Monday, November 30, 2015

Direct Needling of the Masseter and Pterygoids

In the last blogpost, I discussed the muscles of mastication with an emphasis on the masseter and the pterygoids. Also, the channel relationships were discussed, including a look at the Large Intestine sinew channel and its possible trajectory traversing the pterygoids.

In this post, we will explore ways in which these muscles of mastication can be influenced with an acupuncture needle directly. Some of these techniques are very straightforward and will be in the range of techniques that are taught in school, though I often find that the actual anatomy is not emphasized. So, it will be useful to look at the specific anatomy associated with common acupuncture points.

Other techniques might be beyond the skill set taught in school and I advise you to use your own judgment when using these, as they involve deeper needling and a more precise understanding of anatomy.

First and foremost, in the last blog post we discussed certain Stomach channel points and their relationship to the masseter muscle. These were ST-5, ST-6 and ST-7. Depending on the source you look at, the masseter has two or three layers of muscle fibers. I described three layers in the last post, a superficial, an intermediate, and a deep layer. I locate ST-5 just anterior to the superficial fibers of the masseter and just superior to the angle of the mandible. The superficial fibers create a very palpable border and the intermediate fibers are less distinct at ST-5. However, a palpable taut band of the masseter is usually apparent if you crossfiber it in an anterior-posterior direction. And you can feel that this band is still anterior to the much more obvious superficial fibers. So, needling ST-5 perpendicularly directly into this taut band will access a common trigger point in this region, one that often refers to the eyebrow and can be a contributing factor to headaches that project pain to the eye region. Another possible needle method would be to thread from ST-5 to ST-6 which would crossfiber the masseter.

ST-6 would be in the belly of the masseter and is another common pain generator, often referring into the teeth, especially the lower teeth. This can be needled at ST-6. The needle direction is mostly perpendicular. Palpation with the finger first can fine tune needle direction, and I often find a slight medial direction slightly angled to ST-4 often elicits the strongest sensation.

ST-7 has the ability to address two muscles depending on depth and angle. It can address the deep fibers of the masseter and a common trigger point with referral to the ear. However, deeper needling can access the lateral pterygoids. The lateral pterygoids refer pain to the ear and to the upper teeth or maxillary sinus region. Pain from the lateral pterygoids can contribute to TMJ disorder and can be a contributing factor to sinus pain.

Dr. Janet Travell, MD describes injection at a region consistent with ST-7 (she does not reference specific acupuncture points, however) for both the medial and lateral pterygoids, but she keeps the patient's mouth in an open position by having a cork between the upper and lower teeth. This is especially necessary for the medial pterygoids. While this is an appropriate method for accessing the medial pterygoids, this would be much more valid if there were not needle retention. She is describing injection, so there would obviously not be needle retention in this case. If however, the plan was to retain the needle, there is another method for accessing the medial pterygoids and that is from an inferior direction by coming below the ramus of the mandible to the medial surface. If you palpate with your finger or thumb, you will feel a space. Your finger is much too large to get deep enough to reach the medial pterygoid, but you might be able to feel the lower attachment and you might note that this is very sore, especially if you have jaw issues.

A 1.5 (40mm) can be used to reach the medial pterygoids from this inferior direction below the angle of the mandible. The direction will be superior in the same direction as your finger would push to reach the inferior attachment of the medial pterygoids and the needle will cross fiber the muscle and will elicit a strong Qi sensation.

Another muscle of mastication which should be assessed when working with TMJ disorder, muscle tension headaches and other related disorders would be the temporalis muscles. The temporalis muscle differs from the masseter and pterygoids, in that it is more in the distribution of the Gallbladder channel. This muscle will be discussed in another post.

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  1. Yes, though I guess it is a bit off the standard location. There is a notch just anterior to the angle of the mandible and along the body of the mandible. I don't know the name and have not seen it listed in anatomic texts. The needle can be inserted here and angled up following the angle of the ramus of the mandible. I use a 40mm (1 1/2 inch) needle and you will contact the point about 1- 1 1/2 inch in. This is probably the motor point of the medial pterygoid.