Course Notes: The Last Craniocervical Mandibular Restoration Evahhhhh

You’d Think I’d Learn it the First Time Around

You’d think, but CCM is one of the hardest PRI courses to conceptualize.

Story of my life
Story of my life

 It didn’t hurt that my work was hosting the Ron’s last time teaching this course, as next year we will see Cervical Revolution instead.

I took this course last February, and it’s amazing how different the two courses were. We had a room filled with PRI vets, and the Ronimal went into so much more depth this time around.

It was such a great course that I would love to share with you some of the clarified concepts. If you want a course overview, take a look here.

Three generations of...Oh sorry wrong family.
Three generations of…Oh sorry wrong family.

 The TMCC

 The right TMCC pattern consists of the following muscles with the following actions:

Cranial retruders/mandibular protruders

  • Right anterior temporalis
  • Right Masseter
  • Right medial pterygoid

Sphenobasilar flexors

  • Left rectus capitis posteror major
  • Left obliquus capitis

OA flexors that maintain appropriate cervical lordosis

  • Right rectus capitis anterior
  • Right longus capitis
  • Right longus colli

If this chain stays tonically active, then there is better accessory muscle respiratory capacity present. These muscles provide the fixed point needed for an apical breathing pattern.

Great for SCM day at da gym.
Great for SCM day at da gym.

We want the muscles on the other side, the left TMCC, to be active. Their activity will allow alternating reciprocal cranial function to be possible.

We also call this gait.

 Keep Ya Sphenoid Flexed

One cranial goal we have is to achieve sphenobasilar flexion, but what does this mean?

In the RTMCC pattern, the sphenoid is in an extended position. When the sphenoid is extended, the foramen magnum becomes larger and the spinal cord descends. This positioning explains all the chiari malformation jokes that we like at PRI-land.

Hence why I'm starting my Chiari brand clothing line. High heels shall be designed first.
Hence why I’m starting my Chiari brand clothing line. High heels shall be designed first.

This position would also create a forward head posture to create a compensatory airway. Consequently, occlusion may be altered.

The goal is to flex the sphenoid, which closes the foramen magnum and produces appropriate OA extension. This position keeps the brainstem happy.

 Lordosis is Important

 When the SCMs are overactive, especially on the left, a reversed cervical lordosis can occur.

If I see someone who cannot flex his or her neck, I’m not thinking of stretching them into flexion. I’m thinking about restoring cervical lordosis. If no cervical curve is present, then the neck is already at end-range. Stretching farther in this position could create potential pathology.

Lordotic position is achieved by the deep neck flexors listed above and maintained by a twisted levator scapula position under a foundation set by an active lower trap.

Things are just better when kept twisted.
Things are just better when kept twisted.

SCMs

 I learned to appreciate the SCM much more at this course.

In the RTMCC pattern, my OA joint is sidebent to the left. This position occurs due to the left SCM, rectus capitis lateralis, and levator scapula.

When an active left SCM is present, we usually see a corresponding frontal plane positional tug occur at the thorax and pelvis. Left SCM often works with the right quadratus lumborum and right adductor to push the sphenoid, sternum, and sacrum into a right lateralized state.

Pterygoids = Money

 When lateral trusion in protrusion is assessed, we are not really assessing jaw mobility but pterygoid function.

The left lateral pterygoid moves the mandible anterior and to the right no doubt, but it also moves the cranium posterior and to the left. We call this left acetabulofemoral internal rotation aka shifting into your left cranium.

I get the same look when I see lateral trusion restored.
I get the same look when I see lateral trusion restored.

This Really Bites

We discussed a lot about bites this weekend. One bite that would most certainly need dental integration is an anterior open bite. This bite is when the front teeth are unable to contact due to a very high palette.

I believe the technical term is nightmare.
I believe the technical term is nightmare.

This bite type would be the equivalent of rib flares on a PEC individual. When one has an open bite, the mandible retrudes far enough to increase pressure onto the mandibular condyles.

The TMJ essentially begins to act like a molar.

We also got to see an individual with a cross bite, in which the part of the teeth go so far inward that teeth contact occurs at an angle.

Not fun
Not fun

This positioning is very similar to the feet in a left AIC pattern. The right foot is in a supinated position, but the first ray will oftentimes create first ray plantarflexion to touch the ground. A cross bite is a similar phenomenon.

Other Fun Clinical Tips

  • The louder and earlier the click upon TMJ opening the healthier the joint is.
  • Front teeth contact keep temporal bones alive.
  • Back teeth keep head from going forward.

(in)Famous Ron Quotes

  • “I’m not interested in your 45 mm of opening.”
  • “I’ve learned one thing in life. Jaw surgery does not work.”
  • “I call it the quadratus eboli.”
  • “We’re going to talk about sciatica of the head.”
  • “You know, my mother is not so bad after all.”
  • “I want you to take this course because this is life.”
  • “I’ll say feeling cerebrospinal fluid is a bunch of you know what.”
  • “If you’re a mammal you suck. You suck as a mammal.”
  • “If you don’t suck you don’t have a neck.”
  • “Are you a mammal? No Zac you’re weird.”
  • “The IC lateral pterygoid. Oh sorry wrong course.”
  • “You didn’t know getting your IC adductor would help you taste Pepsi better?”
  • “Guess I’ll go to PT school. Maybe I’ll learn something there. NOPE!”
  • “The best thing you can do is invest your retirement dollars on CPAP machines and ambien.”
  • “The system knows everything.”
  • “This patellar, excuse me, temporalis region.”
  • “Buy some Bose headphones and listen to Lady Gaga. Wow! That worked.”
  • “I just walked you through evidence that has been there for years and no one can handle it. Oops.”
  • “Surely. Don’t call me Shirley…Sahrmann.”
  • “I’m not here to recapture someone’s disc…Oh but I am.”
  • “The biggest shim that anyone does is a heel lift and it makes me want to puke.”
  • “If you have one foot that pronates and one that supinates, you’ll need a podentist.”
  • “The number one concussion is the Iphone.”
  • “Salt, pepper, and left lateral pterygoid.”
  • “I want his pube to like his malleolus. Oh I didn’t mean that.”
  • “I’m probably about 1% there.”
  • “Because I’m not the maker.”
He's not Shirley Sahrmann but...
He’s not Shirley Sahrmann but…