RU2849739C1 - Method for osteopathic correction of somatic dysfunction of temporomandibular joint (tmj) of intraocclusal and extraocclusal origin - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention can be used for osteopathic correction of somatic dysfunction (SD) of the temporomandibular joint (TMJ) of intraocclusal and extraocclusal origin. Diagnosis and identification of the aetiological factor of SD formation of intraocclusal or extraocclusal origin are performed. Osteopathic correction is performed in at least 3 sessions within 1 month. The following interdisciplinary approaches are used: in cases of TMJ of intraocclusal origin, the dentist eliminates the aetiological factor contributing to the formation of TMJ. Next, the osteopath performs osteopathic correction of the dominant TMJ dysfunction and secondary somatic dysfunctions of the TMJ according to the algorithm "elimination of compression - elimination of hypercapnia - elimination of hypoxia". In cases of TMJ SD of extraocclusal origin, the osteopathic physician performs osteopathic correction of the dominant SD and secondary somatic dysfunctions according to the algorithm "elimination of compression – elimination of hypercapnia – elimination of hypoxia". Interdisciplinary interaction between the dentist and the osteopathic physician is based on the clinical picture and the patient's personalised anatomical and functional characteristics.

EFFECT: increased effectiveness of TMJ dysfunction treatment by taking into account all aetiological factors of TMJ SD formation, their diagnosis and sequential elimination of the aetiopathogenetic chain of adaptive changes.

1 cl, 1 ex

Description

The invention relates to medicine, namely to neurology, osteopathy and dentistry, and can be used in the treatment of somatic dysfunctions of the temporomandibular joint (TMJ).

The development of methods for timely and effective osteopathic correction of somatic dysfunctions of the body is currently one of the pressing challenges facing medicine.

Somatic dysfunction (SD) is a potentially reversible structural and functional disorder in tissues and organs, manifested by palpably determined limitations of various types of their movements and mobility [1].

From the point of view of etiological factors influencing the formation of diabetes, physical factors are distinguished in the form of static and dynamic mechanical effects of varying intensity, the consequences of various injuries, metabolic changes in the form of consequences of neuroendocrine and immunological disorders, as well as emotional-sensory factors and emotional reactions of varying duration [1].

In response to the influence of etiological factors, in cases where the strength, intensity and duration of the influence causes an adaptive reaction on the part of the main cells, the structural and functional changes are functional and reversible in nature [2, 3].

In the initial stages of the adaptive response, diabetes can be diagnosed even in the absence of clinical symptoms. The location of dominant somatic dysfunctions may differ from the location of secondary somatic dysfunctions and clinical manifestations. The structure of somatic dysfunction is conventionally divided into three main components: biomechanical, hydrodynamic, and neurodynamic.

The biomechanical component of diabetes mellitus represents various variants of the adaptive response of connective tissue (CT) with changes in its qualitative and quantitative characteristics, in some cases with the formation of fibrosis and sclerosis with an increase in the number of collagen fibers and their relative positions. Furthermore, connective tissue is restructured in the event of circulatory disorders, changes in nutrition, and with age [4].

The hydrodynamic component of SD is a reversible change in hydrophilicity with subsequent disruption of turgor, viscosity, fluidity, production and conduction of global endogenous rhythms.

The neurodynamic component of somatic dysfunction is a reversible impairment in the perception, production, and conduction of nerve impulses. The neurodynamic component of diabetes can occur during the functional adaptation phase without clinical manifestations, or within the context of the disease entity and clinical manifestations.

These three components unite all organs and subsystems of the body into a single, integral system.

In the practice of correcting somatic dysfunctions of the body, numerous options for performing hardware and manual interventions aimed at eliminating macro- and micro-mobility disorders in the human body are known. Various systems of manual medicine, along with various methods of manual diagnostics, distinguish a large number of manual correction methods. Among osteopathic correction methods, a number of basic techniques and approaches are known, relying on which an osteopathic physician performs diagnostics and subsequent interventions on identified disorders and dysfunctions in tissues and organs. Different osteopathic schools may use different classifications of osteopathic techniques, which does not affect their essence. As sources of information on basic techniques, one can cite the works of Mokhov D.E., Aptekar I.A., Belash V.O., and others, who formed domestic recommendations and approaches to osteopathic treatment [1, 2, 4, 5, 6, 7].

In turn, somatic dysfunctions of the TMJ occupy third place in the structure of dental diseases, after caries and periodontitis.

TMJ disorders lead to the development of such nosological entities as: TMJ pain dysfunction syndrome K07.60, clicking jaw K07.61, TMJ arthrosis M19.0X, dysfunction of the masticatory muscles (bruxism) F45.82, which, in turn, belong to the category of socially significant diseases of the dental profile.

Functional disorders of postural equilibrium and balance, the formation of SD of the body due to SD of the TMJ determine the high importance of interdisciplinary interaction between a dentist and an osteopathic physician.

In the structure of somatic dysfunctions of the TMJ, it is necessary to distinguish two groups of etiological factors:

• Extraocclusive SD

• Intraocclusive SD

The first group of SDs— extraocclusal somatic dysfunctions leading to changes in the TMJ—is associated with etiological factors in the form of somatic dysfunctions affecting the body as a whole, various organs and systems, and individual organs in particular. In this case, we are talking about adaptive changes in the TMJ during the process of adaptation to somatic dysfunctions in that part of the human body that is not related to the parts of the body that directly contribute to occlusion and are directly involved in inhalation, chewing, and sound production.

Thus, extraocclusal SD is a group of etiological factors, adaptation to which leads to the formation of a pathogenetic chain and the emergence of dominant somatic dysfunction of the TMJ.

If a patient with extraocclusal diabetes mellitus (EDM) contacts a dentist, before receiving dental care, a consultation with an osteopathic physician and osteopathic correction of the EDM that initiates the development of TMJ diabetes are recommended.

It is recommended to carry out osteopathic correction in the following sequence:

1. Correction of diabetes mellitus, in which the leading biomechanical component of functional disorders of micro and macro mobility is compression in the motor joints (osteopathic correction - elimination of compression).

2. Correction of diabetes mellitus, in which the leading hydrodynamic component of the functional disorder is functional disorders of the venous circulation of the head region and an increase in the concentration of CO2 - the formation of hypercapnia (osteopathic correction - elimination of hypercapnia).

