TMJ Disorders

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TMJ is an abbreviation commonly used for temporomandibular joint, the paired right and left jaw joints that connect the mandible (lower jaw) to the skull. TMJ disorders are an assortment of interrelated problems associated with the temporomandibular joint.

The signs and symptoms of TMJ disorder can range from minor discomfort and inconvenience to extremely painful, dysfunctional debilitation. Patients suffering from TMJ disorder commonly experience facial muscle and temporomandibular joint pain, jaw stiffness, difficulty chewing, difficulty opening the mouth and a ‘clicking’ sound.

These symptoms occur when the temporomandibular joint and the muscles of mastication (chewing muscles) do not work together correctly. Since some types of TMJ problems can lead to more serious conditions, early detection and treatment are important.

In general, no single treatment can resolve TMJ disorders completely and treatment usually takes time to become effective. In order to successfully manage TMJ disorder the etiology (cause) must be identified and treated. 

What Causes TMJ Disorders?

Temporomandibular joint disorder can occur at any age; the incidence among males and females is approximately equal. The following list represents some of the most common problems that can produce TMJ disorders.

• Emotional Stress/Bruxism

Many TMJ disorder cases are related to emotional stress. People frequently clench or grind (brux) their teeth when under stress. Bruxism (often referred to as parafunctional habits) can overwork the muscles of mastication (chewing muscles) causing muscle fatigue, inflammation, soreness and spasm. In addition, the forces applied to the joints during bruxism can cause joint inflammation, and pain.

Initially, there are symptoms of muscle pain, muscle tightness, joint pain, joint stiffness and occasionally clicking. Over a prolonged period of time, excessive bruxism can lead to anatomic damage such as disc displacement (misalignment), tearing of the disc or its posterior attachment, and eventually degenerative changes with wearing or flattening of the mandibular condyle.

Treatment for TMJ disorder due to bruxism (parafunctional habits) depends on the patient’s history and clinical findings. Treatment typically includes patient education, occlusal splint therapy (usually a night guard), stress management, anti-inflammatory pain relievers, soft diet, gentle exercises, and occasionally muscle relaxants. The TMJ disorder will persist if bruxism is not discontinued.

• Acute Trauma

Acute traumatic injury to the jaw joint usually produces a sprain. This type of injury results in bruising of the joint tissues causing inflammation, pain and stiffness with limitation of opening. A sprain is treated with rest (soft diet for several weeks), anti-inflammatory pain relievers (Advil, Motrin, ibuprofen) and ice during the first 72 hours followed by heat. Pain and functional problems associated with a TMJ sprain usually resolve in four to six weeks as long as the joints are allowed to rest by maintaining a soft diet.

Severe traumatic injuries can cause disc displacement (misalignment) and tearing of the disc or its posterior attachment. This results in clicking, crepitus (grinding sound), pain and limitation of opening. In these cases, anti-inflammatory pain relievers and rest may not be enough to recover full joint mobility and eliminate pain; additional treatment may be necessary.

• Rheumatoid Arthritis

Rheumatoid Arthritis can damage the Temporomandibular Joint directly resulting in joint degeneration. Usually there are several other joints that are affected earlier and more severely than the TMJ.

• Malocclusion

A malocclusion (misaligned bite) is uncomfortable and inefficient for chewing. It creates stress on the muscles of mastication (chewing muscles) and misalignment of the discs which can contribute to muscle spasm, muscle pain, joint pain, clicking, crepitus (grinding sound), closed lock and other functional problems.

Patients with many missing teeth that have not been replaced and patients with old worn out dentures often develop an over-closed bite due to loss of posterior vertical support. With an over-closed bite, the condyle swings to the back (posterior) of the joint space behind the disc. As the mandible over-closes, the disc becomes anteriorly misaligned relative to the mandibular condyle. During function, the condyle creates pressure against the posterior attachment of the disc resulting in joint pain, clicking or crepitus and possibly locking (see: Functional Problems With TMJ Disorders). With an over-closed bite the muscles of mastication are no longer optimally positioned and they cannot function at peak efficiency. Consequently, they become easily fatigued and can go into painful spasm.

