Course Notes: PRI Craniocervical Mandibular Restoration

“The Head and Neck Runs The Show.” ~Ron Hruska

Hello, my name is Zac Cupples, and I have an addiction. I am addicted to attaining CEUs. But not just any CEUs, I want me some of that purple haze from the Postural Restoration Institute.

I got my fix and then some.

This past weekend I was at Endeavor Sports Performance in Pitman, NJ. I got to spend time learning about the neck and the cranium from none other then PRI founder, Ron Hruska.

From the get-go, Ron was adamant in saying that this class was his baby. That this information is what started it all.

And what I learned did not disappoint.

A bunch of happy addicts for sure.
A bunch of happy addicts for sure.

When I took Advanced Integration this past winter, I understood that we were affecting a system, but it didn’t really settle in with me until now. What we are predominately using to affect the nervous system is not specific muscles, but namely triplanar muscle families.

I am not trying to turn on the hamstrings, but I am trying remap the brain’s sagittal plane. I am not trying to turn on the IC adductor, but remapping frontal plane adduction to send me into left stance.

Similarly, we can affect these movement planes with cervicocranial mandibular muscles. It is just another location in the system to which sensory input is applied. Though seeing what outputs resulted will leave you just as surprised as your patients and cleints.

Watching Ron affect a person’s mobility throughout the entire body by manipulating a bite left me awestruck.

You do not realize the power of the human body, the nervous system, and autonomics until you see alterations at seemingly irrelevant areas creating system-wide changes.

I have been so excited to utilize this information clinically, so here is what I learned.

The Boomin’ System

LL is so down with PRI.
LL is so down with PRI.

The introductory courses focus predominately on testing/affecting certain body regions. When you move up to Impingement and Instability, the system slowly ties together via more bottom-up influences.

In this class, we see how we can influence the system from a top-down perspective. We have a new diaphragm that we work with called the maxilla. As we phase through respiration, the maxilla, albeit to a lesser degree, expands and domes via eating activities.

The goal then, is to maximize maxillary position to create thoracic flexion via the sphenoid.

Sphen-what??!?

Yes, you read that correctly, the sphenoid. We played with cranial bones quite a bit in this course. Much like the rest of the body, when I am in right or left stance the cervico-cranial- mandibular bones assume particular positions.

If you have read my reviews on PRI’s myokin and pelvis courses, visualizing cranial positioning will be a breeze. The craniomandibular system mirrors the pelvis (the temporal bones), sacrum (sphenoid) and femur (mandible).

As you can see, the above bones and corresponding motions are quite similar.

When I am in right stance (aka the pattern), my temporal bones and sphenoid are positioned as follows:

  • Left temporal bone: Flexed and externally rotated; an inspiratory position.
  • Right temporal bone: Extended and internally rotate; an expiratory position.
  • The sphenoid: The left-most portion is anteriorly rotated, and the right-most portion is more posteriorly rotated.

Continuing down the pathway, the mandibular region positions as follows:

  • The maxilla orients right.
  • The mandible laterally deviates to the left.
  • The left TMJ capsule: Posterior/medial  (retruded mandible)
  • The Right TMJ capsule: Anterior/lateral (protruded mandible)

And the cervical spine orients as such:

  • Left OA is extended and sidebent to the left.
  • Right OA is flexed and right rotated.
  • The cervical spine is oriented right and left side bent.
  • C2-C6 are flexed.
  • C7-T8 are extended.

An easy way to observe this normalcy, aside from the tests we will do, is to look at someone’s face. Often the following observations can be noted:

  • Full right lateral face.
  • Right temporal indentation compared to the left.
  • Forward, opened, wider, larger right orbit.
  • Right eyeball protruded, left eyeball retruded.
  • More visible left flared ear.
  • Larger and more opened right nostril.
  • Increased distance between side of face and lateral ocular angle on the right side.
  • Elevated right eyebrow.
  • Mandible slightly deviated to the left.
  • Tongue is thicker on the right side, and tends to stick out toward the left.

aka Gary Busey

It is insane how right you are Bill.
It is insane how right you are Bill.