3. Correction of diabetes mellitus, in which the leading hydrodynamic component of functional disorders is a decrease in arterial circulation indicators (osteopathic correction - elimination of hypoxia).

The second group of TMJ dysfunctions is intraocclusal somatic dysfunctions . The etiological factor in the development of dominant somatic TMJ dysfunctions is somatic dysfunctions of the dentoalveolar system. This group is directly related to the process and outcome of dental care. Added to this is the widespread increase in the frequency of orthodontic treatment, which in turn initiates adaptive and functional changes in the dentoalveolar system in general and the TMJ in particular. All this increases the frequency of diagnosed somatic TMJ dysfunctions. In turn, somatic TMJ dysfunction initiates the development of an adaptive chain within the body and, as a consequence, somatic dysfunctions in the anatomical and physiological regions of the body. Primarily, these are the anatomical regions of the head and neck, the thoracic and abdominal regions, the back, and the lower and upper extremities.

In the case of patients with the intraocclusal form of TMJ disorder seeking help from an osteopath, interdisciplinary collaboration with a dentist is recommended for the effective correction of functional TMJ disorders associated with somatic dysfunctions of the dental system.

In this case, the osteopathic physician carries out preparatory diagnostics and correction to prepare the patient for medical care in the dental field.

After dental treatment and elimination of the cause of the somatic dysfunction of the TMJ, the patient is referred to an osteopathic physician for correction of TMJ dysfunction.

The correction algorithm is implemented according to a standardized methodology described in clinical guidelines. Osteopathic care differs in that, at the global, regional, and especially local levels, osteopathic care is provided according to an algorithm that sequentially eliminates compression, hypercapnia, and hypoxia. After performing corrective techniques and repeat testing, biomechanical balance and synchronization of TMJ mobility with one of the body's global functions are achieved.

Currently, various methods are used to correct somatic dysfunctions of the TMJ, including medication, dental (orthodontic), physiotherapeutic, and osteopathic treatment methods.

When highlighting methods based on manual impact on the body and its parts, the following well-known methods of treatment and correction of TMJ disorders can be noted:

- RU 2 167 679 C1 describes a combined treatment for pain associated with temporomandibular joint dysfunction, including sequential physical therapy, gymnastics, and facial massage. Additionally, TMJ oscillation is performed with increasing intensity until reaching the level of countercontracture mobilization, while simultaneously eliminating functional blocks in the spinal motion segments of the cervical spine. This treatment utilizes a supersonic frequency current with a current strength of 3-5 μA, increasing by 2-3 μA per session. The treatment is performed on the TMJ and masticatory muscles, with a total course of 10-12 daily procedures. This method reduces treatment time.

- RU 2 294 188 C2 describes a treatment method for temporomandibular joint dysfunction syndrome. Treatment is performed in two stages: release (relaxation) of the pterygopalatine fossa tissues by stretching the pterygoid muscles, which helps restore the correct position of the intra-articular disc and condyle; harmonization of the TMJ, release of the temporoparietal and temporoparietal sutures, decompression of the bilaminar zone and, consequently, improvement of TMJ nutrition, and return of the intra-articular disc to its correct position.

- RU 2 689 205 C1 describes a method for identifying and planning correction of human body system characteristics associated with malocclusion. This involves collecting a general and dental medical history, examining the musculoskeletal system, performing a polysomnographic examination, and performing an instrumental examination of the head and TMJ. If respiratory pathology is detected in combination with musculoskeletal pathology, orthopedic and/or orthodontic treatment is combined with osteopathic treatment. Prior to orthopedic and/or orthodontic treatment, the desired malocclusion is modeled on a virtual model of the patient's head, followed by splint therapy. This method helps reduce functional problems after malocclusion correction through a comprehensive approach to diagnosis and treatment and a combination of objective functional analysis in various fields of medicine during the treatment planning stage.

- RU 2 770 664 C1 describes a method of manual therapy for TMJ. The technique involves grasping the horizontal branches of the mandible with one hand and the posterior cranial fossa with the other, including the mammillary processes of the temporal bones and the occipital bone. Then, with coordinated hand movements, head flexion is increased. The hands are then smoothly brought together, increasing compression of the TMJ area and maintaining the achieved relative position of the cranial bones and cervical spine. Myofascial release of the TMJ area is performed until muscle relaxation and equilibrium tension under the hands are achieved. This method improves the effectiveness of treatment for temporomandibular joint dysfunction.

A common drawback of the above known methods and techniques is the incomplete influence on the factors that lead to or directly cause the development of TMJD, which is why there is a risk of recurrence of TMJD.

In the process of providing medical care to patients with somatic dysfunction of the TMJ, it is necessary to take into account the etiological factors in the form of primary somatic dysfunctions, the adaptive/pathogenetic chain, the results of instrumental examination methods, the results of osteopathic and dental diagnostics of somatic dysfunctions of the TMJ, and the general condition of the patient.

The closest in technical essence and the achieved result is the method of treating dysfunction of the temporomandibular joint, including its osteopathic correction, consisting of restoring the mobility of the spheno-basilar synchondrosis (SBS) and subsequent decompression of the TMJ, described in the journal “Les A.T.M. Évaluation, Traitements odontologiques et ostéopathiques” (Jean Marie LANDOUZY, De Verlaque, 1993; pp. 179-197).

The disadvantage of the known method is the high probability of recurrence of TMJ diabetes, associated with the persistence of etiological (extraocclusal and intraocclusal) factors, in the form of diabetes, leading to the formation of TMJ diabetes.

According to a number of authors, intraocclusal TMJ dysfunction, the cause of which has a direct anatomical and topographic relationship to the anatomical and functional structures that make up the dental-jaw system and the TMJ in particular, can involve the musculoskeletal system of the body in the pathological process, including the skeletal muscles of the head and neck, the entire spine and various joints, the postural system of the body, as well as internal organs and systems. For these reasons, dental treatment of somatic TMJ dysfunction and osteopathic correction are recommended to be carried out in the format of interdisciplinary interaction between a dentist and an osteopath [8].

