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  • Dr. Brian Abelson

Unlocking the Jaw: Temporomandibular Disorders

Updated: 5 days ago


Temporomandibular Disorders (TMD), a term denoting a common set of conditions, have become a pervasive issue affecting a substantial number of individuals each year. Despite the high incidence, TMD poses a complex challenge.


Individuals with TMD may exhibit similar symptoms, yet the underlying causative factors and affected anatomical components may vary significantly from one individual to another. Nevertheless, effective treatment modalities are available for this multifaceted condition, especially when a comprehensive evaluation is conducted and personalized interventions are designed to meet each individual's distinctive needs. (1,2,3)


 

TMJ ANATOMY


The TMJ (Temporomandibular Joint) is one of the most complex joints in the human body. The TMJ comprises two osseous structures the temporal bone and the mandible.


Here are some of the critical anatomical aspects of the TMJ: (28,29,30)

  • The TMJ functions as a hinge or sliding synovial joint.

  • In addition to sliding, it also performs spinning and compression movements.

  • The TMJ operates synergistically on both sides, with rotation and anterior translation of the condyles during mouth opening.

  • During lateral jaw deviation, the TMJ undergoes a complex process involving ipsilateral rotation and contralateral anterior translation with medial rotation.

  • A biconcave intra-articular disc is present within the TMJ, divided into an upper (discotemporal) and lower (discomandibular) joint capsule region.

  • The TMJ disc connects to the medial and lateral aspects of the mandibular condyle, as well as to surrounding ligamentous and muscular tissues. The TMJ surfaces are lined with fibrocartilage, not hyaline cartilage.


Clinically


When a patient experiences jaw pain related to the joint (arthrogenous), they typically exhibit joint line pain. Pain is generally felt directly over the TMJ during movement or palpation, often accompanied by a grinding sound or sensation during joint motion (crepitus).


Constraints or imbalances in one or both joints (including associated soft tissues) can result in various symptoms such as headaches, tinnitus-like sensations, facial pain, vision issues, eye pain, tooth pain, balance problems, swallowing difficulties (dysphagia), neck pain, and dizziness.

 

WHAT IS TMD?

TMD, or Temporomandibular Disorders, encompass a range of conditions impacting both the joints and soft-tissue structures within the orofacial region. Orofacial pain refers to any discomfort experienced in the mouth, jaw, and face.


Annually, TMD affects a significant number of people, with prevalence rates ranging from 5% to 12% in the general population. The condition is more prevalent in women, occurring twice as often compared to men (1, 2). Furthermore, TMD ranks as the second most frequent musculoskeletal disorder, with chronic low back pain being the most common (1).

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

  • Intra-articular disorders typically involve joint inflammation, degeneration (such as osteoarthritic processes), or alterations in internal structure.

  • Extra-articular disorders commonly result from overactivity or imbalances in the mastication muscles and frequently have contributing factors originating from the cervical spine (3).

 

TMD SYMPTOMS

TMD symptoms include: (11, 30)

  • Discomfort or soreness in the jaw

  • Pain directly over the Temporomandibular Joint (along the jawline or in front of the ear)

  • Pain radiating behind the eyes, in the face, neck, shoulder, and upper back

  • Unusual joint sounds (clicking, popping, snapping, or grating sensations (crepitus) during eating or opening and closing the mouth)

  • Clenching or grinding of teeth (Bruxism)

  • Limited or locked jaw movement

  • Challenges with chewing

  • Difficulty opening or closing the jaw (restricted mobility)

  • Pain around the ear

  • Dizziness

  • Teeth sensitivity (in the absence of oral health problems)

 

CONCURRENT CONDITIONS

  • Insomnia

  • Tinnitus

  • Neck pain

  • Shoulder pain

  • Headaches (tension headaches, migraine headaches, temporal headaches), with temporal headaches being common and often modified by jaw movement

  • Trigeminal neuralgia

  • Difficulty swallowing (dysphagia)

