Effect of Myogenous Temporomandibular Joint Disorders on Cervical Range of Motion: A Prospective Study

Junaid Ahmed; Mandovi Nath; Nanditha Sujir; Nandita Shenoy; Ravikiran Ongole; Almas Binnal

doi:10.4103/jofs.jofs_158_19

ORIGINAL ARTICLE

Year : 2021 | Volume : 13 | Issue : 1 | Page : 33-38

Effect of Myogenous Temporomandibular Joint Disorders on Cervical Range of Motion: A Prospective Study

Junaid Ahmed, Mandovi Nath, Nanditha Sujir, Nandita Shenoy, Ravikiran Ongole, Almas Binnal
Department of Oral Medicine and Radiology, Manipal College of Dental Sciences, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India

Date of Submission	26-Dec-2019
Date of Decision	12-Mar-2020
Date of Acceptance	14-Sep-2020
Date of Web Publication	06-Aug-2021

Correspondence Address:
Dr. Nanditha Sujir
Department of Oral Medicine and Radiology, Manipal College of Dental Sciences, Mangalore, Manipal Academy of Higher Education, Manipal 576104, Karnataka
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/jofs.jofs_158_19

Abstract

Introduction: Temporomandibular joint disorders (TMDs) involve abnormalities of either the disc or associated muscular structure. Evidence continues to accumulate regarding the untreated diseases of stomatognathic system, in particular, malocclusion and TMDs, which eventually carry a risk of development of postural disorders. The present study was undertaken to assess the correlation between TMDs and altered cervical range of motion and to review its association with the myogenous causes of TMD. Materials and Methods: A total of 80 patients were recruited and were divided into two groups; those diagnosed with TMDs were classified as cases and those who did not suffer from TMDs and/or cervical spine anomalies were classified as controls. Patients reporting with a positive history of painful joints and muscles were examined and were later referred to the department of physiotherapy, where the cervical range of motion was assessed using Baseline® bubble inclinometer. Cervical range of motion in healthy patients was compared with those affected with TMDs using posthoc Tukey test. Results: There was a significant difference in the values for range of motion and was found to be considerably restricted among the TMD subjects. Disability for the range of motion was statistically significant with a P-value of <0.001 for tests of active flexion, passive flexion, left active flexion, and left passive flexion in patients with myogenous TMDs. Conclusion: TMDs were found to be a significant factor in the occurrence of an impaired cervical range of motion.

Keywords: Masticatory muscles, neck muscles, range of motion, temporomandibular joint disorders

How to cite this article:
Ahmed J, Nath M, Sujir N, Shenoy N, Ongole R, Binnal A. Effect of Myogenous Temporomandibular Joint Disorders on Cervical Range of Motion: A Prospective Study. J Orofac Sci 2021;13:33-8

How to cite this URL:
Ahmed J, Nath M, Sujir N, Shenoy N, Ongole R, Binnal A. Effect of Myogenous Temporomandibular Joint Disorders on Cervical Range of Motion: A Prospective Study. J Orofac Sci [serial online] 2021 [cited 2023 Jun 9];13:33-8. Available from: https://www.jofs.in/text.asp?2021/13/1/33/323352

Introduction

The temporomandibular articulation consists of bilateral, diarthrodial, temporomandibular joints (TMJs). The TMJ and its associated structures play a vital role in guiding jaw motion and distributing stresses created by everyday tasks such as chewing, swallowing, and speaking. TMJ disorders (TMDs) are the category of chronic conditions related to morphological and functional deformities.^[1],[2] The term TMDs include abnormalities of the intra-articular discal position and/or dysfunction of the associated musculature.^[3] Signs and symptoms include painful joint sounds, restricted or deviated range of motion, and/or muscular pain.^[4]

Etiology and progression of TMDs are poorly understood. As a result, treatment choices are restricted and fail to fulfill the long-term demands of the comparatively young patient population.^[5] Diagnosis of TMDs arises from assessment of the clinical signs and symptoms, and the most often cited diagnostic classification systems are the research diagnostic criteria for temporomandibular disorders (RDC/TMDs) and the classification by the American Academy of Orofacial Pain.^[6] The former provides a uniform assessment for a restricted set of TMDs that generate reliable information for researchers, whereas the latter does not have an equivalent standardized approach. However, it consists of a wider cluster of disorders and has a widespread clinical acceptance.^[7]

