Joseph Schames, D.M.D.; Mayer Schames, D.D.S.;
James P. Boyd, D.D.S.; Euel L. King, D.D.S.; William M. Gabriel, D.D.S.
(Submitted and accepted for publication
The Journal of Pain Management)
ABSTRACT: Therapeutic Motion of the Joint (“TMJ”) is based on active neuromuscular integrative movements to the temporomandibular joints by the patient using an Anterior Midline Point Stop (AMPS) appliance. It allows the patient to attempt to receive the 30 years of documented advantages of unstrained motion, in healing and regeneration of the temporomandibular joints, synovial fluids, articular cartilage, collagen fiber cross-links, proteoglycans of the periarticular connective tissues, and the surrounding muscles of mastication. Therapeutic Motion of the Joint (“TMJ”) has been an underused treatment for Temporomandibular Disorders, due to potential strain in excursive movement allowed by traditional full-coverage and anterior bite plane therapy. Previously, unstrained Therapeutic Motion of the Joint (“TMJ”) was available only through Continuous Passive Motion (CPM) machines, used primarily post surgically. Now the benefits of Therapeutic Motion of the Joint (“TMJ”) is presented as a logical inclusion to the treatment regime of patients, by using the same AMPS appliance used for the treatment of their muscular pains.
DESCRIPTORS: Therapeutic Motion of the Joint, Anterior Midline Point
Stop appliance, Continuous Passive Motion, TMJ, AMPS, CPM
The two major motions of the temporomandibular joint are rotation and translation. A healthy joint’s first movement is rotation of the condyle allowing for 20 to 25 mm of intercincisal opening(1 ,2 ).
Translational movement then occurs during the downward and forward movement of the disc-condyle complex along the posterior slope of its articular eminence, and is the function of the inferior belly of the lateral pterygoid muscle.
Active movements include lateral excursion which results when translation of the mandible is unilateral. During lateral excursion, the disc and condyle of the nonworking joint move medially as they approach the articular eminence, displacing the disc and condyle in an inferior direction. These movements are a result of the lateral pterygoid muscle’s orientation, i.e., function follows form, and form dictates function.
If a condyle has translational movement, it is a given that it also has rotational movement. If a joint has rotational movement it does not mean that it also translates. Even though rotational and translational movements are important for normal function, translation is the primary measurement of intra-articular function(3 ).
There are active accessory movements of the joint occurring in
response to muscle contractions which are guided by the slope of the articulating
surfaces and the periarticular tissues. These active accessory movements
include spinning, rolling, sliding, distraction and compression(4,5 ,6
Passive accessory movements produced in response to an outside source are called “joint play movements”(7 ). These “joint play movements” allow the joint to “give,” and are critical factors in efficient functional movements of the joint(8 ).
The temporomandibular joint contains 4 types of receptor nerve endings which have different functional characteristics(9,10 ).
These synovial receptors are located in the fibrous joint capsule, in the lateral ligaments, and in the retrodiscal pad. They are not contained in the central portion of the disc, nor in the synovial tissues. The temporal, masseter, and auriculotemporal nerves terminate on these synovial receptors(11,12 ).
Type I receptors provide continuous movement and postural perception of the mandible. They also coordinate facilitory and inhibitory reflex effects of the masticatory muscles(13 ).
Type II receptors effects the masticatory muscles when mandibular movements are initiated.
Type III receptors are only active when excessive tension is developed in the temporomandibular joint’s lateral ligament. Type III receptors are activated in pterygoid and mylohyoid muscle spasms as well as temporalis and masseter muscle inhibitions.
Type IV receptors are the pain receptors of the articular tissues, and in normal/healthy joints they are inactive. They become activated if the joint capsule, retrodiscal pad, and the temporomandibular joint ligament are subjected to marked mechanical deformation and tension, or with direct chemical irritation(14).
Other receptors in the skin, subcutaneous tissue, and from the muscles around the synovial joints converge with Type I, II, and III receptors and modulate activity of the joint tissues that contain Type IV receptors. The degree of temporomandibular joint pain not only depends on the intensity of Type IV receptor irritation, but also on the frequency of the stimulation of the mechanoreceptors embedded in the temporomandibular joint capsule and the surrounding soft tissues and musculature( ).
Active stimulation of Type I, II, and III receptors in the temporomandibular joint capsule and adjacent tissues by unstrained “Therapeutic Motion” can modulate Type IV pain receptor activity in the Temporomandibular joint. If capsular tightness is the primary cause of this Type IV activation, then alleviation of pain may occur when unstrained “Therapeutic Motion” is applied and restores the capsular extensibility(16).
