative of synovitis (compression of the retrodiscal
Area)
Swallowing test
Neurological examination of Cranial Nerve V
Contraindications to mandibular manipulation
-conditions that weaken the mandible; extreme bony resorption,
cystic lesions, infections, turmors, or osteoporosis (may lead to
iatrogenic fracture)
-conditions that weaken the dentition: periodontal disease,
caries or temporary restorations (do not use strong manual
force on the mandible or the mandible as a lever
-patients level of anxiety
-level of muscle splinting across the TMJ
“Myofascial Pain Syndromes”
Trigger point genesis
-pain is modulated at what 4 levels?
1. mechanoreceptors at injury site
2. cord
3. thalamus/subcortical
4. cortex
Factors which contribute to the sustained muscle contraction
Susanne’s notes summer 2008
Factors which contribute to pain
What factors contribute to chronic inflammation?
1. no physiological debridement
2. persistent mechanical and/or chemical irritation
3. antigenic stimulus- immune responses, food allergies,
environment, DM 2x the healing time
4. immobility
What are 3 ways to inactivate trigger points?
-ischemic compression
-needling/acupuncture
-vapocoolant spray and stretch
-passive stretching without spraying
-injections of saline or anesthetic acupuncture
-ultrasound
What is the difference between latent and active trigger
points?
ACTIVE TRIGGER POINT
-produces pain WITHOUT digital compression
-very tender on palpation
-characteristic pain pattern for the muscle (either with ischemic
compression or without)
-impedes muscular flexibility
-produces muscle weakness
-may elicit a local twitch response with compression (or needle
stimulation)
Susanne’s notes summer 2008
LATENT TRIGGER POINT
-usually silent- no spontaneous pain
-tender on palpation
-produces referred pain pattern only ischemic compression
-impedes muscle flexibility
-produces muscle weakness
-may elicit a local twitch response with compression (or needle
stimulation)
Active TrP may become latent in a chronic stage
May become active with microinjury/microtrauma or
Macrotrauma
Be able to apply the tenderness scale
-Grade I: Pt. complains of pain
-grade II: Pt. complains of pain and winces
-Grade III Pt. winces and withdraws the joint
-Grade IV Pt. will not allow palpation of the joint
Bruegger’s Position: purpose and method
-
microbreak for 10 seconds recommended ever 20-30 minutes
while working in a seating position
-perch on the edge of the chair
-separate the legs
-turn feet out slightly
-push breastbone forward and up, thus gently
arching the lower back
-tuck the chin slightly so that the head moves
backwards over your shoulders
-put hands down by the side, palm forward, until the
shoulders gently roll backward and your thumbs
point outward
-take a breath into your abdomen and then relax
What muscles are weakened in the Upper Crossed Syndrome?
-deep neck flexors weak, rhomboids and serratus anterior
Susanne’s notes summer 2008
Lower Syndrome weakened muscles?
-abdominals and weak gluteus maximus
What muscles are hypertonic/shortened in the upper crossed
syndrome?
-tight pectoralis, trapezius, and levator scapula
Lower Syndrome?
-erector spinae and tight iliopsoas
Know the 5 types of functional hypertonicity of muscles
-limbic system dysfunction: meditation, psychological
Counseling, relaxation strategies
-interneuron dysfunction: PIR, and/or adjustments. Due to
spinal or peripheral joint dysfunction- hypertonicity of muscles
that are segmentally related.
-myofascial trigger points: PIR, ischemic compression, spray
and stretch, Hyperirritable spot, usually within a taut band of
skeletal muscle or muscle fascia. Painful on compression and
gives rise to characteristic referred pain, tenderness and
autonomic phenomena
Reflex spasm: treat underlying cause. Acute response to
nociception, frequently acts as splinting. Ex. antalgia due to low
back pain, abdominal rigidity due to appendicitis. Can lead to
trigger poits after acute pain decreases. Possibly use PIR after
acute phase.
Overuse muscle tightness: Post-facilitation stretch (PFS),
perpendicular myopathological and neuropathological muscle
folding, state where muscle becomes hypertonic and shortened.
Antagonist reciprocally inhibited which sets up imbalanced
activity.
Susanne’s notes summer 2008
Matching questions:
these techniques:
types of techniques and application of
Graston- remove fibrotic tissue
PIR- trigger points, good for anxious or geriatric patient, muscle
hypertonicity, and muscle overuse
Transverse Friction Massage- for chronic, localized pressure usually
on a ligament or on the components of muscle, possibly chronically
painful bursae
Barnes Myofascial Release- active myofascial trigger points and
adhesions, pain patterns that follow no known dermatomes, myotome,
or sclerotome
Ischemic Compression- trigger points
Which techniques are utilized in acute care?
Which techniques are used in rehabilitative care?
Which techniques are used in remodeling phase of care?
Susanne’s notes summer 2008