So, our goals here are to protrude the mandible, retrude the cranium, flex the sphenobasilar system, restore cervical lordosis, restore “normal” resting bite, and slight OA extension so the neck is able to turn.

I know I am talking a lot about cranial movement, which I am certain the craniosacral police may come calling. I don’t think that cranial motion is necessarily why we see such changes with these techniques (though cranial bones do move, see here and here).

What seems more plausible to me is the fact that the trigeminal nerve covers so much of this area and is so interconnected towards many body regions.

Moreover, look at the face’s representation in the somatosensory homunculus. It’s huge. Therefore, I feel any input to this region can lead to profound neurological effects.

If you want some literature on how altering bite influences the system, I would check out the following studies here, here, and here (part of my PRC application), as well as my good friend Lance Goyke’s blogs here and here on dentition and foot posture

That’s a Nice Butt You Have on Your Cranium

Now obviously, the craniocervical bones do not just become positioned like this on their own. We have a new muscle chain that helps us achieve right cranial stance called the Right temporomandibular cervical chain, or right TMCC. It involves the following muscles:

  • Longus capitis
  • Superior oblique
  • Rectus capitis posterior major
  • Rectus capitis anterior
  • Temporalis (anterior fibers)
  • Masseter
  • Medial pterygoid

To oppose this chain, we will utilize some of the following muscles:

  • Sagittal repositioners: Left SCM and upper trap
  • Frontal plane abductors: Left rectus capitis anterior and lateralis; longus capitis
  • Frontal plane adductors: Temporalis
  • Transverse plane: Right rectus capitis posterior major and minor, superior and inferior oblique
  • Internal rotators: stylohyoid, styloglossus, stylopharyngeus, left lateral and medial pterygoids.
  • Integration (aka da abzzz): longus colli

If you have taken Myokin, again we can try to make some comparisons to lower quadrant muscles

  • Temporalis = gluteus medius
  • Lateral pterygoid = ischiocondylar adductor
  • Longus colli = Internal obliques and transversus abdominis
  • Suboccipitals = glute max
  • SCM = Hamstring

The Big 3

The only real big three are Jordan, Pippen, and Rodman. However, this class shows us a big three that help us get into a Left TMCC, or more functionally, left cranial stance. And these three muscles are utilized to influence certain bones:

  1. Lateral pterygoid – sphenoid
  2. Temporalis – temporal bone
  3. SCM – temporal bone
I want you to use those Bulls of your cranium.
From left: SCM, temporalis, lateral pterygoid

What predominately moves in this system is the sphenoid. This bone is very thin and airy, thus making it one of the more mobile cranial bones. It is also a very rich location for nervous tissue. The glossopharyngeal, vagus, and spinal accessory nerve all pass through this bone. More ammo to see the cranium as a neurologically-rich area, thus potentially impacting multiple body systems.

Tests

To assess this position, we are not palpating cranial position. Instead, we look at the neck and jaw via:

  1. Cervical axial rotation (total cervical spine rotation)
  2. Mandibular lateral trusion with protrusion

Typically, in the right TMCC pattern, you will see limited axial rotation to the left and decreased right mandibular lateral trusion. These limitations are due to the spinal and mandibular orientation mentioned above.

There are instances in which you may have one but not the other, which PRI would consider “patho.” For example:

  • Decreased Right trusion + non-limited Left axial rotation = OA laxity.
  • Limited left axial rotation + Increased right trusion = TMJ hypermobility.

Treatment

There was actually not many new treatment techniques in this course, as many other activities target the planar muscle families we are trying to use. But I was exposed to a couple new things I really enjoyed.

My favorite exercise from the class focuses on performing a TMCC movement while performing the exact opposite pattern at the thorax and pelvis. So a Left TMCC, left AIC, right BC technique:

The show for me was the manual technique we went over, called the frontal-occipital hold. I had been exposed to this technique before, but learning how to properly perform it has made a huge difference.

It doesn’t seem like much, but clinically I have seen big changes with several of my patients. At this course in particular, Ron was able to increase mandibular opening on a classmate from 30mm to 46 mm. The change in motion throughout the rest of this patients body, as well as his general affect was unreal.

