Journal of Craniomandibular Practice

ISSN: 0734-5410 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/ycra19

Physical Therapy and Dentistry: An Overview

Mariano Rocabado R.P.T., Ben E. Johnston Jr. R.P.T. & Mitchell G. Blakney
R.P.T.

To cite this article: Mariano Rocabado R.P.T., Ben E. Johnston Jr. R.P.T. & Mitchell G. Blakney
R.P.T. (1982) Physical Therapy and Dentistry: An Overview, Journal of Craniomandibular Practice,
1:1, 46-49, DOI: 10.1080/07345410.1982.11677818

To link to this article: http://dx.doi.org/10.1080/07345410.1982.11677818

Published online: 19 Feb 2016.

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Download by: [University of Saskatchewan Library] Date: 28 February 2017, At: 09:23
Physical Therapy
and Dentistry:
An Overview
Temporomandibular joint problems begin early in life even
though the symptoms are not present until the adult years.
Physical therapy in collaboration with dentistry provides an
increasingly successful approach to longer lasting treatment. A
correlation between Class 11 occlusion and forward head
posture provides further evidence that the team approach is
essential. Many TMJ headaches and referred pains of the neck
and shoulders are caused by compression of the cervical
joints. The proper orientation of four planes: the vertical
plane, the bipupilar line, the plane of the otic system, and the
occlusal plane are necessary for case success. Treatment
involves the proper body mechanics, overcoming
parafunctional oral habits, and instruction to restore mobility
of the spine. The coordinated approach to treatment involves
dental and medical professionals and physical therapists to
intercept many serious conditions.

Mariano Rocabado, R.P.T.

Ben E. Johnston, Jr., R.P.T.
Mitchell G. Blakney, R.P.T.

Mariano Rocabado, R.P.T.

Mariano Rocabado, who has been in clinical practice for fifteen years, is now
Associate Professor and Coordinator of the Dental School at the University of
Chile. He is also Director of the Rocabado Institute as well as Director of the
Centro de Rehabilitacion Integral.
Soon after receiving his degree from the Physical Therapy School at the
University of Chile at Santiago (1966), Mr. Rocabado studied for six months in
France on a scholarship for specialization on the spine. From 1970 to 1973 he was a
member of the Executive Committee of the World Confederation for Physical
Therapy, and he is now also an Honorary Member of the American Academy of
Craniomandibular Disorders. Mr. Rocabado has lectured in Argentina, Colombia,
Peru, Ecuador, Panama, Honduras, Costa Rica, Canada, Norway, and the U.S. He
resides in Santiago, Chile.

0734-5410/82/01046-04$0.65/0 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 46

