Temporomandibular Disorders (TMD) are a group of common but complex conditions that affect the jaw and surrounding areas, often due to a variety of underlying anatomical factors. This article explores the key bone and soft tissue structures involved in TMD, its diagnosis, and the multidisciplinary treatments available, including Motion Specific Release (MSR) techniques, to enhance patient outcomes.
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Article Index:
Introduction
Temporomandibular Disorders (TMD) are common yet complex conditions that affect millions of people each year. Despite its prevalence, TMD remains a challenging condition due to the variety of underlying causes and the different parts of the orofacial region it can impact. However, effective solutions are available with thorough evaluations and personalized treatment plans.
TMD involves issues with the joints and soft tissues of the jaw, leading to pain in the mouth, jaw, and face. This condition affects about 5% to 12% of the population, and women are twice as likely to experience it as men. TMD is the second most common musculoskeletal disorder, following chronic low back pain.
TMD can be categorized into two main types: intra-articular and extra-articular disorders. Intra-articular issues typically involve joint inflammation, degeneration (like osteoarthritis), or structural changes within the joint. Extra-articular disorders often stem from overactivity or imbalances in the jaw muscles, frequently with contributing factors from the cervical spine.
Osseous Anatomy
The Tempromandibular Joint (TMJ) is one of the most intricate joints in the human body. It consists of two bone structures: the temporal bone and the mandible.
Here are key anatomical features of the TMJ:
The TMJ functions as a hinge and sliding synovial joint, capable of spinning and compression movements.
It operates in coordination on both sides, with the condyles rotating and moving forward when the mouth opens.
During lateral jaw movement, the TMJ experiences a complex action involving rotation on one side and forward, inward rotation on the opposite side.
A biconcave disc within the TMJ divides it into an upper (discotemporal) and lower (discomandibular) joint capsule.
This disc attaches to the medial and lateral sides of the mandibular condyle and surrounding ligaments and muscles.
Unlike most joints, the TMJ surfaces are covered with fibrocartilage instead of hyaline cartilage.
Soft Tissue Anatomy
Muscles of Mastication
The muscles involved in chewing often play a significant role in Temporomandibular Disorders (TMD). Discomfort may arise directly from these muscles or be caused by referred pain from other areas impacting them.
The key muscles of mastication involved in TMD are:
Masseter muscle
Temporalis muscle
Lateral Pterygoid muscle
Medial Pterygoid muscle
Note: The following section is more technical and geared toward students, anatomy enthusiasts, and clinicians. If you'd prefer, feel free to skip ahead to the "TREATMENT OF TMD" section.
The Masseter Muscle and its Role in TMD-related Pain
The masseter muscle often plays a crucial role in TMD-related pain[35]. When involved, palpation may trigger a specific pain-referral pattern, referring pain to the TMJ and ear[11]. Here are some key characteristics of the masseter muscle:
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 Trigger Points: Trigger points in the deep masseter muscle can cause pain radiating to the TMJ and ear, sometimes leading to tinnitus. Applying pressure to these points might even alter tinnitus symptoms, highlighting the importance of distinguishing between neurological and myofascial origins. The superficial sections of the masseter muscle often refer pain to the jaw, maxilla, and eyebrow. These trigger points can limit mouth opening, causing the jaw to deviate toward the affected side. Additionally, masseter muscle trigger points are commonly linked to tension headaches and mechanical neck pain.
The Temporalis Muscle and its Role in TMD
The temporalis muscle is another muscle frequently involved in TMD and tension headaches[41]. Here are some key characteristics of the temporalis muscle[11]:
Temporalis Muscle Overview:
Origin: The temporalis muscle originates from the Temporal Fossa and Temporal Fascia, located above the Zygomatic Arch.
Insertion: It attaches to the Coronoid Process and the anterior border of the Mandible's Ramus.
Action: This muscle elevates and closes the mouth while also aiding in the retrusion and protrusion of the Mandible. Notably, it can contract antagonistically during mouth opening in patients with masseter muscle contracture.
Innervation: The temporalis muscle is innervated by the anterior and posterior deep temporal nerves, which branch from the mandibular division of the trigeminal nerve (CN V).
Trigger Points: Trigger points in the temporalis muscle can cause headaches, deep temple pain, eyebrow pain, upper teeth pain, and pain behind the eyes. These points can also refer pain to the Maxilla and TMJ. Common triggers include trauma, activities that shorten or lengthen the muscle (like gum chewing or jaw clenching), and poor posture, particularly forward head posture, which increases tension on the temporalis muscle.
