Keywords; tmj anatomy, trigeminal neuralgia, chiropractic help, tmj exercises, migraine headaches.
This page is not designed to be a highly academic tour of this complex joint; however it is a difficult topic that has had chiropractors scratching their heads. The sensory nucleus of the large nerve that supplies the jaw is located in the cervical spine, and hence the strong connection between migraine headache, neck and facial pain.
It will give you some insights if you can struggle with the anatomy, and provide some understanding of how the temporo mandibular joint can cause severe
It is also the joint that contributes to a complex and extremely painful condition called trigeminal neuralgia. You can go to our TMJ ear pain page for more information.
Shall we sully forth on our TMJ anatomy tour? It
will help you understand any jaw joint symptoms you may be having and how it
can cause such misery.
Two cranial structures form the joint.
Hence temporo mandibular and then, of course, joint to get TMJ.
The pterygoid pocket is a cul de sac behind the upper molars; it can be very painful.
This picture is taken from a book called Grays Anatomy. Come back later and take a short tour about this amazing man. A real pioneer. Click here for more about Henry Grays Anatomy tour.
Notice the mandible has two prongs.
Notice two features in this second picture of our temporo mandibular joint anatomy tour.
The actual joint, where the posterior prong fits into a socket in the temporal bone.
The three muscles that slam the jaw closed.
A very powerful trio, strong enough to bite your own finger off! Literally. As we will see in due course, these muscles can contribute to your headache and facial pain, and neck pain if the temporo mandibular joint is not functioning as it should.
You will discover four primary jaw muscles on your tmj anatomy tour. They open, close, protrude and move the jaw sideways, enabling you to talk, chew, and swallow, kiss and many other things we do with our mouths. We'll come to the fourth muscle in due course.
There are three kinds of tmj anatomy pain:
1. Primary muscle pain is not really common but overuse, as in chewing gum or in South Africa, biltong, in association with disc malfunction can commonly causes jaw pain, facial pain headache and sometimes neck pain.
If the jaw joints are functioning optimally then muscle overuse is not usually a problem. But if the jaw joints are not moving in sinc then the more you chew, the greater the problem.
The important feature on this leg of our TMJ anatomy tour is the disc, or meniscus as it is known, that rides in the joint, which functions as a moving shock absorber between the condyle and the fossa, or, socket, separating the two bony structures.
It's unique, quite different to any other joint in the body. As you open your jaw, the condyle first rotates and then slides forward in the fossa.
When the disc malfunctions, often after the jaw has been opened too wide, or taken a blow as in a punch, then it gives the familiar clicking and popping sound so often associated with temporo mandibular joint pain.
Please, please, do not slap your child's face, your spouse, even your enemy. You may just cause them a life time's temporo mandibular joint anatomy pain.
Joint related pain may occasionally result from inflammation, as in rheumatoid arthritis, but more usually from degeneration of the tissues within the temporo mandibular joint.
This wear and tear in the joint, and dislocation of one of the menisci,
are the two most common joint disorders of the temporo mandibular joint. The two joints then no longer work together in harmony causing facial pain, jaw joint pain and migraine headache. And, upper neck referred pain.
Note two things here. How the condyle (posterior prong) sits in its fossa, and the position of the normal disc. See how the disc is attached another very important muscle, the lateral pterygoid? Because of this attachment to the disc, this muscle can become supremely, exquisitely, extremely painful.
This is the muscle that opens the jaw, pulling the condyle forwards out of its fossa, protected by the disc from grinding bone on bone. Used on one side only, it moves the jaw from side to side when chewing the cud. Juggle your jaw from side to side - that's the Lateral Pterygoid you are using. Now protrude the jaw, push it forwards. That's the two Lateral Pterygoids working together. See in the next picture how the condyle has slid forwards out of its fossa? That's normal.
Dislocated disc (meniscus)
Notice in the next picture how the disc has been displaced forwards. This is definitely not normal. Should you now open your jaw there will be a popping sound as the disc pops back behind the prong of the jawbone (the condyle). When this happens repeatedly the disc starts to wear, and sets up a pain pattern in the muscles around the jaw joint.
Try placing the pads of your index fingers in your ear, and slowly open your mouth. Do they open nicely together? Any clicks or pops?
Often patients are terrified of words like disease and degeneration sometimes used in describing this wear-and-tear process. No need, it's no different to your hair turning grey. What is now clearly recognised in the literature though is that, untreated, joint malfunctions, or fixations as we call them, lead to unnecessary, premature degeneration. Every time the displaced disc has to pop over the condyle, it is probably equivalent in terms of wear and tear to 100 openings of a healthy jaw.
