The craniosacral mechanism and the temporomandibular joint STEPHEN D. BLOOD, DD., FAAO Alexandria, Virginia mandibular overlay dental appliance functions in patients. A review of the extensive work by I think that many of the TMJ research projects, dentists Fonder and Smith to resolve studies, and observations are actually studies and temporomandibular joint (TMJ) observations of the craniosacral mechanism, and syndrome shows awareness of the that dentists for years have been using this mecha- unity of the body and the effect of nism unknowingly to treat TMJ dysfunction and to TMJ dysfunction on all body systems. improve the health and well being of their patients. However, the role of the craniosacral Effects of dental stress mechanism has not been appreciated sufficiently. Results of a retrospective In his 1977 book The Dental Physician, Dr. Aelred study of 130 TMJ patients evaluated Fonder4 presented a well-researched and organized for craniosacral dysfunction over a collection of theories and documented observa- 9-year-period are reported. More than tions. This dentist quoted sources from Pottenger 57 percent of the patients had a to Selye defining dental stress and its effect on the history of trauma. The number of total body. upper cervical restrictions was also Fonder emphasized that the unity of the organ- impressive. A viscerosomatic reflex is ism is a primary and fundamental medical princi- postulated as a mechanism for the ple that has not been sufficiently explored. He also association of cervical and cranial discussed the adaptation syndrome in relation to restrictions and TMJ dysfunction. the musculoskeletal system in health and disease, Osteopathic cranial treatment will and he explored the relationship between the endo- assist resolution of TMJ symptoms crine system and the central and autonomic ner- and improve results with the dental vous systems. Fonder theorized that an imbalance in the neu- splint. The benefits of a team romuscular system of mastication and deglutition approach by dentists and physicians are discussed. inhibits normal synergistic action of all muscles controlling the mandible. He expressed the view that confusion arises in the relay of neural im- pulses to and from the brain. These confused im- pulses result in erratic, unnatural contractions of the musculature, which lead to muscle spasm and Temporomandibular joint (TMJ) dysfunction has improper muscle tonus. been estimated to affect 20 percent of the American He stated that TMJ dysfunction routinely coex- population. Of these patients, 60 percent are ists with the imbalance of the masticulatory mus- symptomatic. 2 There is an increasing interest in cles. This distress continues until there is a this clinical problem by the dental and medical physiologic change in the rest position of the man- professions across the country. The 1985-86 Cra- dible. He defined this improper contraction of the nial Academy3 reports 227 active D.O. members. muscles as a proprioceptive dysfunction relayed Also, the Academy has 89 dentists who are "associ- directly to the brain, and he said that findings such ates," and this is a rapidly growing membership as premature contact of occlusal surfaces and other segment. There continues to be a strong demand abnormalities in the occlusion prevent rhythmic, from the dental profession to learn more about the well-coordinated mandibular movement. cranial concept. One source estimates that 38 percent of the ner- This paper will present some physical findings of vous input to the brain and output to the rest of the my TMJ patients. It will also provide an anatom- body is mediated through the face, mouth, and TMJ icophysiologic theory as to how the commonly used region. 2 When confused stimuli are received by the The craniosacral mechanism and the temporomandibular joint 512/85 brain, it will, in turn, send out faulty information elusion. Of the 40 students with severe malocclu- to the body that will affect the entire organism. sion, only one worked up to tested ability. All In light of these observations, Fonder proposes children whose occlusion was normal functioned to that the most important element of TMJ treatment their tested ability or above. is the establishment of a physiologic rest position of All students who worked below their ability had the mandible through correction of occlusal posi- psychologic problems. The depth of psychologic tion. Often this is achieved with an acrylic tem- problems was related to the severity of the maloc- plate or "splint," which is periodically adjusted to clusion. accommodate changes in mandibular position Of children in the remedial group who had severe while muscles heal and gain tone. In other cases malocclusion, all had scholastic problems, and 53 correction is