In the process of implementing the algorithm for correcting somatic dysfunction of the TMJ, it is necessary to take into account the structure of the primary SD and the dominant SD, its components in the form of biomechanical, neurodynamic and hydrodynamic components and the predominance of one of them.

The proposed method for correcting TMJ dysfunction is aimed at increasing the effectiveness of treating TMJ dysfunction by taking into account all the etiological factors in the formation of TMJ dysfunction, their diagnosis and the consistent elimination of the etiopathogenetic chain of adaptive changes.

The specified result is achieved by the fact that after the implementation of osteopathic correction of extraocclusal SD, which consists of restoring the mobility of the motor joints in the predominant biomechanical component of SD, primarily spheno-basilar synchondrosis, osteopathic correction of SD of the dentoalveolar system and decompression of the TMJ are carried out, according to the stated method.

Initially, a differential diagnosis of TMJ dysfunction is performed and the etiologic factor for its development is identified. Orthodontic, osteopathic, and instrumental diagnostics are performed (ultrasound Doppler imaging of the head, neck, abdomen, and chest vessels, and contrast-enhanced MRI if necessary). The dominant and primary somatic dysfunction is determined. The dominant etiologic factors for TMJ dysfunction are identified.

In case of confirmation of the diagnosis of dominant somatic dysfunction of extraocclusive genesis, with a predominance of the biomechanical component in the structure of somatic dysfunction, osteopathic correction is performed, which consists of the sequential implementation of the following osteopathic techniques, including osteopathic diagnostic and corrective techniques:

They eliminate compression of the sacroiliac joint, pubic symphysis and somatic dysfunction of L5-S1, C0-C1, correct suture dysfunctions of the anatomical region of the head and non-physiological patterns of the anatomical region of the head, and correct compression of the spheno-basilar synchondrosis (SBS).

Performed by:

- Correction of compression of the sacroiliac joint (SIJ) on both sides

- Correction of L5-S1 compression

- Correction of somatic dysfunction C0-C1.

- Correction of membranous and suture somatic dysfunction

- Correction of compression of the zygomatic bone on the side of the dominant somatic dysfunction

- Correction of the temporal bone

- Correction of somatic dysfunction of the SBS of compression genesis.

They eliminate somatic dysfunctions of the thoracoabdominal and pelvic diaphragm, osteopathic technique for correcting venous sinuses and the CV4/EV4.4 technique.

Performed by:

- Correction of normal mobility of the pelvic diaphragm using the chest breathing function.

- Correction of the functional mobility of the thoraco-abdominal diaphragm using the chest breathing function.

They stimulate positive functional changes in arterial circulation using appropriate osteopathic correction techniques.

Osteopathic correction of TMJ dysfunction is performed in the order of its component predominance (biomechanical, neurodynamic, and hydrodynamic). TMJ correction is performed using compression or decompression techniques, with therapeutic force applied by the osteopathic physician in the form of kinetic force and functional chest breathing at the local level.

Following osteopathic correction, somatic TMJ dysfunction is reduced in severity or eliminated, as evidenced by the absence of clinical manifestations and restoration of TMJ motor function. Interdisciplinary collaboration between the dentist and osteopath is based on the patient's clinical presentation and individualized anatomical and functional characteristics.

If an intraocclusal etiologic factor is identified, dental care is provided and the etiologic factor of the intraocclusal TMJ disorder is eliminated. After dental therapy to correct the dental and jaw disorders, the patient is referred to an osteopath for osteopathic correction of secondary somatic TMJ dysfunctions, similar to that described for extraocclusal TMJ disorder.

It is important to note that in this case, the patient's visit to an osteopath may be the initial one; the patient's complaints may not be directly related to TMJ, but during the osteopathic diagnosis, the osteopath reveals that the dominant diabetes mellitus is related to TMJ.

Osteopathic correction is carried out in at least 3 sessions within 1 month .

The criterion for achieving a therapeutic effect is a reduction in clinical symptoms by at least 25% compared to the initial state based on pain assessment using a visual analogue scale (VAS), an assessment of the dynamics of motor activity - an increase in the amplitude of movement when opening the mouth, positive dynamics of changes in the occlusal component, diagnosed in the process of osteopathic, orthodontic and, in some cases, instrumental diagnostics of the functional state of the TMJ.

The stated sequence of osteopathic techniques allows for the step-by-step correction of diabetes mellitus in accordance with the formula “elimination of compression – elimination of hypercapnia – elimination of hypoxia,” which leads to an increase in the effectiveness of osteopathic treatment compared to “classical” approaches to osteopathic correction.

These manipulations are performed using any accepted osteopathic techniques known to man. Examples of osteopathic techniques for diabetes correction include:

- Decompression of the sphenobasilar synchondrosis by approach through the cranial vault.

Patient position: lying on his back.

Position of the doctor: sitting at the head of the patient, knees apart, heels on the floor, support on the ischial tuberosities.

Position of the doctor's hands: the 2nd fingers are on the zygomatic processes of the frontal bones (external columns), and the 4th fingers are located on the lower lateral angles of the occipital bone, elbows on the table.

Correction:

Synchronization with the patient (palpation, respiratory, at the PDM phase).

Palpatory chord - palpatory output to parameters.

Evaluation of parameters of the cranial rhythmic impulse (primary respiratory mechanism of the PDM).

During the flexion phase of the primary respiratory mechanism, the physician will use the second fingers of both hands to lift the frontal bones in the cephalic direction, while simultaneously fixing the occipital bone.

In the achieved position, the physician maintains the selected parameters in the flexion phase and in the extension phase of the primary respiratory mechanism.

In the next phase of the PDM flexion, the doctor strengthens the parameters of the SBS flexion, limiting the return of the frontal bones to the extension phase.

The correction technique is repeated several times until the movement of the PDM in the SBS is completely restored.

Several types of osteopathic techniques are used to correct compression of the sphenobasilar synchondrosis, including: decompression of the SBS using the fronto-occipital approach and indirect decompression of the sphenobasilar synchondrosis.

- Correction of the thoracoabdominal diaphragm in bilateral somatic expiratory dysfunction.

Patient position: sitting on the couch, back straight, physiological curves preserved.

Physician's position: standing behind the patient, the physician's position is stable, legs are spread, hips touch the couch, creating an additional point for a stable position, close contact is established between the physician's chest and the patient's back.

