Thursday, November 6, 2008

CranioSacral Treatment of the Hard Palate and Facial Bones

By Kailas, LMT, NCTMB, CST, Cert. Ayu. CranioSacral Therapist and Certified Ayurvedic Practitioner in Los Angeles

Bones of the Hard Palate and Face

The Maxilla

The maxilla is the bone of the upper jaw, and is formed by two symmetrical bones. The roots of upper teeth (1-16) insert into the alveolar process of the maxilla, and palatine process forms the roof of the mouth. Above the alveolar, the maxilla forms the floor and lateral walls of the nose. It then contributes bilaterally to the medial orbits of the eyes. Continuing bilaterally, its zygomatic processes contribute to the formation of both cheeks. Within the body of each lateral portion of the maxilla, the maxillary sinus (the largest paranasal sinus) is located.

Both halves of the maxilla articulate with each other, and with the two nasal bones along the medial saggital plane. Superiorly, they articulate with the frontal, lacrimal, and ethmoid; laterally with the zygomae; and medially deep with the palatines, vomer, and inferior nasal concha.

Some of the important muscular attachments to the maxilla include buccinator and masseter, which close the jaw and clench the teeth; orbicularis occuli, which closes and protrudes the lips; alae nasi, which flare the nostrils, and inferior oblique, which move the eye.

The movement of the maxilla in response to the craniosacral system in flexion is anterosuperior, with bilateral spreading. In extension, the two halves move medially and posteroinferiorly. The lateromedial movement is easily palpated from the median palatine suture during evaluation of the hard palate.

Acupuncture points stomach 3, 4; large intestine 19-20; and governing vessel 26-27 are located in tissues superficial to the maxilla. The midline energy currents run through the maxilla, and the maxillary sinus is considered in the yoga pranayama tradition to be a major transducer of prana between the higher organs of consciousness in the head, and the energy anatomy of the lower body. In addition, each tooth is connected energetically to various organs and joints. In light of these connections, the maxilla is a sacred bone, and its balance and health are very important. 

The Palatines

The palatines are two “L” shaped bones located directly posterior to the maxilla. Each palatine consists of a horizontal plate which inferiorly forms the posterior part of the hard palate, and superiorly the floor of the nose; and a perpendicular plate, which contributes to the wall of the maxillary sinus and gives rise to the sphenoid process and the orbital process.

Palatines articulate with each other via the median palatine suture at the midline of the hard palate, posterior to the transverse palatine suture where they articulate with the maxilla. The palatines also articulate with the vomer superiorly at the median palatine suture.

The palatine orbital process contributes to the orbital wall and has three articulations; with maxilla, sphenoid, and ethmoid. The vertical part of the body, called the perpendicular plate, helps to form the wall of the maxillary sinus, and articulates with the inferior nasal concha and the ethmoid bone.

Each palatine has two articulations with the pterygoid plate of the sphenoid; on the posterior surface of the pyramidal process, which is directed backward from the base of the “L,” and from the sphenoid process, which articulates with the sphenoid and vomer.

The palatines move anterioinferiorly with craniosacral flexion, and posterosuperiorly in extension. I suspect there might be some natural bilateral motion along the transverse palatine suture occurring in concert with the bilateral motion of the maxilla. During treatment the palatine bones are mobilized along both their horizontal and vertical axes and are palpated as somewhat free-floating. They are delicate cushions between the sphenoid and maxilla.

The Vomer

The vomer is a wafer-thin wedge shaped bone named after its likeness to a plow. It is covered in a mucous membrane, and forms the inferior posterior wall of the nasal septum.  At the superior border it has two small alae with a groove between them into which the rostrum of the sacrum fits (as a schindylesis). Its inferior border articulates with the maxilla and palatines along the median palatine suture. The anterior border also articulates with the maxilla inferiorly, and then posterosuperiorly, it articulates with the triangular nasal cartilage and then the ethmoid bone. The choana is separated by the posterior border of the vomer.

The vomer rocks like a see-saw in response to craniosacral movement. In flexion, the anterior border moves superiorly, as its posterior border moves inferiorly. The directions reverse during the extension phase.

The Ethmoid

The ethmoid is an extremely complex bone which consists of a wafer-thin perpendicular plate descending from the underside of a horizontal cribriform plate. From the cribriform plate, a pyramidal, spike-like projection called the crista galli ascends. The lateral aspects of the cribriform plate support two vertical rectangular, box-like labyrinths containing air cells made of spongy bone. The ethmoid air cell network is a major pathway for the flow of air and energy between the frontal sinus and sphenoid sinus.

The perpendicular plate itself forms the superior posterior wall of the nasal septum, articulating inferiorly with the vomer, which forms the wall of the nasal septum below it. The medial aspect of each labyrinth is fluted, forming the middle and superior nasal conchae and meatuses; thereby contributing to the outer walls of the nasal cavity, and providing moistened air to the lungs. The lateral wall of each labyrinth is slightly concave and contributes to the inner surface of the orbit, articulating with the lacrimal, maxilla, sphenoid, palatine, and frontal bones.

The cribriform plate wedges superiorly into the ethmoidal notch of the frontal bone. The plate supports the olfactory bulb, and is perforated with numerous tiny foramina through which olfactory nerves pass; medially into the top of the nasal septum, and bilaterally into the superior nasal concha. On the midline of the cribriform, the crista galli arises and attaches the falx cerebri. The posterior cribriform plate articulates medially with the ethmoidal spine of the sphenoid, and the sphenoidal crest.

Energetically, the ethmoid is a gateway for prana, and one of several bones that contain the iron crystals called magnetite, which are associated with magnetoception.

The movement of the ethmoid during craniosacral flexion is anteroinferior. An additional driver for ethmoidal movement is the attachment of the falx cerebri to the crista galli.

The Frontal Bone

The frontal bone makes up the forehead and the ceiling of the orbits. Its shape is semi-circular with a superior apex, the edge of which is heavily interdigitated, forming the frontal suture with both parietal bones. The site where the parietals and frontal meet is called bregma.

The anterior surface of the frontal bone is convex and its upper half is called the squama. This surface has the medial and vertical metopic, or frontal suture, from which the bilateral frontal eminences bulge, forming the two slight domes at the top of the forehead. Slightly inferior and medial is glabella, a flat area between the two eyebrows, the bony structures of which are the region of the superciliary arch and the margin of the orbits.

At the lateralmost corners of the orbits are the zygomatic processes of the frontal bone, which articulate with the zygomae. Beneath glabella is a caudal projection called the nasal nasal notch, which articulates along the midline with the nasal bones, the frontal process of the maxilla, and the lacrimal bones, forming the bridge of the nose.

Posteriorly, the convex surface of the squama is vertically bisected by a double ridge, the edges of which are the attachments to the falx cerebri, with a grove called the saggital sulcus lying between, into which fits the saggital sinus. Inferiorly and bilaterally directed is the orbital or horizontal part, which consists of two orbital plates separated by the ethmoidal notch which receives the cribriform plate of the ethmoid bone. The frontal sinuses extend bilaterally on both sides of the ethmoid notch.

Along the lateral posterosuperior wall of the orbit is the frontal articulation with the great wing of the sphenoid. Moving medially along the rear concavity of the orbit the frontal bone articulates with the lesser wing of the sphenoid. Medially, the orbital plate forms the lip of the ethmoidal notch.  

The movement of the frontal bone during craniosacral flexion is anterosuperior. In addition, there is a slight widening as the falx cerebri pulls the centerline of the frontal bone posterior.

Energetically, acupuncture points Governing Vessel 22-24, Urinary Bladder 2-4, Stomach 8, and Ayurvedic marma points sthapani, simanta, and utkshepa are also located along the frontal bone.

The Zygomae

The zygomae are anchor-shaped cheek bones. They present an anteriolateral convex surface called the malar surface, which through its temporal process, articulates with the zygomatic process of the temporal bone.  Opposite the temporal process, toward the midline, is the orbital process, which forms the lateral wall and floor of the orbit. Inferior to the orbital process, is the lower angular edge where the zygomae articulate with the maxilla.

The posteriolateral surface is called the temporal surface. It serves as the attachment site for the masseter. The superior and vertical projection (akin to the shaft of an anchor) is called the fronto-sphenoidal process because its anterior aspect articulates with the frontal bone and its posterior aspect articulates with the sphenoid.

The movement of the zygomae is in concert with the eccentric wobbling rotation of the temporal bones. In craniosacral flextion they rotate anteriorly and externally.

Energetically, acupuncture points Small Intestine 18 is over the zygomae.

The Nasal Bones

The nasal bones form the bridge of the nose. They are rectangular and oblong in shape, and articulate with each other along the midline. At the top of the medial border, the posterior surface contributes to the nasal septum and articulates with the spine of the frontal bone, the cribriform plate of the ethmoid bone, and the septal cartilage.

Superiorly, the nasal bones articulate with the nasal notch of the frontal bone at (a spot called) nasion, and inferiorly they articulate with the lateral nasal cartilage. The lateral borders articulate with the frontal process of the maxilla.

The movement of the nasal bones is similar with all paired facial bones. The nasal bones externally rotate during craniosacral flexion, and internally rotate during the extension phase.

The Lacrimal Bones

The lacrimal bones contribute to the anterior part of the medial wall of the orbit. They are somewhat rectangular, and carry a portion of the lacrimal duct, the nasolacrimal duct, and the lacrimal sac.

