Postsurgical temporomandibular joint

hypomobility
Rehabilitation technique
Mark H. Friedman, DDS,a Joseph Weisberg, PT, PhD,b and
Frank L. Weber, DDS,’ Valhalla and Huntington, NY.

NEW YORK MEDICAL COLLEGE, TUORO COLLEGE, AND WESTCHESTER COUNTY MEDICAL
CENTER

Specific techniques to treat temboromandibular joint (TMJ) hypomobility caused by capsular

restriction are explained. initially inflammation must be controlled. TMJ manipulation by condylar
distraction during opening, protrusion, and lateral movements, and a simple stretching exercise to
maintain increased mandibular range of motion, are described. Resistive opening and closing
exercises at full opening to relax the lateral pterygoid muscles are prescribed. For all exercises five
repetitions, repeated five times per day, are prescribed. These techniques are demonstrated in the
successful treatment of a child with a presurgically and postsurgically hypomobile right TMJ.
(ORAL SURC ORAL MED ORAL PATHOL 1993;75:248)

T emporomandibular joint (TMJ) hypomobility

often results from trauma, prolonged immobiliza-
tion, or both. Procedures to increase mandibular
range of motion (ROM) such as hot and cold com-
presses, increasing numbers of tongue depressors
placed between the teeth, midrange jaw-resistive
exercises, or manipulation with the patient under
general anesthesia usually resolve the condition.
However, some patients improve slowly or not at
all.
The hypomobile TMJ, unrelated to an anteriorly
displaced disk, infection, or systemic disease,is char-
acterized by a restricted joint capsule and may be
painful if inflammation is present. Because of joint
capsule tightness, common techniques that force the
jaw open may not be effective becauseof condylar in-
terference with the articular eminence during trans-
lation. ’
%linical Associate Professor, New York Medical College, Val-
halla.
bDean, Barry Z. Levine School of Health SciencesTuoro College,
Huntington.
CClinical Assistant Professor, Department of Oral Surgery, West-
chester County Medical Center, Valhalla
7/12/39418
TMJ HYPOlUOBlLlTY MANAGEMENT
PRINCIPLES
Inflammation control
Both TMJ mobilization (manipulative procedures)
and muscle exercises, described later, should be per-
formed in a pain-free environment. In addition to in-
creasing patient discomfort, these procedures are not
effective if significant TMJ synovitis is present. Effi-
cient methods for managing the inflamed TMJ in-
clude nonsteroidal anti-inflammatory drugs, ice cube
massagelateral to the TMJ, direct corticosteroid in-
stillation, and cold (He:Ne, infrared) laser applica-
tion.
TMJ manipulation
Normal voluntary joint movements are compro-
mised unless the ability to perform additional passive
movements are present.2-4These small, precise move-
ments, termed joint play, are independent of the ac-
tion of the voluntary muscles. The most significant
TMJ play movement is condylar distraction, a move-
ment for which no muscle action exists.” 3 TMJ ma-
nipulative procedures combine condylar distraction
and pure lateral condylar movement with passive as-
sisted movement and must be performed precisely
(Fig. 1).
In Fig. 2, note that the clinician stands on the side

24 0030-4220/93/$1.00+.10
Volume 75 TMJ hypomobility rehabilitation 25
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Fig. 1. Arrows representcondylardistraction during op-

ening, protrusive,and lateral movements.

