The temporomandibular joint (TMJ) is a joint that connects the mandible to the skull. Since the mandible is suspended from the skull this type of joint is physiologically unique. Anatomically, this is formed by very unique steps like architecture of the joint. An intricate suspension system composed of the ligaments and muscles. These muscles of mastication (chewing) although very small in size are considered the strongest muscles in the human body. The load transfer through the TMJ with opening and closing can exceed 200lbs. The other muscles connecting to the TMJ are delicately connecting digestive, respiratory and phonation systems with locomotor system (moving apparatus responsible for posture and walking). TMJ is considered as a balance control system since it provides significant amount of proprioceptive feedback (sensation of where the body is arriving from the body rather then vestibular system) necessary for postural control of the body. The TMJ system is also part of deep postural stability system of the spine through its functional connections with the diaphragm and pelvic floor.
TMJ pain syndrome has been misrepresented be dentist as being their specialty. The truth is that the structural aberrations of bite are rarely responsible for TMJ pain. In other words they are rarely a causative factor. The research evidence suggests that very complex (and expensive) dental appliances have failed to show any value over the counter dental appliances.
Most researchers agree that psychological tension is one of the causative factors in this disorder.
Temporomandibular pain syndrome is a clinical diagnosis, rarely if ever requiring any radiological investigation.
The TMJ is a muscular joint and muscular dysfunction within the joint, that may cause the jaw to deviate from its normal alignment. The joint will stay in proper alignment and should work well if any muscle imbalance is corrected (i.e. by ensuring both sides of the jaw muscles are of equal length, to prevent uneven pulling of the jaw muscles). However, the complexity of TMJ system may necessitate treatment in the areas functionally connected to the joint but anatomically located distantly. Such as the shoulder blades, chest or the pelvis. There is always a local component that must be addressed. This involves a variety of manual osteopathic techniques of working with bones of the skull and muscular releases on the outside of the face as well as intraoral. Movement of the joints of the cervical spine as well as the muscles need to be balanced to restore the cervico cranial alignment as well as to decrease forces traveling through the TMJ. Deep Cervical fascia is another component of a TMJ complex and its movement needs to be restored as it connects to deeper structures such as covering layers of the lungs and heart, upper ribcage and pharynx into the mastication system. Deviation in this tissue affects breathing and swallowing.
Patients with Temporo-Mandibular joints (TMJ) pain often become victims of excessive fragmentation of our complex healthcare system. An individual with persisting pain in the TMJ area may very soon find himself on a long, if un-amusing, journey through the complicated maze of the medical profession. From a dentist office to a neurologist and chiropractor, through physical therapist, to an otolaryngologist he would go. Even psychiatric advice is often sought when everything else fails. Each specialist would undoubtedly have the insight on the heart of the matter subjecting the patient to various tests and devising a treatment using methods specific to his area of medicine. Much too often however such a patient would emerge from his quest with his insurance coverage strained and his TMJ pain fully intact.
Most of the time a patient with TMJ problem initially will be seen by an orthodontist or a neuromuscular dentist, because in theory TMJ pain falls within the scope of their expertise. The truth however is that even though TMJs are anatomically located inside the oral cavity their dysfunction and pathology is rarely, if ever, caused purely by strictly dental problems, such as malocclusion or poor dentition. The simplest proof to this is in the fact that elderly people who, for obvious reasons, have much greater incidence of malocclusion statistically suffer much less problems with their TMJs. Another study involving postmortem examination found that a large number of deceased individuals in whom severe malocclusions were detected had no documented history of TMJ problems.
Due to the deficiencies in healthcare classification standards and overabundance of conflicting scientific evidence about the origin of symptoms like pain in the facial area and TMJ region, persistent headaches, earaches, ringing in the ears, decreased hearing, limited mouth opening, popping or locking of the jaw, hypertonicity of the masticatory musculature and other similar complaints they all are regarded as related to an assortment of conditions involving the Temporo-Mandibular apparatus. The collective term Temporo-Mandibular Disorder or TMD has been coined to describe these conditions without pointing out their etiologies. However, doctors and patients still refer to these symptoms as TMJ pain syndrome.
TMD is a set of related pathological changes, which produce musculoskeletal symptoms in the jaw. The term TMD is deliberately broad and is only used to organize a variety of dysfunctions and disorders that result in abnormal function of the muscles and joints of the jaws.
In order to understand TMD and Orofacial pain the clear definition of Temporo-Mandibular complex must be laid out. Temporo-Mandibular complex is an indelible part of the locomotor system responsible for such vital functions like chewing, swallowing, speaking and breathing. It includes mandible (lower jaw) bilaterally articulated with the maxilla (upper jaw) by highly versatile Temporo-Mandibular joints (TMJs). The skeletal infrastructure is powered by masticators (chewing muscles), which depress, elevate, protrude and retract the lower jaw. The lower jaw is the main movable component of the Temporo-Mandibular system. Supra- and infra- hyoid muscles, which assist the hyoid bone in its various movements, are closely connected with the above-described functionality. Last, but not least, another important element of Temporo-Mandibular system is the cervical segment of the spine, which is intimately linked to the functioning of the orofacial system. Of utmost importance is the fact that Temporo-Mandibular complex represents an integral part of the whole Locomotor system, meaning that TMJ movement is controlled by the same neurological mechanisms that control any movement in the body.