You don’t have to get super-fancy with these techniques, as even performing simple jaw exercises can have profound effects.

Reinforcements

We also learned a couple new reference centers which you can utilize to further maintain changes. These include:

  • Posterior mid-neck
  • Teeth

The more you can feel and contact these areas, the better TMCC neutrality can be maintained.

My other favorite ways to maintain neutrality include:

  • Keeping tongue on roof of mouth behind upper incisors.
  • Keeping teeth slightly apart throughout the day.
  • Make a clucking noise on the palette with your tongue throughout the day.
  • Touch your back upper molars on either side with the tongue.

When to Refer and other Dental Fun

Although I was pleasantly surprised by how much we clinicians can affect this pattern, there are certain cases in which you will need extra help. Here is where dentists come into play.

Referring out usually occurs when structure maintains the right TMCC pattern. It is in the following instances in which you may need to enlist a dentist to maintain neutrality:

  • Can’t contact molars after neutral
  • The jaw and mandible open towards the side of a displaced disc.
  • Really strong open bite.

Not every dentist is going to possess the skills necessary for maintaining neutrality, so the following qualities ought to be sought for in a dentist:

  • Look for a craniofacial dentist.
  • One who uses Alternative lightwire fixation (ALF) splints for palette expansion.
  • Should also be familiar with Elastic Mandibular Appliances for airway management.

Other splints that are good to utilize throughout the day include flat occlusal plane splints. These splints help free up occlusion while working on a PRI program.

When looking for one of these splints, you want diurnal mandibular acrylic splint for two reasons. First off, if your splint in on the maxilla, the mandible is going to have a tendency to create contact by biting. A mandibular splint keeps the jaw relaxed. You also want the splint to be acrylic because we have a tendency to chew plastic, which again would increase jaw tension.

Sometimes pterygoid exercises aren't enough.
Sometimes pterygoid exercises aren’t enough.

 (in)Famous Ron Quotes

On Systems

  • “We are built asymmetrical so we can move.”
  • “Peripheral issues are not working in subsystems.”
  • “I can’t wait to see the day where you succeed at failing [to get into extension].”
  • “90% of patients have a degree of dizziness.”
  • “When you start to play with the body, you play with everything.”
  • “If I have flexion, I can have fun at a party without any liquor.”
  • “If you can’t communicate, you cannot succeed.”
  • [After restoring shoulder and mandibular movement with cranial manual therapy] “Welcome to my world. I am out there alone and I would like some friends.”

On cervical-cranial mandibular Function

  • “I don’t want you to suck at sucking.”
  • “Sucking reduces knee pain.”
  • “The first orthotic you should use is your tongue.”
  • “Cervical Traction is reverse autonomics.” [because cervical lordosis is minimized]

On Muscles

  • “If you want to swallow, you want a levator.”
  • “SCMs take over the world and you lose frontal plane.”
  • “Pterygoids are your built-in CPAP.”
  • “If you want to be orthopedically minded work on a butt muscle and say a lot of rosaries.”
  • “Lats rotate when other areas don’t.”
  • “If you want to treat lats you better move bregmas.”

On the Cranium

  • The head is the fifth extremity.”
  • “The sphenoid knows what the entire body is going through…it owns you.”
  • “Your temporal bone owns trigeminal neuralgia.”
  • “Atmospheric pressure is regulated by a temporal bone.”
  • “The Cranium loves Bob Ross.” [frontal plane = creativity]

On Respiration

  • “People who can’t breathe through a nose have no lips.”
  • “Mouth Breathers are floor addicts.” [Look at ground to get cranial flexion]
  •  “Got nose.”
  • “Oxygen is the new modality.”

On Teeth

  •  “Every tooth you lose makes you unstable.”
  • “Chewing is gait 101.”
  •  “Teeth are passengers on a boat moved by muscles. The way they come out depends on the torque put on the tooth.”
If a picture of Ron in a meat dress being painted by Bob Ross doesn't scream frontal plane than nothing does.
If a picture of Ron in a meat dress being painted by Bob Ross doesn’t scream frontal plane than nothing does.