  • Peripheral neuropathy

  • Thoracic outlet syndrome


Some of these conditions could be related to autonomic nervous system dysfunction, especially in increased stress or anxiety cases. Abnormal breathing patterns are commonly seen in cases of increased stress or anxiety. (4, 5, 30)

 

DIAGNOSIS OF TMD

The diagnosis of TMD should be based on a review of the patient’s clinical history and a comprehensive physical examination. (62, 63, 64)


When ruling out the presence of Red Flags, check for:

  • Abnormalities in cranial nerves (cranial nerve examination)

  • Central nervous system dysfunction

  • Symptoms of vertebrobasilar insufficiency

  • Cardiac abnormalities

  • History of psychological stress

  • History of trauma

  • Signs of infection, or unexplained weight loss or gain

The following are some factors that should be evaluated during the physical examination of TMD patients. This is in addition to any imaging that is required.


History

  • Check for pain intensity (graded pain scale)

  • Pain location (pain drawing)

  • Jaw function (graded scale) - assessing how pain is affected by jaw function and movement

  • Presence of arthritis in other body regions

  • Slow progression of jaw limitations (indicative of TMJ arthrosis)

  • Tinnitus, vertigo, or hearing problems (related to vestibular impulses)

  • Observed changes in sensation in the head, neck, and shoulders (suggestive of peripheral neuropathy)

  • Bruxism or grinding

  • Coexisting medical conditions

Observation - Check for:

  • Local swelling, apparent asymmetry, scars.

  • Observed deviation of the mandible when opening the jaw.

  • Resisted deviation of the mandible

  • Lowering of the ipsilateral side of the mouth – (Bells Palsy)

  • Abnormalities of both oral and extra-oralwear structures.

  • Abnormal Wear of teeth.

  • Crepitus (continuous grating)


Mandibular Range of Motion. (6,7)

  • Record deviations to either side during mouth opening.

  • A number of knuckles in the open mouth: (Normal 40-55 mm. ☐ 3-Normal, ☐ 2-reduction ☐ 1-decreased function.

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

  • Maximum unassisted mouth opening.

  • Maximum assisted mouth opening.

  • Lateral deviation (normal 7 mm).

  • Jaw protrusion (6 mm).

  • Resisted mouth opening

  • Resisted closing of the mouth

Sounds

  • Clicking/Popping – Record any clicking sounds and identify which motions caused the clicking. (possible anterior subluxated meniscus)

  • Crepitus - Record any sounds of crepitus or grinding sounds (DJD/OA)

Test & Range of Motion

  • Compression Test for TMJD – Create an overpressure during jaw movements, and evaluate the results. Compression Test article.

  • Palpation of the muscles of mastication. Typical results are: (8,9)

  • A localized pain in 57% to 97% of patients with TMD.

  • A localized pain in 10% to 29% of patients without TMD.

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

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

  • Include a postural assessment for all TMD patients.


 


MUSCLES OF MASTICATION

Muscles of mastication frequently play a role in TMD.


The discomfort experienced by a patient may be directly associated with the muscles of mastication or may result from referred pain originating from other regions affecting these muscles.

The muscles of mastication involved in TMD cases are:

  • Masseter muscle.

  • Temporalis muscle.

  • Lateral Pterygoid muscle.

  • Medial Pterygoid muscle.


Note: The following section is technical in nature and intended for students, anatomy enthusiasts, and clinicians. If you prefer, you may skip ahead to the next section titled "TREATMENT OF TMD."

The Masseter Muscle

The masseter muscle frequently plays a role in TMD-related pain (35). When this muscle is implicated, palpation often triggers a specific pain-referral pattern (referring pain to the TMJ and ear). Below are some key characteristics of the masseter muscle (11):

Masseter Muscle Origin:

  • Both superficial and deep portions attach to the Zygomatic Arch.

Masseter Muscle Insertion:

  • Connects to the Coronoid Process, the superior half of the Ramus, and the angle of the Mandible.

