Specialist article: jaw joint
Understanding TMDCauses rather than symptoms
Jaw pain, jaw clicking, teeth grinding and often already the second or third occlusal splint. Here you will learn what can lie behind craniomandibular dysfunction (TMD), why the lower jaw is a muscularly guided system and how training addresses breathing, swallowing and head balance.
Does this sound familiar?
Recurring problems with your jaw?
What applies to you?
Tap whatever applies to you.
If several of these points apply to you, it is worth looking beyond the jaw joint: at breathing, swallowing and head balance. That is exactly what this article is about.
To the causesWhat you can do yourselfThe key points at a glance
- TMD is an umbrella term for complaints in the masticatory system and describes where it hurts, not why.
- The lower jaw is guided by muscles, and in our view this guidance usually arises from the basic functions of breathing, swallowing and head balance.
- An occlusal splint imposes a position on the jaw from the outside; training addresses the guidance itself.
Video
Dr. Berndsen explains TMD
Das Video lädt erst nach dem Klick. Dann werden Daten an YouTube (Google) übertragen.
The term
What is TMD?
In German, the condition is called CMD, short for craniomandibular dysfunction, literally a functional disorder between the skull (cranium) and the lower jaw (mandible). The term covers complaints in the masticatory system, such as pain in the chewing muscles and the jaw joint, jaw clicking, restricted mouth opening, teeth grinding and clenching. Headaches and neck pain, ringing in the ears or dizziness often occur as well. In the international specialist literature, the same field is called temporomandibular disorders, TMD for short.
TMD describes where it hurts. Not why.What matters is what the term does not do. TMD describes where it hurts and what is no longer running smoothly. It does not explain why. Much like “headache”, TMD is a description and not a cause. If you stop at the diagnosis, you can easily end up looking for the solution where the complaints occur rather than where they arise.
To understand the connections, it helps to look at the mechanics. The upper jaw is firmly attached to the skull. Only the lower jaw is mobile, and it does not rest on its joints. It hangs in a muscular sling made up of the masseter, the temporalis, the pterygoid muscles and the floor-of-mouth muscles, which are connected to the throat and neck via the hyoid bone. Its position at any moment is the result of a balance between the closing muscles, the opening muscles and gravity.
Even when you are not chewing, these muscles are working. Recordings of individual muscle fibres show sustained baseline activity in the temporalis when the jaw is relaxed1. At the same time, the activity of the chewing muscles drops considerably as soon as the rows of teeth are a few millimetres apart2. The lower jaw is therefore held suspended with very little effort, and the teeth only touch briefly when swallowing and chewing. How well this guidance works determines whether the jaw joint is relieved or continuously loaded.
Typical TMD symptoms
Jaw pain
Pain in front of the ear, in the cheek or at the temple, often when chewing, yawning or in the morning after waking up. The chewing muscles feel tired or tense.
Jaw clicking and grinding noises
A clicking or grinding noise in the jaw joint when opening and closing. It occurs when the articular disc no longer moves smoothly with the condyle.
Restricted mouth opening
The mouth no longer opens fully, the lower jaw deviates to one side when opening, or taking large bites is difficult.
Teeth grinding and clenching
Worn tooth edges, sensitive teeth, tension in the morning. In otherwise healthy people, bruxism is regarded as a behaviour that can become a risk factor, and not as a disease in its own right3.
Headaches and neck pain
The jaw and the upper neck share the same relay stations in the brainstem. Pain can therefore be passed on between face and neck in both directions4.
Ringing in the ears and dizziness
The jaw joint lies directly in front of the ear canal. Ringing in the ears, pressure in the ear or dizziness are therefore often associated with TMD. If they appear for the first time, they should be checked by a doctor.
3D film
Muscles guide the jaw
In 45 seconds, the animation shows why, with TMD, we look at the muscles first and not at the bite. Green lines stand for an even balance, red lines for an uneven pull.
Causes
Causes of TMD: looking beyond the jaw joint
For a long time, the bite was considered the main suspect: if the teeth do not meet properly, the jaw joint is loaded incorrectly. Research paints a different picture.
A systematic review found no clinically relevant association between bite and TMD. The authors recommend abandoning this old way of thinking5.
The OPPERA study followed people who were initially free of symptoms. Accompanying complaints in the mouth and face area and worsening sleep were the strongest predictors of later TMD6.