Physician's hand position: The physician's forearms maintain firm contact with the patient's body. During exhalation, fingers 2 through 4 are slowly inserted under the lower edge of the costal arch on both sides, toward the inner surface of the patient's costal arch.

On the doctor's command, after inhalation, the patient leans forward by 10-15 degrees during the exhalation phase, to more fully place the doctor's hands under the edge of the patient's costal arch on both sides.

On the doctor's command, the patient straightens the torso to the starting position. At this point, the doctor applies traction to the ventral edge of the diaphragm in a cranial direction.

Additional diagnostics. While the patient leans forward 10-15 degrees on the doctor's command, to more fully position the doctor's hands under the patient's costal margin on both sides, the doctor rotates their body to the right and left with an amplitude of no more than 45 degrees, determining any limitation of diaphragmatic mobility.

Osteopathic correction: After identifying the restriction, using the direct technique, the therapist rotates the patient's body, maintaining palpatory contact to the elastic barrier until fascial tension is felt. A corrective pause is performed until myofascial release occurs. On the therapist's command, the patient exhales long, holds their breath for 10-15 seconds, and then takes a deep breath.

Repeat diagnostic test.

Techniques on the ventricles of the brain:

- Technique of compression of the fourth ventricle (CV4).

The CV4 technique results in increased cerebrospinal fluid flow not only through the large ventricles but also in the propagation of the cerebrospinal fluid wave into the most distant spaces through the nerve and vascular sheaths, through the fascial channels, and into the extracellular and intracellular fluid. Thus, the ultimate effect of the fourth ventricle compression technique is improved cellular nutrition, lymph flow, and tissue regeneration, as well as stimulation of the cranial nerve nuclei in the floor of the fourth ventricle. The biodynamic, bioelectrical, and biochemical properties of cerebrospinal fluid provide every reason to believe that all metabolic processes in the body are stimulated during the technique (Bolet P., 1993).

Patient position: lying on his back.

Position of the doctor: sitting at the head of the patient, knees apart, heels on the floor, support on the ischial tuberosities.

Position of the physician's hands: fingers 2–5 are closed and crossed, the distal phalanges of the thumbs are positioned close to each other (in a V-shape), the physician's palms are cupped under the occipital bone so that the tips of the thumbs are located approximately at the level of the spinous processes of C2–C3. The thenars of the hands are in contact with the squama of the occipital bone (not higher than the occipito-mastoid suture).

Correction:

1. Synchronization with the craniosacral rhythm.

2. During the exhalation phase of the PDM, the doctor accompanies the occipital bone into extension, slightly strengthening it.

3. During the inhalation phase of the PDM, the therapist holds the occipital bone, preventing its flexion. This is achieved by contracting the deep flexor muscles of the fingers, m. flexor digitorum profundi (Magoun H., 1976). It is important not to completely block the mobility of the occipital bone.

4. In the next phase of exhalation of the PDM, the doctor follows the occipital bone into extension and holds it in flexion, as described above.

5. After several such cycles, the pressure on the thenar muscles during inhalation weakens and ceases. This means the flexion/extension movement has stopped: the still point has been reached.

6. The physician should maintain the position of their hands on the occipital bone, following any slight movement of the nuchal muscles. This movement signifies "unwinding" and relaxation of the fascia, muscles, and bones. This still point can last from a few seconds to several minutes.

7. Signs of successful induction of still point are: deep breathing, light sweat on the forehead, decreased muscle tone, and drowsiness of the patient.

8. At the end of the still point, the therapist should feel a fairly strong pressure in the hands on each side of the occipital bone, moving from the inside out. The therapist follows the movement passively, paying attention to the quality of the craniosacral rhythm. Having assessed the craniosacral rhythm, the therapist should be able to decide whether further still point induction is necessary.

Note: The CV4 technique can be performed in several ways.

Option #1. Through the bone and dura mater. To do this, the therapist must sense changes in the elasticity of the occipital bone during the inhalation/exhalation phases and also assess the treatment effects at the level of the tentorium cerebelli.

Option #2: Direct your attention directly to the fluid component of the skull (intracranial fluid), visualize the skull and the 4th ventricle as a water-filled ball, and apply the technique to this fluid.

Option #3. Focus your attention on the tissues around the fourth ventricle, but simultaneously sense all levels of density in this area. Very gently facilitate the exhalation of the PPM and contraction, without changing the tempo of the movement or limiting the inhalation of the PPM (or expansion). Passively follow the inhalation phase of the PPM. Continue this procedure until you reach a still point.

Option #4. Follow the tissues, be relaxed and empathetic. Synchronize with the existing homeodynamic forces and rhythmic patterns. These are inherent to the primary respiratory mechanism and determine whether CV4 or EV4 has occurred. The osteopath acts as a fulcrum in these processes. This method requires the osteopath to avoid encountering tissue resistance and not "fight" it. This can be achieved through resistance training during the PDM phases.

Option No. 5. Korth, when performing the CV4 technique, focused on the center of the fluid structures and fluid patterns (this method is used when performing intraosseous techniques).

- Technique of expansion of the fourth ventricle (EV4).

(by J. Jealous)

Unlike the CV4, where centripetal work predominates, the EV4 works centrifugally.

Patient position: lying on his back.

Position of the doctor: sitting at the head of the patient, knees apart, heels on the floor, support on the ischial tuberosities.

Position of the doctor's hands: the doctor's fingers, closed and pressed against each other with the backs of the fingers, are positioned along the midline on the squama of the occipital bone just above the inion.

Correction:

1. Synchronization with the craniosacral rhythm.

2. During the inhalation phase of the PDM, the physician follows the movement of the squama of the occipital bone into flexion and external rotation.

Note: When discussing the classic parameters of the occipital bone during the inhalation phase of the posterior muscle movement, we often omit the parameter of external rotation of the occipital squama, as rotation is characteristic of paired bones. Rotation affects the superolateral part of the squama (above the asterion). In external rotation, this part of the squama follows downward and outward along all edges.

3. During the exhalation phase of the PDM, the doctor counteracts the extension and internal rotation of the squama of the occipital bone by applying light pressure with the terminal phalanges of the fingers in an anterior direction along the midline of the occipital bone.