Masseter Muscle Action:

  • Elevates the Mandible and clenches the teeth (closes the jaw).

Masseter Muscle Innervation:

  • The masseteric nerve originates from the anterior branch of the mandibular division of the trigeminal nerve (CN V) (34).

Masseter Muscle Palpation:

  • Begin with the three-knuckle test. If the patient passes, they are unlikely to have trigger points in the masseter or temporalis muscles.

  • The superficial section of the masseter muscle is most commonly involved with trigger point formation.

  • Palpate the entire masseter muscle for trigger points using cross friction pincer palpation, with one digit inside the cheek and one outside.

  • It is easier to detect trigger points inside the mouth due to the presence of the parotid gland outside.

  • Near the angle of the mandible, externally palpate the masseter using a cross-fiber palpation method. Have the patient bite down to feel the muscle.

Masseter Muscle Trigger Points:

  • Deep masseter muscle trigger points often refer pain to the TMJ and ear, potentially causing tinnitus symptoms (38). In some cases, applying pressure to the masseter muscle can alter tinnitus symptoms. Differentiate between neurological and myofascial origins of tinnitus.

  • Superficial masseter muscle sections frequently refer pain to the maxilla, mandible, and eyebrow (35).

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

  • Trigger points in the masseter muscle often contribute to tension headaches and mechanical neck pain (36, 37).

The Temporalis Muscle

The temporalis muscle is another frequently implicated muscle in TMD (as well as tension headaches) (41). Below are some key characteristics of the temporalis muscle (11).


Temporalis Muscle Origin:

  • The Temporal Fossa and the Temporal Fascia, located above the Zygomatic Arch.

Temporalis Muscle Insertion:

  • The Coronoid process and the anterior border of the Ramus of the Mandible.

Temporalis Muscle Action:

  • Elevates and closes the mouth, and participates in retrusion and protrusion of the Mandible. Interestingly, the temporalis muscle has shown antagonistic contraction during mouth opening in patients with masseter muscle contracture (40).

Temporalis Muscle Innervation:

  • Anterior and posterior deep temporal nerves originate from the anterior branch of the mandibular division of the trigeminal nerve (CN V).

Temporalis Muscle Palpation:

  • Exercise caution when palpating the temporalis muscle, as trigger points can be very painful even with gentle touch.

  • Trigger points are often found in the anterior portion of the muscle but can be located anywhere.

  • The patient can be supine or sitting with the jaw slightly open in a relaxed position (increases muscle fiber stretch).

  • Use cross-fiber flat palpation externally, searching for tight bands.

  • For the section near the coronoid process, use a gloved internal exam on the inner surface of the coronoid process, applying outward pressure.

Temporalis Muscle Trigger Points:

  • Trigger points in the temporalis muscle are often related to headaches, deep head pain throughout the entire temple region, eyebrow pain, upper teeth pain, and pain behind the eyes. In some cases, pain refers to the Maxilla and the TMJ (10).

  • Direct trauma from a fall, motor vehicle accident, or any type of impact can cause trigger points to form in the temporalis muscle.

  • The pain-referral pattern for the temporalis muscles often reproduces the same pain pattern as a tension headache.

  • Actions that keep the temporalis muscle in a shortened or lengthened position can aggravate trigger points, such as gum chewing, grinding teeth, jaw clenching, or even keeping the mouth open for an extended period (dental appointments).

  • Forward head posture (anterior posture) increases tension on the temporalis muscle due to increased pressure on both the suprahyoid and infrahyoid muscles.


In clinical practice, patients who grind their teeth (bruxism) frequently aggravate issues related to the temporalis muscle (10). When treating the temporalis, it is essential to rule out temporal arteritis as one of the differential diagnoses.

The Medial Pterygoid Muscle

The medial pterygoid is situated deep to the mandible and consists of two heads (superficial and deep).


The medial pterygoid performs a function parallel to the masseter muscle. Both of these muscles can support the mandible. Additionally, the masseter and temporalis muscles aid in closing the jaw.