In our view, the starting point usually lies even further back, in the basic functions of breathing, swallowing and head balance. They run around the clock, with every breath and with many hundreds to a thousand swallows a day7. Together, they determine how the tongue, lips and chewing muscles guide the lower jaw. We call this interplay the triadic functional circuit. It is at the start of many causal chains, and TMD is often a late, clearly visible link in them.
Breathing
Anyone who habitually breathes through their mouth loses the calm lip seal. The tongue drops, the lower jaw hangs lower, the muscles around the mouth and cheeks work less, and the lateral guidance of the jaw becomes weaker. In animal experiments with a blocked nose, the animals held their lower jaw lower and gradually developed a different face and a different bite8. More recent literature also summarises that mouth breathing influences the development of the jaw and dentition9. In a cross-sectional study of 945 children and adolescents, signs of TMD were considerably more common in mouth breathers10. A study of this kind shows an association; on its own, it says nothing about the direction.
Swallowing and tongue reference position
Many people search for the correct “tongue resting posture”. In fact the tongue is never completely at rest; it is continually adjusted, and yet everyone understands what is meant. We speak of the tongue reference position. Here the tip of the tongue rests on the palate at a small elevation behind the upper incisors, the incisive papilla, without touching the teeth. From there the tongue braces itself against the palate and helps carry the position of the lower jaw. If this support is missing, or if the tongue presses against the teeth when you swallow, the masseter and temporalis muscles take over holding tasks they are not built for. This repeats with every swallow.
Head balance
If the head sits in front of the body instead of above it, for example during long hours at a screen, the position and pull of the hyoid bone change, and with them the pull of the floor-of-mouth muscles on the lower jaw. The neck then also works against the weight of the head. In a randomised study with 60 TMD patients, symptoms improved considerably more with posture training than with behavioural advice alone, especially in those whose head was far in front of their shoulders11.
And stress? It plays a role, but in our view more as an amplifier. It explains why symptoms appear right now, and it hits the spot that is already under strain.
How a disturbed function can turn into TMD
The basic function tips over
Mouth breathing, a low-lying tongue, swallowing with tongue pressure or a head that sits in front of the body. This often begins in childhood and goes unnoticed for a long time.
Muscles lose their task
Lips, cheeks and tongue are no longer involved in their actual function, are hardly used and lose tone. Other muscles step in.
The pull on the lower jaw becomes uneven
The masseter and temporalis muscles maintain a baseline tension, the floor of the mouth pulls differently via the hyoid bone, and lateral guidance weakens. The jaw deviates.
The jaw joint bears the load
The joint and the articular disc are loaded unevenly. Clicking, pain, restricted opening, clenching or grinding occur.
The symptoms spread
Via the shared control points of jaw and neck, headaches and neck pain follow. Now the picture gets a name, TMD, and yet it stands at the end of the chain.
A path we often hear about
Anna and six splints
In his book, Dr. Berndsen describes the path of a patient who came to his practice at the age of 32. Her story stands for many who come to us with TMD.
two long orthodontic treatments, three permanent teeth extracted
Night guard, special splint, finally an anti-snoring splint
TMD treatment with physiotherapy and osteopathy, finally a planned jaw operation
- Childhood
Open mouth
Infections, middle ear infections, adenoid operations. Anna already breathes through her mouth as a baby; later come a lisp and speech therapy.
- Adolescence
Braces
Two long orthodontic treatments. When the retainer comes loose, the incisors move back within a few days.
- Early 20s
Six splints
Headaches, dizziness, a tense neck. Diagnosis TMD, one splint after another. After four years she feels rather worse.
- Later
Snoring
Pauses in breathing at night. A mandibular advancement splint is supposed to help, but her mouth opens even further at night.
- At 32
Looking back
Together, Dr. Berndsen goes through her path with her, starting from her first years of life. Therapy now focuses on breathing, swallowing and head balance. After six weeks, Anna notices the first changes.
Different specialities intervene, but always look at the same section.Dr. Berndsen calls this “symptom therapy in variation”. Each individual step was understandable. The question of what caused the finding itself remained open.
Anna’s story is an individual case from the book “Trust the Triad”. Every course is different; there is no guarantee of results.
Splint
Putting occlusal splints and night guards into perspective
The most common treatment for TMD is the occlusal splint, also called a night guard, bite splint or Michigan splint. It is meant to protect the teeth from wear, relax the chewing muscles and relieve the jaw joint. Many of those affected experience relief in the first few weeks.