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 and its Role in TMD
The medial pterygoid muscle, located deep within the mandible, consists of two heads—superficial and deep—that function parallel to the masseter muscle, assisting in jaw closure and mandible support. Despite limited research, this muscle can contribute to TMD.
Origin: The superficial head originates from the maxillary tuberosity and the pyramidal process of the palatine bone. The deep head originates from the lateral pterygoid plate of the sphenoid bone, situated deep in the lateral pterygoid muscle.
Insertion: It attaches to the ramus's medial surface and the mandible's angle.
Action: Bilateral contraction elevates and protrudes the mandible, while unilateral contraction rotates the mandible, deviating it to the opposite side.
Innervation: The medial pterygoid muscle is innervated by the medial pterygoid branch of the mandibular division of the trigeminal nerve (CN V).
Trigger Points: Trigger points in the medial pterygoid can refer to pain in the mandible, maxilla, teeth, and ear, often making jaw opening painful and physically restrictive. These trigger points frequently co-occur with those in the masseter, temporalis, lateral pterygoid, and SCM muscles.
The Lateral Pterygoid Muscle and its Role in TMD
The lateral pterygoid muscle plays a crucial role in jaw movement and control. Its superior head attaches to the articular disc, and tension in this muscle may lead to anterior disc displacement, contributing to TMD, headaches, oromandibular dystonia, and other conditions.
This muscle has two heads—upper and lower. The upper head originates from the greater wing of the sphenoid bone, while the lower head arises from the lateral plate of the sphenoid bone. Both heads converge to insert into the pterygoid fovea on the neck of the mandible.
Innervation: The muscle is innervated by branches of the buccal nerve and the mandibular nerve.
Action: While there is some debate, most agree the lateral pterygoid opens the mouth (mandibular depression) and enables contralateral jaw movement during chewing. It also helps maintain the TMJ disc’s position beneath the condyle, reducing tension on the disc.
Palpation: To palpate the lateral pterygoid, have the patient lie supine. Place your index finger along the cheek pouch’s vestibule, press posteriorly, and move past the maxillary tuberosity, squeezing between the maxilla and coronoid process. Jaw deviation to the ipsilateral side widens the space for easier palpation.
Trigger Points: Trigger points in the lateral pterygoid can cause sinus pain, throat discomfort, and even tinnitus. These points may refer pain to the TMJ and maxillary sinus region, and can be linked to increased mucus secretion and limited jaw movement. Trigger points in the cervical region may also refer pain to the lateral pterygoid, meaning cervical issues may need addressing to resolve these trigger points.
TMD Symptoms: Jaw Pain
Common symptoms of Temporomandibular Disorders (TMD) include:
Jaw discomfort or soreness
Pain over the temporomandibular joint (along the jawline or in front of the ear)
Pain radiating to the eyes, face, neck, shoulder, or upper back
Unusual joint sounds like clicking, popping, snapping, or grating (crepitus) when eating or moving the jaw
Clenching or grinding of teeth (bruxism)
Limited or locked jaw movement
Difficulty chewing
Restricted ability to open or close the jaw
Ear pain
Dizziness
Tooth sensitivity (not related to dental issues)
Diagnosis of TMD
Diagnosing Temporomandibular Disorders (TMD) involves carefully reviewing your symptoms and a physical exam.
Red Flags to Rule Out:
Nerve or brain issues
Blood flow problems
Heart conditions
Psychological stress or trauma
Signs of infection or unexplained weight changes
Key Areas to Evaluate:
History:
Pain: Rate your pain and map where it hurts.
Jaw Function: Note how jaw movements affect your pain.
Arthritis: Check for arthritis in other joints.
Jaw Limitations: Gradual difficulty in opening your mouth could suggest joint issues.
Other Symptoms: Include things like ringing in the ears or dizziness.
Sensation Changes: Pay attention to any numbness or tingling in the head, neck, or shoulders.
Teeth Grinding: Check if you grind your teeth, especially at night.
Other Conditions: Mention any other health problems.
Observation:
Look for Swelling or Asymmetry: Check for visible signs like swelling or unevenness in your face or jaw.
Jaw Movement: Watch for any jaw deviation when opening your mouth.
Tooth Wear: Look for unusual wear patterns on your teeth.
Sounds: Listen for clicking, popping, or grinding sounds in the jaw.
Jaw Range of Motion:
Mouth Opening: Measure how wide you can open your mouth and if there’s any pain.