Although there is less research on the medial pterygoid muscle compared to other muscles of mastication, it can still play a role in TMD. Some key features of the medial pterygoid muscle include (11):


Medial Pterygoid Muscle Origin:

  • The superficial section originates from the tuberosity of the maxilla and the pyramidal process of the palatine bone; the deep section originates from the medial surface of the lateral pterygoid plate of the sphenoid bone, situated deep to the lateral pterygoid muscle.

Medial Pterygoid Muscle Insertion:

  • The muscle inserts onto the medial surface of the ramus and angle of the mandible.

Medial Pterygoid Muscle Action:

  • When contracting bilaterally, it elevates and protrudes the mandible. When contracting unilaterally, it creates medial movement (rotation) of the mandible, deviating it toward the contralateral side.

Medial Pterygoid Muscle Innervation:

  • The muscle is innervated by the medial pterygoid branch of the mandibular division of the trigeminal nerve (CN V).

Medial Pterygoid Muscle Palpation:

  • Have the patient lie supine and perform an intraoral examination (wear gloves).

  • Cross over the molars to the anterior edge of the ramus of the mandible (posterior and lateral to the first molar). The muscle's belly is immediately behind the border edge of the ramus.

  • The medial pterygoid muscle's belly is covered by a very thin layer of mucosa. Note that palpation can be extremely painful when a trigger point is present.


Medial Pterygoid Muscle Trigger Points:


  • The pain-referral patterns for the medial pterygoid muscle tend to be more dispersed (not localized), with pain referring to the mandible, maxilla, teeth, and ear (12,42).

  • Patients with trigger points in the medial pterygoid will experience increased pain when opening the jaw and may have an actual physical jaw restriction.

  • Patients with a trigger point in the medial pterygoid often have associated trigger points in the masseter, temporalis, lateral pterygoid, and SCM muscles.


The Lateral Pterygoid Muscle


The lateral pterygoid muscle is crucial for jaw movement and control. One unique aspect of this muscle is that its superior head is attached to the articular disc (12). Tension in the lateral pterygoid may lead to progressive anterior displacement of the disc.


The lateral pterygoid muscle can play a significant role in TMD cases. It can also be involved in headaches, nerve entrapment syndromes, oromandibular dystonia, otolaryngic symptoms (affecting ears, nose, throat, head, and neck), and even myositis ossificans.


The lateral pterygoid muscle consists of an upper and lower head. Here are some notable features of the medial pterygoid muscle (11):


Lateral Pterygoid Muscle Origin:

  • The Lateral Pterygoid has two heads. The upper head attaches to the greater wing of the sphenoid bone, while the lower head originates from the surface of the lateral plate of the sphenoid bone.

Lateral Pterygoid Muscle Insertion:

  • The two heads converge to insert into the pterygoid fovea on the front of the neck of the mandible (mandibular condyle).

Lateral Pterygoid Muscle Innervation:

  • Superior and lateral parts of the inferior division are innervated by a branch of the buccal nerve. The medial aspect of the lower head is innervated by a branch that comes from the anterior trunk of the mandibular nerve.

Lateral Pterygoid Muscle Action:

  • There is some controversy in the literature about lateral pterygoid actions. Most authors agree that the lateral pterygoid muscle opens the mouth (causes mandibular depression) and enables contra-lateral excursion, particularly during chewing (46).

  • Another function noted in the literature for the lateral pterygoid is decreasing tension on the TMJ disc by maintaining its position beneath the condyle. Lateral pterygoid contraction creates forward pressure on the disc and the neck of the mandible (47).

Lateral Pterygoid Muscle Palpation:

  • With the patient supine, place your index finger along the vestibule that forms the cheek pouch and press posteriorly.

  • Move your finger past the maxillary tuberosity and squeeze between the maxilla and the coronoid process.

  • Lateral deviation of the jaw to the ipsilateral side will increase this space, making it easier to palpate (50).