4. In the next phase of inhalation, the doctor increases the external rotation of the squama of the occipital bone.

5. Next, continue the technique as for CV4.

- Third ventricle compression technique (CV3).

(by J. Jealous)

Patient position: lying on his back.

Position of the doctor: sitting at the head of the patient, knees apart, heels on the floor, support on the ischial tuberosities.

Position of the doctor's hands: the index (or third) fingers of the doctor are placed on the large wings of the sphenoid bone, the thumbs are located on the coronal suture.

Correction:

1. Synchronization with the craniosacral rhythm.

2. The doctor reaches his own neutral state.

3. The physician senses and differentiates mobility from restriction at the lower level (hypothalamus and pituitary gland), then at the back (pineal gland) and on the anterior wall of the 3rd ventricle.

4. CV3 begins precisely when the long wave (tide) enters the midline of the body. At this moment, the "spark" or "tide" is directed toward the fulcrum of the third ventricle. It is very important not to hold or fixate the wave in the fulcrum of the third ventricle or in the midline of the body.

5. Immediately after this, the physician should feel the inhalation phase begin. This moment means the "spark" has reached the fulcrum, the "ignition system" has been activated, and the "recharge" can begin.

6. Then the doctor should feel how the wave begins to rush from the 3rd ventricle along the midline to the coccyx.

7. Next, the physician evaluates the long-term effects of longitudinal fluctuations at the fluid and tissue levels.

Note: It is important to understand that in this technique you are not actually manipulating the hydraulic pressure in the 3rd ventricle, and no fluid is being compressed either in the ventricle or towards the midline of the body.

Like the previous technique, the CV3 technique can be performed in one of the following 4 ways:

Option No. 1. Through the bone and dura mater.

Option #2: Direct your attention directly to the fluid component of the skull (intracranial fluid), visualize the skull and the 3rd ventricle as a water-filled ball, and apply the technique to this fluid.

Option #3. Focus your attention on the tissues around the third ventricle, but simultaneously sense all levels of density in this area. Very gently facilitate the exhalation of the PPM and contraction, without changing the tempo of the movement or limiting the inhalation of the PPM (or expansion). Passively follow the inhalation phase of the PPM. Continue this procedure until you reach a still point.

Option #4. Follow the tissues, be relaxed and empathetic. Synchronize with the existing homeodynamic forces and rhythmic patterns. These are inherent to the primary respiratory mechanism and determine whether CV3 has occurred. The osteopath plays the role of a fulcrum in these processes. This method requires the osteopath to avoid encountering tissue resistance and not "fight" it. This can be achieved through resistance training during the PDM phases.

Techniques for correcting somatic dysfunctions of the cranio-mandibular system:

- Technique for TMJ correction (semi-indirect).

Patient position. Lying on the back.

Physician position: Sitting at the end of the couch, on the side facing the patient's head.

Position of the doctor's hands. The 2nd and 3rd fingers of both hands are placed on both sides along the edge of the lower jaw, the 4th fingers are at the corners of the lower jaw, and the 5th fingers are free.

Correction technique.

• The osteopath synchronizes with the patient’s cranial rhythm (or other global physiological rhythmic activity, as a manifestation of primary breathing, in the form of chest breathing or the rhythm of the body’s integrity - 2-3 per minute).

• “Palpatory chord” with tissues (attention is distributed - the entire lower jaw - 5%, the patient’s body 95%).

• During the first stage of correction, the doctor slowly and consistently creates compression by minimally shifting the mandible in the cephalic direction. The goal is to create support for relaxation of the dura mater and external rotation of the temporal bones.

• In the second stage, the doctor initiates decompression by traction of the lower jaw in the caudal direction.

• Against the background of traction of the entire TMJ, the temporal bone goes into internal rotation.

• After correction, the angles of the lower jaw are brought out at an angle of 10 degrees

• Retest. Diagnosis of TMJ mobility.

• Rebalance. Synchronization of the mobility of the lower jaw and TMJ with general, global mobility.

N.B. For children under 8 years old, the technique is performed without the first stage.

- Technique for TMJ correction.

by E.T. Still.

For unilateral somatic dysfunction. For example, on the right side.

Patient position: Lying on your back.

Physician's position: Sitting or standing on the side of the dysfunction, in the area of the patient's head (at the head of the bed).

Physician's hand position. Cephalic hand: The physician places the 2nd and 3rd fingers on the left TMJ (the "listening hand").

Caudal hand: The first finger is placed intraorally on the dental arcade of the left half of the mandible. The second through fourth fingers grasp the mandible from the outside: the second and third fingers are positioned on the gonion of the mandible.

Correction.

The corrective movement is performed from L3 through the wrist joint.

The principle of the technique: traction to the physiological barrier (the first resistance of tissues in joint movement) - tissue reorganization - tissue relaxation - still point.

The technique is performed in several stages.

Stage one: The doctor applies minimal caudal traction to the mandible with his caudal hand.

Stage two. After the still point, maintaining the achieved position of the mandible, the doctor uses minimal force to shift it ventrally (toward the ceiling if the technique is performed in a prone position) until the physiological barrier is reached.

Tissue reorganization and the next still point.

Stage three. Maintaining the established parameters, the doctor applies minimal force to the mandible, applying medial traction (toward the patient) until the physiological barrier is reached. Tissue reorganization.

Still point

TMJ retesting.

Rebalance.

N.B. The technique is usually performed without taking into account the global rhythms of the body, but its effectiveness increases significantly after performing a global rebalance with the functional integrity of the entire organism.

A functional version of the technique is possible when the lower jaw is suspended within the body and the body corrects its position, restoring function.

- Technique for correcting somatic dysfunction of the TMJ on the left

by H. Magoun.

Patient position. Lying on the back.

Physician position: Sitting on the patient's right side, on the side opposite the dysfunction.

Position of the doctor's hands.

Cephalic hand, four fingers grasp the zygomatic process of the temporal bone from below, the first finger fixes the zygomatic process of the temporal bone from above.

Caudal hand. The first finger is placed intraorally on the left dental arcade of the mandible. Fingers 1–4 perform a "palpatory chord" externally relative to the tissues of the mandible. Fingers 2 and 3 are placed on the gonion of the mandible.

Correction technique.

"Palpatory chord" with tissues.

