Temporomandibular Joint (TMJ)

Recover from Temporomandibular Joint (TMJ) Pain for good.

Physical Therapy can eliminate TMJ pain by normalizing the mechanics of the joint, decreasing inflammation and eliminating trigger points via manual therapy, dry needling, and joint mobilizations and manipulations.

How we can Help with TMJ Dysfunction

Dry Needling

Correct the physiologic chemical imbalance of the tissue for a permanent fix

Winback Therapy

Increase oxygen delivery, mitochondria production, and the cells natural healing metabolism

Spinal Manipulation

Downregulate abnormal hypersensitivity of the Trigeminal cervical nucleus and corrent joint dysfunction

Mobilization and exercise

Diagnose and fix postural components and muscular imbalances

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What is Temporomandibular Dysfunction?

  • According to a study by Kumar et al, 81.8% of patients with TMD experience a displacement of the articular disc, and a majority of the time, this displacement occurs in the anterior direction. This disruption typically involves degeneration of the posterior joint capsule, which leads to a significant imbalance of the muscles of the mastication. Physical therapy can assist in normalizing this imbalance.
  • Genetic, pathoanatomic, and hormonal factors can lead to TMD, but trauma, habitual activity, occlusal variation, and psychosocial issues play a strong role in the condition.

Checkout our video to better understand TMJ Disorder

Want to understand where your TMJ pain is coming from? Listen to this 5-Minute video with Dr. Butts, a well-published expert in successful conservative treatment of TMJ disorder.

TMJ Disorder

Introduction

Temporomandibular dysfunction (TMD) is a complicated condition that affects 5-12% of the population and is associated with a number of factors, to include degenerative changes, systemic disease, hormonal imbalance, habitual activity, psychosocial variance and jaw occlusion.1  There also seems to be a relationship between the osteokinematics of cervical and thoracic spine, shoulder, and scapula and TMD.2For patient with physical characteristics related to TMD, the literature describes three broad classifications:3 1. Disorders of the muscles of mastication, 2. Joint disorder related to temporomandibular disc derangement, and 3. Temporomandibular joint disorder related to arthralgia. While inter-occlusive splint therapy leads to enhanced range of motion and decreased jaw pain, physical therapy is presently the preferred strategy for the conservative management of TMD, and Symmetry Physical Therapy therapists are well trained to treat this patient population.

Pathophysiology of Temporomandibular Dysfunction

The muscles primarily responsible for chewing are the masseter, temporalis, medial pterygoid, and the superior and inferior head of the lateral pterygoid.4While contraction of the temporalis, masseter, and medial pterygoid are requiredto elevate the mandible during chewing, the inferior head of the lateral pterygoid contracts with the suprahyoid digastrics to depress the jaw.5The superior head of the lateral pterygoid is attached the anterior aspect of the intraarticular disc and is primarily responsible for maintaining its position on the mandibular condyle.5Interestingly, the posterior aspect of the intraarticular disc attaches to the posterior temporomandibular joint capsule.  As this attachment weakens due to degeneration, trauma, and overuse, the disc slips anteriorly, which can interfere with movement of the mandibular condyle and cause clicking and popping sounds during chewing.6According to Scully et al., anterior movement of the disc, which occurs >80% of the time in patients with TMD,7 also causes a slackening of the superior pterygoid tendon, disrupting its disc tracking ability.8, 9In an effort to compensate for the imbalance, the inferior head of the lateral pterygoid becomes active 100% of the time in the opening/closing cycle of the mouth, resulting in overuse, micro tearing, trigger point formation, and pain.8, 9Based on the pathophysiology described by Scully et al., it is perhaps not surprising that the primary pain generators in TMD are the posterior joint capsule and the pterygoids.10

Anatomically, the spinal aspect of the trigeminocervical nucleus overlaps with the dorsal horns in the upper cervical spine.11, 12  Given that the trigeminal nerve provides sensation to the TMJ via the auriculotemporal branch of the mandibular nerve and motor innervation of the muscles of mastication, it follows that pain afferents from the anatomical structures of the upper neck can often be misinterpreted as TMD.11, 13Considering that the natural pain avoidance strategy of the body is to protect a painful joint via the activation of agonistic and antagonistic muscle groups, this misinterpretation likely leads to hypertonic muscles of mastication followed by an energy depravation and trigger point formation.14Pain afferents from the upper neck may also disrupt the balance between the reticular formation and trigeminal motor nuclei, further pushing the masticatory central pattern generator into overdrive.12According to Olson and Furto, poor head and neck posture not only places the mandible in an overly retruded position, it also adds stress to the cervical extensors and paraspinal muscles, driving trigger point facet dysfunction, which reflexively impacts the arthrokinematics of the TMJ via the trigeminocervical nucleus.2