Lateral Pterygoid Muscle Trigger Points:

  • Patients with trigger points in the lateral pterygoid muscle often report sinus pain (or recurrent sinusitis) and may have throat or neck discomfort (including congestion, sore throat, nasal congestion, or pressure) (48).

  • Research has also shown a possible link between trigger points in the lateral pterygoid muscle and tinnitus (48).

  • Pain from the trigger point in the lateral pterygoid muscles can refer deep into the temporomandibular joint (TMJ) and the maxillary sinus region.

  • Trigger points can contribute to increased mucus secretion in the maxillary sinus, tinnitus symptoms, and limitations in the range of motion of the TMJ (48).

  • It should be noted that trigger points in the cervical region can refer directly to the lateral pterygoid muscle. Because of this, the lateral pterygoid muscle trigger points may not resolve until cervical issues are addressed (48).


Anatomy and Palpation Video

Are you interested in exploring the anatomical structures of the jaw and head, as well as learning how to palpate them? This comprehensive guide is perfect for students, practitioners, and patients alike.


Click to play this video - " 9 Muscles of the Head & Jaw".




 

TREATMENT OF TMD

Strong evidence supports the effectiveness of manual therapies and exercise in treating TMD. There is substantial evidence for the efficacy of these methods (16). Besides using soft-tissue techniques, mobilization of the cervical spine has been demonstrated to decrease overall pain intensity and increase mandibular movement (16).


Jaw Adjustments Vs. Jaw Mobilization


Adjusting the Jaw


I am in favor of performing manual therapy on both the osseous and soft tissue structures surrounding the jaw. However, I am not keen on High Velocity Low Amplitude (HVLA) jaw adjustments. There is limited research to support these procedures.


Based on my clinical experience (spanning over 30 years), HVLA adjustments to the jaw can be counterproductive (while neck adjustments can be beneficial). I have encountered numerous patients who were previously treated with osseous adjustments of the TMJ by other practitioners. Many of these patients either did not experience any improvement or had a significant increase in symptoms, particularly when the joint being adjusted was already hypermobile.


Jaw Mobilization


Practitioners who are trained in TMJ disorders can use various mobilization procedures to improve joint mobility and reduce pain.


Articular Fossa Mobilization
  • This procedure is designed to get in between the superior part of the disc and the articular fossa [61]. This technique involves stabilizing all the way up to the neck of the condyle and taking the patient's cranium and head and doing a subtle lateral rotation on a coronal plane. This moves the articular fossa on a fixed condylar head and helps to reduce adhesions that can occur with a sticky disc or chronic disc displacement without reduction and limited opening.

Long Axis Distraction
  • One procedure that practitioners use to improve TMJ mobility is long axis distraction [59]. This technique involves gently finding the point of least resistance in the joint and applying a very gentle distraction force. The therapist may stretch the tissue, hold it, or oscillate back and forth to warm up the tissue and get it to stretch more.

Lateral or Medial Gapping
  • Another procedure is lateral glide or medial gapping of the condylar head and the TMJ [60]. This involves grabbing the mandible and doing a gentle supination of the forearm to bring the condylar head laterally. This stretches both the outside and inside capsule, which is important for those who have a medially displaced disc.


All of these procedures are very purposeful and gentle, with the goal of improving mobility in the TMJ [59][60][61]. The practitioner will encourage the patient to relax and let go of any muscle tension or clenching aspects so that they are not fighting against the mobilization techniques.


 

Collaboration

I have discovered that adopting a multidisciplinary approach often leads to outstanding results.


