Welcome to HeadWorks Physiotherapy, where we help you overcome face and jaw pain.

At HeadWorks Physiotherapy, we focus on the treatment of Temporomandibular Disorders (TMD), orofacial and craniofacial pain.

TMDs are problems such as pain or reduced movement which affect the temporomandibular joint (TMJ), commonly known as the jaw joint.

Orofacial pain is a general term covering any pain which is felt in the mouth, jaws and the face.

Craniofacial pain is an overlapping topic which includes pain perceived in the head, face, and related structures, sometimes including neck pain.

Some symptoms of TMD, orofacial and craniofacial pain include:

  • Headaches
  • Face pain
  • Neck pain
  • Jaw pain
  • TMJ clicking
  • Locking jaw or limited jaw movement
  • Earaches
  • Dizziness

If you experience any of the above symptoms, we can help you find relief at HeadWorks Physiotherapy.

TEMPOROMANDIBULAR JOINT

What is the TMJ?

The temporomandibular joint (TMJ) is the name of the joint that connects the lower jaw, called the mandible, to the bone at the side of the head—the temporal bone. It is located on either side of your head, just in front of your ears. If you place your fingers just in front of your ears and open your mouth, you can feel the joints. The TMJ, which can rotate and move forward, backward and side to side, is considered one of the most complex joints in the body. This joint, in combination with other muscles and ligaments, lets you chew, swallow, speak and yawn. When you have a problem with the muscle, bone or other tissue in the area in and around the TMJ, you may have a Temprormandibular Disorder (TMD). The TMJ is a major factor in orofacial and craniofacial pain.

When we open our mouths, the rounded ends of the lower jaw, called condyles, glide along the joint socket of the temporal bone.

The condyles slide back to their original position when we close our mouths. A soft disc which lies between the condyle and the temporal bone keeps this motion smooth. Shocks to the jaw joint from chewing and other movements are absorbed by this disc. The TMJ is different from the other joints in the body. Because of the combination of hinge and sliding motions, this joint is among the most complicated in the body.

The TMJ is also made up of tissues that differ from other load-bearing joints, like the knee or hip. Because of its complex movement and unique makeup, and also because it is closed and opened thousands of times a day while eating, speaking, breathing, swallowing and yawning, the jaw joint and its controlling muscles can pose a tremendous challenge to both patients and healthcare providers when problems arise.

Disorders of the TMJ are often called Temporomandibular Disorders (TMD) or TMJ Dysfunction (TMJD).

Diagram of the Temporomandibular Joint with cross sections showing the jaw in neutral position and opened

TEMPOROMANDIBULAR JOINT DISORDERS (TMD)

A Brief Overview

*There are 12 common TMD. These include:

1. Arthralgia
Painful joint affected by movement, function, or parafunction (any habitual use of the mouth that is not related to normal function use, i.e., speaking, eating or drinking). This pain is reproducible by joint testing.

2 i) Myalgia
Muscle pain affected by movement, function, or parafunction. This pain is reproducible by muscle testing of the masticatory (chewing) muscles. This can be further differentiated into three different types:

ii) Local myalgia:
Muscle pain as described above. Pain is localized only to where the muscle is palpated on muscle testing.

iii) Myofascial pain:
Muscle pain as described above. Pain spreads beyond the site of palpation but is contained within the muscle tested.

iv) Myofascial pain with referral:
Muscle pain as described above. Pain is referred beyond the muscle boundaries. Pain may also be spreading.

3. Disc Displacement Disorders
These are biomechanical disorders within the joint capsule which involve the condyle-disc relationship. When the mouth is closed, the disc is in a position anterior to the head of the condyle. There are four forms of disc displacement disorders:

i) Disc displacement with reduction:
On mouth opening, the disc reduces, i.e., gets back into position. The disc may also displace sideways. Disc reduction may occur with clicking, popping, or snapping noises.

ii) Disc displacement with reduction with intermittent locking:
On mouth opening, the disc reduces intermittently. Limited mouth opening occurs when the disc fails to reduce with mouth opening. When this happens, the jaw may be unlocked by a therapeutic maneouver. The disc may also displace sideways. Disc reduction may occur with clicking, popping, or snapping noises.

iii) Disc displacement without reduction with limited opening:
On mouth opening, the disc does not reduce and may also displace sideways. Therapeutic or manipulative maneouvers are not usually effective in reducing the limited mouth opening that is persistent in this disorder. This is also known as a “closed lock”.

iv) Disc displacement without reduction without limited opening:
On mouth opening, the disc does not reduce and may also displace sideways. Mouth opening is not limited in this disorder.

4. Degenerative Joint Disease:
Deterioration of articular (joint) tissue characterizes this degenerative disorder. There are also accompanying bony changes in the condyle and/or articular eminence. The joint is “creaky” and this can be felt in an examination by palpation during opening, closing, sideways movements or protrusive movements (drawing the lower jaw forward).