Spinal Manipulation and Mobilization

While manipulation and mobilization of the temporomandibular joint directly has been shown to decrease hypertonicity of the muscles of mastication, the evidence is inconclusive.15, 16 However, manipulation of the upper cervical spine has been shown to improve TMJ pain, mouth opening, pressure sensitivity, mandibular arthrokinematics in patients with TMD with or without neck pain.17Calixtre et al. reported low to high quality evidence for using either non-thrust mobilization or high-velocity, low-amplitude manipulation of the cervical spine for patients with TMD.17Moreover, Oliveira-Campelo et al.11 and Mansilla-Ferragut et al.,18 found that a single session of OA manipulation or soft tissue release of the suboccipital muscles resulted in decreased pain and improved mouth opening inpatients with TMD.

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Dry Needling

While the terminology, philosophy, and theoretic construct differ between western-based dry needling and traditional acupuncture, the procedure of inserting monofilament needles is essentially the same.19Therefore, manual and electric dry needling is used synonymously with manual and electroacupuncture related to TMD. Cho and Wang published a systematic review of 15 randomized control trials, including 808 patient with TMD.20By qualitatively grouping the patients, the authors found moderate evidence that acupuncture is superior nonpenetrating placebo, wait-list control, pharmaceutical intervention, and physical therapy for patients with TMD.20In a recent systematic review, DN outperformed procaine, methocarbamol and paracetamol for improving TMD pain intensity.21Moreover, a systematic review of 28 clinical trials concluded that both wet needling (i.e., botulinum toxin, platelet-rich plasma, or collagen) and dry needling are effective for improving TMJ pain.22Finally, a recent multi-clinical site randomized control trial published by Symmetry physical therapists revealed that dry needling and cervical manipulation was superior to occlusal splint therapy, prescription NSAIDs, and temporomandibular joint mobilization in 120 patients with TMD.23

Exercise, Myofascial Release, Splint Therapy, and Electrophysical Modalities

In a published review of the literature by Symmetry Physical Therapy therapists, there was limited support of strengthening exercises targeting the muscles of mastication for TMD.24While Kraus proposed exercises that inhibit excessive activity of the muscles of mastication while facilitating neuromuscular control so as to counter clicking, asymmetry, and spasms, this theoretical framework has yet to be validated.25Notably, a recent systematic review by Shaffer et al. concluded, “...no evidence exists to direct clinicians toward which exercises, if any, may be useful in the conservative management of TMD. Additionally, because many, if not most, patients with TMD over-recruit their muscles of mastication, it may be more advantageous to focus on relaxation techniques and patient education than therapeutic exercise.”26While there is limited evidence for splint therapy and electrophysical modalities in patients with TMD, there is moderate evidence that myofascial release and massage are as effective as BOTOX injections into the masseter and temporalis muscles.17, 27Moreover, 2 sessions of WinbackTecar therapy resulted in significant a reduction in pain related to TMD.28  To our knowledge, Symmetry PT  the only rehab. centers in Miami to offer Tecar Therapy as part of a comprehensive treatment strategy for TMD.

Physiotherapy-for-Jaw-TMJ
Headache and Migraine physicalt therapy treatment in Miami

How can Physical Therapy help?