Fig. 2. Patient headsupport.Arrows indicate downward

opposite that to be treated and firmly supports the thumb pressure and upward pressure on chin with remain-
patient’s head; the clinician’s forearm is in the sagit- ing fingers.
tal plane so as not to introduce rotation to the move-
ment.5 While maintaining distraction by strong down-
ward thumb pressure on the last lower molar on the
affected side and upward chin pressure, the patient is
aided in opening, forward mandibular translation,
and lateral movements from the protrusive position
(Fig. 1). Often the clinician’s forefinger is extended to
rest on the mandibular angle to aid in mandibular
advancement. This procedure is identical to that used
in recapturing an anteriorly displaced disk.‘7 3,5,-7An
immediate clinical result is usually seenas the adhe-
sions are stretched or torn. These manipulations are
performed several times at each visit, both on the af-
fected side and then bilaterally (Fig. 3). The cumu-
lative effects of mobilization on connective tissue
leads to realignment of collagen fibers in a longer ar- Fig. 3. Bilateral mobilization starting position.
rangement, permitting more movement.8
Because TMJ manipulation increases mandibular
ROM gradually at each treatment session,a specific exercise at full opening stimulates the Golgi tendon
exercise is prescribed to minimize loss of ROM organs of the jaw opening muscles (Fig. 4). These or-
between visits. In this simple stretching exercise the gans interpret this force as a muscle overload and
patient’s thumb and forefinger on each side are causeprotective muscular relaxation at full length.9 If
inserted on the posterior teeth as far posteriorly as this exercise is done incorrectly (at less than full op-
possible, with the tip of the thumb on the upper mo- ening), the reverse effect, reduced jaw opening, may
lars and the forefinger tip on the lower molars, and occur because of muscle spindle stimulation.” An-
spread apart.’ other prescribed exercise applies resistive force to the
mandibular closing muscles,also at full opening (Fig.
5). Becauseof reciprocal inhibition, this exercise also
Lateral pterygoid muscle relaxation
aids in relaxation of the opening jaw musc1e.t’
TMJ hypomobility affects the main jaw opening Each of the three exercise usually is performed five
muscles, because full muscle contraction is depends times in successionwhile the resistance is held for 1
on normal movement at the joint. A resistive opening to 2 seconds.The entire program is usually repeated
26 Friedman, Weisberg, and Weber
Fig. 4. Resistive opening exercises performed at full op-
ening. Patient exerts upward force on chin and resists jaw
closure.
Fig. 5. Resistive closing force. Patient exerts downward
force on lower incisal edges at full opening.
five times daily. Although making patient compliance
more difficult, briefer and more frequent exercise ses-
sions have proven significantly more effective than
longer exercise sessions once or twice daily. 1 Initially
the prescription may require less frequent or less
forceful exercise, depending on individual patient re-
quirements.
ORALSURGORALMEDORALPATHOL
January 1993
Fig. 6. Maximum preoperative jaw opening.
It is emphasized that a resistive opening exercise
requires a closing force and vice versa. The same
physiologic effect is obtained whether the patient at-
tempts to move the jaw against a preventive hand or
the dominant hand applies an outside force that the
patient resists. Clinically a more powerful and better
controlled force can be applied by the hand rather
than by the jaw.
CASE REPORT
A 10%year-old boy was seenfor a presurgical consulta-
tion with a restricted jaw opening of 21 mm, deviating to the
right, with no palpable right condylar translation (Fig. 6).
He had fallen off his bicycle 18 months previously, injuring
the right condyle. The computed tomographic scan illus-
trates a perforation into the middle cranial fossa and two
large bony projections as a responseto the injury (Fig. 7).
He had a Class III malocclusion, for which orthodontics had
been prescribed. Three days after the examination the pa-
tient’s right mandibular ramus was removed (Fig. 8),
enabling the surgeon to eliminate the large bony growths
and reshape the fossa. A dural graft (cadaver dura from
brain covering) was cut to size and molded around the
condyle stump to create a smooth surface, and the ramus
was reattached with bone plates.
Immediately after the surgery, in the operating room, the
patient’s passiveopening was 51 mm. In the ensuing 3 to 4
days, his mandibular opening decreasedto 28 mm. Despite
the usual procedures, the opening restriction worsened.
Twenty-one days after surgery the patient’s interincisal
distance had decreasedto 19 mm, and a physical therapy
program specific to TMJ hypomobility was instituted.
The patient was treated approximately every 12 days.
Both unilateral and bilateral (Fig. 3) TMJ mobilization
Volume 75 TMJ hypomobility rehabilitation 27
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Fig. 7. Computed tomographic scan showing bony growths in right condylar area. Arrow denotescondylar
perforation into middle cranial fossa.

Fig. 9. Patient with 41 mm opening at completion.

were used several times at each treatment session. As in

Fig. 8. Osteotomized mandibular segment with dural
graft before reinsertion.
unilateral manipulation, condylar distraction and upward
chin force were maintained during jaw opening, protrusion,
and lateral movements.
Intraoral stretching with the thumbs and forefingers, as
described previously, were prescribed. This nonphysiologic
exercise is used simply to maintain the increased ROM ob-
tained by manipulative procedures and is ineffective by it-
self. Fig. 4 illustrates the resistive opening exercise at full
opening. The patient had a tendency to allow his head to
drift slightly posteriorly and to partially close his mouth
28 Friedman, Weisberg, and Weber
during the force application. The patient was made aware
of these common errors at subsequent visits. Fig. 5 illus-
trates the resistive closing exercise at full opening. Some
patients prefer to place a piece of 2 x 2 gauze over the sharp
lower anterior incisal edges.
These exerciseswere done five times with resistance held
for 1 to 2 seconds,and the entire program was repeated five
times daily. Ten weeks later the patient’s opening had
increased to 41 mm interincisally (Fig. 9). This full ROM
(the patient was 5 feet tall) was maintained at two 6-month
recall visits. The opening deviation to the right was not cor-
rected becauseof partial severing of the right lateral ptery-
goid muscle during surgery.
DISCUSSION
The techniques describedare physiologically sound,
and the results appear to be consistently better than
other commonly prescribed postoperative rehabilita-
tive procedures. This program can be effective for the
oral surgeon for a wide variety of conditions, partic-
ularly where jaw opening is restricted for several
weeks after either fracture or orthognathic surgery.
REFERENCES
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ORALSURGORALMEDORAL PATHOL
January 1993
2. Mennell JM. Joint pain diagnosis and treatment using manip-
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3. Friedman MH, Weisberg J. Joint play movementsof the tem-
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Rehabil 1984;65:413-7.
4. Corrigan B, Maitland GD. Practical orthopedic medicine.
London: Butterworths, 1985:13-5.
5. Weisberg J, Friedman MH. Displaced disc preventing man-
dibular condyle translation: mobilization technique. J Orthop
Sports Phys Ther 1984;3:62-6.
6. Friedman MH, Anstendig HS, Weisberg J. Case report:
treatment of a disc dysfunction. J Clin Orthod 1982;16:408-11.
7. FriedmanMH, WeisbergJ. Thetemporomandibular
joint. In:
Gould JA, ed. Orthopedic and sports physical therapy. 2nd ed.
St Louis: CV Mosby, 1990:593-4.
8. Eneels M. Tissue resoonse.In: Donatelli R. Wooden M. eds.
Orrhopedic physical iherapy. London: Churchill Livingstone,
1989:24-6.
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Louis: CV Mosby, 1980:116.
10. Eldrid E. Functional implications of dynamic and static com-
ponents of the spindle response to stretch. Am J Phys Med
1967;46:129-31.
11, Eyzaguirre CE, Fidone SJ. Physiology of the nervous system.
Chicago: Year Book, 1975:163-4.
Reprint requests:
Mark H. Friedman, DDS
660 Gramatan Ave.
Mt. Vernon, NY 10552