TMJ or Temporo Mandibular Joint

TMJ (Temporomandibular Joint) connects the lower jaw (mandibular) to the skull at the temporal bone, hence the name Temporomandibular Joint.  The function of this joint is to allow the jaw to move in different directions and make chewing food possible.

TMJ pain can cause a great deal of pain in the jaw, face, neck, and shoulder. The causes may be the effect of physical stress on the structures approximate to the joint, these structures include:
  • The teeth; the variation between centric relation and centric occlusion caused by clenching and grinding of your teeth as in Bruxism
  • The jaw, neck, and face muscles, e.g. muscle spasm neurosis, clenching or biting your teeth during stress or habits 
  • The cartilage disk; a systemic disease that affects the cartilage such as arthritis
The cause
Temporomandibular Joint disorders (TMD) are problems of the chewing muscles and joints that connect the lower jaw to the skull. Often when jaw muscle tightens and stays tight causing the misalignment of TMJ results in pain at the joint area and sometimes extending to the ear causing ear pain.  Clenching the teeth, bad occlusion (malocclusion) contribute to tightening the muscle and cause TMJ pain or ear pain. Early diagnosis and treatment for TMJ are crucial. Find a dentist in your area who treats TMJ disorders through this site, use "state" function.

TMJ disorders can vary from being very mild to severe. A mild case may not cause any discomfort and may even go unnoticed and resolved on its own. But a severe case can be very painful.  In a chronic case, the jaw may be locked when open wide or yawning.

Symptoms of TMJ disorders may include any or all of symptoms listed below:
  1. Radiating pain to the ear
  2. Difficulty in chewing, biting, opening and closing of the mouth due to a limitation of jaw movements and facial muscle tensions
  3. Clicking sound during opening and closing jaw due to a slipped disc at the TMJ
  4. Muscle tenderness in front of the ear on the affected side
  5. Headache
  6. Pain at jaw joints, shoulder, or back
  7. Deflecting of the lower jaw from its usual path, caused by occlusal disharmonies
  8. Dizziness
  9. Jaw locking when open wide caused by prolonging problem with TMJ.  The damaged disc allows a condyle (the end part of the lower jaw) to travel further than normal range and slip in front of the disc and lock in that location during jaw opening.  The dislocated condyle prevents jaw closing. Occasionally, the person can unlock the jaw back to the original position by shifting the lower jaw in a downward (to release the locked condyle) and then backward toward the back of the neck.  But it is better to let the dentist assess the problem.
Examination of TMJ problem
  1. Visual exam for any premature contact during occlusion that causes the bite to shift
  2. Tenderness at the front of lower third of the ear
  3. Clicking sound during opening and closing of the jaw
  4. X-ray of the jaw helps identify the damaged disc

Differential diagnosis of TMJ disorders:

The dentist sometimes misdiagnosed Temporomandibular Joint Disorder or TMJ disorder due to the similarity of the location of the pain.

From toothache
The offending tooth (or teeth) is sensitive to tapping. Pain seems to be localized to the front of the ear causing ear pain on the affected side. The dentist may need to take an x-ray to differentiate the cause of pain to be certain whether the cause originates from TMJ disorder or the tooth (teeth).

From sinusitis
Sinusitis may involve one or both sides of the cheek. Often, sudden changes of posture may result in pain or dizziness. Patients may have a history of allergy accompanied by a postnasal drip and loss of olfactory discernment. An x-ray may show clouding of the affected sinus.

From a migraine headache
A migraine headache is a chronic condition, and the patient has been diagnosed and aware of the condition. The most Migraine headaches case involves nausea, vomiting, intolerance to light.

From Ernest Syndrome
Click to enlarge
Ernest Syndrome arises when Stylomandibular ligament becomes inflamed due to trauma, injuries to the head, excessive movement of the jaw, excessive yawning, wisdom tooth surgery or general anesthesia. Ernest syndrome can be unilateral or bilateral.

Stylomandibular ligament originated from a styloid process (a bony protuberance attached to the temporal bone) and attached at the posterior medial border of the mandibular (lower jaw).

  1. The pain of the Stylomandibular ligament has a referral pattern, commonly described as Orofacial pain.  In the early stage; the pain begins from feeling tenderness below the ear to the angle of the jaw (gonial angle). In the later stages, pain may radiate to the ear, cheekbone (zygomatic arch), TMJ, temporal, lower posterior teeth, eye, throat, and other facial areas. 
  2. In some cases, Stylomandibular ligament restraint causes posterior displacement of the lower jaw, results in clicking and locking jaw during jaw opening and closing
  3. Restricts jaw movements and impairs normal functionality of the jaw

  • Patient has a history of injuries in the head and neck areas, trauma to the head, recent surgeries or wisdom tooth removed

  • By pressing the posterior medial border of the gonial angle with a small blunt instrument and the patient experiences intense pain.  The pain often refers to one or more sites; such as ear, cheekbone, TMJ, temporal, lower posterior teeth, eye, throat, and other facial areas. 