  • Non-thrust mobilization and high-velocity, low amplitude thrust manipulation of the temporomandibular joint has been shown to increase joint range of motion and pain while decreasing hypertonic activity of the muscles of mastication.
  • Non-thrust mobilization and high-velocity, low amplitude thrust manipulation of the cervical spine helps to inhibit pain and quiet hypertonic muscles of mastication by rebalancing the trigeminal nerve in the trigeminocervical nucleus of the brainstem.
  • Multiple systematic reviews have reported a reduction in pain and disability associated with myofascial trigger points in muscles of mastication following dry needling.
  • Dry needling has been shown to increase blood flow to the temporomandibular joint, facilitating the recruitment of opioid producing cells required to reduce inflammatory factors.  There is also some evidence that suggests that dry needling inhibits osteoclast activity while increasing lubricating hyaluronic acid, thereby improving the overall health of the temporomandibular joint.
  • Winback technology has been shown to activate mitochondria to produce ATP while normalizing cell excitability and membrane transport, which are crucial components of temporomandibular tissue repair.
  • Stretching, relaxation, strengthening, and endurance of muscles of mastication has been shown to improve neuromuscular control of the temporomandibular joint, thereby decreasing joint clicking, spasming, and asymmetry.

 

Significant decrease in jaw painpost PT treatment compared to prescription NSAIDs and interocclusal splint therapy

Significantly less inflammation associated with TMD

Better long-term, functional outcomes for TMD than BOTOX injections

Significant improvement in measurement of jaw opening

Improved activation and strength of muscles of mastication

Benefits of Multi-modal Physical Therapy for Temporomandibular Dysfunction (TMD) AT A GLANCE

Decrease in headaches related to TMD

Improved mechanotransduction of peri-articular connective tissue associated with the temporomandibular joint

Reduced temporomandibular degeneration via increased vasodilation and lubrication of the joint

Neurophysiologic desensitization of the temporomandibular joint

Improved temporomandibular joint mechanics

Bottom Line:

  • Physical therapy is the preferred approach for temporomandibular dysfunction, as it provides a multimodal treatment strategy that is patient specific and targets the anatomical structures that are associated with the patho-anatomy of the condition.
  • Multi-modal physical therapy has been shown to improve pain and disability associated with temporomandibular dysfunction for >6 months following treatment.
  • In a multi-clinical site randomized control trial by Dunning et al, multimodal physical therapy has been shown to be more effective than interocclusal splint therapy and prescription NSAIDs for TMD.
Physical Therapy for TMJ Disorder

