Isometric exercises and a simple appliance for temporomandibular joint dysfunction: a case report.

Isometric Exercises and a Simple Appliance for Temporomandibular Joint Dysfunction: A Case Report Temporomandibular joint (TMJ) dysfunction associated with postural abnormalities and complaints of cervical pain are reported to be common. [1-3] Postural deviations such as forward head may lead to retrusion of the mandible and posterior cervical pain. [3] Forward head postures may also contribute to alterations in the TMJ condylar mechanics with subsequent manifestations of TMJ clicking and locking. Muscle tension and associated jaw clenching have also been implicated in TMJ dysfunction.

Treatment for TMJ dysfunction associated with cervical dysfunction may include postural exercises for the neck, shoulder and back, plus exercises for the TMJ. Resting splints are sometimes prescribed for the TMJ to allow stretched or inflamed tissues to heal.

This case report describes a patient whose chief complaint was cervical and thoracic pain but who exhibited clinically significant temporomandibular signs and symptoms. The case report is presented using a modified SOAP (subjective, objective, assessment, plan) note format.

Patient Data

Subjective Data

The patient was a 21-year-old female university student who was referred for physical therapy with a chief complaint of cervical and thoracic pain. She described herself as being emotional and hot tempered; she also had much self-imposed school pressure. The pain in the lower neck and upper thoracic area was usually achy but could become sharp during sitting and writing. Home remedies consisting of hot baths, ointments, and massage helped relieve the pain temporarily. She also complained of having jaw pain, clicking, and intermittent locking for about one year. She was unaware of episodes of clenching or grinding of teeth. The jaw pain was a constant ache that radiated down both jaw lines and was not usually associated with jaw locking episodes. There was some diminution of pain when the patient made an effort to relax. Almost every morning upon waking she found the jaw locked; an effort to relax allowed the jaw to unlock. Hightension periods were associated with an increased incidence of jaw locking.

Objective Data

A forward head posture was observed, and the mandible was slightly protruding. On mandibular opening, the incisal path exhibited a 6-mm deviation of the mandible involving a C-shaped motion to the right. During opening and closing of the mandible in speech, the incisal path deviated toward the right on opening and the left on closing. In the resting position, the mandible deviated to the left the width of one half of an upper incisor (4 mme. The right masseter muscle had greater fullness as measured by palpation and inspection when the jaw was closed in a relaxed position. This fullness may suggest increased masseter muscle tension. The other palpable jaw muscles appeared to relax normally during rest. No jaw clicking was palpable, and excursion of the condyles appeared equal although the motion of the left condyle was less smooth than that of the right condyle. Smoothness was evaluated by palpating the condyles simultaneously. The right condyle had a cogwheel effect during the excursion. The maximum mandibular opening exceeded 5 cm. Both TMJs exhibited some hypermobility in the anteroposterior and lateral directions when mobility tests, as described by Friedman and Weisberg, [3] were performed at 1 cm of mandibular opening. Dentition was complete except for the inferior third molars. Cervical range of motion was normal. Bilateral upper extremities exhibited Normal muscle strength, deep tendon reflexes, and touch sensation. Central spring tests to C3 and C6 and a spring test to the left articular process of C3 yielded positive results. Cervical musculature exhibited Normal strength when measured manually. Other objective tests to the cervical spine yielded negative results. The fourth thoracic vertebra demonstrated positive central spring test results; otherwise, the thoracic spine was normal.

Assessment

The physical therapy assessment was that the patient's posture and stress were producing increased tension in the musculature of the jaw thereby modifying the biomechanics of the TMJ. The patient's poor posture also contributed to the cervical pain.

Treatment

The goals for treatment were to decrease the TMJ pain, improve jaw opening and closing, reduce jaw locking, and improve posture. A series of exercises for the forward head posture were instituted. This series included exercises consisting of gentle isometric contractions resisted by fingertip pressure to the forehead, occiput, and temples. The exercises were held for three seconds and repeated six times in each of the four directions several times per day. The key was that the exercises must be gentle.

At the next visit, the exercises were made more difficult by having the clinician (AJS) provide random gentle resistance to the forehead, temple, and occiput. Hence the patient was required to respond to random stimuli that may act to improve cervical muscle coordination and awareness of neck and head position. The patient was instructed to continue these exercises at home four times per day.

Standard shoulder retraction and chin-tuck exercises were also taught. Gentle retraction of the mandible with resistance at the angle of the jaw (Fig. 1), posterior and inferior to the chin (Fig. 2), and upon jaw opening with gentle pressure to the left mandible (Fig. 3) were performed twice daily for two sets of 10 repetitions each. The purpose of the mandibular exercises was to enhance the patient's mandibular muscle coordination. The exercise of gentle resistance to the left mandible was instituted to remediate the deviation in the incisal path. Relaxation techniques including deep breathing and contrasting muscle tension and muscle relaxation exercises were prescribed for daily home use. The patient was also advised to seek the consultation of a dentist with a special interest in the TMJ.