See that long black structure in the picture below? (in the next pic it's highlighted in green). That is the huge trigeminal nucleus extending right down into the spinal cord in the neck.
It's called the TRI-geminal nerve, because it has three different sensory branches, seen here in green, blue and brown, supplying primarily the face, teeth, sinuses and TMJ. It is by far the largest cranial nerve.
Whilst I don't want to overdo the complexity of TMJ anatomy, this next slide will show you how the TMJ can cause neck pain, perhaps CAUSE subluxations, and how subluxations in the cervical spine can make the TMJ vulnerable to injury.
On the right hand side you have the four functions of the Trigeminal nerve. Focus only on the one labelled "Pain and Temperature". If you follow it along the "Spinal Trigeminal Tract" you will see that its sensory nucleus (called the "Spinal Trigeminal nucleus") is right down in the neck. From there a dark-coloured tract reaches up into the sensory cortex of the brain (those two dark arrows) where the pain is perceived.
So, noxious pain and temperature signals from the TMJ feed right down into the neck, where they meet up with other nerves from the neck, swapping messages. Pain!
Enough, right! Well done, you're a perseverer!
There's nothing simple about the human body. Nothing! and certainly not the TMJ anatomy. "Fearfully and wonderfully made" as one great surgeon named his book. Amen!
I said there are four jaw muscles. The fourth, the Internal Pterygoid is also a jaw closer. I include it here, partly for completeness, but also so that you can see the four branches of the Trigeminal nerve in situ. One motor branch to the muscles of the jaw, and three sensory nerves (labelled 1st Div, 2nd and 3rd). See the proximity of the nerve to the Internal Pterygoid muscle? This is why jaw muscle pain can so readily become intense nerve pain.
For anatomy students only: See the tiny branches supplying the Tensor Tympani muscle in the inner ear (dampens overly loud sounds) and the Tensor Veli palatini muscle that has two vital functions: in swallowing it helps raise the soft palate so food doesn't enter the sinuses, and opens the auditory tube, allowing for equalising the pressure between the inner ear and the outside air. Vital for example when driving up a steep hill, or ascending in an aeroplane. That pop in the ear... Tensor Veli Palatini doing its job.
So, the very complex fifth cranial nerve, the Trigeminal nerve, is almost continuously in use in chewing, speaking, swallowing, hearing and bringing sensory information from the teeth, face, jaw joints to the brain.
Not a pain, but there is an irritating condition, sometimes it becomes extreme, ringing in the ears, that is common and sometimes associated with vertigo, and sometimes a result of a TMJ anatomy problem. But not usually, alas. But if you have crackling sounds, pain and stiffness coming from your jaw, then your tinnitus MAY be coming from the TMJ. May. If there is hearing loss, then Meniere's disease also needs to be considered.
Vertigo, similar to but not quite the same as dizziness, is a dreadful condition that we will consider elsewhere at Chiropractic Help in a chapter about Benign Paroxysmal Positional Vertigo ( Vertigo dizziness ) ...
Like all other chronic joint conditions there is no real permanent cure for TMJ anatomy wear and tear. An acute pain or click which has just begun, correctly addressed should pass over, and the trick is not to allow it to become chronic. Like any other condition, once you know it's not going to get better on its own, then it's better to contact the relevant health professional sooner rather than later.
Not unlike neck and back pain, good care of chronic TMJ pain aims at reducing the pain, restoring normal function, and avoiding the known no-no’s. Like biting a whole apple and chewing gum.
The pain and dysfunction is often temporary, lasting a few days or weeks, even a month or two perhaps, so adventurous surgery which cannot be reversed should only be contemplated when all else has failed. Your first port of call, of course! should be your chiropractor.
I have done no research in my practice, but I would guess at least 75 percent of patients have good to excellent results with chiropractic treatment of the TMJ.
What will your chiropractor do? Firstly a good history of how the pain or clicking started, how long it's been there, what aggravates it and so on. Whether you are getting headaches, and any of the sharp stabbing pain associated with trigeminal neuralgia. Then there will be an examination of the TMJ anatomy, and your neck. Treatment will include mobilising the joint, treating any active trigger points in the muscles, and stretching of the muscles and the joint capsule.