The movement of the lacrimal bones in craniosacral flexion is external rotation. I presume the lacrimals have some unique movement and energetics associated with weeping.

Clinical Application of Hard Palate and Facial Bone Techniques

Evaluation and treatment of the hard palate and facial bones should be commenced after the client has been evaluated and treated for any lesions of the transverse diaphragms, occipital cranial base, intracranial meninges, dural tube, temporal bones, and temporomandibular joints.

The hard palate evaluation and treatment protocol may be followed, or the therapist may be guided to work in an organic sequence. However, the zygomae, palatines, and nasal bones can often be corrected automatically during the evaluation, mobilization, and treatment of the larger bones in relation to the sphenoid.

Spheno-maxillary Evaluation

Lesions or restrictions may produce disorganized motion patterns or degrees of immobility to bones in the craniosacral system. Therefore, prior to evaluating the hard palate and bones of the face for specific lesions, a general evaluation of the synchrony, or similar motion, of the maxilla in relation to the sphenoid is conducted. This evaluation serves as the palpatory ingress into the mouth in a gentle way and helps the therapist determine if an intervention to mobilize and balance the maxilla is indicated. If so, the palatines and vomer should be also evaluated.

The spheno-maxillary evaluation technique is performed by using one hand to monitor the motion of the sphenoid through the greater wings or frontal bone, and the other hand to palpate the corresponding state of the maxilla. With client permission, two fingers of the hand palpating the maxilla are inserted gently into the client’s mouth with the finger pads contacting the biting surfaces of the upper molars. The transverse motion of the maxilla can be easily detected and evaluated from the molars because during craniosacral flexion the maxilla widens along the median palatine suture and narrows correspondingly during craniosacral extension.

After evaluating the motion synchrony of the maxilla, torsion, shear, and impaction lesions may be tested for. The torsion and shear tests require the therapist stabilize the sphenoid bone so non-physiological motion induced during evaluation and treatment is not transmitted to the sphenoid and will not produce corresponding adverse affects. The hand and finger positions are the same as in the previous evaluation. To stabilize the sphenoid, set a strong intention for it to be stable and as you induce non-physiological motion with your evaluating hand, gently resist any corresponding motion.

To test for spheno-maxillary torsion, very gently rotate the hard palate around an imaginary vertical running through bregma, first in one direction and then in the other, allowing 10-15 seconds for the motion of the hard palate to completely engage.  If you feel asymmetry or resistance in either direction, apply careful treatment to release the torsional positioning and normalize the relationship between the maxilla and sphenoid, taking into account the vomer and palatines.

To test for spheno-maxillary shear, very gently shift the hard palate laterally, first in one direction and then in the other, allowing 10-15 seconds for the motion of the hard palate to completely engage.  If you feel asymmetry or resistance in either direction, apply treatment to release the shear positioning and normalize the relationship between the maxilla and sphenoid, taking into account the vomer and palatines.

To test for spheno-maxillary impaction, during the palpation of the hard palate, note whether maxilla and sphenoid posess their own independent motion identity, in addition to their synchrony. If they appear rigidly connected, spheno-maxillary impaction may be the cause and treatment is advised.

Palatine Evaluation

After maxillary evaluation and treatment, which itself tends to correct most problems with the palatine bones, palatine motion can be evaluated to determine if there are any remaining restrictions. The hand positions are the same, with a slight modification of the fingers palpating the oral cavity. These fingers are moved slightly posterior and medially to the last molar, where the transverse palatine suture bisects the hard palate, and placed onto the palatine portion of the hard palate itself.

Caution is to be exercised due to the delicacy of the palatine bones. It is advised that one begin to mobilize and evaluate the palatines through intention alone, inviting the bones themselves to initiate responsive movement, first cephalad with returning motion, then laterally with returning motion. If restrictions are encountered, begin treatment.

Vomeral Evaluation

Because the vomer is located between the maxilla and sphenoid, it is usually involved with conditions of spheno-maxillary torsion, shear, and impaction. The vomer should therefore be evaluated and treated if those conditions are detected. However, the independent and natural motion of the vomer can be evaluated separately.

To evaluate the motion of the vomer, use the same hand positions as in the previous evaluations, with the modification that only one finger is inserted into the oral cavity and gently placed on the posterior portion of the medial palatine suture. The vomer articulates with both the maxillary and palatine contributions to the hard palate on the obverse side of this suture, the therapist should therefore meld with the client’s hard palate in order to palpate the motion of the vomer.

Zygomatic Bone Evaluation

If there is direct facial trauma, or lesions and restrictions of the maxilla, frontal, or temporal bones, the zygomae should be evaluated for external and internal rotation in synchrony with sphenoidal motion. This can be done by monitoring the sphenoid and zygomae with the fingers. If motion restrictions are encountered, the sutures and the zygomae should be mobilized.

