15 Extravertebral Disorders: Temporomandibular Joint, Nasal Septum, and Sinus TRENT R. BACHMAN In reviewing the itemture on disorders ofthe temporo- ‘mandibular joint (TM), two distinct characteristics are ‘Immediately apparent. Firs, the majority claim tobe suc cessful with their mahods of conection ofthis mala. Second, there i ite interprofesional collaboration in andardization of tratment. Therefore, i providing a ‘temporary approach othe diagnosis and treatment of temporomandibular disorders, i i the intent of the author to provide a concise protocl for chiropractors ‘which also incorporas a corroboration with the various Allied professionals specializing inthis area. The chiro- actor's unigue tring in detecting and correcting joint Aysfunction lends a cistnct advantage in providing care to patients with TM disorders ‘Oflen, the most uefultoolin determining the cause of temporomandibula disorders is derived fom the patient history. Seldom isa sngular underlying traumatic event the causeaf the condiion. TMI dysfunction isconsidered to bea multifactorial disease (Table 15.1)(1). ‘When the chiropactor encounters a patient present the ably to derive an accurte diagnosis and provide @ correaive treatment program. For TMJ disorder, asin the cae ofthe vertbal subluxation comple, the logical And most productive course of management is (0 sar “with noninvasive revsble forms of weatment and the- _apy and to escalate necessary, asthe severity ofthe con- ‘dition dictates, All co often, chiropractors ae quick to refer TMJ patentstodentstsand othe aed health ro- fessionals when they can be managed, and often times tweated, with chiroprictic methods. When the severity of ‘the condition dictate a teamwork approach, the chiro- practor should refer tea dentist o other lied heath ro- Fesional familiar wit the TMi and with whom working relationship can thea be established. The chiropractor ‘may also want to ref the patient oa diagnosticimaging ‘center or compreheasive rehabilitation faiityo obtain ‘scitional information inorder to get an accurate dag- nosis oF 10 incorporte adjunctive therapies that may ‘enhance the patient's recovery. Additionally, there i & hee forthe chiropractor to incorporate ss many objec: ‘ivetools avaiable ss uteome measures fr man iea- ‘ment and any adjunctive therapies. ‘Surface Anatomy of the Temporomandibular Joint “The temporomandibulr joints stated just anterior to the extemal acoustic meatus and below be posterior end ‘ofthe zygomatic arch, When th mouths open, the con ‘gles move ou ofthe mandibular fossa into the articular ‘tubercle, at which time a depression isnoted on palpation ‘ofthe joint. When palpating forte locaton of the TM, itis the posterior lateral aspect ofthe condyle which the clinician locates to monitor the maverent through its range of motion 2, ‘The temporomandibular joint isa threejoint com- plex that consists of the head of he conde and its atc- Ultion with the inferior border ofthe articular discs. The ‘superior boundary of the joints housed within the glen- ‘id fossa which articulates with he superior border ofthe larticular dis, The head of the mandibular condyle is Kknuckle-shaped and convex in all directions and is accepted via the articular disc in theglenoi fossa which isoval and deeply concave (Fig 151) "The articular die is described as rm, ova, fibrous. plate, Whea vewedin thelateralplane (Fig 152), itscen ‘Propeeed Causes of Tomporomandhula Joint Oytunton* Exaraleanaio ips eer macoeFrontal ew ure 161, Antar ow of fe tengo ft Wut ‘tg te arto eirare fh he compos (ty DeDerycut) tealportion suit thin wth respect the periphery. The Posterior border is especialy thick. The discs fused tothe ‘capsule atthe anterior aspect where i extends forvardin Front ofthe condve. Thi allows forthe attachment ofthe superior fibers ofthe lateral pterygoid muscle, The cap- Sale is continuous posteriorly withthe retrodisal pad, “The anterior portion ofthe aiclar disci avaseular Jn contrast tothe retodieal pa, which ia vascularized And innervated thik layer of connective ussve attached to the posterior wall ofthe capsule The unique avascul characterise of the articular ese is complemented by vascular fibrous layers covering the mandible and the ‘enoid temporal surface of the TMJ. The lack of