Temporo-Mandibular system is densely innervated and its motor control is provided through the integration of stimuli projected from various receptors within the oral cavity, cervical proprioceptors, and receptors located in the nasopharyngeal and gastro-esophageal areas. Sensory input coming from visual, auditory and vestibular areas also affect the function of Temporo-Mandibular system. Not least important is the association of the respiratory system with Temporo-Mandibular functionality. Integration of all of these stimuli with the input coming from muscles and joints of entire Locomotor system, provide the neurological basis for motor control of the Temporo-Mandibular complex.
Temporo-Mandibular system is one of the most active and powerful structures of human body. It works during the day and while we are asleep. Due to the massive continuous workload and considerable forces exerted by its components it is a subject to breakdowns. Fortunately for the patient the Temporo-Mandibular system is very resilient and capable of self-repair when a proper treatment is administered.
Causes of Orofacial pain arising from within the Temporo-Mandibular system:
Diagnosed TMDs fall into three basic etiological categories:
The first category belongs to pure myofascial etiology resulting strictly from hypertonicity of muscle of mastication and muscles of the cervical spine.
The second category is a mixed etiology. Hypertonicity of masticatory muscles in conjunction with some degree of intra-articular TMJ dysfunction (hypo- or hypermobility in one or both joints, with or without periarticular adhesions).
Resulting from true intra-articular pathology with locking of the jaw.
It must be mentioned that mixed etiology includes various contributing factors listed above.
TMDs of any etiology in general seldom require a surgical intervention. Historical research data has shown that jaw repositioning (one of the common measures taken in combating TMDs in adults) has failed to yield any significant improvement in the recovery ratio. It is a risky and expensive procedure that seems to have been developed by creative dental specialists out of desperation due to the lack of better, scientifically proven alternatives. Such dental measures like occlusal grinding, expensive crowns and bridges, and full mouth restorative procedures also lack sufficient statistical evidence proving them to be effective as cure of TMDs. However, TMJ custom made appliances based on radiographic positioning in combination with specific TMJ physical therapy or chiropractic has proven to be the most effective measures in treatment of TMJ pain disorders.
Conditions from Categories 1 and 2 (see above) fall into the field of neuromuscular therapy , such as chiropractic or physical therapy specializing in TMJ treatment. Special attention has to be devoted to dysfunction in the Locomotor system as a whole because the local manual approach alone may not be sufficient. Treatment of the entire Locomotor system is necessary to avoid recovery delay and subsequent chronicity. This is especially the reason why intraoral appliances, such as dental splints, should only be used in conjunction with neuromuscular physiotherapy or as a supplemental home therapy to consolidate the recovery achieved by the neuromuscular treatment. Over the counter splints can be tried at first before committing to more expensive custom made appliances.
TMDs caused by intra-articular pathology (category 3) require close cooperation between orthodontist or maxillofacial surgeon and neuromuscular specialist. The world’s scientific authority recommends treating these cases conservatively until maximum improvement is achieved before committing to surgery. At present about fifty percent of such cases are managed without any orthodontic or orthoghnathic surgical intervention. At this stage custom made appliances is a must. Only when long rehabilitative approach with specific TMJ physical therapy has failed surgical intervention may be considered. It must be up to the neuromuscular specialist to make a sound judgment, based on good clinical skills and clear understanding of structural pathology of the TMJ, whether the conservative care is no longer effective and refer the patient for surgical consultation.
Although, most of TMJ pain disorders are self-limiting, they could generate excruciating pain and cause significant distress to the patient. Improper TMJ treatment can lead to chronicity, emotional distress and create a devastating impact on the patients’ quality of life. When chronic TMJ pain is present pain medication and neuromuscular therapy may not be sufficient. Meditation, relaxation and referral to a psychosocial specialist or a pain clinic may be warranted.
At DNR’s office located in Manhattan, Midtown we use comprehensive TMJ treatment approach consisted from specialized TMJ physical therapy exercises such as Roccabado and others well-accepted protocols. Manual intraoral TMJ therapy we use in our NYC facility is combined with cranial osteopathy. TMJ function is intimately related to function of the cervical spine and shoulder girdle. We use DNS ( dynamic neuromuscular stabilization ) approach to restore functional connections between masticatory muscles and cervicocranial and scapulomandibular muscles. We use soft tissue mobilization techniques to address deep cervical fascia and its interconnection with craniomamdibular system. For myofascial trigger points in temporo mandibular and cervical muscles we use low energy ESWT devise and cold laser, which are quite hard to find even in New York.
TMJ pain can become chronic and resistant to treatment if professionals who specialize in TMJ therapy do not timely address it.
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