Nasal Bone Evaluation

If there is direct facial trauma the nasal bones should be evaluated for external and internal rotation in synchrony with sphenoidal motion. If restrictions are encountered the sutures and the nasal bones should be mobilized.

Spheno-maxillary Treatment

Correction of maxillary movement involves sutural and osseous mobilization to restore synchrony with the movement of the sphenoid and craniosacral system, and the release of any torsion, shear, or impaction lesions. During lesion treatment the sphenoid must be stabilized as above.

To mobilize and balance the maxilla, use the same hand position for evaluation. Monitor the sphenoid and follow the transverse motion of the maxillary portions of the hard palate until you perceive asymmetry or motional restriction. When the lesion has been identified, first treat indirectly either by following the craniosacral motion back to neutral and then providing a barrier to return motion for several cycles, or provide a barrier to return when the craniosacral motion begins to cycle back from the point the lesion is first identified. After treating indirectly and gaining a release, re-evaluate the symmetry and motion, and if needed, direct technique with subtle and sustained force can be employed.

Spheno-maxillary torsion usually involves the palatines and vomer as well. Torsion is a positional lesion, not solely a motion restriction, therefore correcting torsion involves gently exaggerating the lesion until an initial release occurs, followed by applying gentle force through direct technique to realign and rebalance the structure properly. Evaluate the palatines and vomer and treat accordingly.

Spheno-maxillary shear usually involves the palatines and vomer as well. Treat first with indirect technique, exaggerating the motion in the direction of ease. Then re-evaluate motion and symmetry after a release has been gained. Use direct technique if further release is indicated. Evaluate the palatines and vomer and treat accordingly.

Spheno-maxillary impaction usually involves the palatines and vomer as well. Use gauze to prevent slippage. Treat by grasping the alveolar ridge of the maxilla along the centerline, with thumb on the anterior surface and fingers directly posterior. Traction gently until a release is gained. Evaluate the palatines and vomer and treat accordingly.

Palatine Treatment

The sequence described in the palatine evaluation section above is also the treatment procedure.

Vomeral Treatment

To treat the vomer use the hand positions for vomeral evaluation. During lesion treatment the sphenoid must be stabilized as above. For restriction or asynchrony of motion, employ direct technique using the finger placed on the midline of the hard palate.

To treat vomeral torsion modify the finger in the oral cavity so that it contacts more of the hard palate, from the posterior aspect of the midline to the ridge posterior to the incisors. With this increased leverage, rotate the vomer first using indirect technique, and then direct technique, applying slow, sustained and very gentle force.

To treat vomeral shear use the same positions as in torsion treatment. Slide the vomer and sphenoid in opposite transverse directions, first using indirect technique, and then direct technique, applying slow, sustained and very gentle force.

To treat vomero-sphenoidal impaction, carefully modify the spheno-maxillary impaction procedure by setting intention on the vomer and shifting the anterior traction slightly inferiorly.

Zygomatic Bone Treatment

To treat the zygomae, mobilize the sutures through direction of energy. Evaluate by monitoring sphenoid and zygomae. Then with permission, insert an index finger slowly along the upper molars, making sure to gently traverse the masseter, which can be stiff and require direction of energy to release. Contact the zygomatic bone posterior to masseter and apply direct technique, while grasping the bone externally with the fingers to support and monitor movement. Work the opposed zygomatic bone after gaining a release.

Nasal Bone Treatment

To treat the nasal bones, stabilize the frontal and sphenoid with one hand, and very gently grip the nasal bones, applying traction and direction of energy anteroinferiorly. Alternately, thumb and forefinger can be used as magnets to mobilize nasals.

Individual Teeth Treatment

Treatment of the individual teeth is an optional closing for a CranioSacral Therapy session with the hard palate and facial bones. The therapist palpates the teeth by placing the palmar surface of a finger on the biting surfaces. If motion in a tooth is detected, apply slight compression and decompression to invite the tooth to release and resettle.

Treatment Conclusion

At the end of treatment, use the spheno-maxillary synchrony assessment technique to ensure the maxilla and sphenoid are moving in synchrony. Gently rebalance the maxilla if indicated.

Indications for Treatment of the Hard Palate and Facial Bones

In CranioSacral Therapy, treatment of the bones of the face and hard palate are generally indicated. It is shown to contribute to facial relaxation and increased freedom of facial motion, as sutural and osseus structures are mobilized.

Specific indications for treatment include neuromuscular stiffness and pain, TMJ syndrome, facial trauma, dental trauma, sinus and nasal issues, eye strain, trigeminal nerve affectations (tic de la rue), tooth and gum pain, birth injuries, chewing on one side of the mouth, bulimia, Bell’s palsy (facial nerve paralysis), and oral sexual abuse.