The Dural Connection, July 2002, Volume 4, Number 1

The March 8-10th “Hands-On-Training” Conference in Jacksonville, Florida, was the historic site of SOTO-USA’s first combined chiropractic-cranial-dental collaboration. TMJ specialists from both disciplines came together to share Sacro-Occipital Technique (SOT) and TMJ dental models of treatment in an atmosphere of mutual exchange.

The conference featured presentations by chiropractors (Drs. Jonathan Howat and Robert Walker) as well as dentists (Drs. James Carlson and Steven Rose) to a combined audience. Dr. Walker, the originator of Chirodontics, noted that the most difficult cases for dentists are usually the easiest for chiropractors and the most difficult cases for chiropractors are the easiest for dentists. The goal of this conference was not only to display the inter-dependence between our two professions and open a dialogue between them but to provide networking opportunities necessary for us to develop working relationships. Thanks to the success of this conference we are planning future craniodental seminars at next year’s SOTOUSA Clinical Symposium.

Our 2002 SOTO-USA Clinical Symposium in Phoenix (August 15-18) will feature James Kennedy, DDS and Norman Murphy, PhD who will speak about additional cranio-dental topics.

I pride myself on my diverse knowledge of biomechanics, anatomy, neurology, adjusting technique (including SOT), and craniopathy but I was truly overwhelmed by the depth and scope of the information offered at SOTO-USA’s “HOT” Conference in Jacksonville in regard to treating the TMJ.

My previous working relationships with dentists consisted of (a) the DDS adjusted the appliance until the patient developed symptoms, then (b) sent them to me to “put out the fire.” I, on the other hand, adjusted the patient’s musculoskeletal and cranial systems until the symptoms subsided, at which point (c) I sent them back to the DDS and the cycle was repeated. There was little attempt at communicating and even less understanding between us concerning our methodologies. Drs. Carlson, Rose, and Walker introduced me to a whole new approach.

On one hand I learned how our two professions share basic similarities (just different points of view). Dr.Carlson demonstrated the relationship between the condyle of the mandible and its point of articulation with the temporal bone (the articular eminence).

The articular eminence forms the anterior border of the TMJ. It defines both the A-P as well as the S-I “glide path”of the condyle as the mandible opens and closes.

He then showed how the slope angle of the articular eminence affects the glide path of the condyle and the way this affects the way the teeth inter-digitate. For the first time, I was able to see from a dentist’s maxilla and ultimately, the TMJ. And I was also able to see how I, as a craniopath, could significantly affect the slope of the articular eminence by directing my attention to the movement pattern of the temporal bone.

The Effect of Slope on the Articular Eminence and TMJ

Moderate Angle (Class 1)
A moderate degree of overbite is found at closure.

Steep Angle (class 2)
The steeper the angle, the further the condyle drifts posterior and superior at closure.
This steeper angle allows the overbite to increase, causing a retrognathic mandible.

Shallow Angle (class 3)
The shallower the angle, the further the condyle drifts inferior and anterior at closure.
This shallower angle allows the overbite to decrease, causing a prognathic mandible.

On the other hand, I learned we have some fundamental differences. The ultimate goal of the dentist is to create an optimized bite pattern (“optimized plane of dental occlusion”) in order to achieve a stable, static relationship between the mandible and the maxilla. In contrast, the craniopath’s goal is to promote free and unrestricted movement of the cranium. That’s like saying that their purpose is get the pudding to set while ours is to keep it liquid.

The Effect of Temporal Rotation on the Articular Eminence and TMJ

The temporal bone rotates EXTERNALLY during the inhalation (expansion) phase of cranial motion and INTERNALLY during the exhalation (contraction) phase.
This has a direct effect on the angle of the slope of the articular eminence.

TEMPORAL BONE in NEUTRAL
Moderate Angle (Class 1)
A moderate degree of overbite is found at closure.

TEMPORAL BONE RESTRICTED in INTERNAL ROTATION
Steep Angle (class 2)
When the temporal bone rotates anteriorly (internal rotation) it steepens the angle of the articular         eminence, causing the condyle to drift posterior and superior at closure.
As the temporal bone rotates internally the overbite increases, causing a retrognathic mandible.