There is a second point. In the floating position the teeth do not touch, and that is exactly when the chewing muscles manage with the least effort2. A splint places a plastic surface between the rows of teeth and creates contact where there would otherwise be none. In our view, this tends to keep the chewing muscles working rather than releasing them from their pattern.
What the studies say
Cochrane review: no evidence that splints relieve pain more than no or minimal treatment12.
Meta-analysis: short-term benefit of the stabilisation splint, later on a par with other methods13.
Current Cochrane review with around 2,800 participants: the data are insufficient for a judgement14.
We view splints critically.The lower jaw is guided by muscles: by the tongue, lips, chewing muscles and neck. A splint imposes a position on it from outside; it does not change this guidance. It is precisely this guidance that we adjust with the training.
Like a crutch
If you break your leg, you use crutches for a while. They take the load off and help you through everyday life. But you can only walk again once the bone has knitted together, and that is not the crutch’s doing. This is how we understand the splint: with severe symptoms it can bring short-term relief. In our experience, however, this effect wears off over time, and then the next splint follows. It does not reach the underlying cause. Why the jaw needs support lies in its muscular guidance, and that is exactly where the training comes in.
From practice we know a typical course. The first splint brings relief, the symptoms return, a new splint follows, along with physiotherapy, osteopathy or grinding of the teeth. Each of these measures can temporarily relieve symptoms. If the same findings come back, this is an indication that the conditions producing them are continuing unchanged. We call this symptom therapy in variation.
If you wear a prescribed splint, do not stop wearing it on your own initiative. During the day you train without restriction. You do not wear the splint and the FaceFormer in your mouth at the same time. Whether the FaceFormer takes the place of the splint at night is something you discuss with your dental practice.
Occlusal splint and training compared
Occlusal splint
- Imposes a position on the lower jaw from outside when you bite down
- Is meant to protect the teeth from wear and relieve the jaw joint
- Works as long as it is worn
- Creates tooth contact where the teeth would otherwise be floating
- Breathing, swallowing and head balance are not practised alongside
- Benefit for pain uncertain according to systematic reviews
Training
- Targets the muscular guidance of the lower jaw
- Practises lip closure, nasal breathing, tongue reference position and head balance together
- The aim is patterns that run correctly by themselves in everyday life
- Needs your participation, a few minutes three times a day
- At night with the FaceFormer ZERO, once the basic exercise is established
- Patterns change over months, not overnight
Do not stop wearing a prescribed splint on your own initiative. You do not wear the splint and the FaceFormer at the same time. Whether the FaceFormer takes its place at night is something you discuss with your dental practice.
In the 3D model
Four states compared
Tap a state. The lines show whether the lower jaw is guided centrally.
In balance
The chewing muscles pull evenly on both sides, as the green lines show: the lower jaw is centred. The tongue rests on the palate, and air flows through the nose.
When the pattern gets out of balance
If the muscles pull unevenly, the lower jaw shifts and the lines diverge. The jaw joint bears the load. Symptoms can develop from this.
With an occlusal splint
The splint centres the jaw from outside when you bite down. The chewing muscles, shown here in red, work against the splint. It does not change the muscular guidance itself.
The training approach
The training targets the guidance itself: lip closure, tongue reference position, nasal breathing and head balance. The aim is for the muscles to guide the jaw evenly again, even without conscious attention.
Botox
Botox in the masticatory muscles: paralysed is not guided
For TMD and teeth grinding, botulinum toxin, Botox for short, is now also injected into the masseter and temporalis muscles. It paralyses the muscles for a while. But these muscles are part of a functional system that guides the lower jaw together with the tongue, lips and neck. The injection does not change this guidance, and while immobilised, the muscles do not learn a new pattern. In our view, this consequence is rarely considered, and the functional disorder behind it can thus become more entrenched rather than resolved.
The body of studies also calls for restraint. An overview of 18 systematic reviews on muscle-related TMD found less pain compared with placebo, no advantage compared with standard treatments and no improvement in the mobility of the lower jaw. At the same time, the authors saw a higher risk of side effects in muscle and bone tissue and advise using Botox only as a last resort16.
Our approach
TMD exercises: training the basic functions
If the guidance of the lower jaw arises from the basic functions, that is also where the approach lies. In our view, correcting breathing, swallowing and head balance in TMD is not one option among many, but the prerequisite. Whether anything else is needed afterwards is decided case by case.
Research on exercise therapy shows that active practice can have an effect in TMD. A meta-analysis of randomised studies found moderate short-term effects of jaw exercises on pain and mouth opening15. Many of these programmes train the mobility of the jaw. FaceFormer therapy starts one step earlier, with the functions that guide the jaw.
