• Dr. Brian Abelson

Temporomandibular Dysfunction (TMD)

Updated: May 8


Temporomandibular Dysfunction (TMD) affects millions of people each year. Although this is a commonly occurring condition, it is actually a very complex problem.

Individuals suffering from TMD may experience similar symptoms, and yet, from individual to individual, the actual affected anatomical structures and causes of this injury can be quite different.

The good news is that this complex problem can often be treated effectively, especially if one is willing to take the time to properly evaluate, and then customize each treatment to address that individual’s specific needs.

The TMJ (Temporomandibular Joint) is one of the most complex joints in the human body. Restrictions or imbalances of one (or both) joints and their related soft-tissues can lead to headaches, tinnitus, facial pain, vision problems, eye pain, dental problems, balance issues, dysphagia, neck pain, and dizziness.

The key to effective treatment is to formulate a treatment that is specific or customized to the needs of that individual. This requires the collection of a comprehensive medical history along with a complete physical examination. Some cases of TMD require more of a localized approach in treatment (Local Tensegrity), while others require a more systemic approach (Global Tensegrity).

In all cases of TMD, the practitioner must consider kinetic chain connections, tissue remodeling of previous injuries, muscle imbalances, postural stresses, and even the neurological effects of long-term stress.

WHAT IS TMD?

Temporomandibular Disorders (TMD) are a group of conditions that affect both the joints and the soft-tissue structures of the orofacial region. Orofacial pain is a general term covering any pain which is felt in the mouth, jaw and the face.

Temporomandibular Dysfunction affects millions of people each year. The prevalence of TMD is between 5% to 12% percent of the general population. It is also twice as common in women as men. (1, 2)

Temporomandibular disorders are divided into intra and extra‐articular disorders.

  • Intra‐articular disorders are often related to inflammation within the joint, degeneration (osteoarthritic processes), or some type of internal structural change.

  • Extra‐articular disorders are often due to over-activity or muscle imbalances within the muscles of mastication, and often have contributing factors from the cervical spine. (3)

TMD SYMPTOMS

TMD symptoms include: ​

  • Pain from the Temporomandibular Joint (jaw pain or pain in front of the ear).

  • Joint sounds (clicking sound or grating sensation when eating food).

  • Grinding of the teeth (Bruxism).

  • Difficulty chewing.

  • Difficulty opening the jaw (limited mobility).

  • Prevalence of oro‐facial pain.

  • Pain in, and around, the ear

CONCURRENT CONDITIONS

Many TMD patients suffer from other concurrent conditions such as sleeping problems, tinnitus, neck pain, shoulder pain and headaches, all of which can be related to dysfunctional breathing and the autonomic nervous system. (4, 5)

The autonomic nervous system (ANS) is responsible for the control of bodily functions that are not consciously directed, such as breathing, heartbeat, and digestive processes.

Other concurrent conditions can also include trigeminal neuralgia, trouble swallowing (dysphagia), peripheral neuropathies, and even thoracic outlet syndrome. (4, 5)

DIAGNOSIS OF TMD

The diagnosis of TMD should be based on a review of the patient’s clinical history and a comprehensive physical examination. The following are some of the factors that should be evaluated during the physical examination of TMD patients. This is in addition to any imaging that is required.

  • Mandibular Range of Motion. (6,7) Record deviations to either side during mouth opening.

  • Pain free – unassisted mouth opening (Normal is 35 to 40 mm).

  • Maximum unassisted mouth opening.

  • Maximum assisted mouth opening.

  • Lateral deviation (normal 7 mm). (6,7)

  • Jaw protrusion (6 mm). (6,7)

  • Clicking – Record any clicking sounds and identify which motions caused the clicking.

  • Compression Test for TMJD – Create an over pressure during jaw movements, and evaluate results.

  • Palpation of the muscles of mastication. Typical results are: (8)

  • Localized pain in 57% to 97%of patients with TMD. (9)

  • Localized pain in 10% to 29% in patients without TMD. (9)

  • Check for myofascial pain with referral in jaw muscles (trigger points). (9)

  • Assess both the cervical and thoracic spine in all TMD cases.