vascu- Tarized tissue suggests the presence of considerable ‘mechanical sireses along this portion ofthe joint ‘The eapsule and articular diss are independently attached inferiony tothe medial and lateral pols ofthe ‘condyle. Thisuniqueatachment ofthe dsc othe respec- tive pokes ofthe condyle assures synchronization of nor ‘mal biomechanical movements by the mandible and the Fibrous Capsule ‘The ibrouscapsule of the TMJ is attached tothe anicular tuberele ofthe temporal bone and along the limits ofthe posterior oot ofthe zygoma Posterior, the fibrous eap- Sale aries fom the posterior aspect ofthe articular lip. “Although the capsule is stongy reinforced laterally, it tends tobe loosely arranged antenely, posteriorly, and medially. ‘The lateral capsular region it strongly rei forced via the emporomandibularigament.A wide fn shaped lateral portion and 2 narow medial band com- [se the two separate layers of the temporomandibular ligament. The broad fan-shaped portion ofthis igament ‘connected slong the zygomatic process ofthe temporal ‘TEXTBOOK OF CLINICAL CHIROPRACTIC ‘Superior jin space igure 182. Lanra vow of me tporonenebur fort com ‘rman The denon vosauread wre he voc ste [Shy acre (Cosy ODay Cut) ‘bone ands natow portion isattached to the neck ofthe ‘mandible Is posterior fibers present a vertical arange ‘ment between te mandible and temporal bones, whereas ‘the anterior fibers are obliquely arranged inferiorly and posteriory. The medial poction ofthe fibers travel pe marily ina horizontal manner and comprise a iamen- ‘ous band which atiaches to the crest ofthe articular ‘tubercle and extends along the lateral pole ofthe mandi ularcondyie and attaches to the die “The Function of the ligaments is primarily to limit ‘movementsof the mandible. The teal fan-shaped bers prevent the mandibular condyle from being displaced ay from the aniclar eminence, The medial band pre ‘vents excessive etrusive movements and thus prevents ‘he condyle from pressing against and damaging the ts ‘ies behind the articulation (3), ‘The sphenomandibular and the stylomandibular are considered tobe the accesor gaments of the TMJ. The siylomandibular ligament extends from the syloidpro- ‘essand stylohysid ligament tothe angle ofthe mandible. ‘The ligament tenses when the mandible s protruded and isloose when te jaw isclosed. When the jaw sat it max- imal opening his ligament i in ite moet relaxed sate ‘The suggested function ofthe stylomandibuar ligament isto imitexcesiveprotusve movements (3). The sphe- nomandibular ligament originates from the sphenoid Spine and inserts nto the mandibular ligula and neck of the mandible. Shore (4) supgrsts thatthe accessory ia ‘ments function in a restrictive manner to keep the con Ayle, temporal bone and articular disc firmly opposed, ‘Synovial Membrane ‘The synovial membrane consists ofa highly vascularized {orm of connecive tissue which lines the entire fbrous capsule. also covers the superior and inferior surfices of the retrodiscal pad and the loose connective tisues anchoring the posterior border of the disc to the capsule,conaeres ‘The rich vascular supply which the synovial tissue require is located in the posterior compartment via the Superficial temporal artery. Essentially, the synovial ‘membrane line ll of the TMJ articular structs which ‘re not subject searing or compressive steses. The synovial membranes absent inthe articular surfaces sub- [ected to compressve and shearing forces, such athe ‘mandibular cond, articular dis, and the temporal bone, Masticatory Muscle Acton ‘When examining the masticatory muscle structures for possible exacapsuar involvement, the clinician must farefully evaluate the agonist as well a the antagonist ‘muscles. ‘The musculoskeletal system provides the ‘mechanical power i stabilizing, positioning, and move- ‘ment of the TMI ariculation. tis critial to understand that no single musce structure acts lone inthis proces. In order for normal movement tobe performed, a coop- ‘erative effort between the agonist musles and the aniag- nist musclesis necessary. As the agonist muscles initiate Joint movement, he antagonist muscles working in con- er. spon in oppston by producing arated and ‘controlled muscularcontracton. Muscle Tone “Muscle tonus is characterized primarily by the muscles’ resistance to elongation or stretch. Clinically, muscle tons i described a: hypertonic or hypotonic. Hyperto- city relates othe mustes relative expansion in passive resntance to steiceing of ie must ies Fiypouicty ‘lates toa diminished passive resistance to stretch. Muscle Spasm ‘Muscle spasm is characterized by an abrupt involuntary ‘muscle contracture, sither individually orasa group, Tai ‘henomenon involes functionally related musculature land is accompanied by pain and mechanical interference {normal joint atity, When spat muscle contraction is present, it may tke the form of isometric or isotonic ‘behavior. sotonic muscle spasm creates a shortening of the muscle which leads to aberration in muscular move- ment and tone. Isometric muscle spasm produces & ‘marked resistance stretching and is characterized as ‘muscular rigity. Muscle spasm i readily observed and ‘sil palpated on craluation Muscle Splinting ‘Muscle splinting is characterized by an involuntary increase of tonicity of the musculature, which in turn ais the stability and normal movement of the TM is believed that muscle splinting isa response to altered JAR JOINT, NASAL 435 1, ano SINUS. ‘mechanical or proprioceptive sensory impulses. In con- {rast muscle spasm, splinting readily returns the muscle fibers to normal tomusonceszation of the causative factor. Clinical Implications ‘Often, masticatory conditions may be dificult o if entate into exact categories, therefore hindering the ‘dminisation of proper weatment. Masiatory muscle contractures are often categorized into. involuntary Fesponses and actuation of normal biomechanical move- ‘ments, Muscle tons, muscle splinting and muse spasm ae categories of involuntary responses. Muscle tonusis haraterized as a varying degree of continuous contrac- fons of a muscle at rest which farishes mechanical st bilty to the craniomandibular articulation, Muscle splinting is 2 momentary sate of hypertonicity induced by the body's protective mechanism in an attempt to sta- bilzea threatened aicular structure. Muscle splinting in And of its doesnot produce any srutural muscular is used to detect the presence of Joint sounds during mandibular movements. Tradiion- itis considered that the occurrence of any joint sounds such as creptes, popping, and clicking are indi- ative of TMI dysfunc, (Osborne (22) desebes the mechanism of reciprocal lickingon opening and closing ofthe jaw as it occurs r= ing TMA die failure. n the resting postural poston, the ‘isc isdistored and is onthe anterior aspect ofthe con- {yl As the mandible begins the opening movement, the ise becomes wedged abead of the conde. Thi move- ment becomes restrained because of the anterior attach- ment ofthe articular disc to the neck ofthe condyle. The Involved compresive forces dstored the die within the Joint As the potential energy increases inthe distorted disc it eventually overcomes the posterior anmulls and ‘etrodiseal restrain, ad the dsc pops posteriorward with fan audible click. Wien the mandibular movement is ‘eversed in the clsing direction, the condyle tends 10 Squerze the disc antevorward. The anterorward move- ‘ment ofthe discs again restrained by the posterior annu- sand rerodisca tissues. As this wedging eet squeezes the dsc anterorard the condyle snaps against the artic- ular eminence with at aricula cick ‘Vincent (23) and Saunders (24) suggest that the oceur- ‘ence ofsomejoint sounds on evaluation isa norma vat- fant. When joint noi ha been ascertained by the use of uscultation, the linisian an note the type of sound and fits duration, as well as when the sound occurs during ‘mandible “TMJ palpation is performed to ascertain the integrity of ‘he joint prope, a wel asitsrelated sof tisue structures. Inaddition, joint palpation is used to asit the auscule sion examination fo ttier differentiate the source ofthe Joint sounds. Tae two methods of joint pation are ae Tollows 1, The enteral auctor meats is sed a pint of eference Inwhich he padded Enger tip fhe th cg s places. This is permed wih the cca fang the paint we the alien iin seated ston. the conde has signs Ian anterior infor diction, he casi may ela ‘atta ante positon ofthe imsived TNO Ith cone as maligna ia perio nd superior Seton the ie TEXTBOOK OF GUNICAL CHIROPRACTIC nan may fe the posterior