The FaceFormer is a silicone training device that sits in the oral vestibule, in front of the teeth and behind the lips. The lips hold it, breathing runs through the nose, and the negative pressure in the mouth brings the tongue up against the palate. In this way lip closure, nasal breathing, tongue reference position and swallowing pattern are practised in one sequence. What counts is not strength but the pattern.
The mechanism behind it is simple. Muscles that are no longer involved in their actual function are hardly used and lose their tone, while others step in and become overloaded. The training establishes the basic functions so that they run correctly again in everyday life. Then the muscles are used in their actual task, and the pull on the lower jaw can even out again.
How the training is structured
- Day 1
Basic exercise
Module 1, three times a day, with a few repetitions that you increase week by week.
- Week 3
Pull exercise and night
Module 2 is added. At night you wear the ZERO. If you wear a splint at night, clarify this beforehand with your dental practice.
- Week 6
Head balance rotation
Module 8 links lips and tongue with head balance, for guiding and stabilising the jaw joints.
- Later
Switching to the ONE
For training during the day. ZERO and ONE are the same size and shape; only the hardness of the material differs.
- 6 to 12 months
Until it runs by itself
This is how long the exercise manual allows for the new patterns to run automatically.
The free FaceFormer app guides you through the basic exercises, and you can find all modules on the exercise pages. If you would like support, the practitioner directory lists practices that work with FaceFormer therapy.
Why training and not support
Imagine your backhand in tennis isn’t working. Nobody would put your arm in a splint to improve the stroke. A splint could force the movement into a path as long as it is on, but your arm would learn nothing from it. You train the stroke until it is established, and at some point you no longer think about it. This is how the nervous system learns movement patterns: when cycling, speaking and swallowing. Once anchored as a programme, it runs by itself. In our view, the same applies to the lower jaw. Its guidance is a movement pattern, and movement patterns can be trained.
TMD in everyday life: what you can observe yourself
Teeth apart
Pay attention during the day to whether your teeth are touching. Except when chewing and swallowing, they are slightly apart and the lips are closed. If you catch yourself clenching, release your teeth and place the tip of your tongue on the palate.
Finding the tongue reference position
Use the tip of your tongue to feel the small elevation behind your upper incisors. That is where it rests correctly, without pressing against the teeth. Just thinking about it is not enough, however; the position has to become established as a pattern.
Observing nasal breathing
Do you breathe through your nose when reading, during sport and at night? A dry mouth in the morning can be an indication of mouth breathing at night. Taping your mouth shut is not a solution; it closes it mechanically and does not change the pattern.
Head balance at the screen
Set up your screen and seat so that your head stays above your body and does not drift forward. Short breaks in which you balance your head freely take load off the neck and jaw.
Give your chewing muscles a break
Chewing gum for hours keeps the masticatory muscles working without a break. In a small observation without a comparison group, 26 of 30 adolescents with chronic headache were better after one month without chewing gum, and all 20 who started again had complaints again after a few days17. Chew on both sides if possible and give the jaw time to find its way back to its resting balance.
Dropping old habits
Thumb sucking, nail biting, lip biting or drawing in the lips practise the lips, tongue and masticatory muscles in exactly the pattern you want to replace with the training. As long as they remain, in our view they work against the training, and old sequences return more easily. Pay attention to when they occur and replace them with lip closure and the tongue reference position.
Start gently
At first, the training may feel like muscle soreness in the chewing muscles. In that case, reduce the repetitions in the app and increase them more slowly; strength is not the goal. If it hurts after the night, pause night-time use and continue training during the day.
When to see a practice promptly
If you suddenly can hardly open your mouth or can no longer close it, after an accident, or with swelling or fever, this should be examined by a dentist or doctor.
Conclusion
The key points about TMD
The guidance of the jaw arises from breathing, swallowing and head balance.TMD describes symptoms in the masticatory system; it does not explain them. The lower jaw is guided by muscles, and this guidance arises from breathing, swallowing and head balance. In our view, that is usually where the starting point lies, and that is where the training comes in. An occlusal splint imposes a position on the jaw; it does not change its guidance. You can find more on the basics under How does FaceFormer therapy work?.
Questions
Frequently asked
What is TMD (craniomandibular dysfunction)?
TMD is an umbrella term for complaints in the masticatory system, that is, in the chewing muscles, the jaw joint and tooth contact. The term describes where the complaints occur but does not explain their cause. In German it is called CMD (craniomandibular dysfunction); internationally, the term used is temporomandibular disorders (TMD).