accomplished with removable ap- percent performed far below their tested ability. pliances or occlusal fillings. Also, 53 percent had more than a 25 percent hear- Fonder has successfully treated an extraordi- ing loss. nary number of clinical problems with these pro- Of the children working to or above their tested cedures. For instance, with serial postural x-rays, ability, 75 percent complained of less than 33 per- he was able to demonstrate reduction in the ante- cent of the symptoms of dental distress. Well over roposterior and lateral spinal curves in two young 50 percent of the dental distress symptoms about men with scoliosis and/or kyphosis and lordosis. which the children were questioned were among Fonder conducted a controlled study of 247 pa- those working below ability. tients with TMJ dysfunction. All of these subjects Audiometric studies showed that children in the had the classic symptoms of crepitus, subluxation, gifted group possessed much better hearing than pain or tenderness at the joint, and disruption of students in the remedial group. The acuteness of the opening and closing mechanism. In addition to the hearing was related to the normality of the auriculotemporal problems, there were multiple occlusion. symptoms involving respiratory, visceral, ocular, gynecologic, psychologic, postural, and other gen- Role of craniosacral dysfunction eral symptoms. There is no question but that Fonder has made a Individual treatment varied but always was di- tremendous contribution to both medicine and den- rected to the maxillomandibular relationship and tistry with his outstanding documentation of the normalization of mandibular positions, often by "dental distress syndrome" and its many man- means of an acrylic template. Fonder reported that ifestations. However, is there a common factor that 91-92 percent of the treated subjects became was not recognized in his examination of these asymptomatic, whereas only 6 percent of untreated children with ear problems, respiratory problems, patients improved. Normalization of the spinal and malocclusion? As a practicing osteopathic phy- posture and resolution of recurrent upper respira- sician, I believe that what was not recognized was tory infections occurred with treatment. the status of the craniosacral mechanism. Is there a Fonders book shows that when physiologic oc- cranial membranous distress syndrome present? clusion was provided, the mouth chemistry and pH The findings of other investigators lend support to normalized, and teeth remained clean and rela- this possibility and to Fonders observations. tively free of caries. The alleviation of signs and Dr. Stephen Smith,5 who is the director of the symptoms throughout the body reflect rebalancing TMJ clinic at the Philadelphia College of Os- of the autonomic nervous system throughout the teopathic Medicine, has demonstrated an associa- total person, and a rebalancing of the endocrine tion between TMJ dysfunction and coronary system. problems in a middle-aged woman. Her history In a separate study, Fonder 4 performed dental included traumatic injury of the sacrum and coc- health evaluations of 100 children. Other compe- cyx, structural imbalance, myocardial infarctions, tent professionals also evaluated the children by hearing problems, menstrual disorders, bladder questionnaire, audiometric testing, determination problems, speech and swallowing difficulties, os- of intelligence quotient, assessment of academic teopathic lesions in the thoracic region, and poor output, and judgment of psychologic adjustment. cervical and head posture. After prosthodontic The children, who ranged in age from 9 to 14 years, treatment providing molar support, increased ver- were divided into either "gifted" or "remedial" tical dimension, and an ideal head-neck balance, groups according to their test scores. her overall clinical health improved greatly. Children in the remedial group generally had Smiths also has described two other cases. One malocclusion leading to a dental distress syn- patient had a maxillary right toothache of nonden- drome. The gifted children possessed relatively tal origin, which had been preceded by right-sided better dental occlusion. All children working below mastoid and cervical pain. A week prior to the their ability possessed varying degrees of maloc-. development of the cervical pain, he had fractured 513/86 August 1986/Journal of AOA/vol. 86/no. 8 the fourth toe of his right foot. As a result his gait stricted motion of the temporal bones, and all of pattern had shifted with pronation and inversion of them lacked normal sphenobasilar symphysis mo- the foot, which consequently altered his body me- tion. Every patient who had restriction of the chanics. Once the swelling of the foot diminished