TMJ Disorders

How does My TMJ Work?

The disk sits between the upper and lower jawbone and is attached by ligaments mainly on the sides and on the backside of the disk which helps to stabilize the disk in position. When you open your mouth the lower jawbone rotates in the socket like a hinge; and then as you open wider, the lower jawbone and disk slide forward.

The disk, attached by the ligaments, should move together with the lower jawbone. Stretching of the ligaments, breakdown in the bones (arthritis) or cartilage, scar tissue formation, or changes in the lubrication system (synovial fluid) can cause the disk to become stuck out of position leading to pain, jaw locking, jaw clicking and popping, and bite shifting. This can then lead to muscle pain within the head, ear and neck and can be a trigger for migraine disorders.

What are the symptoms of TMJ Disorder?

The most common symptoms of TMJ disorders (TMD) include headaches, jaw and facial pain, ear pain, jaw clicking or grinding, bite shifting, ear stuffiness and limited mouth opening.  Other common symptoms include neck and shoulder pain, tooth pain, throat pain, difficulty swallowing, ringing in the ears (tinnitus), dizziness, eye pain, and sinus congestion.

Myofascial Pain

Myofascial pain occurs when the nerve that is connected to the muscle becomes irritated and small nodules or contractures form, causing the muscle to bunch-up and become painful. These contractures are called trigger points. Trigger points will often refer pain in distant locations. For example it is very common for jaw muscles with myofascial pain to refer pain into the teeth or ears. In addition to pain, muscles with myofascial pain also fatigue more easily and have decreased strength and range of motion.

Myofascial pain within the jaw muscles can also be associated with many other autonomic symptoms such as dizziness, ringing in the ears, eye twitching, sweating, nausea, and tearing. Tension headaches in the temples are usually the result of myofascial pain within the temporalis muscle, which is a jaw closing muscle. Myofascial pain may also trigger other headaches such as migraines.

The cause of myofascial pain is over-stimulation of the nerve connected to the muscle. This can occur when the muscle is either, chronically strained such as in teeth clenching or poor posture, or through an acute trauma. Additionally, nerve or joint pain and dysfunction can be a cause of Myofascial pain.

Treatments are aimed at decreasing any joint influences or repetitive strain (clenching or gum chewing) and through massage, stretching, heat, ultrasound, trigger point injections, IMS, medications and Botox.

Disk Displacment With Reduction

The jaw will “click” or “pop” when the ligaments that hold the disk in place become stretched or torn thereby allowing the disk to slip forward (and usually either medially or laterally). As the mouth opens the lower jawbone begins to slide forward and this causes the disk to “click” or “pop”.

The jaw will usually curve or deviate to the affected side during mouth opening. Pain can vary from none to severe. Often the musculature of the jaw and neck will tighten up leading to headaches, facial pain and neck pain. As the condition worsens patients will typically notice a “catching” sensation where they have to shift their jaw to open or close normally.

Patients will also at times notice a feeling of their bite shifting and feeling off. If this is left untreated it will often progress to jaw locking and degenerative changes. Treatment will typically consist of medications, jaw exercises, manual jaw manipulation, oral appliance therapy, and in a minority of cases (approximately 5%) minimally invasive TMJ arthroscopy. Referrals to physical therapy, massage therapy, osteopathic and chiropractic therapy may also be given to address cervical disorders.

Disk Displacement Without Reduction

This occurs when the ligaments are stretched more and the disk slips too far out of position so that it can no longer “click” back into place. It then acts like a door-jam and blocks the normal movement of the joint. As the mouth opening is limited it is also called “locked jaw” even though typically a person can still open to two-finger widths. 

When the disk is positioned forward there is increased load onto the painful and compressible retrodiscal tissues which can lead to increased TMJ/ear pain, deviated mouth opening, bite changes and osteoarthritis. Acute jaw locking episodes can usually be unlocked using manual jaw manipulation and oral splints. If the locking is left untreated then the disk displacement becomes chronic as there are more permanent anatomic changes within the TMJ. 