We frequently treat our TMD patients alongside their dentists, following their advice. The Canadian Dental Association discusses this collaboration on their website in a section titled "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 behavioural 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


Strong evidence supports a multi-modal approach that combines soft tissue treatments and osseous mobilization with exercise. (31,32,33,65)


Addressing Soft Tissue Restrictions

The specific soft tissue treatments employed to address trigger points or soft tissue restrictions can greatly vary depending on the patient and practitioner. Some of the methods we have found to be clinically effective include:

  • Motion Specific Release (MSR) Protocols

  • Active Release

  • Cross friction massage

  • Instrument assisted modalities

  • Acupuncture and Dry Needling

  • Myofascial Release

Clinically, we have found that optimal results are achieved when addressing both intra-oral and extra-oral structures. In addition to the muscles of mastication, muscles in the cervical spine and related restrictions in the shoulders (often involving posture) need to be addressed.


Motion Specific Release - TMD Protocols


Motion Specific Release (MSR) is a "Treatment System" that combines the advantages of various therapeutic perspectives. MSR is not a technique; it is a treatment system! The following protocol is designed to be integrated with other treatment modalities. (66,67,68)


The three videos below demonstrate some of the MSR procedures developed by Dr. Brian Abelson DC. Caution: MSR protocols should only be performed by certified MSR practitioners and are not intended for practice by the general public. The videos provided are for demonstration purposes only.


MSR Masseter Muscle Release The MSR Masseter Muscle Release Protocol, developed by Dr. Brian Abelson, is a specialized procedure that targets the masseter muscle - one of the most common muscles involved in TMD pain.



MSR Lateral Pterygoid Release The lateral pterygoid muscle is a crucial component in both jaw movement and control. Interestingly, the superior head of this muscle is attached to the articular disc, which can result in a progressive anterior displacement of the disc when tension in the lateral pterygoid is present.


MSR Temporalis Release

This technique targets trigger points within the temporalis muscle, which are often associated with headaches, deep head pain throughout the entire temple region, eyebrow pain, upper teeth pain, and pain behind the eyes. In some cases, pain refers to the Maxilla and the TMJ.


Don't Forget the Kinetic Chain


Practitioners often integrate this protocol with cervical and shoulder/thoracic protocols, depending on the individual's specific needs. Some cases of TMD call for a localized approach (18), while others necessitate a more systemic approach (18). In all cases of TMD, the practitioner must take into account kinetic chain connections, tissue remodelling from past injuries, muscle imbalances, postural stressors, and even the neurological effects of long-term stress (central sensitization mechanisms). Joint restrictions in the cervical and thoracic spine must also be addressed. We have discovered that the key to effectively treating TMD lies in developing a treatment plan tailored to the individual's needs.


 

ACUPUNCTURE

Acupuncture points, also known as acupoints, are specific locations on the body that have been identified in Traditional Chinese Medicine (TCM) as having therapeutic effects when stimulated. These points are found along meridians or channels, which are believed to be pathways of energy flow called "Qi" (pronounced "chi") throughout the body.


According to TCM, stimulating acupuncture points can help restore balance, regulate the flow of Qi, alleviate pain, and promote healing in the body.


Modern research has revealed that acupuncture points often correspond to areas where there is a high density of nerve endings, blood vessels, and lymphatic vessels, as well as increased electrical conductivity. This suggests that the stimulation of acupuncture points may have physiological effects, such as the release of endorphins, neurotransmitters, and other pain-relieving substances, as well as the regulation of blood flow and the immune system. (69,70,71,72)


Acupuncture Techniques


When acupuncturists treat a patient, acupuncture needles are not just inserted; they are rotated and pulled back and forth until the acupuncturist feels a response in the tissue (sometimes called a tug response). When performing acupressure, we do the same thing: stimulate a region to activate the nervous system and release tension in a fascial network of interconnected tissue.


Specific Acupuncture Points


In Traditional Chinese Medicine (TCM), acupuncture points acupuncture points ST6, ST7, ST8, SI8, LI4, and GB20 are frequently used to alleviate the pain experience with jaw pain. The location of these points is often described using the Chinese term "cun," which is a unit of measurement used in acupuncture for locating points on the body. One cun is approximately equal to the width of the patient's thumb at the knuckle. Specific points: (73,74,75,76)


ST 6 (Jiache):

  • Location: At the prominence of the masseter muscle, one finger-width anterior and superior to the angle of the mandible.