PHYSICAL THERAPY
A Perspective
O rthopedic manual therapists are graduates of tradi-
tional physical therapy programs who have pursued
training in evaluation and treatment of the neuro-
muscular skeletal system. The training of a manual
therapist includes management of peripheral and spinal
joints through neuromuscular and joint mobilization
techniques. Most manual orthopedic physical therapy
is an expansion from the traditional modes of physical
therapy treatment, which are highly dependent upon
the mechanical and electronic machinery in the field.
In addition to standard training, many therapists
have also taken post-graduate training in the anatomy
and physiology of the head, neck, and maxillofacial
region. This additional training enables the physical
therapist to understand the biomechanics of the head,
neck, and craniomandibular system for a broader per-
spective of evaluation, differential diagnosis, and
approach to treatment.
In the past few years there has been increasing com-
munication between the professions of physical ther-
apy and dentistry. This communication began as these
practitioners gradually realized that the multiple com-
plaints of the adult patient with head, neck, and facial
pain were all parts of one syndrome. Physical thera-
pists and dentists working as a team observed that,
with their joint efforts, results were more complete and
longer lasting, and the length of time necessary for
treatment was reduced considerably.
47 DEC '82-FEB '83, VOL. I, NO. I
Physical Therapy
and Dentistry:
An Overview
By Mariano Rocabado, R.P.T.
Ben E. Johnston, Jr., R.P.T.
Mitchell G. Blakney, R.P. T.
Malocdusion and Posture
The correlation between Class 11 occlusion and for-
ward head posture is as high as seventy percent (70%)
and is probably the strongest evidence that we have
been able to observe in the relationship between head
posture and malocclusion. The typical adult symp-
tomatic TMJ patient has a deep overbite or a Class 11
occlusion and a forward head posture. He or she may
develop facial pain, abnormal mechanics at the level of
the temporomandibular joints, inducing excessive
anterior translatoric glides of the condyles, or fatigue
and spasm of the facial musculature. The patient may
also develop headaches as referred pain from the mus-
cles or the temporomandibular joint, since the forward
head posture causes overwork of the suboccipital mus-
culature.
Compression of the upper cervical facet joints some-
times occurs, and occasionally there is entrapment of
the greater or lesser suboccipital nerves as they pass
between the occiput and the atlas, or C 1 vertebra. This
may result in suboccipital headaches or referred
headaches to the cranial-facial regions from the mus-
cles of the cervical spine. If the neurovascular struc-
tures are compressed, the patient may complain of
neurogenic pain in the distribution of the affected
nerves.
In addition to these problems, abnormal head pos-
ture also creates fatigue of the neck muscles and com-
pression of the facet joints of the cervical spine, which
may cause neck pain and referred pain into the arm and
to the interscapular area. In advanced cases, neck
posture may also create degenerative changes that gra-
0734-5410182/01()46.()4$0.65/0

dually encroach upon the intervertebral joints and pro-
duce cervical nerve root compression, neurogenic pain
in the arm, and paresthia and weakness of the upper
extremities. The forward head posture favors abduc-
tion and protraction of the scapula, which over long
periods may create shoulder girdle syndromes which
can cause further changes in the curvatures of the
spine.
The dynamic relationship between head posture and
dental occlusion can be demonstrated by testing the
occlusion with occlusive wax or bite paper. When the
head is side bent in a simple manner and rotated, the
occlusal contact becomes stronger on the side toward
which the head is bent. When the head extends, occlu-
sal contact becomes more posterior. When the head
flexes, the occlusal contact becomes more anterior.
The effect of head posture on occlusion and the resting
tone of the facial and neck musculature is the subject of
current research.
Importance of Horizontal Planes
The three dimensional orientation of the head in
space is dependent on four planes: the vertical plane,
the bipupilar line, the plane of the vestibular system or
otic system, and the occlusal plane. If any of the three
horizontal planes (the bipupilary plane, the otic plane,
and the occlusal plane) are not horizontal, adaptive
position will be made over time by the rest of the spinal
column to restore these planes to level. The drive to
level these three planes is so strong that if the bipupi-
lary and bite planes are not parallel and horizontal, a
gradual warping of the face will occur. resulting in
facial asymmetry. It is important to realize thauhe
correction made by the spinal column at the level of the
bite or bipupilary plane wiU always be three dimen-
sional, involving tlexion, rotation, and side bending of
the vertebral segments. This creates abnormal stretch-
ing of the soft tissue structures at the apex of the
correcting curvature.
Diflkulties of Establishing
Correct Ocdusion and Posture
If the reciprocal relationship between head posture
and occlusion is understood, it becomes clear that
physical therapists may not be able to stabilize head
posture in a patient with malocclusion. In addition, the
dentist may not be able to restore a definite occlusion
or correct craniomandibular relationships in patients
with obvious postural problems. Physical therapists
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
PHYSICAL THERAPY AND DENTISTRY
may treat the soft tissue and instruct the patient in a
posture in which he or she should function, but the
patient may gradually assume the head posture that
allows the teeth to occlude in a satisfactory manner.
Conversely, the patient who has adapted head pos-
ture to a malocclusion may not be able to assume
normal head postures even when the occlusal problem
is solved. This is due to shortening of connective tissue
and muscles, soft tissue memory, and weakness of the
postural musculature. Often once the original maloc-
clusion and posture are solved, there remain other
secondary problems such as abnormal shoulder girdle
conditions or low back problems. These will need to be
treated for full structural posture and normal body
mechanics.
Treatment
Following a complete history in structure and a
neuromuscular examination, the physical therapist will
decide the treatment plan to restore mobility of the
spine, to stretch and strengthen selectively the postural
musculature. and to instruct the patient in proper body
mechanics. The therapist should help the patient over-
come parafunctional oral habits and/or mouth breath-
ing and should work on repositioning of the resting
position of the tongue as well as coordinating and
strengthening of the muscles of mastication. The ther-
apist may also suggest assessment by other members of
the medical profession, possibly including the ENT or
the orthopedic surgeon.
We, as physical therapists, are proud of our succes-
ses with the symptomatic adult patient and are also
developing a perspective of treatment that will allow us
to prevent and intercept several conditions which are
present in the pediatric field as atypical headaches and
neck problems. In addition, our relationship with the
profession of dentistry is growing.
Condusion
We believe that temporomandibular joint problems
begin early in life. These problems are progressive, but
the patient may not exhibit symptoms until his or her
third, fourth, or fifth decade. A TMJ problem may
begin as an injury to the neck, as an allergic process, or
as a result of poor oral habits in infancy and childhood.
It will manifest itself as a postural problem or poor oral
habits in the child. The teenager with an orthodontic
problem, the adult with headaches and facial pain, and
the older adult with incapacity caused by headaches
and multiple muscular skeletal imbalances are also
48
ROCABADO, JOHNSTON, BLAKNEY