Immobilization of the Joint
All synovial joints in the body, including the temporomandibular joint, function according to the same biological rules. Orthopedic literature and research over the past 30 years has demonstrated that joint immobility has deleterious effects on joint morphology as well as deleterious biochemical and biomechanical effects on synovial joints, the periarticular tissues, and the surrounding musculature(17). Numerous research studies on the effects of immobilization of knee joints of animals have been performed demonstrating these deleterious effects(18-31).
Immobilization effects the synovium by proliferation of fibrofatty connective tissue obliterating the joint space, as well as adhesions being formed between synovial folds. These adhesions then tear cartilage surfaces when associated with forced manipulations(32-34).
Immobilization thins out the articular cartilage(35,36 ). It causes necrosis of the cartilage at areas of compression( ). It causes fibrilation as well as cartilage erosion(37). Immobilization also causes the adherence of fibrofatty connections to cartilage surfaces; as well as loss of matrix staining properties (39-42).
Immobilization effects the ligaments by disorganized deposition of fibrils and cells, which then reduces the ability of the ligament to resist tensile forces (43,44). Due to the osteoclastic activity of the bone where the ligaments insert, it weakens or destroys the ligament fibers (45).
Immobilization causes osteoporosis of cancellous and cortical bone (46 ) Proliferating primitive mesenchymal tissue from the marrow spaces then invade subchondral bone (47).
Immobilization causes the surrounding musculature to atrophy and have a reduction in blood vessels, muscle fiber diameter, with a decrease in contractile and metabolic proteins within the muscles (48-50).
Immobilization of the joint reduces collagen mass and causes a higher ratio of collagen degradation to collagen synthesis. It causes production of less mature and weaker collagen, with improper cross links between the collagen fibers. Immobilization thereby causes shortened tendons and fascia (51-55).
Immobilization of the joint impairs in lubrication of the joint by causing reductions in glycosaminoglycans, hyaluronic acid, chondroitin 4 and 6 sulfate, and dermatan sulfate, as well as reduced water content (56-61).
Patients with Temporomandibular Joint Dysfunction typically can immobilize and strain their temporomandibular joints by clenching in centric or excursive (condylarly translated) positions.
Continuous Passive Motion
Continuous Passive Motion (CPM) machines used on joints post-surgically, first researched by Salter, et al in 1970, demonstrated stimulation of healing of articular cartilage, regeneration of articular tissues, and prevention of joint stiffness (62).
Salter, et al, in 1982, completed a follow-up study confirming signs of superior tissue repair one year after experimental surgery with CPM (63).
Importantly, O’Driscoll and Salter in 1984 demonstrated healing of defects in hyaline cartilage and concluded that CPM stimulates neochrondrogenesis of mesenchymal tissue into hyaline cartilage (64-66).
Another study showed that 80% of CPM post-surgically treated knee joints had healed cartilage without any evidence of post-traumatic arthritis, while most of the non-treated post-surgical joints developed severe degenerative arthritis (67).
A study on incisions treated with CPM showed histological resemblance to normal skin in patterns of collagen organization and strength (68).
Continuous Passive Motion of the Temporomandibular Joints
The effects of CPM on the temporomandibular joint after surgery have confirmed the voluminous findings and results performed on the knee joint (69-78).
Notable studies are the eight month study performed by Glineberg, et al (79) which demonstrated a return in glycosaminoglycan content of condylar cartilage, showing that degenerative changes resulting from immobilization are reversible; as well as Robinson (80) demonstrating that mature mandibular condylar cartilage is capable of regeneration, as long as function of the temporomandibular joint occurs through unstrained motion.
McCarty in 1993 observed that patients undergoing unilateral surgery, but also having some pain on the opposite side, had a decrease in symptoms in the non-surgically treated temporomandibular joint following post operative rehabilitation with a CPM machine (81).
Israel and Syrop reported success with treatment of non-surgically treated
temporomandibular joints as well as with the surrounding tissues and musculature,
using a CPM machine (82).
Recently, using an animal model, investigators found that daily continuous passive motion (CPM) for 5 days elicited a significant growth response in condylar cartilage. The articular cartilage of nonoperated condyles was significantly larger in the animals that underwent CPM (average 345 mm, range 330-360 mm) than controls (average 232.5 mm, range 150-270 mm)(83)
Therapeutic Motion of the Joint (“TMJ”)
Therapeutic Motion of the Joint (“TMJ”) is based on active unstrained neuromuscularly integrative movements to the temporomandibular joints performed by the patient, using an Anterior Midline Point Stop (AMPS) appliance, commercially available from NTI-TSS, Inc., as the NTI Tension Suppression System. (1-877-4-NTI-TSS)
An AMPS appliance has been used and documented in the scientific literature over the past 30 years by prosthodontic dental specialists for the reduction in muscular activity as well as in the reduction of pain in the muscles of mastication (84-108).