Synchronization with cranial rhythm (synchronization with thoracic breathing or a rhythm of 2-3 per minute is possible)

Stage One. During the flexion phase of the PDM, the physician externally rotates the temporal bone and holds it in its extreme physiological position.

Stage two. Maintaining the achieved parameters, in the next flexion phase, the doctor performs a minimal displacement of the mandible, creating tension in the caudal direction to the physiological barrier.

Stage 3. MET. The therapist asks the patient to clench their first finger with their teeth (using light pressure). Hold for 3-5 seconds, wait for a response, and pause for 3-5 seconds. Tissue reorganization. Relaxation of the tissues under the arms. MET is repeated 3 times without changing the parameters.

Retest.

Rebalance.

- Technique for correcting somatic dysfunction of the TMJ

according to F. Mitchell.

Patient position. Lying on the back.

Physician position. Sitting on the right side at head level with the patient. Alternatively, the physician may stand.

Position of the doctor's hands. Caudal hand: finger 1 intraorally, on the dental arcade of the left half of the mandible, fingers 2–4 externally. A "palpatory chord" is established with the mandible, with the fingers 2 and 3 of the caudal hand placed on the gonion.

Cephalic hand. 2nd and 3rd fingers on the left TMJ.

Correction technique.

Stage one. Setting parameters for performing the technique.

The doctor moves the lower jaw in the caudal direction, applying traction to the physiological barrier.

Next, maintaining the achieved parameters, the lower jaw is shifted ventrally (towards the ceiling) to the physiological barrier.

Maintaining the previous parameters at the level of the physiological barrier, the doctor shifts the lower jaw medially (towards himself) to the next physiological barrier.

Stage two. MET (isometric) on the TMJ.

After explaining the technique to the patient, the doctor, maintaining the achieved parameters, asks the patient to move the lower jaw to the left against the doctor's resistance. The patient maintains this force for 3-5 seconds.

Pause for 3-5 seconds. Next, the doctor moves the lower jaw to the next physiological barrier and repeats the muscle-energy technique.

Number of repetitions - 3.

Retesting.

Rebalance.

- Technique of two-sided correction of somatic dysfunction of the TMJ disc.

Patient position. Lying on the back.

Physician's position: Standing facing the patient, near his head.

Position of the doctor's hands. The first fingers of both hands are placed intraorally on the dental arcades of the lower jaw (right and left).

The remaining fingers perform a “palpatory chord”, covering the lower jaw from both sides.

Correction technique.

Stage one. Release of the articular heads of the mandible.

"Palpatory chord." Inducing tissue tension: gentle traction of the mandible in the caudal direction to the physiological barrier. The doctor then moves the mandible ventrally (toward the ceiling) to the physiological barrier. The set parameters are maintained for correction.

Stage two. The doctor shifts the mandible cephalad, applying traction to the physiological barrier. Then, maintaining the previous parameters, the doctor shifts the mandible dorsally toward the table, applying a dorsocephalic thrust to the articular discs.

Tissue reorganization.

Still point.

Retesting.

Rebalance (global)

N.B. The technique is performed gently, in the rhythm of the tissues. The therapist's body moves from L3 through the wrist joints.

- Technique for correcting unilateral somatic dysfunction of the left articular disc.

Patient position. Lying on the back.

Physician's position: Standing facing the patient at the head.

Position of the doctor's hands. The first fingers of both hands are placed on the dental arches of the lower jaw. The second through fifth fingers, from the outside, perform a bilateral "grasp" of the lower jaw.

The correction technique is performed in two stages.

At the first stage:

• the right hand, located on the left half of the lower jaw, performs traction in the caudal direction and moves the lower jaw ventrally (towards the ceiling) to the physiological barrier.

• the left hand, located on the right half of the lower jaw, makes a simultaneous counter movement, namely, traction in the cephalic direction and shifts the lower jaw dorsally (towards the table) to the physiological barrier.

At the second stage of performing the technique:

• the right hand tractions the lower jaw in the caudal direction to the physiological barrier and moves it caudally (towards the table) to the next physiological barrier.

• the left hand simultaneously moves in the opposite direction, performing traction in the caudal direction and shifting the lower jaw ventrally (towards the ceiling) to the physiological barrier.

The doctor waits for tissue reorganization, relaxation and a still point.

Retest.

Rebalance.

- Technique for correction of somatic dysfunction of the stylomandibular ligament.

Clinical manifestations. Shortening of the stylomandibular ligament may cause hearing loss, ear pain, difficulty swallowing, and pain associated with compression of the carotid artery. This may include increased sensitivity over the styloid process of the temporal bone. In some cases, this is asymptomatic.

Patient position. Lying on the back.

Physician position: Sitting on the side opposite the dysfunction, near the patient's head. Alternatively, the technique can be performed standing.

The position of the doctor's hands. The cephalic hand forms a "palpatory chord" on the temporal bone, due to the "grasping" of the zygomatic process of the temporal bone with five fingers.

The bone is “captured by volume”, with the perception of all anatomical and physiological relationships.

Caudal hand: The dentist advances the first finger intraorally along the dental arcade on the side of the correction to the last tooth (if there is no last tooth, then to the place where it should be on the lower jaw). The remaining four fingers are placed on the body of the lower jaw, grasping the angle of the lower jaw – the 2nd and 3rd fingers.

Bilateral testing. The doctor evaluates the qualitative characteristics of mandibular movement, the presence or absence of restrictions, and the quality of the various phases of the LMP.

If the angle of the mandible is elevated and does not shift laterally or dorsally during flexion, then the ligament can be assumed to be shortened on one side. Bilateral ligament shortening is rare.

Correction technique: the position of the patient and the doctor does not change, the correction is performed from the opposite side.

During flexion of the PDM, the physician accompanies the movement of the temporal bone into internal rotation and shifts the mandible dorsolaterally to a physiological barrier at the level of the stylomandibular ligament, maintaining this position during the extension phase. The technique is repeated three times, each time accompanies the temporal bone during the flexion phase and shifts the mandible dorsolaterally, placing the ligament tissues under pretension to a new physiological barrier.

After unilateral correction, the doctor performs local rebalancing at the level of the TMJ joints.

Retest.

Rebalance (global).

- Balancing the stylomandibular ligament

by V. Frymann.