So, what's the good news? This is a very treatable condition. You don't have to live with TMJ anatomy pain for month after month. The bad news? If the pterygoids have active trigger points, they can only be reached from inside the mouth, and the treatment may be wretchedly painful, sometimes lasting a few days. Hang in with your chiroprator, that pain too will pass. This treatment is very effective.
What can you do for yourself? Jaw exercises for TMJ? An iceblock rubbed directly on the painful spot, followed by moist heat; do it in the shower. Now that you've taken your TMJ anatomy tour, you know where to find these muscles, right? Gently massage them. Your chiropractor will give you some stretches and, for more tips about TMJ exercises, scroll down.
If appropriate, your chiropractic treatment may include cervical spine adjustments too, if there are associated fixations. For more about the neck adjustments, scroll down to neck pain treatment.
For an interesting case from the coalface, click on this link and scroll down to Mrs Hol. Chiropractic Coalface ...
There is a tool for self treatment of the internal pterygoid muscle; I regret I've seen no research on how effective it is, but you might like to try it; you'll find it at this treatment for tmj page.
Interestingly, research shows that migraine sufferers, clench their Temporalis muscles 14x more often ... More about Migraine headache / TMJ headaches.
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Interesting challenges of the day
1. Mr D has very severe midback back. He bent and twisted, feeding his son, and then laughed. Every breath is a nightmare. A sprung rib is every chiropractor's delight. He or she has golden hands. 30 percent better after one treatment.
2. Mrs C has a long history of severe, disabling migraine headaches since having her wisdom teeth removed. She clenches her teeth at night. After six treatments she has no migraines but some jaw joint discomfort remains; a bite plate is in the offing.
3. Mrs U has the trophy for the worst back this year. After major surgery with plates and screws two years later she still had paresis in the lower leg and severe disabling back pain. She's doing far better than expected, in no little part due to a lift in her shoe for a very short leg.
4. Mr V is 86 years old and hurt his back helping his wife into the car. Just one treatment of the sacroiliac joint and he's eighty percent better. It's not always like that.
5. Mr W lay on his back knocking down a pillar. Turning his head causes severe vertigo. He needs the Epley exercises, not pills, research shows. Update, he's fine.
6. I myself had an acute exacerbation of a femoral nerve lesion last year. One immediate treatment by my colleague has fixed the pain in the lower back, but there's some residual numbness in the lower leg; no soaring tomorrow alas.
7. This lady is a 86 year old woman with a 63 scoliosis. Chronic lower back has been her lot in life but she's well pleased with chiropractic and comes for chiropractic help once a month; some conditions you can never cure.
8. She is an 78 year old woman, is doing remarkably well with a bad sciatica. But over 200 pounds she is not losing weight; in fact, gaining despite my suggestions. She's high risk for a stroke. I have referred her to a dietician to crack the whip.
9. A 61 year old man with upper cervical pain yesterday; it's not severe but also not getting better of its own accord. He's afraid it may turn very acute as when I treated him three years ago. Since then it's been fine.
10. A 64 year old woman has had scheuermanns disease; it's left her with a spinal kyphosis and chronic middorsal pain. She responds well to chiropractic treatment provides she come every six weeks or so for maintenance treatment.
11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.
12. Mrs D, a middle aged woman with hip pain of one year duration, despite other treatment. Xrays reveal an impingement syndrome and early hip arthritis. There's much to be done.
13. Mrs B has had one of the nastiest of conditions; vertigo caused by a disturbance in the inner ear. Falling repeatedly and vomiting she consulted her doctor but medication didn't help. After two sessions of the Epley manoeuvres she was 50 percent better. After two weeks 75 percent improved. No longer vomiting all falling. She's not enjoying the Brandt Daroff home exercises.
And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.
Have a problem that's not getting better? Looking for a different slant on your pain? Want to pose a question?
Greetings, Dr B.
You helped me quite some time back with a soothing and professional response which turned out to be exactly correct. I now consult a local chiropractor. You write a superb newsletter, too.
Your own unresolved problem. Pose a question
Knowing that up to 70% of the time the correct diagnosis is made with no examination, no special tests, no xrays, but just from the history, there's a fair chance I can add some insight to your unresolved problem. But at least 30% of the time, I may be quite wrong! Give plenty of detail if you want a sensible reply.
You visited this chiropractic help site no doubt because you have a problem that is not resolving and want to know more about what chiropractors do.
The quickest and most interesting way is to read one of my ebooks of anecdotes. Described by a reader as gems, both funny and healthful, from the life and work of a chiropractor, you'll love them. Priced right at $2.99, though Kindle fiddles the price without telling me.