5. Subluxation:
This is a hypermobility disorder also known as an “open lock”, in which the disc-condyle complex, which is in an anterior position to the articular eminence in the open mouth position, requires a maneouver to return it to a normal closed mouth position. This dislocation, which lasts for varying lengths of time, is usually self-reduced. When it cannot be self-reduced, it is termed a “luxation”.

6. Headache attributed to TMD:
This refers to a headache that is reproducible by jaw muscle or jaw joint testing. This pain is usually located in the temple area and arises from pain-related TMD. Jaw movement, function or parafunction affect this pain.

*J Oral Facial Pain Headache 2014;28:6-27.

One or more of these conditions may be experienced at the same time. Other health problems may co-exist with TMD, such as chronic fatigue syndrome, sleep disturbances or fibromyalgia, a painful condition that affects muscles and other soft tissues throughout the body. These disorders share some common symptoms, which suggests that they may share similar underlying mechanisms of disease. However, it is not known whether they have a common cause. Studies are also underway to establish a link between TMD and Parkinson’s Disease as well as Multiple Sclerosis.

Cross section of the TMJ showing a dislocated disc
Cross section of the TMJ showing joint degeneration

CAUSES OF TMD

What Causes TMD?

  • spasm, tightness and inflammation of jaw and associated muscles due to stress or overuse leading to clenching or bruxing (teeth grinding)
  • spasm of jaw muscles and/or disc displacement following lengthy dental procedures
  • a dental restoration or filling that is too high resulting in an altered bite position
  • trauma to the jaw or face
  • whiplash injury  
  • poor posture or other injury resulting in upper neck joint stiffness
  • muscle spasm and tightness in neck and upper back due to stress or other factors
  • poor/unsupported sleeping position
  • parafunction, eg., nail biting, gum chewing
  • diet, e.g., habitual or frequent chewy or crunchy foods
  • obstructive sleep apnea which may lead to night time bruxing (teeth grinding)

SYMPTOMS OF TMD

What Are the Symptoms of TMD?

If you experience:

  • frequent headaches
  • sore facial muscles, especially on waking
  • pain or stiffness in neck, back of head, shoulders
  • jaw muscle tenderness
  • jaw stiffness, achiness, pain or locking
  • popping, clicking, cracking or grating sounds when opening the mouth or chewing
  • aching jaws after eating
  • pain or difficulty in yawning (opening the mouth wide) or chewing
  • uneven jaw movements (one side moving differently from the other)
  • tooth wear more or faster as observed by dentist
  • loose, broken, worn or sensitive teeth
  • fullness in ears, earache and/or referred pain into face, or ringing in ears
  • sensitivity to sound
  • dizziness (vertigo)

If you:

  • are aware of clenching or grinding teeth while asleep, frustrated or stressed
  • suffer from depression or decreased energy level as a result of any of the above symptoms
  • have been hit in the jaw or had a whiplash injury
  • find it difficult or painful to bite or tear food with your front teeth
  • have been told that you might have TMD

then you most likely have some form or degree of Temporomandibular Disorder. We can help you find relief from your TMD symptoms with HeadWorks Physiotherapy.

Orofacial Myofunctional Therapy (OMT) 
is the neuromuscular re-training of the oral and facial muscles. Orofacial Myofunctional Therapy treats Orofacial Myofunctional Disorders (OMDs).

Orofacial Myofunctional Disorders (OMDs):

These are disorders of the muscles and functions of the face and mouth. Some signs and symptoms of OMDs may include:

  • Improper swallowing: A tongue thrust occurs when the tip and/or sides of the tongue press against or spread between the teeth. This may result in an anterior open bite. A facial grimace occurs when the muscles of the cheeks, chin and lips purse and tighten on swallowing, resulting in the over-development of the chin (mentalis) muscle.
  • Improper lip seal: Constantly parted lips due to weak oral muscles and/or mouth breathing. This may result in anterior gingivitis.
  • Dull, sluggish facial appearance: Indicative of incorrect oral posture when muscles are not operating properly.
  • Forward Head Posture: The head is held in a forward position and may cause neck and shoulder pain.
  • Retruded chin: This may result from the lower jaw moving back to meet the narrowed upper jaw for batter occlusion.
  • Malocclusion and/or orthodontic relapse: Most likely due to persistent improper tongue position.
  • Difficulty articulating sounds: Incorrect oral muscle patterns may prevent sounds of normal speech from forming. When the muscles in the tongue are incorrectly postured, this may result in a lisp, for example.
  • TMJ dysfunction, posture problems, neck and shoulder pain: These may be linked and will be discussed in detail below.
  • Headaches: May result from mouth breathing (less oxygen to brain and muscles).
  • Stomach distress: May result from swallowing air (chewing food with open mouth because of mouth breathing), the improper chewing of food due to malocclusion.
  • Airway obstruction: Improper tongue position may be unable to support airway. This may contribute to sleep apnea.
  • ADHD: Children who have undiagnosed sleep apnea are likely to be sleep deprived. They may try to stay awake during the day by being or becoming hyperactive. Many sleep deprived children and children with ADHD have the same behavioural challenges. More research needs to be done in this area.