Postural adjustments are the outcome of a multifaceted mechanism which are controlled by numerous systems (visual, vestibular, and somatosensory) unified with the central nervous system (CNS).^[8] Along with the CNS, the stomatognathic system (SS) also plays a vital role in postural management. Evidence continues to accumulate regarding the untreated diseases of SS, in particular, malocclusion and TMDs, which eventually carry a risk of development of postural disorders.^{[9],[10],[11],[12],[13]}

The association between postural changes and TMDs has been widely discussed in the literature.^{[14],[15],[16],[17],[18]} It is believed that biomechanical stress and changes in head posture may be associated with the development and/or perpetuation of TMDs. The pathophysiological relationship between TMDs and cervical spine impairment could be due to the neurophysiological interplay, including the confluence of trigeminal and upper cervical afferent transmissions in the trigemino-cervical nucleus. Another possible reason could be the intimate biomechanical link between the cervical spine and the TMJ.^[19]

Few studies have demonstrated postural pattern alterations in patients with TMD when compared with healthy subjects without any TMD symptoms.^[11] The studies, however, did not find any differences in postural patterns between patients with TMD and healthy subjects.^[20] The aim of the current study was to assess the influence of myogenous TMDs on cervical range of motion and to assess the possibility of any correlation between the different muscles involved with TMDs and its effect on cervical range of motion.

Materials and Methods

Ethical approval for this study (Protocol Number IEC:17032) was provided by the Institutional Ethics Committee, Manipal College of Dental Sciences, Mangalore, on 12th May, 2017. Patients visiting the department of oral medicine and radiology were recruited for the study after obtaining their informed consent. A total of 80 patients were recruited and were divided into two equal groups of 40 patients. Those diagnosed with TMDs were classified as cases and those who did not suffer from TMDs and/or cervical spine anomalies were classified as controls. Patients with a history of pain in the face, jaw, temple, anterior to the ear, or in the ear were further evaluated by the provocation of patient’s pain and digital palpation of masticatory muscles based on the revised RDC/TMD. Screening orthopantomogram (OPG) radiographs were taken wherever necessary to rule out TMDs caused due to arthropathic cases.

Patients above 20 years of age, with painful muscle/TMJ on palpation and painful mandibular function (myogenic TMD), were included in the case group. Patients with a history of cervical spine disorders, history of trauma to the spine and condylar changes evident on OPG were excluded. Age- and gender-matched subjects with no history of orofacial pain or cervical disorders and above 20 years of age were included in the control group.

The patients selected (both cases and control group) were referred to the department of physiotherapy and an experienced physiotherapist assessed the cervical range of motion using Baseline® bubble inclinometer (Baseline, USA) [Figure 1]. The cervical range of motion was recorded for the following movements: active extension, active flexion, right active rotation, left active rotation, right active flexion, left active flexion, passive extension, passive flexion, right passive rotation, left passive rotation, right passive flexion, and left passive flexion. The values for individual range of motion were recorded separately in degrees. The disability was assessed as values <60° for extension/flexion tests, <45° for lateral bending/lateral (right/left) flexion tests, and <65° for lateral rotation/lateral (right/left) rotation tests.^[21]

Figure 1 Shows assessment of (A) Passive extension, (B) Left Passive flexion, (C) Left Passive Rotation, using Baseline^® bubble inclinometer.

Click here to view

Statistical analysis

Independent Student t test was used to compare the cervical range of motion between the cases and control group. Posthoc Tukey test was used to compare the association between individual muscles of mastication and cervical range of motion. The P-value of <0.05 was considered to be statistically significant.