TMJ disorders caused by malocclusion must be treated by correcting the malocclusion.  Providing the patient with an appropriate, comfortable, stable, repeatable occlusion with proper vertical support will often relieve the pain, eliminate clicking and reestablish normal function. This may require extensive restorative dental treatment with crowns, implants and/or bridges to replace missing teeth. In select cases, orthodontic treatment may be required to correct the malocclusion. Sometimes, simply replacing an old worn out denture is all that is required. Additional treatment may be necessary, depending on the patient’s history and clinical findings.

In all cases of TMJ disorder a slight malocclusion (misalignment of the bite) can develop due to disc misalignment, inflammation in the joint and/or spasm of the muscles of mastication. The malocclusion can promote increased muscle fatigue, soreness and spasm due to changes in jaw position and chewing patterns. It can also exacerbate joint inflammation, pain and injury since it further impairs disc alignment. These enhanced muscle and joint problems, in turn, can worsen the malocclusion. This interrelationship between muscle fatigue, muscle spasm, joint inflammation, disc misalignment and malocclusion can trigger a vicious cycle.

• Postural Problems

Patients with neck and/or back problems often thrust the upper part of their body slightly forward in attempt to relieve pressure on the spine. This posture causes a small constant stretch of the ‘strap muscles’ attached to the anterior inferior region of the mandible. This constant stretch creates a small continuous force on the mandible pulling it backward (posteriorly). It only takes a millimeter or two of posterior repositioning (retropositioning) of the mandible to position the condyle posteriorly to the disc. The disc becomes anteriorly misaligned relative to the mandibular condyle. During function, the condyle creates pressure against the posterior attachment of the disc resulting in joint inflammation, pain, clicking or crepitus and possibly locking (see: Functional Problems With TMJ Disorders).

Due to poor posture and slight retropositioning of the mandible, the shoulder muscles, neck muscles, upper back muscles and muscles of mastication (chewing muscles) are no longer optimally positioned. They are stretched slightly, constantly, in a position where they can never fully rest and never function at their peak efficiency. This can cause fatigue, pain and spasm of the involved muscles in the shoulder, neck, back and face.

A malocclusion develops due to the slight retropositioning of the mandible, muscle spasm, joint inflammation and disc misalignment. The malocclusion can promote increased muscle fatigue, soreness and spasm due to changes in jaw position and chewing patterns. It can also exacerbate joint inflammation, pain and injury since it further impairs disc alignment. These enhanced muscle and joint problems, in turn, worsen the malocclusion. This is a classic vicious cycle.

Treatment for TMJ disorder due to a postural problem varies widely, depending on the patient’s history and clinical findings. It often includes occlusal splint therapy, physical therapy, patient education, soft diet, anti-inflammatory pain medication, muscle relaxants and heat for chronic problems or ice for acute problems. Sometimes treatment by a chiropractor is helpful. The TMJ disorder will not resolve unless the underlying postural problem is identified and corrected.

Vicious Cycle

One common factor that can play a role in all TMJ disorders is the classic vicious cycle. There are several interrelated problems that can trigger vicious cycles; two examples have already been discussed above. Another example of a vicious cycle is the relationship between bruxism (parafunctional habits), emotional stress, pain and functional problems. The patient bruxes (clenches and or grinds his/her teeth) due to emotional stress; this leads to muscle fatigue, muscle spasm, muscle and joint pain and functional problems (joint stiffness, difficulty opening). The pain and functional problems further contribute to the already present emotional stress. The increased stress and anxiety caused by the joint and muscle problems contributes to increased bruxism.  The greater the emotional stress the more the patient bruxes. The more the patient bruxes the greater the muscle spasm, muscle pain, joint pain and emotional stress. These vicious cycles must be recognized and broken if the TMJ disorder is to be controlled.

Patient education is often the first and most important step in treating TMJ disorders and short circuiting vicious cycles. Suffering from a severe TMJ disorder is not only unpleasant, for most patients it is frightening. Not knowing what is wrong with your jaw joint can be quite worrisome and stressful. Often, providing the patient with a diagnosis, a clear understanding of the etiology (cause) and establishing a sensible treatment plan will help to eliminate much of the stress related to worrying about the unknown. TMJ disorder patients must be cooperative and play an active role in their treatment if they wish to improve their condition. Patient education is essential in order to promote motivation for full participation in treatment of the condition.

Headaches and Earaches with TMJ Disorders

Headaches and earaches are common symptoms of TMJ disorders. The temporalis muscle has an extensive origin on the side of the skull and is inserted into the coronoid process of the mandible. The temporalis muscles assist in closing the jaw.  Painful spasm of the temporalis muscle can occur due to excessive bruxism, malocclusion and postural problems. Because of its location on each side of the skull, spasm of the temporalis muscle can contribute to headaches.