Causes of OMDs:

  • Habitual oral breathing
  • Improper tongue position
  • Habitual thumb, finger or tongue sucking: This pushes the tongue into an incorrect position and leads to an improper functioning pattern.
  • Prolonged use of pacifiers and/or sippy cups: This has a similar effect as thumb/finger/tongue sucking.
  • No-chew diet: The jaw joint and muscles are not fully developed, and the tongue loses its proprioceptive sense.
  • Enlarged adenoids or tonsils: This may be caused by allergies. This may also be caused by mouth breathing because of allergies– a vicious cycle.
  • Inherited oral patterns, such as mouth breathing, thumb sucking or tongue posturing (when the tongue seems “busy” and pushing around in the mouth frequently).
  • A tight frenum (tongue tie) which holds the tongue down.


Why is tongue position so important?
The proper place for your tongue is up against the roof of your mouth, with your teeth apart and lips together. Your tongue on the roof of your mouth creates a suction force which keeps it up there, and, together with a proper lip seal, supports your facial muscles. If your tongue is up, it acts as an “oral splint” to support your upper palate so that the pressure from your cheeks does not push your upper teeth in.

If you have a low tongue position, the roof of your mouth may become high, narrow and vaulted (from your upper teeth being pushed in). This may result in a deviated nasal septum; it buckles from being pushed up. Having a narrow upper palate may also result in your lower jaw moving back to meet for your teeth to occlude. (This may give you an appearance of a “too small” jaw or a retruded chin). When this happens, you may have jaw pain as your jaw joints are now “jammed” together. Here is a good clip to watch: https://www.youtube.com/watch?v=CBYwxndys2E

At the same time, because your lower jaw is now in a relatively posterior position, your airway becomes compromised, so you end up holding your head in a forward position in an attempt to open up your airway. This may cause tension and soreness in your neck and upper back as these muscles work to hold your head out front. For every inch that your head is forward, it weighs 10 pounds heavier: more weight for your muscles to hold up. http://erikdalton.com/forward-heads-funky-necks/

A compromised airway could also contribute to sleep apnea.  If your oropharyngeal muscles are not strong enough to support your airway, when you fall asleep, your muscles relax and have even less tone. This obstructs your airway, giving rise to snoring and sleep apnea.

Why is nasal breathing important?
When you breathe through your nose:

  • The inhaled air is warmed and moistened, and does not irritate the sensitive airways.
  • The inhaled air is filtered through turbinates so that any allergens, dirt, dust, microbes, etc, stick to the mucous lining of the airways and destroyed by enzymes and anti-microbial gases.
  • You are not mouth breathing. Mouth breathing may cause the gums to dry out and cause cavities and gum disease by increasing the acidity in the mouth.
  • It encourages good facial development and straight teeth with a closed mouth and proper tongue position.
  • It may help reduce snoring and sleep apnea.
  • It helps to regulate the volume of air breathed to effectively match the body’s oxygen needs.
  • You are not as likely to blow off too much Carbon Dioxide (CO2). Lower than normal CO2 levels may result in narrowed airways and blood vessels. A certain concentration of CO2 is necessary for the release of oxygen from haemoglobin to supply the brain and muscles. (Bohr, Hasselbalch, Krogh. “Concerning a Biologically Important Relationship – The Influence of the Carbon Dioxide Content of Blood on its Oxygen Binding”)


Orofacial Myofunctional Therapy:

  • Is painless.
  • Is a program of simple exercises over a 6 – 12 month period (length of treatment may vary by individual).
  • Helps to activate specific muscles to function properly for proper coordination of tongue and facial muscles.
  • Helps to retrain and correct poor swallowing habits.
  • Supports orthodontic treatment to help retain proper occlusion.
  • May improve facial aesthetics by improving tone and function of facial muscles.
  • Is the re-patterning and normalizing of oral and facial muscles and building strong pathways between the brain and these muscles.
  •  Is employed in conjunction with other treatments or therapies to successfully overcome OMDs.
  • May reduce the symptoms of sleep disordered breathing (such as snoring), and ameliorate mild to moderate OSA (obstructive sleep apnea). Camacho M. et al. Myofunctional therapy to treat obstructive sleep apnea: a systemic review and meta-analysis. SLEEP 2015;38(5):669-675.