Which symptoms are typical of TMD?
Typical symptoms are jaw pain, jaw clicking or grinding noises in the jaw joint, restricted mouth opening, teeth grinding and clenching, and tired chewing muscles in the morning. Headaches and neck pain often occur as well, sometimes ringing in the ears, pressure in the ear or dizziness. Newly occurring ear noises or dizziness should be checked by a doctor.
What are the causes of TMD?
According to systematic reviews, the bite plays a much smaller role than long assumed. In our view, the starting point usually lies in the basic functions of breathing, swallowing and head balance. They determine how the tongue, lips and chewing muscles guide the lower jaw. Stress acts more as an amplifier.
Does an occlusal splint help with TMD?
Many people initially experience relief with a splint. The studies show at most a short-term benefit, and systematic reviews, including a Cochrane review, consider the data to be uncertain. We take a critical view of splints because they impose a position on the lower jaw from the outside without changing anything about its muscular guidance.
Does Botox in the masticatory muscles make sense for TMD?
Botox paralyses masticatory muscles for a while and can dampen pain. It does not change the guidance of the lower jaw, and the muscles do not learn a new pattern while immobilised. An overview of 18 systematic reviews found no advantage over standard treatments and a higher risk of side effects in muscle and bone tissue; the authors see Botox as a last resort. In our view, it addresses the wrong end of the chain.
Can I combine the FaceFormer with a night guard?
During the day you can train with the FaceFormer without restriction. You do not wear the splint and the FaceFormer in your mouth at the same time. Whether the FaceFormer ZERO takes the place of the splint at night is something to discuss with your dental practice.
What exercises are there for TMD?
FaceFormer therapy does not have a special exercise for TMD. You start with the basic exercise three times a day; from around the third week the pull exercise and night-time use are added, and from around the sixth week the head balance rotation, which is used to guide and stabilise the jaw joints. The free app guides you through the basic exercises.
Is jaw clicking dangerous?
Clicking shows that the articular disc no longer moves smoothly with the condyle. Without pain and with free mouth opening, it is no cause for concern, but it is a sign of uneven guidance. If you suddenly can hardly open your mouth or can no longer close it, have it seen by a dentist promptly.
How long does training take for TMD?
That depends on the starting point. Patterns that have become ingrained over years change over months. The exercise manual expects six to twelve months until the new sequences run automatically. How your symptoms develop during this time cannot be predicted in individual cases.
Does a splint protect the teeth when grinding (bruxism)?
Yes, it provides this protection. When you grind and clench, tooth enamel no longer rubs against tooth enamel, but against plastic. This protects the hard tooth substance from wear. However, the splint does not change the pattern from which grinding and clenching arise. That is why we see it as a crutch: it protects the teeth, but it does not reach the muscular guidance of the lower jaw.
Does that mean: never a splint again?
Our video on TMD is titled “Never a splint again?”, and the question mark is meant seriously. A splint imposes a position on the jaw from the outside; in our view, it is a crutch. The aim of the training is for the lower jaw to be guided by the muscles again, so that the splint can become unnecessary over time. Whether and when this succeeds in your case cannot be predicted; you take the path there step by step with your dental practice.
Can impaired jaw guidance also be linked to back or knee pain?
In our view, both can be links in the same causal chain. Via the hyoid bone and the floor-of-mouth muscles, head balance helps determine how the lower jaw is guided and, at the same time, how the neck and spine carry the head. If the head is permanently in front of the body, posture has to adapt. Whether such a chain continues down to the knees has not been demonstrated and cannot be stated in general terms for the individual case.
More articles from the knowledge section
Experiences on this topic
Where to go next
Sources
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Get started
Ready for the training?
The free FaceFormer app guides you through the basic exercises, counts along and reminds you of your sessions. If you wish, a practice from the practitioner directory can support you.
FaceFormer ZERO + ONE
Both material hardnesses for getting started, day and night. The set for adults.
FaceFormer ZERO
The softer FaceFormer for getting started, for children and for the night.
FaceFormer ZERO Children’s Set
ZERO with hygiene box, plush bag and success book with stamp.
FaceFormer training aims to restore the physiological setting of the basic functions of breathing, swallowing and head balance, with lip closure and the tongue reference position, thereby creating the conditions under which symptoms can improve. It does not replace a medical assessment. You can find practitioners near you in the practitioner directory.