Unlike a “deprogrammer,” which can allow for canine contact on the device in excursive movement (thereby providing the occlusal contact resistance necessary for the lateral ptergoid muscle to apply strain to the joint), the AMPS appliance’s design of a narrow horizontal ramp parallel to the occlusal plane, prevents canine and posterior teeth from occluding, thereby allowing for unstrained protrusion and lateral excursions. This allows controlled, unstrained exercises to be performed by the patient, to help return intra-articular health and function of the joint.
Therapeutic Motion of the Joint (“TMJ”) allows a patient to perform these unstrained movement exercises in attempting to receive the documented benefits of Continuous Passive Motion in healing and regeneration of the temporomandibular joints, synovial fluids, articular cartilage, collagen fiber cross-links, proteoglycans of the periarticular connective tissues and the surrounding muscles of mastication.
Rhythmic therapeutic motions used in rehabilitation have been described as 5 grades of motional treatment (109).
Grade 1 rehabilitative motion is small amplitude motion performed at the beginning of the available range of motion.
Grade II rehabilitative motion is larger amplitude motion performed within the available range, but not up to the limit of range of motion.
The principles of Grade’s I and II, gradual, yet persistent, motion is more beneficial then short and sudden motions of the mandible.
Unstrained Therapeutic Motion of the Joint (“TMJ”), using techniques of Grades I and II, influences the mechanoreceptors. The neurophysiologic effects are a decrease in pain, reflex inhibition of muscles, and promotion of relaxation results; followed by an increase in ROM (110-112).
The key element for success of Therapeutic Motion Joint(“TMJ”) is patient compliance. If the patient does not mobilize the mandible due to lack of compliance, the rehabilitation regime will fail.
Instructions to the patient include use of an AMPS appliance every night while they sleep; as well as demonstrable times of bruxism during the day.
Therapeutic Motion of the Joint (“TMJ”) is then performed by the patient with an AMPS appliance for 10 minutes out of every hour of the waking day; performing gradual, yet persistent, protrusive and lateral excursive motions, as well as circular motions on the AMPS appliance’s ramp, in a non-clenching, gliding manner.
Protrusive and lateral excursion exercises allow natural translation to occur, thereby eventually increasing interincisal opening. The patient is additionally instructed to gently and slowly stretch and hold the mouth open for a few seconds.
At White Memorial Medical Center’s, Craniofacial Pain/TMJ Clinic, we have been instructing patients in the performance of Therapeutic Motion of the Joint (“TMJ”) using the AMPS appliance for the past year, with excellent results.
Performance of Therapeutic Motion of the Joint (“TMJ”) using an AMPS appliance allows the patient to attempt to receive the documented advantages through active mobilization of the temporomandibular joints, as well as the documented advantages in reducing muscular pain through the AMPS appliance’s night time use. Therapeutic Motion of the Joint (“TMJ”) has been an underused treatment for Temporomandibular Disorders, where previously it was only available through CPM machines used primarily post-surgically. Now the benefits of Therapeutic Motion of the Joint (“TMJ”) are available in the treatment regime of patients, by using the same AMPS appliance used for the treatment of their muscular pains.
About the Authors
1. Joseph Schames, D.M.D. is the Co-Director of White Memorial Medical Center’s Craniofacial Pain/TMJ Clinic in Los Angeles, California. He is a Diplomat of the American Academy of Pain Management.
2. Mayer Schames, D.D.S. is a Clinical Director of White Memorial Medical Center’s Craniofacial Pain/TMJ Clinic in Los Angeles, California. He is a Diplomat of the American Academy of Pain Management.
3. James P. Boyd, D.D.S. (Jim@DrJimBoyd.com)is the Director of Research and a Senior Clinical Instructor at White Memorial Medical Center’s Craniofacial Pain/TMJ Clinic in Los Angeles, California and is a member of the American Academy of Head, Neck and Facial Pain. Dr. Boyd developed the therapeutic protocol of the Anterior Midline Point Stop appliance and has a financial interest in NTI-TSS, Inc., which sells the NTI Tension Suppression System. NTI-TSS, Inc. can be contacted at 1-(877)-4-NTI-TSS. email:
4. Euel L. King, D.D.S. has been the Director of White Memorial Medical Center’s Craniofacial Pain/TMJ Clinic in Los Angeles, California for 30 years. He is a Diplomat of the American Academy of Pain Management.
5. William M. Gabriel, D.D.S. is a Senior Clinical Instructor at White Memorial Medical Center’s Craniofacial Pain/TMJ Clinic in Los Angeles, California. He is an elected member of the American Academy of Oral Maxillofacial Pathology.
CONTACT: Joseph Schames, D.M.D.
12243 S. Hawthorne Boulevard
Hawthorne, California 90250
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