Successful treatment will usually result in increased mouth opening, decreased pain and increased ability to eat normally. Typically the clicking will return and not go away. Treatment usually consists of medications, jaw exercises, manual jaw manipulation, oral appliance therapy and minimally invasive arthroscopy.

Osteoarthritis

This occurs when the there is more stress put on the jaw joint than the adaptive capacity of the joint is able to handle. This can occur because of a structural problem within the jaw (i.e. trauma, disk displacements or certain bad bites) or due to excessive loading forces on the jaw joint (i.e. jaw clenching or gum chewing).

The cells which make synovial fluid and the cartilage surrounding the bone are damaged before there is damage to the bone. The cartilage helps bring fluid in and out of the joint thereby eliminating waste products and bringing in nutrients. Typical symptoms include crackling or crepitation when opening and closing, pain in and around the ear, ear stuffiness, and bite shifting. 

This can lead to shifting of the chin to the affected side and increased bite contact on the back tooth of the affected side. When the changes are more severe there can be a noticeable facial asymmetry from the chin shifting. When disk displacements without reduction are not properly treated, unwanted osteoarthritic changes have a greater chance of occurring.

Tumors, Osteonecrosis and Systemic Arthritis

TMJ Synovitis

Pain in the TMJ is usually described as a sharp shooting, burning or aching pain in front of the ear. The pain comes when the nerve structures become compressed or irritated and/or the jaw structures become damaged causing the release of pain chemicals into the surrounding joint fluid (synovium). 

This usually happens when either the joint has too much pressure put on it (i.e. trauma or clenching), or when the disks dislocate from their proper position causing the pain sensitive tissues to be compressed and irritated. Additionally, the adverse loading can lead to the formation of free radicals causing further reduction in the joint fluid and destruction of the cartilage.

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Anchored Disc Phenomenon

This occurs when there is a severe loading of the TMJ which pushes the synovial fluid out of the superior joint space causing the disk to stick to the superior surface of the joint fossa. On MRI the disk will appear in normal position however there will be significant limitation in mouth opening. This is typically treated effectively with a minimally invasive arthroscopy.

TMJ Adhesions

Adhesions can also form between the disk and the cartilage and bone above and below the disk. These are like small areas of scar tissue that keep the disk from moving freely. These are often associated with long standing disk displacements or trauma. This is typically treated effectively with a lysis and lavage procedure or progressive manual manipulations.

TMJ Osteonecrosis

When the blood flow to the joint is compromised, as can happen with trauma, part of the jawbone can die. This can lead to severe degenerative changes within the TMJ and bite shifting. The use of Bisphosphonates for osteoporosis may increase the incidence of this.

Systemic Inflammatory TMJ Arthritis

About 20% of patients with Rheumatoid arthritis will develop changes within the TMJ although the TMJ is typically not one of the first joints affected. This can lead to pain, swelling, bite shifting and limited mouth opening. Other inflammatory conditions such as in Lyme’s or psoriatic arthritis can also affect the TMJ.

TMJ Tumor

Tumors are not common within the TMJ but Dr. Pehling has seen several cases of osteochondroma. Additionally we have found tumors within the auditory nerve (acoustic neuroma) and within the neck which have referred pain into the jaw. Breast cancer has been observed to metastasize into the TMJ as well.

Jaw Muscle Disorders

The jaw muscles run along the temples of your head, the sides of your face and down the front of your neck. That is why it is common to have headaches along the side of your head, neck pain, and facial pain with TMJ disorders. Jaw muscle pain usually occurs because either there is joint dysfunction leading to protective splinting of the jaw muscles or through excessive contraction (clenching or grinding). 

Sudden onset jaw muscle pain usually occurs because of joint dysfunction. If you slip a disk in your back, the muscles in the area will tighten up to brace you from using that area, the jaw works the same way. The most common jaw muscle disorders are Myofascial pain and Muscle spasm. The jaw muscles are some of the strongest muscles within the body capable of exerting around 300lbs of pressure on the first molars.