Some of my previous patients with TMJ dysfunction derived some relief from jaw locking with a semirigid plastic appliance that was prescribed by a dentist and used during sleep. I felt that at least on a temporary basis the patient would derive some benefit from a similar appliance, an athletic mouth guard acquired from a sporting goods store (Fig. 4). The mouth guard was heated in water, placed on the patient's upper teeth, and molded to encourage slight retrusion of the mandible in centric occlusion. The patient then began to wear the appliance nightly for increasing numbers of hours until she could wear it for the complete hours of sleep. Within three nights, she could wear the appliance continously during sleep. The purpose of the appliance was to keep the jaws out of the closed-pack position during sleep and to counteract the resting jaw posture.

Results

Within one week, the patient reported a decreased incidence of jaw locking and decreased pain. The isometric (static) exercises were increased to three sets of 10 repetitions each twice daily, and she was instructed to continue using the appliance while sleeping.

Two weeks later, the patient reported that her jaw was not locking; the achy pain had decreased significantly. Palpation of the TMJs revealed relatively smooth and even mobility. The incisal path showed a 2-mm deviation to the right on jaw opening, but it was markedly improved. Jaw alignment in the rest position was markedly improved, with a 1-mm deviation of the mandible to the left (Fig. 5). The patient was more aware of her posture and made efforts to correct the forward head posture. Three months later, the patient reported continued improvement of her posture with decreased pain, and the jaw exhibited no locking.

Discussion

Abnormal posture and the inability to cope with stress may be contributing factors to TMJ dysfunction. [1-3] Incoordination of the muscles controlling the mandible and the articular disk, over time, may produce jaw clicking and locking and disk degeneration. This muscle incoordination may be attributed to increased involuntary activity of one or more muscles, thereby producing an imbalance of jaw opening and closing mechanisms. The gentle isometric exercises for the head and neck and the exercises for the forward head posture appeared to make the patient more aware of her posture. She was able to correct her posture on command, but it may be a long-term process to make the desired changes in posture permanent. The isometric exercises to the mandible to encourage retrusion appeared to produce some remediation in the resting jaw posture. Gentle isometric resistance in the resting posture for the left mandibular deviation reduced the lateral deviation significantly. The resistance exercise to the left angle of the jaw also produced significant improvement in jaw opening. These exercises vary somewhat from the types of exercises proposed by others in that they are gentle and their purpose is muscle coordination, not muscle strengthening. [3]

This patient was able to reduce the frequency of jaw locking significantly. This reduction may be due in part to the exercises or to the slight retrusion built into the appliance that helped improve mandibular alignment. Another explanation is that although the patient denied teenth clenching or bruxism, these signs may have been present, and the slight flexibility that the appliance afforded the jaw during biting or teeth clenching may have allowed the musculature to relax.

The appliance described in this case report may be useful for physical therapists treating certain types of TMJ dysfunction. I am not suggesting that this appliance should substitute for a more carefully made and professionally fitted appliance, but it may be useful for those patients who cannot afford a professionally made appliance. It may also be useful in screening patients for the professionally made appliance. The physical therapist could fit the patient with the mouth guard appliance, have the patient wear it for a few days, and then determine whether a change in signs and symptoms occurred. If improvement was noted, a referral to a dentist or orthodontist could be considered.

Summary

I have presented a case report of a patient who experienced TMJ dysfunction signs and symptoms as well as postural abnormalities. She was treated with a series of gentle isometric exercises and an easily fitted appliance. The patient made significant improvement with decreases in pain, locking, and deviations of the jaw. The appliance may have utility in the physical therapy management of certain TMJ dysfunctions.

References

[1] Passero PL, Wyman BS, Bell JW, et al: Temporomandibular joint dysfunction syndrome: A clinical report. Phys Ther 65:1203-1207, 1985

[2] Friedman MH, Weisberg J: Application of orthopedic principles in evaluation of the temporomandibular joint. Phys Ther 62:597-603, 1982

[3] Friedman MH, Weisberg J: The temporomandibular joint. In: Gould JA, Davies GJ (eds): Orthopaedic and Sports Physical Therapy. St Louis, MO, C V Mosby Co, 1985, vol 2, pp 581-602

AJ Santiesteban, PhD, PT, is Associate Professor, Physical Therapy Program, School of Medicine, Indiana University, 1140 W Michigan St, Indianapolis, IN 46223 (USA).

This article was submitted August 15, 1988; was with the author for revision for six weeks; and was accepted January 27, 1989.