  • Include a postural assessment for all TMD patients.


MUSCLES OF MASTICATION & ACCESSORY MUSCLES

The muscles of mastication and several other accessory muscles are often involved in TMD.

The pain a patient experiences may be directly related to the TMJ muscle or it can be caused by referred pain from other areas.

The most commonly involved jaw muscles in TMD cases are:

  • Masseter muscle.

  • Temporalis muscle.

  • Lateral Pterygoid muscle.

  • Medial Pterygoid muscle.

  • Digastric muscle.

  • Mylohyoid muscle.

From this list, four muscles are particularly important when treating any case of TMD. The other two are important, but are only involved in certain cases.

The Masseter Muscle

The masseter muscle is most commonly involved in TMD pain. When this muscle is involved, palpation often elicits a specific pain-referral pattern.

  • Trigger points in the deeper sections of this muscle often refer pain to the TMJ, while the superficial sections of this muscle often refer pain to the maxilla, mandible, and eyebrow.

  • Restrictions or trigger points in the masseter muscle often make it difficult for the patient to open their mouths. A restriction on only one side of the masseter muscle will deviate the jaw inward on the affected side. (10, 11)

The Temporalis Muscle

  • Restrictions in the temporalis muscle are often related to headaches. The trigger point, pain-referral pattern for the temporalis muscles often reproduces the same pain pattern as a tension headache. (10)

  • Practitioners should be careful when palpating this often‐painful muscle. Patients who grind their teeth (bruxism) will often exacerbate problems that involve the temporalis muscle.(10)

The Medial Pterygoid Muscle

Think of the medial pterygoid as serving a parallel function to the masseter muscle.

  • Both these muscles are able to suspend the mandible.

  • Trigger point pain-referral patterns are usually more dispersed (rather than localized) with pain referring to the mandible, maxilla, teeth, and the ear. (12)

  • Again, palpation can extremely painful when a restriction is present in the medial pterygoid muscle.

The Lateral Pterygoid Muscle

What makes the lateral pterygoid so interesting is that the superior head of this muscle is attached to the articular disc. (12)

  • Tension in the lateral pterygoid could cause a progressive anterior displacement of the disc.

  • Palpation of the lateral pterygoid may require lateral deviation to the side being examined.


Want to learn more about the anatomical structures of the jaw and head? Click and play this video - " 9 Muscles of the Head & Jaw" .






TREATMENT OF TMD

There is good evidence supporting the effectiveness of using manual therapies and exercise in the treatment of TMD. 16 In addition to the use of soft-tissue techniques, mobilization of the cervical spine has been shown to decrease overall pain intensity, and increase mandibular movement in patients with myogenous TMD (TMD originating in or starting from muscle). (16)

Working With Your Dentist

We have found that taking a multidisciplinary approach often achieves the best results.

We often treat our patients with TMD in conjunction with the advice of their dentist. In fact the Canadian Dental Association talks about this on their website in a section called "How Your Dentist Can Help". (19)

"After a thorough examination and, if needed, appropriate x-rays, your dentist may suggest a plan to treat your TMD. This treatment plan may include relaxation techniques, a referral to a physiotherapist, a chiropractor, or a behavioral therapist to help you ease muscle pain."

"Your dentist may suggest wearing a night guard, also called an occlusal splint. It is made of clear plastic and fits over the biting surfaces of the teeth of one jaw so that you bite against the splint rather than your teeth. This often helps your jaw joints and muscles to relax."

THE MOTION SPECIFIC RELEASE APPROACH

Motion Specific Release - MSR is a multidisciplinary, hands-on treatment system developed by Dr. Brian Abelson DC. Dr. Abelson has a developed a treatment protocol, specifically designed to address TMD issues - the MSR-10 Point TMJ Protocol (which can be learned in the live MSR courses).


The following two videos demonstrate the MSR-10 Point TMJ Protocol. In Part One he demonstrates the external TMJ procedures, and in Part Two, the internal TMJ procedures.


Caution: MSR protocols should only be performed by certified MSR practitioners, and are not for practice by the general public. The videos we provide are strictly used for demonstration purposes only!

MSR 10‐Point TMJ Protocol (Part 1 and Part 2)























The MSR 10‐Point TMJ Protocol is designed to specifically address the muscles of mastication, along with some other accessory muscles in its kinetic chain.

Practitioners often combine this protocol with cervical and thoracic protocols - depending on the specific needs of the individual.

  • Some cases of TMD require the use of a localized approach (18), while others require a more systemic approach (18).

  • In all cases of TMD, the practitioner must consider kinetic chain connections, tissue remodeling of previous injuries, muscle imbalances, postural stresses, and even the neurological effects of long‐term stress.

  • We would also consider joint restrictions of the cervical and thoracic spine.

  • We have found that the key to effectively treating TMD is to formulate a treatment that is specific to the needs of the individual.

NECK ADJUSTMENT VERSES NECK MOBILIZATION


Restrictions in the cervical region are a common problem affecting the kinetic chain of patients who suffer from TMD. Our custom plan for removing those kinetic chain restrictions is based on understanding both the contraindications and patient's treatment choices.

  • Neck Manipulation is a great tool for removing restrictions. That being said, cervical manipulation is not appropriate for everyone!

  • Neck Mobilization is a safe and effective alternative for releasing restrictions in the neck area.

It is important to inform patients about the alternatives to neck adjustments.

  • In the first video Dr. Mylonas reviews the differences between "Neck Adjustments Vs. Neck Mobilization".

  • In the second video Dr. Abelson demonstrates some of the neck mobilization procedures we use at Kinetic Health, and which we teach in our Motion Specific Release courses.






















Caution: MSR protocols should only be performed by certified MSR practitioners, and are not for practice by the general public. The videos we provide are strictly used for demonstration purposes only!

EXERCISE RECOMMENDATIONS

Supporting exercises are a critical component to any treatment of TMD. The type of exercises that should be prescribed is always dependent on the patient’s needs, and the current phase of treatment.

Dr. Abelson’s book “Exercises for the Jaw to Shoulder” contains numerous exercises that are useful through the various phases of treatment - and range in intensity, progressing through Beginners, Intermediate, and Advanced Jaw Exercises! (18)

Exercises for the Jaw to Shoulder” also contain exercises for the cervical region and shoulders. These are critical aspects of the jaws kinetic chain.



6 Effective - TMJ Exercises: These are examples of exercises that we prescribe to our patients after performing Motion Specific Release - MSR TMJ procedures. Caution: This video is meant for demonstration purposes only, and is NOT meant as an exercise recommendation for a specific case.



CONCLUSION

Temporomandibular Dysfunction (TMD) affects millions of people each year. Individuals suffering from TMD may experience similar symptoms, and yet from individual to individual, the affected anatomical structures and causes of injury can be quite different.

The good news is that this complex problem can be treated effectively, in most cases, if one is willing to take the time to properly evaluate, and then build customized treatments that address that individual’s specific needs.

Research supports treating TMD with a multi-disciplinary approach that involves the dental community, manual therapy, and a functional exercise program. Clinically, we have found that this multi-disciplinary approach provides our patients with faster, more effective lasting results.

REFERENCES

  1. Johansson A, et al: Gender difference in symptoms related to temporomandibular disorders in a population of 50‐year‐old subjects. J OROFAC PAIN 2003; 17:29‐35.

  2. Macfarlane TV, Blinkhorn AS, Davies RM, Kincey J, Worthington HV. Oro‐facial pain in the community: prevalence and associated impact. Community Dent Oral Epidemiol 2002; 30: 52–60.

  3. Balasubramanium, R; Delcanho, R, Temporomandibular disorders and related headache; Headache, Orofacial Pain and Bruxism, Diagnosis and multidisciplinary approaches to management, Chapt 7, pg 76‐77, Churchill Livingston Elsevier, 2009.