Works Cited

  1. Ariji Y, Nakayama M, Nishiyama W, Ogi N, Sakuma S, Katsumata A, et al. Potential clinical application of masseter and temporal muscle massage treatment using an oral rehabilitation robot in temporomandibular disorder patients with myofascial pain. Cranio. 2015;33(4):256-62.
  2. Olson K, Furto ES. Examination and treatment of temporomandibular disorders: an evidence based manual physical therapy approach. 2010.
  3. Schiffman EL, Truelove EL, Ohrbach R, Anderson GC, John MT, List T, et al. The Research Diagnostic Criteria for Temporomandibular Disorders. I: overview and methodology for assessment of validity. J Orofac Pain. 2010;24(1):7-24.
  4. Marieb E, Hoehn K. Human Anatomy & Physiology: Eighth Edition. San Francisco: Benjamin Cummings; 2010.
  5. Moore K, Dalley A. Clinically Oriented Anatomy: Fifth Edition. Philadelphia: Lippincott Williams & Wilkins; 2006.
  6. Manfredini D. Etiopathogenesis of disk displacement of the temporomandibular joint: a review of the mechanisms. Indian J Dent Res. 2009;20(2):212-21.
  7. Kumar R, Pallagatti S, Sheikh S, Mittal A, Gupta D, Gupta S. Correlation Between Clinical Findings of Temporomandibular Disorders and MRI Characteristics of Disc Displacement. Open Dent J. 2015;9:273-81.
  8. Scully C. Oral and Maxillofacial Medicine: the Basis of Diagnosis and Treatment (3rd ed). Edinburgh: Churchill Livingstone; 2013.
  9. Scully C. Oral and Maxillofacial Medicine: the Basis of Diagnosis and Treatment (2nd ed). Edinburgh: Churchill Livingstone; 2008.
  10. Yang X, Pemu H, Pyhtinen J, Tiilikainen PA, Oikarinen KS, Raustia AM. MRI findings concerning the lateral pterygoid muscle in patients with symptomatic TMJ hypermobility. Cranio. 2001;19(4):260-8.
  11. Oliveira-Campelo NM, Rubens-Rebelatto J, Marti NVFJ, Alburquerque-Sendi NF, Fernandez-de-Las-Penas C. The immediate effects of atlanto-occipital joint manipulation and suboccipital muscle inhibition technique on active mouth opening and pressure pain sensitivity over latent myofascial trigger points in the masticatory muscles. J Orthop Sports Phys Ther. 2010;40(5):310-7.
  12. Desmons S, Graux F, Atassi M, Libersa P, Dupas PH. The lateral pterygoid muscle, a heterogeneous unit implicated in temporomandibular disorder: a literature review. Cranio. 2007;25(4):283-91.
  13. Chua NH, Suijlekom HV, Wilder-Smith OH, Vissers KC. Understanding cervicogenic headache. Anesth Pain Med. 2012;2(1):3-4.
  14. Ro JY, Svensson P, Capra N. Effects of experimental muscle pain on electromyographic activity of masticatory muscles in the rat. Muscle Nerve. 2002;25(4):576-84.
  15. Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat. 2010;18:3.
  16. Alves BM, Macedo CR, Januzzi E, Grossmann E, Atallah AN, Peccin S. Mandibular manipulation for the treatment of temporomandibular disorder. J Craniofac Surg. 2013;24(2):488-93.
  17. Calixtre LB, Moreira RF, Franchini GH, Alburquerque-Sendin F, Oliveira AB. Manual therapy for the management of pain and limited range of motion in subjects with signs and symptoms of temporomandibular disorder: a systematic review of randomised controlled trials. J Oral Rehabil. 2015;42(11):847-61.
  18. Mansilla-Ferragut P, Fernandez-de-Las Penas C, Alburquerque-Sendin F, Cleland JA, Bosca-Gandia JJ. Immediate effects of atlanto-occipital joint manipulation on active mouth opening and pressure pain sensitivity in women with mechanical neck pain. J Manipulative Physiol Ther. 2009;32(2):101-6.
  19. Butts R, Dunning J, Perreault T, Maurad F, Grubb M. Peripheral and Spinal Mechanisms of Pain and Dry Needling Mediated Analgesia: A Clinical Resource Guide for Health Care Professionals. International Journal of Physical Medicine and Rehabilitation. 2016;216(4:2).
  20. Cho SH, Whang WW. Acupuncture for temporomandibular disorders: a systematic review. J Orofac Pain. 2010;24(2):152-62.
  21. Vier C, Almeida MB, Neves ML, Santos A, Bracht MA. The effectiveness of dry needling for patients with orofacial pain associated with temporomandibular dysfunction: a systematic review and meta-analysis. Braz J Phys Ther. 2019;23(1):3-11.
  22. Nowak Z, Checinski M, Nitecka-Buchta A, Bulanda S, Ilczuk-Rypula D, Postek-Stefanska L, et al. Intramuscular Injections and Dry Needling within Masticatory Muscles in Management of Myofascial Pain. Systematic Review of Clinical Trials. Int J Environ Res Public Health. 2021;18(18).
  23. Dunning J, Butts R, Bliton P, Vathrakokoilis K, Smith G, Lineberger C, et al. Dry needling and upper cervical spinal manipulation in patients with temporomandibular disorder: A multi-center randomized clinical trial. Cranio. 2022:1-14.
  24. Butts R, Dunning J, Pavkovich R, Mettille J, Mourad F. Conservative management of temporomandibular dysfunction: A literature review with implications for clinical practice guidelines (Narrative review part 2). J Bodyw Mov Ther. 2017;21(3):541-8.
  25. Kraus S. Temporomandibular Disorders In: Saunders HD Evaluation, treatment and prevention of musculoskeletal disorders. Ryan R, editor. Chaska, MN: The Saunders Group; 2004.
  26. Shaffer SM, Brismee JM, Sizer PS, Courtney CA. Temporomandibular disorders. Part 2: conservative management. J Man Manip Ther. 2014;22(1):13-23.
  27. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102.
  28. Poca R. Efficacy evaluation of tecartherapy on tendonitis, trochanteric bursitis, and temporomandibular syndrome. WInback Academy. 2009.

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Symmetry Physical Therapy is a privately owned one-on-one, patient-centered physical therapy clinic in Downtown Miami/Brickell. Every treatment is with the same Doctor of Physical Therapy for the entire hour. Symmetry’s specialized, dedicated, and passionate team of physical therapists is fully committed to each patient’s success.

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