RELATIONSHIPS BETWEEN THE NECK, THE TEMPERO-MANDIBULAR AND THE TEETH ■ by Franne Mallen INTRODUCTION The relationship b etw een the d ental profession and the physio­ therapy p ro fession is trad itio n ally restricted to the tem pero- m and ibu lar jo int. The association is, how ever, m uch closer as the stru ctures o f the neck and the up per quarter are intim ately related to the teeth and the tem pero-m and ibular jo in t (TM J). P hysiothera­ pists are largely concerned w ith rehabilitation b u t rehabilitation for m any years w as m erely functional. P hysiotherapists had little o r no effect on the actual stru cture w hich w as cau sing the sym p ­ toms and ou r role w as m ainly prophylactic w ith the use o f m o­ dalities and exercises to try to im prove or to create the best situation possible. N ow , how ever, there are therapists w h o are specifically trained in the m anagem ent o f jo in t pathology. W ith specific techniques w e are able to change the structure o f the jo in t b y having an effect on ligam ents, capsules and the articular c a r t i l a g e a n d th e r e b y a l t e r i n g th e j o i n t d y n a m ic s a n d biom echanics. W e deal w ith the neurological, m u scular and skeletal system s. It is the assessm ent o f the neurological, m u scular and skeletal structures that w ill establish the cau se o f the disorder. The ob jec­ tive is to find and treat the prim ary or dom inant structure at fau lt and to b e able to assess its effect on the oth er tw o structures. In other w ords, to find the cause o f the disorder and then to assess and treat the second ary effects o f the disorder. All the structures o f the up per quarter are interrelated and each facet is im portant to the w hole and need s to be integrated w ith know ledge, exp eri­ ence and skill. A ll m axillo-facial stru ctures depend on the cranium as the point of origin. Sup rahyoid m uscles are attached to the m andible, w hile infrahyoid m uscles are attached to the shoulder girdle, the scapulae and the sternum . T he spine com prises three m ain fu nctional units in the body: • cranio-cervical and that is related to the synovial tem pero- m andibular jo in t; • cervico-thoracic and its synovial gleno-hu m eral joint; • lum bo-sacral w h ich has the hip jo in t as the synovial joint. Effect of Posture "M o u th b rea th ers" have a posteriorly rotated occiput, so w ith the head b ack the occlusal contacts are posterior, w ith the head forw ard the occlusal contacts are anterior and w ith the head in neutral the occlusal contacts will be even. So the aim o f the physiotherapist is to create an even head on neck posture w hich will then, in turn, create an even cervico-thoracic and lum bar sacral alignm ent. T hen w e w ill b e ab le to create a physiological state o f rest and the m uscles and the jo in t stru ctures w ill b e at rest. In people w ith a "p o k in g -ch in " posture, the posterior m uscles hold the head b ack ie., the cranium is rotated b ackw ard s on the upper p art o f the neck. T h e antagonists o f the m uscles o f m asti­ cation are the posterior cranio-cervical m uscles and therefore the neck is extended. W hen the p o sterior part o f the neck is extended the m andible is pu shed forw ard and the d istance betw een the chin and the sternu m increases. T h e levator scapulae are lengthened and the stru ctures at the b a ck o f the neck are com pressed creating an entrapm ent neuropathy. T he nerves that are affected in this instance are am ong others, the great auricu lar nerve w hich su p ­ plies the tem pero-m and ibular jo in t and the occip ital nerve w hich supplies the m uscles o f the p o sterior occip u t creating occipital headaches. Treatment Treatm ent o f such cond itions, I b elieve, starts w ith the tem- pero-m and ibular jo in t and consists o f m obilisations fo r pain. Sm all oscillatory m ovem ents, gentle m o vem ents that do n ot reach the end o f range are applied. These are used to red uce pain and im prove the cond ition o f the tissues. T h ese m obilisations can be extended to increase range o f m o vem ent as w ell. A n oth er p art of the treatm ent is the application o f m assage and m yofascial release to the lateral pterygoid m uscles and the m asseters and various form s o f electrotherapy to help to reduce the oed em a and thick­ ening o f structures. The second p art o f the treatm ent is to the up per cervical spine to correct the b iom ech an ics o f the cranio-cerv ical and upper cervical segm ents. M obilisations are used to relieve painful jo ints as w ell as to stretch the stiff structures. T reatm en t o f the thoracic spine, the lum bar sp ine and the sacral stru ctu res are also often necessary. T h e third p art is to teach exercises to m aintain the correct position o f the neck and will include a m obilisation type of exercise as w ell as a stabilisation type o f exercise. It is only with the correction o f the m u scular and skeletal stru ctu res that w e can achieve a neutral position and thus create a p hysiological state of rest. By so d oing there will b e proper retraction, o p en in g o f the m outh and lateral m ovem ents o f the m andible. The techniques em ployed are specific, skilled and subtle. W hen d entists put apparatus into the m outh all o f the ab ove are affected and there is a change in proprioceptive and m echano-receptors. There is often a com pen sation in p osture w h ich lead s to neck pain. Conversely, m any a neck pain and a h ead ache has b ee n relieved sim ply b y a b ite plate. Conclusion and Summary C h anges in neck m ovem ent ch an ge the occlusal con tacts and the m and ibular dynam ics. For these to b e norm al one need s a physiological state o f rest o f the head o n the neck, the tem pero- m and ibular jo in ts and o f the neck on the b od y . This can be achieved by p hysiotherapists trained in m anu al th erap y and w ith a sound know ledge o f b iom echan ics and pathology. R ecom m en d ed R e ad in g 1. R ocab ad o M . R elation ship o f the T em p ero-m an d ib u lar Jo in t to C ervical D ysfunction . P ro c 3rd IF O M T conf. V ail, C o lo rad o 1977:103. 2. M aitland G D , C orrigan B. P ractical O rthopaedic M edicin e. Butterw o rth & C o Ltd 1983. 3. M aitland G D . Peripheral M an ipu lation. S e con d E d . B u tterw o rth s 1977. 4. B og d u k N. H eadach es and the C ervical Sp ine. P roceedin gs o f the C ervical Spin e an d H eadache S ym posium . B risban e 1981:1-17. 5. B ogdu k N. G reater O ccip ital N eu ralgia. C u rren t T herapy in N eurological Surgery. L ong D M , M arcel D ekker, T oron to 1985:175. 6. Ju ll G A. H eadach es A ssociated w ith the C erv ical S p in e - a C linical R eview . G rieve G: M o d e m M an u al T herapy o f the V ertebral Colum n. C hu rchill L iv in gsto n e 1986:322. 7. Ju ll G A. H eadach es o f C erv ical O rigin. G ran t R . P hysiotherapy o f the Cervical a n d T horacic Spine. C h u rchill L iv in g s to n e -1 9 8 8 :ll;1 9 5 . SA J o u r n a l P h y s io th e r a p y , V o l 5 2 N o 1 F e b r u a r y 1996 P a g e 9R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )