Jaw Pain 101 - Temporomandibular Disorders (TMD)
Updated: 17 hours ago
Temporomandibular Disorders (TMD) are a common group of disorders that affects millions of people each year. Although this is a commonly occurring group of conditions, it is actually a very complex problem.
Individuals suffering from TMD may experience similar symptoms, but the affected anatomical structures and causes of this condition may vary from person to person.
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. The TMJ is made up of the temporal bone and the mandible.
The are some key anatomical structures in the TMJ joint:
Is a hinge or sliding synovial joint. In addition spinning and compression movements also occur (Its a complex joint). (28,30)
Both sides of the joint act synergistically. On mouth opening both rotation and anterior translation of the condyle occurs. On lateral deviation is a complex process (ipsilareral rotation, and contra-lateral anterior translation and medial rotation (29,30)
It contains a biconcave intra-artiucalr disc, this disc divided the upper joint capsule (discotemperal region) and lower joint capsule region (discomandibular region)
The disc is attached to medial and lateral aspects of the mandibular condyle, in addition to the the surround ligamentous and muscular tissues.
The surface of the TMJ are lined with fibrocartiage (not hyaline)
Note: If the problem is joint related (arthrogenic) there is usually joint line pain, direct joint pain with motion or palpation, and grinding (crepitus).
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 Disorders affects millions of people each year. The prevalence of TMD is between 5% to 12% 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) This article primarily focus on extra-articular disorders.
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 opening the jaw (limited mobility).
Prevalence of oro‐facial pain.
Pain in, and around, the ear
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.
DIAGNOSIS OF TMD
The diagnosis of TMD should be based on a review of the patient’s clinical history and a comprehensive physical examination.
When ruling out the presence of Red Flags check for:
Cranial nerve abnormalities
Central nervous system dysfunction
Symptoms vertebrobasilar insufficiency
History psychological stress
History of trauma
Indications of infection, or unexpected weight loss or gain
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.
Arthritis in any other regions of your body.
Slow Progressive of Jaw Limitations – (Arthrosis of the TMJ.)
Tinnitus, Vertigo, or hearing issue – (Vestibular impulses)
Noticed changes in sensation head, neck, shoulders – (peripheral neuropathy).
Bruxism or grinding
Observation - Check for:
Local swelling, obvious asymmetry, scars.
Observed deviation of mandible when opening jaw.
Resisted deviation of the mandible
Lowering of ipsilateral side of the mouth – (Bells Palsy)
Abnormalities of both oral and extra oral structures.
Abnormal Wear of teeth.
Crepitus (continuous grating)
Mandibular Range of Motion. (6,7) Record deviations to either side during mouth opening.
Number of knuckles in open mouth: (Normal 40-55 mm. ☐ 3-Normal, ☐ 2-reduction ☐ 1-decreased function. (6,7)
Pain free – unassisted mouth opening (Normal is 35 to 40 mm). (6,7)
Maximum unassisted mouth opening.
Maximum assisted mouth opening.
Lateral deviation (normal 7 mm). (6,7)
Jaw protrusion (6 mm). (6,7)
Resisted mouth opening
Resisted closing of the mouth
Clicking – Record any clicking sounds and identify which motions caused the clicking. (possible anterior subluxated meniscus)
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:
Lateral Pterygoid muscle.
Medial Pterygoid 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.
Masseter Origin: Both the superficial and the deep portion attach to the Zygomatic Arch.
Masseter Insertion: Attaches to the Coronoid Process, to the superior half of the Ramus, and the angle of the Mandible.
Masseter Action: Elevates the Mandible and clenches the teeth.
Trigger Points: 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
Temporalis Origin: The Temporal Fossa and the Temporal Fascia, superior to the Zygomatic Arch.
Temporalis Insertion: The Coronoid process and the anterior border of the Ramus of the Mandible.
Temporalis Action: Elevates and closes the jaw and retracts the Mandible.
Trigger Points: 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. The pain often refers throughout the temple region, along the eyebrow, behind the eye adn upper teeth, and in some cases, it may refer to the Maxilla the TMJ. (10)
Clinically: Practitioners should be careful when palpating, this muscle is often painful. 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 serves a parallel function to the masseter muscle.
Both these muscles are able to suspend the mandible.
Medial Pterygoid Origin: Superficial section: Tuberosity of maxilla, Pyramidal process of palatine bone; Deep section: Medial surface of lateral pterygoid plate of sphenoid bone.
Medial Pterygoid Insertion: Medial surface of ramus and angle of mandible.
Medial Pterygoid Action: Bilateral contraction - Elevates and protrudes mandible Unilateral contraction - Medial movement (rotation) of mandible.
Again, palpation can be extremely painful when a restriction is present in the medial pterygoid muscle.
The Lateral Pterygoid Muscle
Lateral Pterygoid Origin: The Lateral Pterygoid has two heads. The upper head attaches to the greater wing of the Sphenoid bone and the lower head attaches to the surface of the lateral Plate of the Sphenoid bone.
Lateral Pterygoid Insertion: Attaches to the anterior neck of the Mandibular Condyle and the capsule of the Temporomandibular joint.
Lateral Pterygoid Action: Extends the mandible, draws teh articular disc forward, and aids in rotational movement while chewing.
Trigger Points: Pain refers deep into the Temporomandibular joint (TMJ) and into the Maxillary Sinus region.
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.
Anatomy and Palpation
Want to learn more about the anatomical structures of the jaw and head, and how to palpate them? This is great information for students, practitioners, and patients.
Click to 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)
My Opinion (based on evidence): Doing manual adjustments of the jaw itself (adjusting the TMJ) can actually be counter productive in some cases. I have had numerous patients who were previously treated by practitioners doing osseous adjustments of the TMJ. Many of these patients did not not see any improvement, or had an increase in symptoms. This is often due to adjusting an already hyper-mobile joint. What can be effect to improve mobility are techniques such as the anterior medial or lateral gliding, or distraction procedures. (27)
That being said my primary focus in this article is on the surrounding soft tissue structures, and on restrictions found in the cervical and shoulder regions (including osseous structures). I prefer to leave temporomandibular joint treatment decisions to our colleagues in the dental community.
Working With Your Dentist (Interdisciplinary Care)
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."
MANUAL THERAPY - MOTION SPECIFIC RELEASE
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 shoulder/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 VS. NECK MOBILIZATION
Restrictions in the cervical region are a common problem affecting the kinetic chain of patients who suffer from TMD (20). While Restrictions in the cervical spine may not be the cause of TMD, limited range of motion (lack of mobility) can be a significant perpetuating factor.
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.
Note: There is research demonstrating that upper cervical adjusting does decreased facial pain (immediate nociceptive modulation in the trigeminocervical complex). (23) This is also research evidence that cervical manipulation, especially when combined with craniomandibular manipulative therapy, decreases pain intensity and increases function. (22,24,26)
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!
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. Below is an example of some of the exercises that we could prescribe to our patients. Please not this is not a prescription for individual cases.
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.
Temporomandibular Disorders (TMD) affects millions of people each year. Individuals suffering from TMD may experience similar symptoms, but 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 the combination of addressing both osseous and soft tissue dysfunction in treating this condition (21,22,25,26). From a clinical perspective I have also found that stress management is often an important aspect of TMD. We have found instruction in mediation, and mindfulness to be very effective.
Bottom-line, research supports treating TMD with a multi-disciplinary approach that involves the dental community, manual therapy, a functional exercise program, and stress reduction strategies. This perspective has provided our patients with faster, more effective lasting results.
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 publication which will be available later this year.
Make an appointment with our incredible team at Kinetic Health in NW Calgary. Just scan the QR code with your phones camera and click the link, or call Kinetic Health at 403-241-3772 to make an appointment today!
Discover more in Dr. Abelson’s book “Exercises for the Jaw to Shoulder”.
This book provides carefully selected exercises that help you to progress through the various phases of addressing TMD and problems of the cervical spine.
Exercises range in intensity, and help you to progress systematically through Beginners, Intermediate, and Advanced exercises for the Jaw, Neck, and shoulders. (18)
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.
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.
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.
Lee WY1, Okeson JP, Lindroth J. The relationship between forward head posture and temporomandibular disorders. J Orofac Pain. 1995 Spring; 9(2):161‐7.
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).
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.
Eur J Oral Sci, Okeson JP. (1998). Management of temporomandibular disorders and occlusion. St Louis: CV Mosby.
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.
Stecco C. (2015). Functional Atlas of the Human Fascial System. Kindle Edition. Canada: Elsevier Health Sciences. Kindle Edition. Canada
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.
Shutterstock: Image(s) or Footage (as applicable), used under license from Shutterstock.com for image IDS: 653145454, 185811473, 185811449.
Schmolke C. (1994). The relationship between the temporomandibular joint capsule, articular disc and jaw muscles. 184(2), J Anat, pp. 335‐345.
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.
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.
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.
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.
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.
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.
TMD (Temporomandibular Joint Disorder) https://www.cda-adc.ca/en/oral_health/talk/complications/temporomandibular_disorder/
Calixtre LB, Oliveira AB, de Sena Rosa LR et al. Effectiveness of mobilisation of the upper cervical region and craniocervical flexor training on orofacial pain, mandibular function and headache in women with TMD. A randomised, controlled trial. J Oral Rehabil 2019; 46(2): 109–19.
Corum M, Basoglu C, Topaloglu M et al. Spinal high-velocity low-amplitude manipulation with exercise in women with chronic temporomandibular disorders. Man Medizin 2018; 56(3): 230–8.
Garrigos-Pedron M, La Touche R, Navarro-Desentre P et al. Effects of a physical therapy protocol in patients with chronic migraine and temporomandibular disorders: A randomized, single-blinded, clinical trial. J Oral Facial Pain Headache 2018; 32(2): 137–50.
La Touche R, Paris-Alemany A, Mannheimer JS et al. Does mobilization of the upper cervical spine affect pain sensitivity and autonomic nervous system function in patients with cervicocraniofacial pain? Clin J Pain 2013; 29(3): 205–15.
von Piekartz H, Ludtke K. Effect of treatment of temporomandibular disorders (TMD) in patients with cervicogenic headache: A single-blind, randomized controlled study. Cranio 2011; 29: 43–56.
La Touche R, Garcia SM, Garcia BS, et al., Effect of Manual Therapy and Therapeutic Exercise Applied to the Cervical Region on Pain and Pressure Pain Sensitivity in Patients with Temporomandibular Disorders: A Systematic Review and Meta-analysis, Pain Medicine 2020; doi: 10.1093/pm/pnaa021
Kalamir A, Bonello R, Graham P et al., Intraoral myofascial therapy for chronic myogenous temporomandibular disorder: A randomized controlled trial, Journal of Manipulative & Physiological Therapeutics 2012; 35: 26-37.
Bronfort G, Haas M, Evans R, et al. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat 2010; 18:3.
Kraus SL. Temporomandibular disorders. In: Saunders HD, Ryan RS, editors. Evaluation, treatment and prevention of musculoskeletal disorders, volume 1 spine, 4th edn. Chaska: The Saunders Group; 2004. p. 173–210.
Friedman MH, Weisberg J. Joint play movements of the temporomandibular joint: clinical considerations. Arch Phys Med Rehabil 1984; 65: 413–7.
Shaffer SM, Brismée JM, Sizer PS & Courtney CA, Temporomandibular disorders. Part 1: anatomy and examination/diagnosis, ournal of Manual & Manipulative Therapy 2014; 22(1): 2-12. doi: 10.1179/2042618613Y.0000000060.
Shaffer SM, Brismée JM, Sizer PS & Courtney CA, Temporomandibular disorders. Part 2: conservative management, Journal of Manual & Manipulative Therapy 2014; 22(1): 13-23. doi: 10.1179/2042618613Y.0000000061.