TEMPORAL BONE RESTRICTED in EXTERNAL ROTATION
(Shallow Angle (class 3)
When the temporal bone rotates posteriorly (external rotation), it reduces the angle, causing the         condyle to drift inferior and anterior at closure.
As the temporal bone rotates exteriorly the overbite decreases, causing a prognathic mandible.

How, then, can we ever hope to work together?  One answer was offered by Dr.Walker and his “Chirodontics” program which is designed specifically to create common ground between our two professions. It stresses that our mutual goals revolve around stabilizing the patient’s biomechanics and not just moving the teeth or cranial bones. It features a unique series of evaluation and correction techniques which dentists and chiropractors can use TOGETHER to treat patients. The schedule for Dr. Walker’s program is available online at Chirodontics.com.

SOTO-USA now offers you the valuable membership option of certification in both SOT and SOT Cranial work. By adding “Certified SOT Practitioner”(CSP) and “Certified SOT Cranial Practitioner” (CSCP) to your professional credentials, you will be recognized in your community as the unique practitioner that you are. As you interface more effectively with other professionals and with your own patients, your referral base will skyrocket, and so will your income! Once certified, you will gain special listing in our world-wide referral directory.

The following courses are required prior to taking the certification exams. They can be taken regionally throughout the year via SOTO-USA’s Regional Seminar Series.

CSP: SOT Levels One and Two, Extremity Adjusting Level One, and Chiropractic Manipulative Reflex Technique.

CSCP: CSP Certification plus Cranial Levels One, Two and Three. [As of 2012 we have cranial level four seminars, also.]

Those who have completed equivalent course work, either through an accredited chiropractic college or another seminar series, may apply to SOTO-USA for exemption from certain courses by providing proper documentation Each certification exam is comprised of a 100-question written exam as well as a “hands-on” practical. The exams are comprehensive and clinical in nature, designed to test your working knowledge of SOT and SOT Cranial in an office setting. Reference texts for study are those manuals published by SOTO-USA for use in the regional seminar series, as well as the DeJarnette 1984 SOT and 1979-80 Cranial Manuals. The fee for each exam is $250, payable to SOTO-USA at the time of registration.

Appropriate documentation of the required courses, along with a copy of your chiropractic college diploma and current state license must accompany registration. Those doctors with prior certification from other SOT organizations may sit for a written Reciprocity Certification Exam through the end of 2002 only. Join us at the Clinical Symposium in Phoenix, AZ in August and take your certification exam. Written exams will be held on Thursday, Aug. 15 at 10 am. Practical exams will begin at 1pm. For more details about any of the exams, please contact either the SOTO-USA office at (360) 793-6524, or Dr. Christine Benner at (212) 929-2424 doctorbenner@gmail.com

TMJ condylar tracking as well as crepitus can often be improved using a combination of active and passive exercises to normalize joint translation and disc tracking.

1. Minor joint dysfunction – first stage of home treatment of joint clicking, popping, or crepitus:

The patient presses the tongue against the center of the roof of the mouth directly behind the front teeth (where the tongue would go to say “la”), then opens and closes the jaw. If this alone reduces crepitus and/or normalizes joint motion, the patient should perform three sets of ten repetitions, 4-5 times a day, for 4-8 weeks. If it doesn’t improve function, increase tongue pressure, if it still does not stop the “clicking” sound then proceed to the next group of exercises.

2. Lateralization of the TMJ:

The patient places the tongue behind the front teeth at the roof of the mouth on the side away usually from the “popping” or pain. The tongue needs to be placed as far left or right suficiently to create the greatest ease in opening and closing while decreasing or eliminating any joint “clicking”. The patient needs to repeat this exercise daily. As improvement is noted, they will gradually be able to centralize tongue position. The exercise repeated until the tongue can be placed centrally at which time the patient should proceed with exercise #1.

3. Protrusion and Retrusion:

The patient places the tongue on the roof of the mouth usually anteriorly (to aid in TMJ dysfunction caused by mandibular retrusion) or posteriorly (if caused by mandibular protrusion). The tongue is placed as far forward or backward as necessary to create the greatest ease in opening and closing while decreasing or eliminating any joint “clicking”.. The exercise is repeated until the tongue can be placed centrally and the patient should proceed with exercise #1.