    Gonial angle located 10-15 mm from the inside of the angle of the jaw.

  • Testing the Stylomandibular ligament with local anesthesia is the best method to differentiate Ernest syndrome from other similar pain originated by other sources in the same areas.

    The dentist uses a blunt, small head tool to locate and mark the attachment of the Stylomandibular ligament.  Then, he inserts a 30-gauge needle with plain 1/2 cc local anesthesia (i.e. 3% carbacaine)  10-15 mm depth at the location marked by the blunt head tool.  The dentist aspires the needle before slowly injects anesthesia solution. 

    If the pain stops, the source of pain is likely from the Stylomandibular ligament.  If the pain reduces, the area is re-evaluated after 10 minutes. If only partial pain reduction is experienced, a second injection may be needed.  But if complete remission occurs, a diagnosis of Ernest syndrome is suspected. Often during injection, the patient feels the pain is being referred to one or more referral sites.

    Prior to injection, the patient should be worn, the possibility of anesthesia to the facial nerve.

Treatment for TMJ
  • Practice muscle exercise
  • Massage the muscles
  • Avoid hard to chew or crunchy foods, eat soft food like soup
  • Learn to relax, stress can tighten the muscle
  • No chewing gums
  • Avoid opening your mouth very wide
  • Use a mouth guard for teeth grinding at night; stop using if the appliance causes pain
  • May use over-the-counter non-steroidal anti-inflammatory drugs: Ibuprofen (Advil, Motrin), Acetaminophen (Tylenol), Naproxen (Aleve, Naprosyn) 
At the early stage of TMJ problem- the pain starts from the jaw or a tooth, radiates to the ear, you may hear the clicking sounds of jaw opening and closing, with or without pain.

If the problem arises from clenching and grinding of teeth, teeth damaged may occur. If the damage occurs to a canine (cuspid) tooth, you will lose the ability to guide posterior teeth to the proper position in accordance to upper and lower teeth while chewing.  Without this important guidance, the chewing pattern changes, and this change can affect the TMJ; causing the clicking sound.

The dentist can restore the canine guidance.  But the patient needs to wear a night guard to prevent the re-occurrence of TMJ problem.

Various TMJ or Temporo-Mandibular Joint home remedies can be used for temporary relieve of pain. Dentist often recommends night guard (mouth guard) for a patient who grinds their teeth at night.  The night guard helps protect the teeth from cracking and protect the Temporo Mandibular Joint from stress.

Exercise for the muscles
See also Trismus

1. Stretching the muscle
: this can be done by slowly opening your mouth as wide as you comfortably can and then slowly closing. Next, slowly open while shifting your jaw to the left as wide as you comfortably can, then slowly close to normal position. Next, slowly open while moving your jaw to the right as wide as you comfortably can, and then slowly close to normal position.

Place the hot moist towels on each side of your face while doing these exercises to improve circulation. Change the towels when they become cold. You can continue to re-heat the towels and repeat the exercise until your muscles feel better.

The hot moist towels can be accomplished by putting the wet towels in the microwave oven, or soak them in hot water.

Repeat these movements until your muscles feel better before moving on to (2). These stretching exercises can be done while driving, watching TV, shopping, and during other activities.

2. Repeat the same movement as in (1) but this time use your hand to push gently a little further in all directions in the first exercises.  Do not apply too much force. If the activities cause a lot of pain, stop the exercise.

3. The yawn-sigh exercise relaxes throat, jaw, face muscles. Practice this exercise after your mouth can open wide without pain.  Take a deep yawn while opening your mouth as wide as possible. Slowly exhale and relax all of your muscles completely. Perform this exercise several times during the day.

Massage the Muscles
In addition to muscle exercise, massaging the muscles around the joint will also help them relax.  The areas to message are:
1. In front of the ears
2. The back and bottom of your jaw
3. Temple area
4. Along your neck
5. Massage muscles from inside your mouth:
Press your finger inside your mouth where the cheekbone is.  You’ll find tender areas. Just press or gently massage for several seconds until you feel improvement as your muscles begin to relax.

If you don't think you can do it yourself, find an acupuncture or acupressure therapist or a massage therapist who familiars with TMJ to help you.

6. Lastly, use your finger to find any other tender spots that typically present in tense muscles. Gently massage these areas.  After massaging the muscles few times, the muscles will begin to relax. Now you may increase pressure to massage the deeper muscles.  Perform the massage 2-3 times a day.  Each time adds a little more weight without causing too much pain.

Be cautious about any nonreversible treatment, such as reconstructive surgery, joint replacement, or orthodontics, that permanently alter the occlusion.  Studies shown that the result is often worse than prior to surgery.