  4. Lee WY1, Okeson JP, Lindroth J. The relationship between forward head posture and temporomandibular disorders. J Orofac Pain. 1995 Spring; 9(2):161‐7.

  5. Edward F. Wright, D.D.S., M.S., Sandra L. Bifano, Ph.D. The Relationship between Tinnitus and Temporomandibular Disorder (TMD) Therapy ; International Tinnitus Journal, Vol 3, No. I, 55‐61 (1997).

  6. Dimitroulis G, Dolwick MF, and Gremillion HA. (1995). Temporomandibular disorders: clinical evaluation: Aust Dent J, 40(5), pp. 301‐305. In: Gould JA, ed, . St Louis: C.V.

  7. Eur J Oral Sci,
Okeson JP. (1998). Management of temporomandibular disorders and occlusion. St Louis: CV Mosby.

  8. Orbach R, Fillingim RB, Mulkey F et al. Clinical finding and pain symptoms as potential risk factors for chronic TMD: descriptive data and empirically identified domains from the OPPERA case‐control study; J Pain 2011; 12: S27‐S45.

  9. Stecco C. (2015). Functional Atlas of the Human Fascial System. Kindle Edition. Canada: Elsevier Health Sciences. Kindle Edition. Canada

  10. Simons DG, Travell JG, Simons LS. Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 1. 2nd ed. Baltimore: Lippincott William & Wilkins; 1999.

  11. Shutterstock: Image(s) or Footage (as applicable), used under license from Shutterstock.com for image IDS: 653145454, 185811473, 185811449.

  12. Schmolke C. (1994). The relationship between the temporomandibular joint capsule, articular disc and jaw muscles. 184(2), J Anat, pp. 335‐345.

  13. Fujita S, Iizuka T, Dauber W. Variation of heads of lateral pterygoid muscle and morphology of articular disc of human temporomandibular joint: anatomical and histological analysis. J Oral Rehabil 2001; 28: 560–571.

  14. Tanaka E, Hirose M, Inubushi T et al. Effect of hyperactivity of the lateral pterygoid muscle on the temporomandibular joint disk. J Biomech Eng 2007; 129: 890–897.

  15. Stelzenmueller W, Umstadt H, Weber D, Goenner‐Oezkan V, Kopp S, Lisson J. The intraoral palpability of the lateral pterygoid muscle: A prospective study. Ann Anat 2016; 206: 89–95.

  16. Armijo‐Olivo S, Gadotti, I. Temporomandibular disorders. In Magee DJ, Zachazeski JE, Quillen WS, Manske RC, Pathology and Intervention in Musculoskeletal Rehabilitation. 2nd ed, pp. 119‐156.

  17. Enix DE, Scali F, DC, and Pontell ME. (2014). The cervical myodural bridge, a review of literature and clinical implications. J Can Chiropr Assoc, 58(2), pp. 
184‐192.

  18. Brian James Abelson, Kamali T. Abelson. Exercises for the Jaw to Shoulder ‐ Volume 1 of Release Your Kinetic Chain. Published by Rowan Tree Books Ltd. 2009.

  19. TMD (Temporomandibular Joint Disorder) https://www.cda-adc.ca/en/oral_health/talk/complications/temporomandibular_disorder/

DR. BRIAN ABELSON DC.

Dr. Abelson believes in running an Evidence Based Practice (EBP). EBP's strive to adhere to the best research evidence available, while combining their clinical expertise with the specific values of each patient.

Dr. Abelson is the developer of Motion Specific Release (MSR) Treatment Systems. His clinical practice in is located in Calgary, Alberta (Kinetic Health). He has recently authored his 10th publications which will be available later this year.

DISCLOSURE

Dr. Abelson is the owner of Kinetic Health, a partner in BKAT Motion Specific Release, and a partner in Rowan Tree Books.

#TemporomandibularDysfunction #TMJ #TMD #JawPain #TMJsymptoms #MusclesofMastication #MSR #motionspecificrelease #kinetichealth #brianabelson #chiropractor #calgary #royaloak

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