Ear pain is a common symptom of TMJ disorder because the temporomandibular joint is located just in front of the ear canal. Branches of auriculotemporal nerve (which is a branch of the mandibular division of the trigeminal nerve) supply sensation to the Temporomandibular joint and portions of the ear canal and tympanic membrane. TMJ pain can cause symptoms of referred pain into the ear due to this common nerve supply and close proximity of the ear canal to the temprormandibular joint.

Functional Problems with TMJ Disorders

The articular disc (meniscus) is made of fibrocartiage and functions as the ‘cushion’ of the jaw joint. Posteriorly, the disc is attached to the articular (joint) capsule by a thin ‘posterior attachment’ of connective tissue filled with nerves and vessels. When disc misalignment occurs, the disc is always anteriorly misaligned relative to the mandibular condyle. Unlike the articular disc, the delicate posterior attachment does not tolerate pressure exerted by the condyle during normal function. When the disc becomes anteriorly misaligned, the condyle may create pressure on the posterior attachment which can cause an injury or tear and eventually degenerative changes (wearing or flattening of the condyle). The patient may experience pain, clicking or crepitus (grinding sound), difficulty opening and closed lock.

Common functional problems associated with TMJ disorder include:

Jaw stiffness with difficulty opening, jaw deviation with opening, clicking, crepitus (grinding sound), intermittent closed lock and closed lock.

• Jaw Stiffness

Jaw stiffness with difficulty opening is most often caused by muscle tightness due to muscle fatigue and/or muscle spasm. Joint inflammation and degenerative joint changes in cases of advanced disease can also contribute to stiffness and difficulty opening.

	Treatment Successful management of TMJ disorders requires identification and treatment of the etiology (cause). The patient must be evaluated for bruxism (parafunctional habits), acute trauma, rheumatoid arthritis, significant related malocclusion, postural problems and vicious cycles. Bruxism must be discontinued, related malocclusion must be corrected, postural problems must be addressed and vicious cycles must be stopped. Patients with chronic (long term) TMJ disorders or acute trauma may have significant injury to the disc, posterior attachment and/or condyle in addition to spasm of the muscles of mastication. Injury involving the temporomandibular joints and muscles of mastication must be identified and treated. There are a wide range of treatment options available for TMJ disorders. Treatment decisions are based on history, clinical findings and etiology of the disorder. MRI, CT and panoramic radiographic imaging studies may be required to help identify injury to the disc, posterior attachment and condyle. The initial treatment goals are; to relieve muscle spasm, muscle pain, joint pain and improve function. Treatment usually begins with patient education, rest (soft diet), anti-inflammatory pain relievers (Advil, Motrin, ibuprofen), and occasionally, muscle relaxants. The following self-care treatments can be very effective: Rest your jaw by eating soft foods when pain is present Keep your teeth apart when you are not swallowing or eating Discontinue bruxism Apply ice for acute problems or heat for chronic problems Gently exercise the muscles that assist in opening your jaw; this helps to stretch the muscles of mastication (closing muscles) and may help relieve tightness or spasm in the muscles of mastication Practice good posture Anti-inflammatory pain relievers as needed (Advil, Motrin, Ibuprofen, Naproxen, Aleve) Use a professionally made occlusal appliance when necessary Promptly replace missing teeth to prevent a harmful malocclusion Physical therapy, chiropractic treatment, stress management (biofeedback) and occlusal appliance therapy may be utilized to treat TMJ disorder. An occlusal appliance, often referred to as an occlusal splint, fits over the maxillary or mandibular teeth and helps keep the teeth apart, thereby relaxing the muscles, relieving joint pressure and reducing pain. There are different types of occlusal appliances used for different purposes. A nightguard helps stop bruxism (clenching or grinding) while sleeping, reduces muscle tension and protects the disc and joint surfaces. An anterior positioning appliance moves the jaw forward, relieves pressure on disc’s posterior attachment and aids in correcting disk misalignment with the mandibular condyle. It may need to be worn up to 24 hours a day initially to help the temporomandibular joint heal. An orthotic stabilization appliance may be worn up to 24 hours a day initially to help move the jaw into proper position and temporarily stabilize the occlusion (bite). Occlusal appliances also can help to protect teeth from becoming worn down due to excessive bruxism (grinding of teeth). All occlusal appliances must be worn strictly according to your dentist’s specific instructions. Failure to follow instructions can result in adverse changes in occlusion. In select cases, arthrocentesis (irrigation of the lower joint space) may be performed to help reposition an acutely anteriorly displaced (misaligned) disc. Occasionally, steroids may be injected directly into the joints to relieve inflammation and pain. What About Bite Correction or Surgery? If Dr Turesky feels that your TMJ disorder has been caused by a malocclusion (poor bite), he will work with your general dentist and/or orthodontist to provide a satisfactory occlusion which will help to eliminate pain and reestablish normal temporomandibular joint function. Surgical options such as arthroscopy and open joint repair or reconstruction are reserved for severe cases. Dr. Turesky does not advise TMJ surgery unless there are significant functional problems (closed lock, limited mobility) and/or pain due to severe degenerative changes or disc damage that has not been responsive to medication, physical therapy and occlusal appliance therapy.