aspect fhe condyle up against {he pad of the finger onthe volved side. 2. Theenteroal eon fh lst proper will ead a3 point of reference in which the finger tp of the inex Rage ‘laced. This ete performed with the cnan sanding [ecind the seated patent Ihe condylehas maligned in an infiepostuon, the linia may fel the onde on he involved ied the condyle the conte side daring opening movements ofthe mandibie. the condyiehat mi Alene ina posterior ané superior direction, the ein ‘nay ela momentary Reston or lapsngsenson of te {involved conde as compared othe convaatera sd, Ing opening movement of the mane ‘While performing the papstory joint examination, the clinician most be sensitive tothe presence of pain o dis- ‘Comfort Jusing opening a ling movement [MUSCLE PALPATION ‘When performinga palpatory muscle examination, many ofthe masticatory muscles are readily accessible, The la eral pterygoid, medal pterygoid, and posterior digastric, Ihowever, are more dificult to palpate. ta performing this ‘examination the clinician should be sensitive to the pres. tence of inflammation edema, trigge points, and changes jn muscle tonus such as splinting, guarding, or spasm ‘When used in conjunction with other clinical examina tion procedures, the information obtained fromthe pal- patory muse examination may be extremely wsefl in Asceraining a specific cause of TMJ dysfunction, Although there are several imaging modalities used t0 objectively examine and evaluate the temporomandibu- lar joint, only two are widely used by the chiropractic pro- fession. They consst of magnetic resonance imaging (MRI) and plain lm radiography (PER). (MRI is used to image histologic disc alterations, remodeling of discal tissues, masticatory mustes, disc adhesions, tumors, dis perforations, oseous remodeling, And anterior and medial disc positional alterations. Tis ‘sues heavily laden with hydrogen ions produce a high sig- nal intensity which appears asa lighter contrast on the MRL Conversely, tissues with minimal amounts of hydrogen ions produce a low signal intensity, which appears asa darker contrast on the MR This character. iste makes the MRI superior modality for evaluating the presence of capsular and disc degeneration Plain film radiography is perhaps the most commonly used imaging modality in evaluating the TMJ. The pro- Jeetions commonly used include the ransorbital (aneror to posterior), lateral cephalometric atral sku, ans cranial (lateral oblique), and submentovertex (axa) Tlnmfard ant Pret (28,35) vt PER ta meee fle ‘ences in condylar positon, PFR enables the clinician toobserve severe osseous degenerative changes inthe con- Syle or emoral region, as well as bone factuesor other ‘osseous patiology. Capsular as well a5 extracapsular {esticion of mandibular movement may also be con- firmed with PFR (19) xAMNATIONOF THE CLD ‘Mechanical derangements ofthe TMA and related struc tures from tithing injuries maybe related toa variety of thildhood itnesses (12,26) If these mechanical derange ‘mentsare let uncorrected inthe infantil, the pathol ‘gy may remain into adulthood (2). Hence, when the ei ‘ician is conducting a neuromusculoskeletal exam on an infant/chia tis imperative thatthe TM and accompe- ‘ied cranial bones be incorporated aswel Wisknovn that restrictions in normal biomechanical ‘movement th eaniomandibular mechanism may lead to chronic bead and neck pain in infants/hiren (26) “The infant/child may also elicit hyperactive behavior due to thephysial stresses inthe craniomandibularstructres ‘caused by aberrant neurologic fonction. These symptoms are oflen asoiated with vertcbrl subluxation complex (ofthe upper cervical spine, thoraci spine or temporo- ‘mandibiar joint. Newer (27,28) presents two hypotheses ‘sto the cause of asthma; vagal nerve reflex Broncho- ‘spasm and intrinsic smooth muscle defect. Both ofthese hypotheses may be directly influenced by chiropractic ‘manipulation and. soft tissue therapy. Gillespie and Bares (12) presenta plausible explanation for the first postulate of vagal nerve reflex bronchospasm. They sug {est thal the mechanical motion and positional influences ‘ofthe temperal bones, ociput, and the atlas as having a possible eflest onthe vagus nerve pasing through the ju Ular foramen. An intrinsic smooth muscle defect