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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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

Physical Therapy
and Dentistry:
An Overview
By Mariano Rocabado, R.P.T.
Ben E. Johnston, Jr., R.P.T.
A Perspective Mitchell G. Blakney, R.P. T.

Malocdusion and Posture

O rthopedic manual therapists are graduates of tradi-
tional physical therapy programs who have pursued
training in evaluation and treatment of the neuro-
The correlation between Class 11 occlusion and for-
ward head posture is as high as seventy percent (70%)
muscular skeletal system. The training of a manual and is probably the strongest evidence that we have
therapist includes management of peripheral and spinal been able to observe in the relationship between head
joints through neuromuscular and joint mobilization posture and malocclusion. The typical adult symp-
techniques. Most manual orthopedic physical therapy tomatic TMJ patient has a deep overbite or a Class 11
is an expansion from the traditional modes of physical occlusion and a forward head posture. He or she may
therapy treatment, which are highly dependent upon develop facial pain, abnormal mechanics at the level of
the mechanical and electronic machinery in the field. the temporomandibular joints, inducing excessive
In addition to standard training, many therapists anterior translatoric glides of the condyles, or fatigue
have also taken post-graduate training in the anatomy and spasm of the facial musculature. The patient may
and physiology of the head, neck, and maxillofacial also develop headaches as referred pain from the mus-
region. This additional training enables the physical cles or the temporomandibular joint, since the forward
therapist to understand the biomechanics of the head, head posture causes overwork of the suboccipital mus-
neck, and craniomandibular system for a broader per- culature.
spective of evaluation, differential diagnosis, and Compression of the upper cervical facet joints some-
approach to treatment. 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-
In the past few years there has been increasing com- cles of the cervical spine. If the neurovascular struc-
munication between the professions of physical ther- tures are compressed, the patient may complain of
apy and dentistry. This communication began as these neurogenic pain in the distribution of the affected
practitioners gradually realized that the multiple com- nerves.
plaints of the adult patient with head, neck, and facial In addition to these problems, abnormal head pos-
pain were all parts of one syndrome. Physical thera- ture also creates fatigue of the neck muscles and com-
pists and dentists working as a team observed that, pression of the facet joints of the cervical spine, which
with their joint efforts, results were more complete and may cause neck pain and referred pain into the arm and
longer lasting, and the length of time necessary for to the interscapular area. In advanced cases, neck
treatment was reduced considerably. posture may also create degenerative changes that gra-