• Jaw Deviation

Jaw deviation with opening is usually due to restricted motion of the injured joint while the healthy joint moves normally. This is often caused by a displaced or damaged disc. The opening will not be symmetrical and the chin will deviate toward the injured side. Jaw deviation will not occur if both joints are equally injured and malfunctioning in a similar manner (See: Intermittent Closed Lock).

• Clicking

Clicking is caused by an anteriorly misaligned disc in relationship to the mandibular condyle. As the jaw opens, the condyle rotates for the first 25mm-30mm, it then simultaneously rotates and translates (slides forward) to its maximum opening of approximately 40mm-55mm. Normal adult opening is approximately 40mm-55mm measured from the incisal edge of the maxillary central incisors to the incisal edge of the mandibular cental incisors.

In healthy joints the disc is always positioned directly on top of the condyle throughout the entire opening and closing cycles, acting as a cushion to promote smooth and comfortable rotation and translation of the condyle. When the disc is anteriorly misaligned relative to the mandibular condyle, the condyle slips under the disc as it translates anteriorly during opening causing an opening click. When the jaw closes, the condyle resumes its former position posterior to the disc often resulting in a closing click as it slips back over the posterior edge of the disc.

There are many problems which can lead to an anteriorly misaligned disc and clicking.

The disc can become anteriorly misaligned or damaged due to injury from excessive bruxism (parafunctional habits) or acute trauma (see: Emotional Stress, Acute Injury).

An over-closed bite due to loss of posterior teeth or poor fitting dentures can cause an anteriorly misaligned disc relative to the condyle. With an over-closed bite the condyle swings toward the back (posterior) of the joint space, behind the disc, as the jaw over-closes (see: Malocclusion).

Patients with postural problems may also have an anteriorly misaligned disc due to posterior positioning of the condyle in the joint space; however, in these patients, the posterior positioning of the condyle is due to muscle pull rather than an over-closed bite (see: Postural Problems).

In some cases (not all cases) clicking due to an anteriorly misaligned disc can lead to pain and locking, as described below. Patients who experience pain and/or locking require treatment. However, clicking is not always associated with pain and locking problems and it does not always require treatment. Many patients tolerate clicking for many years without pain or functional difficulties. Treatment decisions are based on the patient’s history, clinical findings and etiology of the disorder. If there are no functional problems and no discomfort, treatment may not be required.

• Crepitus

Crepitus (grinding sound) is usually an indication of advanced TMJ damage (degenerative changes). Crepitus is usually due to a tear in the disc or the posterior attachment which produces bone to bone contact of the mandibular condyle with the joint socket in the base of the skull (glenoid fossa). Eventually, this causes wearing or flattening of the condyle head. Crepitus is usually associated with pain and limitation of opening.

Injury to the disc or its posterior attachment resulting in crepitus can be caused by chronic (long term) TMJ disorders due to bruxism (parafunctional habits), rheumatoid arthritits, malocclusion, postural problems or acute trauma.

Treatment decisions are based on the patient’s history, clinical findings and etiology of the disorder. It may be necessary to obtain C.T. and/or M.R.I. imaging studies to obtain more detailed information regarding the joint damage.