ofthe trachea and bronchi may be mediated by pater of myo- fascial sof tisue tensioning from the head, jaw and cer- vical spine. lisreasonable to assume that aberrant tensile Toroesplacod on the myofascial structures woud inhibit ‘normal funcion ofthese tisues ths creating patterns of inition. In the adult, the clinician seeks to find the underying cause of TMI dysfunction, which i often a chronic bo- ‘mechanical sbnormalty. Acute TMI trauma does occur however (eg ipiah) Royder (39) makes cas for evaluating the sacroiliac region in patents with TMI disorders. Abnormalities in this region may create postural disturbances above, such asscoiois, which influences the TMJ. I becomes appar ent that a teatment protocol which includes the lower extremities, pelvis, and the lumbar spine is necessary a5 partof the regime fora TMJ disorder should dystunction nist in related eas “Types oF TM Disorders ‘ar cancun scoala espa nae ‘are abage ccs Figure 15.4, Types oI Tl doce caapacy aoe, Inthe corey of Td cso posed oh sve of ‘oe cte prsot nese po oto nh ‘The cerviothoracie region should be examined and ‘evaluated for biomechanical improprieis. Mechanical restrictions in this area may lead to dysfuncion in the {emporomandibular region via the selene, spinais api- tis, plenus capitis, sterocleidomastoideus, and as0<- ated long muscles ofthe neck (See Fig. 15.6 and 15.0. ‘Somatic dysfunction ofthe ociptetlantal and ala ‘oaxal regions can affect mandibular positioning tothe ‘extent tha the suprahyoid and infahyoid muscles would ‘ot beable to open the jaw without distortion of the TMI ‘on one side o the other (30), ‘When examining the TM) region, the clinician must make every effort to determine if thee isan intacap ‘Capsular or extracapsular derangement (Fig. 1.14) 1s important both diagnostically and therapeutically that ‘the clinician's approach to evaluating TMJ dysfunetion be comprehensive s that the precise location of biome- ‘chanical restraint i ented. Bell (31) desibes three Sint symptomatic extesris of mast dyson 1, Reston of biomechanical mandibular movenent, 2. Imerference daring mandibular movement; and 5 Aeste maloetson dsurbancs Inracapsuar restriction is frequently caused by obstruc tion of the aniula dse whieh i tun estries mandib- lular movement by preventing translatory mation ofthe condyle. Several actors that may contribute to the obstruction of the anicular dsc nce, foousadhesion formation or oseous ankylosis, altered goss sue changes inthe joint capsule due to arthritis, and trauma or functional displacement to the intracapsular tissue Structures resulting a dislocated articular ds.46 ‘The impairment to normal translatory movement is ‘commonly associated with lerations in both size and function ofthe capsular ligament. Alterations tothe cap- sular ligament resulting ia restriction to. mandibular ‘movement maybe the result of eapeults (inflammatory ‘cdema) or capelarRbrotic achesion ue to previous ep ‘odes of eapsulitis or taumatic injury. Capsular restraint has efects on condylar movement, such as protrision ‘opening and contralateral excursion Extracaplar retition commonly caused by con- ‘wacted of immobilized mandibular elevator muscula- ture. Tis may be precipitated by inflammation or neu- rologc dysfunction. Clinical evaluation of extracapsular resrction of mandibular movement difere fom caps lar restriction in that opening ofthe jaw is restricted, but ‘protrusion and contalteral excursion remain fil nor tal. The doctor will note a defection o the midline ine- sal path with jaw opening movements. Te direction in ‘which the mine incisal path deviates depends on the location of the involved muse). For example contrac ture ofthe masseter or temporalis musle would permit ipsilateral defection of the midline incisal path. Ifthe patient's deflection is induced solely by a contacted ‘medial pterygoid muscle, the midline incisal paths devi- ted contealatealy Factors that may skew the clinician's ability to visibly note the presence of deflection with opening movement ofthe ja include: contracted musculature involving the ‘media pterygoid muscle in conjunction wth the masseter ‘muscle, o the medial pterygoid muscle in conjunction With the temporalis muscle, and if both TMs. are Involved, the presence of biteral extracapsular