  • Indications: Facial paralysis, trigeminal neuralgia, toothache, and temporomandibular joint disorders.

ST 7 (Xiaguan):

  • Location: Anterior to the ear, in the depression between the zygomatic arch and the mandibular notch.

  • Indications: Facial paralysis, temporomandibular joint disorders, toothache, and tinnitus.

SI 8 (Xiaohai):

  • Location: On the medial aspect of the elbow, in the depression between the olecranon process of the ulna and the medial epicondyle of the humerus.

  • Indications: Elbow pain, upper limb disorders, and conditions affecting the scapular and shoulder regions.

LI 4 (Hegu):

  • Location: Dorsal aspect of the hand, between the first and second metacarpal bones, approximately at the midpoint of the second metacarpal bone.

  • Indications: Headaches, toothaches, facial pain, neck pain, and various conditions related to the face and head.

GB 20 (Fengchi):

  • Location: On the posterior aspect of the neck, below the occipital bone, in the depression between the upper portion of the sternocleidomastoid and trapezius muscles.

  • Indications: Headaches, migraines, neck pain, dizziness, and conditions affecting the eyes and ears.


 


FASCIAL EXPANSIONS


In the world of musculoskeletal medicine, fascia is the new golden child. Practitioners who integrate fascial procedures into their excellent treatment modalities can often obtain outstanding results.


Fascia forms a seamless web of connective tissue, which connects, holds, and infuses the tendons, organs, muscles, tissues, and skeletal structures. Fascia plays a critical role in communication, in maintaining a memory of our body’s history and acting as both a tensional network and as a living matrix. (77,78,79,81)


Restrictions in these facial planes can be addressed with various procedures, including acupuncture. In my opinion, at least three fascial planes in the case of TMD should be considered. (9) These are:


Epicranial Fascia:

  • The epicranial fascia serves as a connection between the occipitalis and frontalis muscles, extending continuously to the temporal fascia, which envelops the temporalis muscle. Towards the front, the epicranial fascia transitions into Tenon's fascia. (76,79,80)


Tenon's Fascia:

  • Tenon's fascia constitutes a protective sheath surrounding the levator muscle of the upper eyelid. The rear third of Tenon's fascia merges with the orbital fat, which in turn becomes continuous with the optic nerve's protective covering. (76,79,80)


Pterygoid Fascia:

  • The pterygoid fascia encompasses the medial and lateral pterygoid muscles and attaches to the temporomandibular joint (TMJ) capsule. A section of the upper head of the lateral pterygoid muscle directly inserts into the anteromedial region of the articular disc. As a result, the lateral pterygoid muscle and its associated fascia can directly impact the articular disc's position during TMJ movement. (76,79,80)


 

EXERCISE & PATIENT EDUCATION

Incorporating supportive exercises and patient education is essential in any TMD treatment plan. The prescribed exercises should always be tailored to the patient's needs and the current stage of treatment.


Exercises

Below are some examples of exercises that could be prescribed to patients. Keep in mind that these are not prescriptions for individual cases; our recommendations will differ depending on the specific situation.


6 Effective Jaw Release Exercises

The following video demonstrates how to perform 6 TMJ exercises for temporomandibular joint dysfunction (TMD/TMJ). These exercises are similar to those we prescribe for our patients after implementing Motion Specific Release (MSR) TMJ procedures.



5 Minute Neck Pain Relief

Consider incorporating our "5 Minute Neck Pain Relief" regimen into your daily routine. Performing these exercises multiple times a day may significantly alleviate your neck pain and associated headaches. Please note that this is not a substitute for professional medical advice.


 

Patient Education


Some of the most common recommendations we provide are related to pain management, dietary advice, and anxiety and stress reduction techniques.


Medications: Adopting a multidisciplinary approach can offer significant benefits to patients, particularly in treating severe cases of TMD. While prescription medications may not be within the scope of most manual practitioners, they may be necessary when a patient's TMD causes extreme pain that interferes with sleep, exercise, or even tolerance for treatment.