• Intermittent Closed Lock

Intermittent closed lock is caused by an anteriorly misaligned disc relative to the mandibular condyle. The patient will not be able to open more than 25mm-30mm. Normal adult opening is 40mm-55mm measured from incisal edge of the maxillary central incisors to the incisal edge of the mandibular central incisors. The condyle needs to rotate and translate (slide forward) in order for the jaw to open fully.

As the jaw opens, the condyle rotates for the first 25mm-30mm, it then simultaneously rotates and translates (slides forward) to its maximum opening of approximately 40mm-55mm. In healthy joints the disc is always positioned directly on top of the condyle throughout the entire opening and closing cycles, acting as a cushion to promote smooth and comfortable rotation and translation of the condyle. With a closed lock the condyle can still rotate, but the anteriorly misaligned disc mechanically obstructs the condyle from translating (sliding forward).

Since movement of the condyle in the injured joint is restricted to rotation and there is no translation, opening will be limited to 25mm-30mm, and the jaw (chin) will deviate toward the injured side as the healthy joint begins to translate (deviation will not occur if both joints are equally injured). There will be severe pain on the injured side during attempted opening due to pressure from the condyle on the posterior attachment and against the back of the anteriorly displaced disc, especially with effort to open more than 25-30mm. As the patient tries to open wider, the condyle in the injured joint attempts to translate forward pushing up against the back of the disc. The posterior attachment of the disc is painfully stretched and the disc may actually be forced to fold over on itself; this is a closed lock.

Patients with an intermittent closed lock will eventually manipulate the jaw and recapture (reduce) the disc. When the disc is reduced (slips back into its normal position) a click occurs, the locking resolves and normal function is reestablished until the problem recurs. If left untreated, intermittent closed lock tends to worsen over time leading to more severe joint damage, often progressing to a closed lock. Treatment will vary depending on the patient’s history, clinical findings and etiology of the disorder.

• Closed Lock

Closed lock; the disc is permanently misaligned in a forward position relative to the condyle and cannot be reduced by the patient with jaw manipulation (see: Intermittent Closed Lock for details). The patient cannot open more than 25-30mm. Treatment will vary depending on the patient’s history and other findings revealed during examination. It may be necessary to obtain a C.T. scan, and/or an M.R.I. scan to help determine more detailed information regarding the joint damage. Treatment for a closed lock may require arthrocentesis (joint irrigation), occlusal splint therapy, and/or surgery.

Do You Have a TMJ Disorder?

The following list represents some of the common symptoms and findings associated with TMJ disorders.

• Are you aware of grinding (bruxism) or clenching your teeth?
• Do you wake up with sore, stiff muscles around your jaws?
• Do you have frequent headaches, neck aches or ear pain?
• Do you have pain localized to the jaw joints in front of the ears?
• Does the pain get worse when you clench your teeth?
• Does stress make your clenching and pain worse?
• Does your jaw click, pop, grind, catch, or lock when you open your mouth?
• Is it difficult or painful to open your mouth, eat or yawn?
• Have you ever injured your neck, head or jaws?
• Do you have neck, back and shoulder pain along with facial muscle pain?
• Have you had problems (such as arthritis) with other joints?
• Do you have teeth that no longer touch when you bite?
• Do your teeth meet differently from time to time?
• Is it hard to use your front teeth to bite or tear food?
• Are your teeth sensitive, loose, broken or worn?
• Are you missing many teeth in the back of your mouth that have not been replaced?
• Are your dentures or partial dentures old (greater than five years) or poor fitting? 

Prognosis

In general, long term TMJ disorders (years) are more difficult to resolve than short term TMJ disorders (months). Patients with short term problems and no prior history of TMJ disorder usually have a good prognosis for complete recovery. Although many patients with long term (chronic) TMJ disorders also benefit from complete recovery, some patients with chronic TMJ disorders experience recurrent episodes of pain and functional difficulties throughout their lives.  Nevertheless, with time and effort these patients can learn to manage their TMJ disorder and enjoy a significantly improved quality of life. Therefore, patient education is a particularly important component of treatment. Patients need to understand the underlying cause for their TMJ disorder, what triggers it or exacerbates it, and what needs to be done to get it back under control. A reasonable goal in cases with chronic, recurrent TMJ disorder is management of the disorder rather than a cure.

 

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Jon D. Turesky, D.M.D., P.C. • 1 Walpole Street, Norwood MA 02062 (781) 762-7077 • 100 Copeland Drive, Mansfield MA 02048 (508) 543-3754

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