Patient position. Lying on the back, head in a neutral position.

Physician's position: Sitting on the side opposite the somatic dysfunction.

Hand position.

The cephalic hand is a “palpatory chord” on the temporal bone, due to the “grasp” of the zygomatic process of the temporal bone with five fingers.

Caudal hand – the dentist advances the first finger intraorally along the dental arcade on the side of the correction to the last tooth (if there is no last tooth, then to its proper location on the lower jaw) and places it on the occlusal surface, usually the third molar. The remaining four fingers are placed on the body of the lower jaw, grasping the angle of the lower jaw – the second and third fingers.

“Palpatory chord” with the tissues of the lower jaw with a perceptual sensation of all the anatomical and physiological relationships of the lower jaw with the body.

Synchronization with the cranial rhythm, or other global endogenous rhythm of the body.

The physician does not perform any additional actions during the synchronization process. The nature of the rhythmic activity with which the osteopath synchronizes depends largely on the state of the physician and patient at the time of osteopathic care.

During the flexion (inhalation) phase of the cranial rhythm, the doctor places the temporal bone into external rotation and maintains it.

It performs a slight displacement of the lower jaw in the caudolateral-ventral direction along the oblique axis, stretching the ligament to the physiological barrier (the presence of pain indirectly indicates possible fibrosis of the ligament).

At each phase of inhalation, the doctor increases the external rotation of the temporal bone and with minimal effort moves the lower jaw downwards, backwards and outwards until tissue resistance disappears.

In most cases, the technique is performed once. If the ligament is severely rigid, the therapist's efforts are further minimized, and the technique is performed no more than three times.

Retest.

Rebalance.

- Decompression of the temporomandibular joint

by V. Frayman.

Patient position. Lying on the back

Physician position: Sitting or standing on the side opposite the dysfunction

The position of the doctor's hands. The cephalic hand forms a "palpatory chord" on the temporal bone, grasping the zygomatic process of the temporal bone with five fingers.

Caudal hand – the dentist advances the first finger intraorally along the dental arcade on the side of the correction to the last tooth (if there is no last tooth, then to its proper location on the lower jaw) and places it on the occlusal surface, usually the third molar. The remaining four fingers are placed on the body of the lower jaw, grasping the angle of the lower jaw – the second and third fingers.

“Palpatory chord” with the tissues of the lower jaw with a perceptual sensation of all the anatomical and physiological relationships of the lower jaw with the body.

Correction.

"Palpatory contact" with tissues.

Synchronization with cranial (or other) global endogenous rhythm.

The doctor applies minimal force to the mandible within the joint (movement vector toward the glenoid fossa), on the one hand, toward the limitation and compression, assessing the internal tension in the joint. By balancing the external force and the internal compression tension within the joint, the doctor finds a neutral zone of balanced forces.

Expectation.

Still point.

The appearance of a feeling of increasing potency inside the joint.

Spontaneous decompression within the joint.

Restoration of tissue and joint mobility.

Retest (control testing).

Rebalance.

- Technique for correction of the sphenomandibular ligament.

Physician's position: Standing or sitting at the patient's side

Patient position. Lying on the back

The diagnostics are bilateral.

In a diagnostic test

Position of the doctor's hands.

Cranial hand: The 1st and 3rd fingers are located on the large wings of the sphenoid bone.

Caudal hand: The dentist advances the first finger intraorally along the dental arcade on the side of the correction to the last tooth (if there is no last tooth, then to its proper location on the lower jaw) and places it on the occlusal surface, usually the third molar. The remaining four fingers are placed on the body of the lower jaw, grasping the angle of the lower jaw (the second and third fingers).

“Palpatory chord” with the tissues of the lower jaw with a perceptual sensation of all the anatomical and physiological relationships of the lower jaw with the body.

Testing. The doctor evaluates the movement of the angle of the mandible and the position of the greater wings of the sphenoid bone. If the ligament is shortened, the angle will be elevated on the side of the shortening, while the greater wing on the side of the restriction will be elevated and lag behind when assessing movement during the flexion and extension phases.

Correction.

"Palpatory chord" with tissues.

We synchronize with PDM (primary breathing).

During the flexion phase, the physician accompanies the movement of the sphenoid bone, on the side of the raised wing, with minimal force, stimulating its ventral and caudal movement. At the same time, a laterodosal movement will occur at the level of the gonion. During the extension phase, the physician maintains this position and accompanies it during flexion.

The movement is performed with minimal effort until the tissues under the fingers relax.

Retest.

Rebalance.

The proposed method for correcting TMJ dysfunction is distinguished by its osteopathic diagnosis, which involves sequentially determining the presence of dysfunction associated with compression, venous congestion (hypercapnia), and arterial insufficiency, confirmed by instrumental diagnostic methods (ultrasound Doppler imaging of the head and neck vessels, abdominal cavity, chest, and contrast-enhanced MRI, if necessary). The most significant component of dysfunction is determined.

• osteopathic correction is performed in a strict, step-by-step sequence, in the form of: osteopathic correction of diabetes with severe compression of the motor joints

• osteopathic correction of somatic dysfunctions that initiate venous congestion

• osteopathic correction of diabetes leading to impaired arterial circulation.

• Osteopathic correction of local diabetes mellitus from the TMJ side.

Osteopathic correction of extraocclusal TMJ disorders is, in order of priority, performed in the sequence of initial correction of functional disorders of macro- and micromobility of tissues and organs of the body, anatomically located outside the dental-jaw system.

Osteopathic correction of intraocclusal SD of the TMJ is performed in the sequence of initial osteopathic correction of SD of the anatomical motor joints that are directly functionally involved in the formation of the bite.

The proposed method of osteopathic correction of TMJ disorder is distinguished by the presence of two sequential algorithms for the correction of TMJ disorder.

The first algorithm allows for osteopathic correction with a differentiated sequence of correction of the etiological factors of the formation of TMJ disorders depending on their form:

• extraocclusal

• intraocclusal

The second algorithm defines a strict sequence of eliminating the etiological factors of the formation of diabetes, in the form of eliminating compression in the motor joints first, venous circulation disorders second, and arterial circulation disorders third.

The use of the above sequence of osteopathic correction of TMJ disorders allows to increase the effectiveness of medical care in the process of treating TMJ disorders and eliminating its clinical manifestations.