Jaw Support: Encourage patients to support their jaw when yawning by placing a fist under their jaw and applying gentle pressure. Advise them to avoid any activities that cause jaw pain, such as yelling, singing, or nail biting.


Hot & Cold Therapy: Practitioners should recommend the use of heat or ice based on sound reasoning. In my clinical experience, heat seems to be more effective for most cases of TMD. If you want to learn more, click the following link and read Dr. Abelson's blog."Ice or Heat - Make an Educated Choice!"




Dietary Recommendations:

Chewing the wrong foods can worsen your patient's problems when they are suffering from TMD. Some of the most common dietary recommendations we make are: (82,83)

  • Choose soft foods to eat, such as scrambled eggs, oatmeal, yogurt, quiche, tofu, soup, smoothies, pasta, fish, mashed potatoes, milkshakes, bananas, applesauce, gelatin, or ice cream.

  • Avoid biting into hard foods, including whole apples, carrots, corn on the cob, and anything that is not soft.

  • Generally, stay away from hard or chewy food, like caramel, chips, dried meats, gum, gummy candies, hard bread, hard vegetables, nuts, popcorn, and pretzels.

  • Cut your food into bite-sized pieces before attempting to chew it. Consider grinding or finely chopping meats and other hard foods.


Postural Recommendations:

In our clinical experience, postural recommendations can have a significant impact on treating TMD. Here are some common postural recommendations we make in cases of TMD:

  • Workstation ergonomics: Use a spinal supported ergonomic chair (with armrests in a position where shoulders are relaxed), adjust monitor position, and use a headset (avoid cradling the phone with your shoulder). Take frequent breaks while working.

  • Maintain a neutral head position and avoid anterior head position. Aim to keep your ears in line with your shoulders.

  • Use an orthopedic pillow during sleep.

  • Be aware that forward head posture can contribute to the development of trigger points in the masseter and temporalis muscles. Research has shown that mouth breathing, compared to nose breathing, can significantly negatively impact posture (44, 45).


Stress Management

In cases where a patient is experiencing severe stress, it would be best to refer them to a professional. However, recommending relaxation techniques such as breathing exercises can be greatly beneficial. To learn more, read Dr. Abelson's article "Mindful Meditation - The Power of Breath".


Note: Forward head posture is often associated with mouth breathing, a contributing factor in the development of trigger points related to TMD. In practices like Tai Chi and Yoga, the tongue is often placed on the roof of the mouth behind the incisor teeth. This effective strategy can be used throughout the day to minimize mouth breathing.


 

CONCLUSION

In conclusion, treating Temporomandibular Joint Dysfunction (TMD) requires a comprehensive and individualized approach. The combination of manual therapies, exercise, acupuncture, and patient education can yield significant improvements in TMD symptoms. A multidisciplinary approach involving dentists, and other healthcare professionals, can further enhance treatment outcomes. Addressing kinetic chain connections, postural issues, and stress management techniques are essential components of a successful treatment plan. By understanding the intricacies of TMD and utilizing a wide range of therapeutic interventions, practitioners can help their patients achieve lasting relief and improved quality of life.


 

DR. BRIAN ABELSON DC.


Dr. Abelson is committed to running an evidence-based practice (EBP) that incorporates the most up-to-date research evidence available. He combines his clinical expertise with the specific values and needs of each patient to deliver personalized care that is both effective and patient-centered.


As the developer of Motion Specific Release (MSR) Treatment Systems, Dr. Abelson operates a clinical practice in Calgary, Alberta, under the name Kinetic Health. He has authored ten publications to date and continues to offer online courses, in addition to his live programs, to healthcare professionals seeking to expand their knowledge and skills in treating patients with musculoskeletal conditions. By staying current with the latest research and offering innovative treatment options, Dr. Abelson is dedicated to helping his patients achieve optimal health and wellness.


 

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