Temporomandibular Joint Syndrome (TMJ)
The Temporal Mandibular Joint (TMJ) is the joint that allows for the opening and closing, as well as the anterior, posterity, and lateral, gliding of the jaw. The TMJ is located between the temporal fossa of the temporal bone, and the condylar process of the mandibular bone. Between the opposing surfaces of the joint lies the articular disk, or meniscus.
In order to stimulate the innate ability of the body to heal the causes of disease must be identified and addressed. With temporomandibular joint syndrome, the causes are variable and include posture, stress and other underlying conditions. A detailed assessment is needed to identify external factors and behaviors that may contribute to the development and progression of carpal tunnel syndrome.
- The absence or abnormal positioning of teeth can cause a displacement of the mandible such that the teeth are not able to bite together in a uniform way. This is called malocclusion. Malocclusion often disturbs the relationship between the teeth, TMJ, and the related musculature, and can cause the deterioration of the joint itself. The type of malocclusion that is most likely to cause dysfunction of the TMJ and surrounding muscles is that where the lower first molar is posterior to the upper first molar while biting down.
- Forward head posture is the most common abnormality of the cervical spine to adversely affect the TMJ. An abnormally forward head posture, results in a change in the position of the mandible. This can both stretch the joint capsule, and offset the proper occlusion of the teeth. These changes can then affect the mastication muscles, and the TMJ.
- A misalignment of the first or second cervical vertebrae, a faulty posture of the cranium, or a faulty curvature of the cervical spine, may induce or contribute to TMJ Syndrome.
- Improper tongue position within the mouth. In it's natural resting position, the tongue touches the superior (upper) part of the mouth called the hard palate. When in this position, it facilitates a resting muscle tone in the elevating muscles of the mandible and other tissues of the stomatognathic system, via the jaw tongue reflex. When these tissues are relaxed, they are more able to regenerate/heal. Thus, when the tongue does not assume its proper resting position, this can contribute to dysfunction of the tissues of the stomatognathic system and of the TMJ.
- Unilateral mastication can lead to disproportionate muscle size and tension of the masticatory muscles.
- Abnormal swallowing can contribute to TMJ syndrome.
- TMJ hypermobility can occur as a result of excessive: gum chewing, nail biting, mouth breathing, nocturnal bruxism, prolonged bottle feeding/pacifier use, and trauma, subluxations, or dislocations of the TMJ.
- Emotional stress typically causes tension of the skeletal muscles. This can manifest as clenching of the teeth (bruxism) which can be harmful to the TMJ if excessive/prolonged.
- Motor vehicle accidents and the musculoskeletal trauma that frequently results from them, is a common cause of TMJ disorders.
- Whiplash injuries can cause tearing or stretching of the masseter muscle, as well as the joint capsule, intra-articular disk, and ligaments of the TMJ.
- There is a high prevalence of TMJ dysfunction in people with cervical spine disorders. Also, TMJ disorders can affect the muscles of the cervical spine.
- Questions for the practitioner to ask when assessing the TMJ include:
- Does the joint grate, click, pop, snap, or lock?
- Is there difficulty opening or closing the mouth?
- Do you experience frequent headaches, and if so, at what part of the head, and how long do they last?
- Have you ever had a severe blow to the head or a whiplash injury?
- Are your jaws clenched or teeth sore when you wake up?
- TMJ syndrome is typically reversible. If it persists for a long duration it can decrease the pain free movement of the mandible.
- TMJ syndrome is a progressive condition if it is not properly treated.
- The lateral pterygoid muscle is the most common muscle involved with TMJ dysfunction. It is responsible for opening the mouth and protruding the mandible, and stabilizing the TMJ. It attaches to the articular disk (manubrium) and joint capsule. If its function is disturbed, TMJ related symptoms can result.
- The most common mechanical disorder of the TMJ is a laxity of the articular ligaments. This permits hyper-translation of the condyles (typically anterior translation), and can lead to TMJ dysfunction.
- The TMJ is part of a larger system called the stomatognathic system. This is comprised of the TMJ, the muscles of mastication, the mandible, maxilla, hyoid, clavicle, sternum, temporomandibular joints, dentoalviolar joints, muscles of the head and neck, the muscles of the cheeks, lips and tongue, the teeth, and the local vascular, lymph, and nervous system.
- This system is involved not only in chewing, but also in swallowing, speech, and respiration, and hence is continuously in use. As the components of this system are anatomically and physiologically related, the impaired function of one aspect can lead to impairments in other aspects as well. Thus, a problem such as the improper occlusion of the teeth can affect the cervical muscles, and thus, the normal posture of the head and neck.
- Because of the relationship between the TMJ and the other components of the stomatognathic system, it is typical for people with TMJ dysfunction to also have: elevated shoulders, forward head, stiff neck and back, and shallow/restricted breathing.
- Some masticatory muscles share common nerve innervation with the tensor tympani which controls the movement of the tympanic membrane in the ear, and the tensor veli palatini which controls the diameter of the eustachian tube. Thus, when masticatory muscles are in spasm they can cause excessive contraction of neurologically associated muscles of the ear.
The conditions associated with temporomandibular joint syndrome include:
- middle ear complaints
- Early symptoms of dysfunction include:
- clicking, subluxation, recurrent dislocation, and locking (locking happens when the disk within the joint becomes lodged anterior to the condyle).
- Later symptoms include:
- tension or spasms in the muscles of mastication and the associated cervical muscles, and a dull aching pain in the area around the joint.
- This pain can radiate to the: ear, face, head, neck and shoulders, and is typically aggravated by movement of the joint.
- Headaches often occur in people with TMJ disorders.
Effective treatment of TMJ syndrome often requires a multidisciplinary treatment approach including:
- Correcting a bite such that the top and bottom teeth can occlude (come together) properly
- Learning to eat properly, slowing down, chewing food slowly and eating in a more relaxed environment is helpful
- Stress reduction is a common component of any therapy
- Addressing postural misalignment is an integral part of therapy
- Establish proper head, neck, and shoulder girdle position
- Exercise is used to:
- Increase range of motion through therapeutic exercise and mobilization techniques
- Muscle retraining
- Deep tissue massage to capsule of joint
- Stroking of inter oral tissue to decrease pain
- Soft tissue manipulation to help release tight masseter, temporalis, and supra- and infra-hyoid muscles
- Resisted opening, closing, and lateral deviation, of the mouth. This helps to relieve tension in masticatory muscles, and to reduce clicking of the TMJ.
- Stretching of the masticatory muscles via repeatedly opening mouth as wide as possible and holding
- Caudal distraction of the lower jaw
Naturopathic Therapies for TMJ syndrome include:
- Clinical Nutritional Supplementation including:
- Botanical remedies such as:
- Acupuncture is very effective in treating TMJ symptoms and in decreasing muscle spasms and muscle tension that contributes to the onset of TMJ syndrome.
- Cranial sacral therapy can be beneficial
- Myofascial release techniques can be helpful
- Dr. Iva Lloyd, BScH, RPE, ND
- Dr. Raymond Trott, ND
- Hertling D, Kessler R (2006) Management of Common Muskuloskeletal disorders: Physical Therapy, Principles, and Methods. Fourth Edition, Lipincott Williams and Wilkins.