showing evidence of craniomandibular problems. We temporomandibular joint and related structures. Such
are, therefore, strong advocates of early screening and disorders can be treated effectively only if they are
intervention as the true solution for problems of the detected early.
Reprint requests to:
Mariano Rocabado, R.P.T.
Rocabado Institute
1624 South "/"Street, Suite /04
Tacoma, Washington 98405

Bibliography
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Deffemines Rospide) Eudeba Ed. Buenos Aires, Argentina:
Universitaria, 1973.
2. Rocabado, S.M. Cabeza y cuel/o, tratamiento articular. Buenos Aires,
Argentina: Editorial Intermedica, 1979.
3. Dalessio, D.J. Wo/jfs Headache and Other Head Pain. New York:
Oxford University Press, 1972.
4. Warwick, R .. and Williams, P. Gray's Anatomy, 35th Ed. Philadelphia:
W.B. Saunders Co .. 1973.
5. Wiliamson, M. Cervical spondylosis. Barcelona: Salvat editores S.A ..
1973.
6. Funakoshi, M., Fujita, H., and Takehana, S. Relation between occlusal
interference and jaw muscle activities in response to changes in
head position. J Dent Research 55, 1976.
7. Rodriguez, E., and Rocabado, M. Algias Craneo faciales de origen
cervical y por disfuncion del sistema estomatognatico Facultad
de Odontologia, Universidad de Chile, 1980.
8. White, A. A., and Paqjabi, M.M. Clincial biomechanics of the spine.
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9. D'Ambrosia, R.D. Musculoskeletal Disorders, Regional Examination
and Differential Diagnosis J.B. Lippincott Co., 1977.

Ben E. Johnston, Jr., R.P.T.

Mr. Johnston is active as a Director of the Physicians' Physical Therapy Service,
Inc., P.S. He is also currently serving as a Director of the Rocabado Institute. Mr.
Johnston has been in clinical practice continuously for nineteen years. He is now
practicing in Tacoma, Washington, where he resides.

Mitchell G. Blakney, R.P.T.

Mr. Blakney, who has been in clinical practice for six years, holds a position as
a Director of the Rocabado Institute. He currently practices in Tacoma,
Washington. In addition to his duties with the Rocabado Institute, Mr. Blakney
also serves as a Director of the Physicians' Physical Therapy Service, Inc., P.S.

49 DEC '82-FEB '83, VOL. I, NO. I