Lateral Movement: See if your jaw can move side to side.
Muscle Palpation:
Pain Points: Check for tenderness in the jaw muscles.
Posture: Evaluate your posture, as it can affect your jaw.
TMD Diagnostic Videos
Diagnosing temporomandibular disorder (TMD) involves a careful review of the patient’s medical history and a thorough physical exam, as TMD often causes persistent jaw and facial pain. Dr. Mylonas guides you through the crucial steps for evaluating TMD in this video. To ensure a comprehensive assessment, it's important to follow the outlined diagnostic steps and evaluate the cervical spine, cranial nerves, upper extremities, and vascular system. Key procedures to consider are highlighted below.
Cervical Examination - Orthopaedic Testing
In this video, Dr. Mylonas performs a cervical orthopedic examination, including palpation, range of motion, and orthopedic tests. These tests are crucial for identifying potential cervical spine issues that often contribute to or exacerbate Temporal Mastication Disorders (TMD).
Cranial Nerve Examination - 12 Cranial Nerves
Welcome to our video on the Cranial Nerve Examination, where we explore the 12 cranial nerves and their role in detecting sensory and motor dysfunction. This exam is particularly relevant for TMD patients, as cranial nerve issues can contribute to abnormal jaw movement, muscle tone changes, and coordination problems.
Peripheral Vascular Examination
The peripheral vascular examination assesses circulation in areas outside the heart and lungs and is important for TMD patients. Vascular issues can influence blood flow to the jaw and contribute to symptoms such as pain and muscle dysfunction.
Coexisting Conditions in TMD Patients:
Insomnia: TMD-related jaw pain can make falling or staying asleep difficult.
Tinnitus: The proximity of the jaw and ear structures can lead to ringing or buzzing in the ears, which is associated with TMD.
Neck Pain: The interconnected jaw and neck muscles often mean that TMD is accompanied by neck pain.
Shoulder Pain: Poor posture or muscular imbalances caused by jaw dysfunction in TMD can lead to shoulder pain.
Headaches: TMD is often linked with various headaches, particularly tension and temporal headaches, influenced by jaw movement.
Trigeminal Neuralgia: This painful condition, affecting the trigeminal nerve, may coexist with TMD due to shared nerve pathways.
Difficulty Swallowing (Dysphagia): In TMD patients, the muscles used in jaw function, which are also involved in swallowing, can lead to dysphagia.
Peripheral Neuropathy: Some TMD patients may experience peripheral neuropathy, possibly from nerve compression in the jaw and neck.
Thoracic Outlet Syndrome: TMD may be associated with thoracic outlet syndrome, where nerves or blood vessels are compressed due to postural issues or muscle imbalances.
These coexisting conditions are often linked to autonomic nervous system dysfunction, particularly under increased stress or anxiety, where abnormal breathing patterns are also common.
Multidisciplinary Collaboration
Before we discuss treatment options, it's crucial to highlight the importance of multidisciplinary collaboration in achieving the best outcomes for TMD patients. Collaboration with other healthcare professionals often leads to superior results.
We frequently coordinate with our patients' dentists, following their expert recommendations. The Canadian Dental Association emphasizes this collaboration, stating that after a thorough examination and possibly x-rays, a dentist might propose a treatment plan that includes relaxation techniques and referrals to professionals such as physiotherapists, chiropractors, or behavioural therapists to alleviate muscle pain.
Additionally, your dentist may suggest wearing a night guard or occlusal splint. This clear plastic device fits over the biting surfaces of your teeth, helping to relax the jaw joints and muscles by allowing you to bite against the splint instead of your teeth.
Addressing the TMJ - MSR Protocols
Effective jaw mobilization is critical to treating TMJ and TMD issues, making it essential for musculoskeletal (MSK) practitioners to master these techniques. Below are some gentle yet purposeful mobilization methods used to relieve symptoms of temporomandibular disorders (TMD). The goal is to improve TMJ mobility, and these techniques are performed with a focus on patient relaxation to reduce muscle tension and clenching.
Temporomandibular Joint Mobilization Demonstration
In this demonstration video, Dr. Abelson, the creator of Motion Specific Release (MSR), presents a variety of effective jaw mobilization techniques. Mastery of these techniques is crucial for managing temporomandibular disorders, but it's important to note that these procedures should only be performed by certified MSR practitioners. The video is for demonstration purposes only, emphasizing the importance of precise hand positioning and controlled, gentle movements to ensure the effectiveness and safety of the techniques.