Literature.

1. Clinical guidelines "Somatic dysfunction", coding according to the International Statistical Classification of Diseases and Related Health Problems: M99.0, M99.8, M99.9. Age group: adults, children. Year of approval: 2023

2. Aptekar I.A. Principles and Methods of Osteopathy Part 1. Biomechanical Method: Textbook. Tyumen: Tyumen Printing House; 2020; 139 p.

3. Aptekar I.A., Kostolomov E.G., Sukhovey Yu.G. Changes in the functional activity of fibroblasts during the modeling of compression, hypercapnia, and hypoxia. Russian Osteopathic Journal. 2019; (1-2): 72-84

4. Babanin Yu.A. Basic concepts and models in osteopathy. Russian Osteopathic Journal. 2017; (1-2): 95-104

5. Mokhov D. E., Aptekar I. A., Belash V. O., Litvinov I. A., Mogelnitskiy A. S., Potekhina Yu. P., Tarasov N. A., Tarasova V. V., Tregubova E. S., Ustinov A. V. Fundamentals of osteopathy: A textbook for residents. M.: GEOTAR-Media; 2020; 400 s.

6. Novoseltsev S.V. Clinical osteopathy. Visceral techniques. OOO Izdatelstvo Foliant. 2013, pp. 97-99. https://med7.net/page/201201231100217222249078099103235023099167032204/

7. Novosel'tsev S.V. Textbook for higher educational institutions. Book 1. 2nd edition, MEDpress-inform, 2022, 688 pp., ill., ISBN: 978-5-907504-20-2

8. Crockett K.E. Dental problems in general osteopathic practice // The Journal of the Kansas Stale Dental Association Vol. 62, No. 1 (1978), p. 16-20

Clinical examples.

Example 1.

Patient N., 32, an engineering and technical worker, underwent treatment with a dentist in September 2022. The course of treatment was one month, with each session lasting 45 to 60 minutes. During the treatment, symptoms such as pain in the earlobe area developed. She took NSAIDs for 5 days. Medication helped relieve the pain. After one month, the pain recurred. After repeated NSAID use, the pain subsided. The patient consulted a dental clinic. Her complaints included pain in the TMJ area, limited mouth opening, and a crunching sound in the joint on the left side. Her medical history includes a history of periodic crunching in the TMJ area since childhood. She had been treated by an orthodontist from the age of 11 to 13.

An MRI of the TMJ revealed partial anteromedial displacement of both articular discs on both sides and metabolic and degenerative changes in the TMJ discs. Diagnostic tests revealed a limitation of mouth opening of 15 mm.

Osteopathic diagnosis: DSD of the head region. Localized TMJ, C0-C1, C1-C2, with a predominant biomechanical component.

Treatment:

Osteopathic treatment was carried out in full accordance with the methodology we developed.

1. Correction of compression of the SIJ on both sides.

2. Correction of L5-S1 compression

3. Correction of normal mobility of the pelvic diaphragm using the chest breathing function.

4. Correction of the functional mobility of the thoraco-abdominal diaphragm using the chest breathing function.

5. Correction of somatic dysfunction C0-C1, C1-C2.

6. Correction of somatic dysfunction of the SBS, compression genesis.

7. Correction of membranous and suture somatic dysfunction of the anatomical region of the head.

8. Correction of compression of the zygomatic bone on the side of the dominant somatic dysfunction.

9. Correction of the temporal bone.

10. Correction of intersutural dysfunction of the temporo-occipital joint in the foramen jagularis area.

11. Correction of venous sinuses of the anatomical region of the head.

12. Correction of the TMJ using compression or decompression techniques with the use of therapeutic force in the form of kinetic effort on the part of the osteopathic physician and the functional activity of chest breathing at the local level, including the SD of the muscular-ligamentous apparatus of the TMJ.

13. Osteopathic correction is initially performed on the TMJ with minimal functional impairments without clinical disorders, then correction of the TMJ with functional impairments and clinical manifestations.

14. Repeated osteopathic testing and joint-muscle-fascial balance can improve the medical effectiveness of TMJ disorder correction.

Claims (6)

A method of osteopathic correction of somatic dysfunction (SD) of the temporomandibular joint (TMJ) of intraocclusal and extraocclusal genesis, characterized by the fact that a preliminary differential diagnosis is carried out and the etiological factor of the formation of TMJ SD is identified, orthodontic, osteopathic and instrumental diagnostics are performed, and the dominant and primary TMJ SD is determined; if the diagnosis of dominant somatic dysfunction of extraocclusive genesis is confirmed, osteopathic correction is performed, including the sequential implementation of the following osteopathic techniques: correction of compression of the sacroiliac joint on both sides, correction of compression of L5-S1, correction of somatic dysfunction of C0-C1, correction of membranous and suture somatic dysfunction of the anatomical region of the head, correction of compression of the zygomatic bone on the side of the dominant somatic dysfunction, correction of the temporal bone, correction of compression of the spheno-basilar synchondrosis, correction of venous sinuses and the CV4/EV4.4 technique, correction of the mobility of the pelvic diaphragm using the thoracic breathing function, correction of the functional mobility of the thoraco-abdominal diaphragm using the thoracic breathing function, stimulation of positive functional changes in arterial circulation using the appropriate techniques of osteopathic correction of the area heads; in case of detection of an intraocclusal etiological factor, dental care is provided and the etiological factor of intraocclusal TMJ SD is eliminated; after dental therapy with correction of disorders of the dentoalveolar system, the patient is referred to an osteopathic physician for osteopathic correction of secondary somatic dysfunctions similar to that described for SD of extraocclusal genesis; correction of somatic dysfunction of the TMJ is carried out in the sequence of predominance of its constituent components using compression and decompression techniques; in this case, osteopathic correction is carried out according to the algorithm of sequential elimination of compression, hypercapnia and hypoxia, in a quantity of at least 3 sessions within 1 month; The criteria for achieving a therapeutic effect are: a decrease of at least 25% compared to the initial state of pain assessment using a visual analogue scale (VAS), an increase in the range of motion when opening the mouth, positive dynamics of changes in the occlusal component, diagnosed in the process of osteopathic, orthodontic and instrumental diagnostics of the functional state of the TMJ.