Osteopathic Manipulative Treatment for Temporomandibular Disorders

OMT Minute: Osteopathic Manipulative Treatment for Temporomandibular Disorders

eVideo. Jordan Keys, DO, demonstrates the use of unilateral temporomandibular joint dysfunction muscle energy to target the muscles of mastication.

Temporomandibular disorder (TMD) is subclassified as a secondary headache disorder that affects more than 25% of the general population, and 85% to 95% of the population will exhibit at least 1 TMD symptom in their lifetime.^1,2 Chronic cases may lead to depression, poor sleep quality, and low energy and can negatively affect social activity and employment.³ While the causes of TMD are multifactorial, including psychological factors, most symptoms are due to hyperactive and dysfunctional musculature.⁴ Thus, addressing the musculature through manipulative techniques may improve TMD.

The muscles of mastication include the masseter, lateral and medial pterygoid, and temporalis, as well as the temporomandibular joint (TMJ) capsule and articular disk, which are crucial players of TMD's most common myofascial etiology.⁴ These muscular and ligamentous dysfunctions can cause abnormal mandibular tracking, clicking, and jaw locking, ultimately leading to pain and disability. Conservative treatment should be attempted before considering invasive options such as orthodontics or surgery.

The TMJ is a complex synovial hinge joint that allows for elevation and depression of the mandible with the assistance of suprahyoid muscles, as well as a gliding action, mostly via ipsilateral temporalis, masseter, and the medial and lateral pterygoids. The TMJ has an articular disk, which cushions the mandibular condyle in the mandibular fossa of the temporal bone and is secured by the temporomandibular and sphenomandibular ligaments.⁵ Clicking and popping, which occur in TMD, may be due to abnormal motion of the articular disk in the joint space.

Normal motion of the joint involves anterior displacement of the head of the mandible and articular disk upon depression (mouth opening). With the help of suprahyoid and infrahyoid muscles, normal bilateral lateral pterygoid muscular activity causes biomechanical depression, whereas a unilaterally hypertonic lateral pterygoid will cause contralateral mandibular deviation due to its origin at the lateral pterygoid plate of the sphenoid and insertion at the joint capsule of the TMJ and mandibular condyle.⁵ Hypertonic temporalis and masseter muscles will cause deviation to the ipsilateral side.⁶ The TMJ itself is innervated via the auriculotemporal nerve of the mandibular division of the trigeminal nerve, which also innervates skin to the temporal region.⁵ The joint may become irritated with daily activity of jaw opening, causing pain and discomfort.

Literature review demonstrates varying evidence to support muscular strengthening exercises, splint therapy, or electrophysical modalities.⁷ Osteopathic manipulative treatment may be an effective, conservative, first-line treatment.⁷ Use of muscle energy techniques on mandibular myofascial attachments and articular dysfunction, among other forms of osteopathic diagnosis and treatment, may reduce pain sensitivity and inflammation and restore oral motor function.^8,9 One technique, unilateral TMJ dysfunction muscle energy (video),¹⁰ can specifically target the muscles of mastication.⁴

Muscle energy techniques can safely be used in many patients presentations, but as it is a direct, active technique involving movement of the joint and joint musculature, it is contraindicated in patients with suspected fractures, joint dislocation or excessive joint laxity, and joint infection or effusion.¹¹

A focus on improvement of the biomechanics of the TMJ via improvement in the hypertonic musculature may be a helpful, conservative component to the management of TMD, allowing for improved motion and decreased pain and discomfort. The treatment described is not intended to manage any specific clinical condition but is only one aspect of the diagnosis and treatment plan an osteopathic physician may use to address the whole patient. (doi:10.7556/jaoa.2019.071)