Muscles of Mastication - MSR Protocols
Motion Specific Release - TMD Protocols
In the videos below, Dr. Abelson demonstrates one of the MSR TMD protocols. Motion Specific Release (MSR) procedures were developed by Dr. Brian Abelson, DC. MSR is a "Treatment System" that merges the benefits of various therapeutic approaches. Rather than a singular technique, MSR serves as a comprehensive treatment system. The following protocols are intended to be incorporated with other treatment modalities (66,67,68).
MSR Masseter Muscle Release
The MSR Masseter Muscle Release Protocol, created by Dr. Brian Abelson, explicitly targets the masseter muscle, which is often a pivotal contributor to TMD pain. This specialized procedure should only be performed by certified MSR practitioners. The video serves as a demonstration, highlighting the critical importance of precise hand positioning and gentle, controlled movements to ensure the technique's effectiveness and safety.
Please note: Additional MSR protocols are accessible with a subscription to MSR Pro.
The Kinetic Chain
When applying this protocol, practitioners must consider the entire kinetic chain, particularly when integrating it with cervical, shoulder, and thoracic protocols, as each patient’s needs are unique. Some TMD cases require a localized approach, while others benefit from a more systemic strategy. They recognize the connections within the kinetic chain and the effects of past injuries, muscle imbalances, postural stress, and the neurological impact of long-term stress (central sensitization). Additionally, restrictions in the cervical and thoracic spine must be addressed. The key to successfully treating TMD lies in creating a personalized treatment plan tailored to the specific needs of each individual.
Fascial Expansions and Their Role in TMD Treatment
Fascial expansions refer to the interconnected network of fascial planes that span various body parts, including the jaw, shoulder, hip, and knee. Fascia, primarily collagenous, surrounds and connects muscles, bones, nerves, blood vessels, and organs, providing structural support and enabling biomechanical communication. These dynamic structures adapt to mechanical forces, allowing efficient force transmission and maintaining musculoskeletal health.
The interconnected nature of fascial planes means that restrictions or imbalances in one area can lead to compensatory dysfunctions elsewhere, resulting in pain and movement limitations. This highlights the importance of therapies targeting the fascial system, such as manual therapies, myofascial release, and acupuncture, which can help restore balance and improve force transmission.
Fascial Expansions and TCM in TMD Treatment
Integrating fascial expansion knowledge with Traditional Chinese Medicine (TCM) offers a comprehensive approach to treating TMD. By combining insights from fascial research with acupuncture points like ST6, ST7, ST8, SI8, LI4, and GB20, and incorporating soft tissue, osseous techniques, and functional exercises, practitioners can enhance treatment outcomes for TMD patients.
Fascial Expansion Demonstration
In this demonstration video, Dr. Abelson explores the fascial planes that influence jaw function and shows how this knowledge is integrated with Traditional Chinese Medicine (Acupuncture/Acupressure). Please note that these techniques should only be performed by certified MSR practitioners. Understanding the connection between fascial planes, jaw function, and specific TCM techniques allows practitioners to effectively relieve pain and promote healing in patients with TMJ/TMD.
Treatment Frequency Recommendations
For TMJ/TMD, start with an initial treatment phase of 4 to 6 weeks, depending on the specific case, followed by a functional review. Based on patient progress, recommendations for ongoing treatment are then adjusted.
Acute Stage:
Goal: Alleviate pain and inflammation.
Frequency: 1-2 times per week.
Sub-Acute Stage:
Goal: Restore function and prevent stiffness.
Frequency: 1-2 times per week, transitioning to once a week.
Chronic Stage:
Goal: Address dysfunction and maintain improvements.
Frequency: Once every two weeks or monthly.
Note: Patients with limited time can opt for a 30-minute session once a week instead of two 15-minute sessions.
Exercises
Incorporating tailored exercises and patient education is essential for any TMD treatment plan. The exercises should be customized to the patient’s needs and treatment stage.
Here are examples of exercises that might be recommended. These are general suggestions, not prescriptions, and will vary based on individual circumstances.
6 Effective Jaw Release Exercises
This video showcases six TMJ exercises to help with temporomandibular joint dysfunction (TMD/TMJ). These exercises are similar to those we recommend for patients following Motion Specific Release (MSR) TMJ treatments.
5 Minute Neck Pain Relief
Consider incorporating our "5-Minute Neck Pain Relief" program into your daily routine. Performing these exercises a few times a day can help alleviate neck pain and reduce related headaches, often associated with TMD. Remember, this is meant to complement, not replace, professional medical advice.