With complex mandibular dysfunction, oblique positions and various pressures might be required. The ultimate goal is to bring the tongue into a central position at roof of the mouth and reduce or eliminate any joint popping or clicking.

4. Disc Centralization:

Once the patient can perform exercise #1 with without crepitus, the patient can then proceed to the following mirror-assisted exercise. With the tongue in central position, the patient attempts to maintain the jaw in the midline while opening and closing, evaluating the center of the bottom and top teeth during motion. The patient should perform this exercise, three sets of ten repetitions, 4-5 times a day.  Once they can learn how to open and close in a balanced manner the mirror would only need to be used to assure proper motion one time per day, however the exercise is still performed 4-5 times a day, until they can begin to reduce tongue tension, there is no joint clicking, and their jaw opens evenly.

Relief of muscular tension:

Difficulty will be observed when the patient attempts to swallow while maintaining a level chin and forehead when supine or while tilting the head back when sitting. Often the patient may complain of respiratory difficulties particularly at night, sometimes leading to a TMJ form of sleep apnea. This is often accompanied by persistent suboccipital and/or submandibular muscle tension.

Instruct the patient to perform the following muscle relaxation exercises.

1.    The patient places the tip of the tongue in a relaxed manner near the roof of the mouth behind the front teeth, in a position if they would make the sound “la.”   The patient then focuses their attention to the back part of their tongue that is the farthest back in the throat and relaxes that part of the tongue as much as possible.

2     The patient next puts their attention to their jaw and relaxes the jaw muscles, allowing the mandible to drop downward and forward.

3.    The patient then consciously attempts to relax their suboccipital muscles as if their nose would nod downward a half inch.

4.     This exercise can become a mediation as the patient attempts to repeatedly go from: “tip of the tongue near the roof of the mouth,” “back part of tongue relaxes,” “jaw drops downward and forward,” and “back part of head relaxes.”

With repetition, the patient will gain greater awareness and control of the muscular tension.  I have often recommended to patients that they perform this relaxation exercise every 20 seconds for the rest of their life.

These home exercises, when used in conjunction with Sacro Occipital Technique cranial treatment for TMJ dysfunction, can be of tremendous help to the patient’s progress. If they fail to normalize joint crepitus, translation or disc tracking, dental co-treatment is usually required.

Ready to be inspired? SOTO-USA will soon offer an exciting opportunity exclusively for its members, an opportunity to work and learn from some of the foremost leaders in the chiropractic profession in some of the most exotic and exciting places in the world: Bali, Peru, India, Costa Rica, and China, to name a few. A select group will be invited to attend humanitarian mission trips created, presented, and designed exclusively for SOTO-USA members.

The only way to truly learn a chiropractic technique is by practicing it. How? By adjusting people–hundreds and hundreds of people. No amount of study or seminars or conferences can substitute for hands-on-training. Not just models, not just demonstrations, but real people with real problems needing real help in real life. No other technique organization has ever offered such an opportunity. This chance is now available to the members of SOTO-USA. What a unique and rare opportunity to learn SOT as you see the results of your own work on a daily basis. Ask anyone who has ever gone on a mission trip and they will all tell you how it was one of the most powerful personal and professional experiences of their lives.

At last year’s Clinical Symposium, Dr Leonardi shared his amazing slides and inspiring stories about the greatness of chiropractic and its many miracles. This presentation alone was well worth the trip. SOTO-USA is honored to work in conjunction with a chiropractor of Dr. Leonard’s stature in offering this unique and inspiring opportunity to really make a difference in the world.

About Dr. Leonardi: Dr. Louis Leonardi has over 20 years in the chiropractic profession. He served as an Olympic team doctor at three Olympic games, was one of the charter members of the ICA Sports Council, and was winner of the ICA International Achievement Award. He has been on TV and radio both nationally and internationally, has written articles for almost every newspaper and chiropractic magazine, and has presented papers at scientific conferences in Australia, China, Korea, Africa as well as America. He has opened 5 clinics on 4 continents, and led successful mission trips all over the world.