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F r e e m u s i c d o w n l o a d s f o r C e r t i f i e d m e m b e r s : w w w. a b m p . c o m / g o / c e r t i f i e d c e n t r a l 99 TMJ joint with osteoarthritis Normal TMJ joint It's not uncommon to be in the fi nal stages of a history intake when the client casually states, "Oh, there is one other thing: sometimes my jaw clicks when I eat or open my mouth." According to The TMJ Association, "A clicking jaw in those presenting with face, head, and neck pain may be a smoldering fi re that should not be ignored." Joint noise is not unusual, but a clicking jaw can represent an incorrect relationship between the condyle disc and the mandibular fossa, or possibly osteoarthritis (Image 1). I fi nd it's best to address jaw-related muscle imbalance patterns before the disc(s) becomes irreversibly deformed. A systematic review by Marega Medlicott and Susan Harris found that active exercise, manual mobilizations, and postural training may be effective in treating temporomandibular joint (TMJ) disorders. 1 However, many therapists choose not to treat the condition unless the client is experiencing pain. I believe this represents a missed opportunity to address anatomical and functional problems in their early stages. The articular disc is vulnerable at various places along its length, but these are the two most common TMJ presentations I see in my practice: • Bilateral condylar jamming secondary to forward-head postures (FHP). • Unilateral masseter and temporalis hypertonicity and medial disc displacement due to atlantoaxial (A-A) joint dysfunction. IS YOUR CLIENT'S HEAD ON STRAIGHT? To assess, draw imaginary horizontal lines through the pupils and across the lip with the client standing facing you. If both lines are elevated on the same side, the client typically will have a C1 (atlas) rotation on the high side (Image 2). Due to the convex-convex A-A condylar surfaces, as C1 right rotates, it lifts the right side of the occiput, causing mild compression (occlusion) of the left TMJ. A high right eye on the side of the rotated atlas is often a dead giveaway. Try this on a plastic skeleton. Prolonged stomach sleeping with the head turned to the dominant side (usually right) dehydrates the A-A facet joints and may lead to articular cartilage degradation, right-side inferior oblique hypercontraction, and joint fi xation. Naturally, the brain won't allow the person to walk around with the head rotated right, so it activates the multifi di, rotatores, and other left cervical rotators to move the head back to a neutral position. Because of the fl at plane of the facet joints C2–3 to C7–T1, sidebending and rotation couple to the same side. Therefore, left rotation further left sidebends and compresses the jaw. Teeth grinding may develop in clients with long-term A-A alignment problems. In Myoskeletal Techniques, we fi rst treat the atlas rotation using suboccipital release techniques, such as the one demonstrated in Image 3. Once the atlas-on-axis fi xation is corrected, hypertonic jaw closers such as the masseters, temporalis, and medial pterygoids are stretched using a simple technique MYOSKELETAL ALIGNMENT TECHNIQUES Clicking Jaw Syndrome Addressing TMJ By Erik Dalton Arthritic mandible and damaged disc. Image courtesy Erik Dalton. 1 Right-rotated atlas causes left TMJ occlusion. Image courtesy Erik Dalton. 2 The therapist's thumb contacts C2 spinous process and glides ½ inch superolaterally on the inferior oblique muscle. The client gently right-rotates the head against resistance from the therapist's hand to a count of fi ve and relaxes. The therapist's thumb and hand left-rotate the client's head, stretching the oblique and dragging the atlas into left rotation. Repeat 3–5 times. Image courtesy Erik Dalton. 3