restic- “Acute malocclusion is sensed subjectively by the patient as spontaneous physical changes inthe way the teeth goede. tis common fr the patent to experience pain and masticatory discomfort when the teth ae fore Fally brought into maximal intreuspation. Two of the ‘more common eauses that mcy influence acute maloeli- sion are muscle spasm or changes inthe TU, specically the dis-condyleeminence complex. Muscle spasm ofthe lateral pterygoid muscle may induce acute maloclasion by drawing the condyle forvard on the ipsilateral side, thus causing oeslusal csariclation of the patent's posterior teeth and prematue contact ofthe anterior teeth contralateally- Spas: of the masseter muscle ‘draws the mandible laterally, while spasm ofthe medial ‘lenpoid muscle would dspace the mandible medially “Trauma tothe TM) structures o osseous surface detrio- sation due to arthritic conditions of infection would ‘efectively change the relationship of the disc conde ‘Complex withthe articular eminence, leading to acute ‘malocclusion. ‘When examining the patient with complaints of mal ‘seclusion, tis important forthe clinician to understand ‘that such altered occlusion is fen accompanied by mas- teatory dysfunction or pain IF pain accompanies the TEXTBOOK OF CUMCAL CHIROPRACTIC patients symptoms of acute maloecusion, the doctor ean fxpect to sce a increase in the sensation of Fin with ‘maximal itercuspation, which may be relieved by biting ‘against a separator on the ipsilateral side ofinvalvement If the chiropractor suspects a eracked tooth, tooth abscess, periodontal disease, of tooth pain as bring the ausative factor contributing to acute maloecusion, it ‘would be reasonable to perform a dental frem-us (pe ‘ussion) test. This test is performed by simply aking the patient to sharply close the teth together withoxt clench- Ing, while the clinician listens and observes fr any sin- {gular striking dentition sounds and/or pain. If this test Fesuls ina psitive nding the clinician should perform 8 tooth-speciie manual percussion test by carefully stk- ing the individual posterior tooth with aim, bunt ste ‘ized metal object To assure doctor-patient hypiene and protection, the wearing of glovesisadvised. Ifthe test ei tsa postive finding for pain o tooth dystuncton, thea refer toa dentist or orthodontists appropra “Anicula is jamming is lasically understood wo be any obstruction of the dise condyle and articalar emi- fence complex which would interfere with transitory ‘movement ofthe jaw, Factors such as dysfunctional ari- lar discal ligaments, increased passive interaricular pressure, physiologic incompatibility beeen articular sliding surfaces, and discal trauma are frequent causes of ‘ic jamming. Provided thatthe ise conde complex function remeins undamaged, disc jamming wil usually ‘cause the patient experience only momentary episodes of obsiructedtranslatory movement ofthe ja. ‘When performing a clinical assessment of 2 patent presenting with die jamming, the elinician sheuld note {he following the patient willbe relatively pain-Fe, max Smal intercuspation wll ot elicit symptoms of autem ‘ccusion, an lateral and protrusive mandibular move- ‘meat willbe normal and unobstructed. Dise jamming usually responds favorably to chiropractic ajusive therapy. ‘A functional anteriorly dislocated dis is deesibed as an obstruction which blocks the return phase of transla tory mandibular movement. A contraction ofthe supe- or lateral pterygoid muscle i often the causatire factor. Because ofthe nonexistence of surface to surfacs contact ofthe condyle, antcular disc, and articular eminence, the Anicular dis is rapped anterior tothe mandibalarcon- Ayle due tothe collapsing ofthe anicular dis saces. ‘During the examination ofa patient presenting with functional anterior distcation ofthe articular disc, the linician should note the flowing: mandibulsr move- ‘ments within the patient’ permitted range of motion wil tlic noses such as grinding and grating: on maximal Fntercuspation the patient wil sense symptoms of acute ‘malocclusion ofthe posterior teeth on the ipsilateral side of involvement; and transitory mandibular movements in protrusion and lateral excursion are proporionasly restricted with opening. Function anterior dislocation of the articular dise