47 DEC '82-FEB '83, VOL. I, NO. I 0734-5410182/01()46.()4$0.65/0

 PHYSICAL THERAPY AND DENTISTRY

dually encroach upon the intervertebral joints and pro- may treat the soft tissue and instruct the patient in a
duce cervical nerve root compression, neurogenic pain posture in which he or she should function, but the
in the arm, and paresthia and weakness of the upper patient may gradually assume the head posture that
extremities. The forward head posture favors abduc- allows the teeth to occlude in a satisfactory manner.
tion and protraction of the scapula, which over long Conversely, the patient who has adapted head pos-
periods may create shoulder girdle syndromes which ture to a malocclusion may not be able to assume
can cause further changes in the curvatures of the normal head postures even when the occlusal problem
spine. is solved. This is due to shortening of connective tissue
The dynamic relationship between head posture and and muscles, soft tissue memory, and weakness of the
dental occlusion can be demonstrated by testing the postural musculature. Often once the original maloc-
occlusion with occlusive wax or bite paper. When the clusion and posture are solved, there remain other
head is side bent in a simple manner and rotated, the secondary problems such as abnormal shoulder girdle
occlusal contact becomes stronger on the side toward conditions or low back problems. These will need to be
which the head is bent. When the head extends, occlu- treated for full structural posture and normal body
sal contact becomes more posterior. When the head mechanics.
flexes, the occlusal contact becomes more anterior.
The effect of head posture on occlusion and the resting
Treatment
tone of the facial and neck musculature is the subject of
current research.
Following a complete history in structure and a
neuromuscular examination, the physical therapist will
Importance of Horizontal Planes decide the treatment plan to restore mobility of the
spine, to stretch and strengthen selectively the postural
The three dimensional orientation of the head in musculature. and to instruct the patient in proper body
space is dependent on four planes: the vertical plane, mechanics. The therapist should help the patient over-
the bipupilar line, the plane of the vestibular system or come parafunctional oral habits and/or mouth breath-
otic system, and the occlusal plane. If any of the three ing and should work on repositioning of the resting
horizontal planes (the bipupilary plane, the otic plane, position of the tongue as well as coordinating and
and the occlusal plane) are not horizontal, adaptive strengthening of the muscles of mastication. The ther-
position will be made over time by the rest of the spinal apist may also suggest assessment by other members of
column to restore these planes to level. The drive to the medical profession, possibly including the ENT or
level these three planes is so strong that if the bipupi- the orthopedic surgeon.
lary and bite planes are not parallel and horizontal, a We, as physical therapists, are proud of our succes-
gradual warping of the face will occur. resulting in ses with the symptomatic adult patient and are also
facial asymmetry. It is important to realize thauhe developing a perspective of treatment that will allow us
correction made by the spinal column at the level of the to prevent and intercept several conditions which are
bite or bipupilary plane wiU always be three dimen- present in the pediatric field as atypical headaches and
sional, involving tlexion, rotation, and side bending of neck problems. In addition, our relationship with the
profession of dentistry is growing.
the vertebral segments. This creates abnormal stretch-
ing of the soft tissue structures at the apex of the
correcting curvature. Condusion

We believe that temporomandibular joint problems

Diflkulties of Establishing begin early in life. These problems are progressive, but
Correct Ocdusion and Posture the patient may not exhibit symptoms until his or her
third, fourth, or fifth decade. A TMJ problem may
If the reciprocal relationship between head posture begin as an injury to the neck, as an allergic process, or
and occlusion is understood, it becomes clear that as a result of poor oral habits in infancy and childhood.
physical therapists may not be able to stabilize head It will manifest itself as a postural problem or poor oral
posture in a patient with malocclusion. In addition, the habits in the child. The teenager with an orthodontic
dentist may not be able to restore a definite occlusion problem, the adult with headaches and facial pain, and
or correct craniomandibular relationships in patients the older adult with incapacity caused by headaches
with obvious postural problems. Physical therapists and multiple muscular skeletal imbalances are also

THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 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
I. Friedman, A.P., and Poch, G. E. Ccifeleas yjaquecas. Chapter V (H. A. 6. Funakoshi, M., Fujita, H., and Takehana, S. Relation between occlusal
Deffemines Rospide) Eudeba Ed. Buenos Aires, Argentina: interference and jaw muscle activities in response to changes in
Universitaria, 1973. head position. J Dent Research 55, 1976.
2. Rocabado, S.M. Cabeza y cuel/o, tratamiento articular. Buenos Aires, 7. Rodriguez, E., and Rocabado, M. Algias Craneo faciales de origen
Argentina: Editorial Intermedica, 1979. cervical y por disfuncion del sistema estomatognatico Facultad
3. Dalessio, D.J. Wo/jfs Headache and Other Head Pain. New York: de Odontologia, Universidad de Chile, 1980.
Oxford University Press, 1972. 8. White, A. A., and Paqjabi, M.M. Clincial biomechanics of the spine.
4. Warwick, R .. and Williams, P. Gray's Anatomy, 35th Ed. Philadelphia: J.B. Lippincott Co., 1978.
W.B. Saunders Co .. 1973. 9. D'Ambrosia, R.D. Musculoskeletal Disorders, Regional Examination
5. Wiliamson, M. Cervical spondylosis. Barcelona: Salvat editores S.A .. and Differential Diagnosis J.B. Lippincott Co., 1977.
1973.

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