Common Recommendations for TMD Management
We frequently suggest pain management strategies, dietary adjustments, and stress-reduction techniques to help manage TMD.
Medications:
A comprehensive approach can be especially beneficial for severe TMD cases. While most manual practitioners don't prescribe medications, they may be necessary if the patient's pain is severe enough to interfere with sleep, exercise, or treatment tolerance.
Jaw Support:
Encourage patients to support their jaw during yawning by placing a fist under it and applying gentle pressure. They should also avoid activities aggravating jaw pain, such as shouting, singing, or biting.
Hot & Cold Therapy:
Practitioners should recommend heat or ice applications based on each patient's specific needs. In my clinical experience, heat tends to be more effective for most TMD cases. For more details, check out Dr. Abelson's blog: "Ice or Heat: Exploring the Logic"
Dietary Recommendations:
Certain foods can worsen TMD symptoms. Here are some common dietary suggestions we offer:
Opt for soft foods: Scrambled eggs, oatmeal, yogurt, quiche, tofu, soup, smoothies, pasta, fish, mashed potatoes, milkshakes, bananas, applesauce, gelatin, or ice cream.
Avoid hard foods: Whole apples, carrots, corn on the cob, and tough or chewy items like caramel, chips, dried meats, gum, gummy candies, hard bread, hard vegetables, nuts, popcorn, and pretzels.
Tips: Cut food into small pieces before chewing, and consider grinding or finely chopping tough foods.
Postural Recommendations:
Proper posture can greatly impact TMD treatment success. Here are some typical suggestions:
Workstation Ergonomics: Use an ergonomic chair with spine support and armrests, adjust monitor height, and use a headset to avoid cradling the phone between your shoulder and ear.
Breaks and Alignment: Take regular breaks, maintain a neutral head position (avoid forward head posture), and align your ears with your shoulders.
Sleeping: Use an orthopedic pillow. Be aware that forward head posture can contribute to trigger points in the masseter and temporalis muscles.
Breathing: Studies suggest that mouth breathing, as opposed to nose breathing, can negatively affect posture.
Stress Management
For patients dealing with high levels of stress, it’s wise to refer them to a professional. However, recommending relaxation techniques like breathing exercises can also be highly beneficial. For more insights, check out Dr. Abelson's article "Mindful Meditation - The Power of Breath."
Note: Forward head posture is often linked to mouth breathing, which can lead to TMD-related trigger points. In practices like Tai Chi and Yoga, placing the tongue on the roof of the mouth, just behind the front teeth, is a common technique to reduce mouth breathing and can be applied throughout the day.
Why Choose Our Approach for TMD Treatment
Our comprehensive approach to treating Temporomandibular Disorders (TMD) consistently achieves a 90% success rate in reducing pain and improving jaw function. Here's why our method stands out:
Established Expertise: Developed by Dr. Brian Abelson, the MSR methodology is backed by over 30 years of clinical experience and the successful treatment of more than 25,000 patients, ensuring you receive the highest standard of care.
Thorough Assessments: We conduct detailed evaluations to identify all contributing factors, including cervical spine involvement or muscular imbalances, often present in TMD.
Advanced MSR Procedures: Our Motion-Specific Release (MSR) techniques precisely target areas of myofascial restrictions and joint dysfunction, delivering effective and lasting relief.
Customized Exercise Programs: We create individualized exercise plans that enhance jaw mobility, strengthen supporting muscles, and restore proper function, facilitating your recovery.
Logical, Evidence-Based Approach: Our treatment protocols integrate manual therapy, exercises, and supportive measures, ensuring a well-rounded and lasting solution.
Choose our proven, patient-centred approach for effective, long-term relief from TMD. Take the first step toward your recovery with confidence.
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DR. BRIAN ABELSON, DC. - The Author
With over 30 years of clinical practice and experience in treating over 25,000 patients with a success rate of over 90%, Dr. Abelson created the powerful and effective Motion Specific Release (MSR) Treatment Systems.
As an internationally best-selling author, he aims to educate and share techniques to benefit the broader healthcare community.
A perpetual student himself, Dr. Abelson continually integrates leading-edge techniques into the MSR programs, with a strong emphasis on multidisciplinary care. His work constantly emphasizes patient-centred care and advancing treatment methods. His practice, Kinetic Health, is located in Calgary, Alberta, Canada.
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