Results

The various parameters for cervical range of motion were compared among cases and control group [Table 1]. Active flexion was higher in the control group (mean value ± standard deviation [SD] of 71.76 ± 10.947) and was statistically significant (P < 0.001). Active extension was higher in the case group with a mean value of 43.27 ± 4.658, and was statistically significant with a P-value of <0.001. Right active rotation revealed a slightly higher value in the control group with a mean ± SD of 68.1 ± 7.382 and was statistically significant with a P-value of 0.004. Right active flexion was higher in the case group with a mean ± SD of 47.27 ± 7.096 and was statistically significant with a P-value of <0.001.

Table 1 Measurement of cervical range of motion between case and control groups.

Click here to view

We also compared the various parameters of cervical range of motion with the muscles of mastication involved in causing TMDs [Figure 2]. Out of 41 cases, 27 patients suffered from myogenous TMD of medial pterygoid muscle, followed by masseter (7), temporalis (4), and lateral pterygoid (3). Correlation of symptomatic muscles of mastication with associated disability for cervical range of motion was observed with a statistically significant P-value of <0.001 for tests of active flexion, passive flexion, left active flexion, and left passive flexion.

Figure 2 Measurement of cervical range of motion among cases affected with myogenous temporomandibular joint disorder. Flexion_Active, flexion active; Exten_Active, extension active; R Rot Act, right-side rotation active; L Rot Act, left-side rotation active; RT Flex Act, right-side flexion active; LT Flx Act, left-side flexion active; R Rot Pass, right-side rotation passive; L Rot Act, left-side rotation active; Rt Flex Pass, right-side flexion passive; Lt Flex Pass, left-side flexion passive; Extn_Pass, extension passive; Flexion Pass, flexion passive. *Statistically significant results.

Click here to view

Values for cervical range of motion were compared between both the genders. However, the results were nonsignificant [Figure 3].

Figure 3 Comparison of ranges of cervical motion among gender. Flexion_Active, flexion active; Exten_Active, extension active; R Rot Act, right-side rotation active; L Rot Act, left-side rotation active; RT Flex Act, right-side flexion active; LT Flx Act, left-side flexion active; R Rot Pass, right-side rotation passive; L Rot Act, left-side rotation active; Rt Flex Pass, right-side flexion passive; Lt Flex Pass, left-side flexion passive; Extn_Pass, extension passive; Flexion Pass, flexion passive.

Click here to view

Discussion

There is a well-established correlation between posture and the SS. De Laat et al.^[22] performed a study to evaluate and compare signs and symptoms of TMD with craniocervical dysfunction in 31 patients who were referred for a clinical examination of the cervical spine. The results indicated that segmental limitations (especially at the c1–c3 levels) and tender points (especially in the sternocleidomastoid muscle and trapezius muscle) are present significantly in patients with symptoms of TMD. Thorp and Willson^[23] reported that the neck disability index revealed a significantly negative correlation with cervical active range of motion in patients with TMD. A study conducted by De Wijer et al. ^[24] suggested that there was an association between cervical musculature and TMDs. He also concluded that patients with disability in the jaw were more likely to have a greater disability of the neck and vice versa. In our study, a significant limitation in the cervical range of motion was observed in the case group. Additionally, when masticatory muscles were evaluated for tenderness, medial pterygoid muscle was the most commonly affected muscle causing significant alteration in the active extension test.

In a study carried out by von Piekartz et al.,^[25] it was noted that there is an evidence of impairment in the cervical range of motion in patients suffering from TMDs. In their study, 144 patients were classified into mild, moderate, and severe TMD cases and their cervical range of motion was examined, along with musculoskeletal impairment. The study confirmed that the degree of cervical musculoskeletal impairment varied according to the severity of TMD. Ferreira et al.^[26] concluded that women with TMDs have limited flexion/extension range of motion and limited upper cervical spine mobility with significant reduction in values of flexion/extension movements and reduced flexion rotation test. Greenbaum et al.^[27] in their study compared cervical range of motion among 20 women with TMDs with 20 healthy controls and found significant reduction in values of right, left flexion rotation test, left lateral flexion, and left rotation in the TMD group. Similar findings were noted in the present in which the tests for flexion (both active and passive) and rotation were lesser in value for cases (symptomatic myogenous TMDs) when compared with the control group and were statistically significant.

Rollman and Lautenbacher^[28] revealed that women had a greater frequency of musculoskeletal pain than men and thus, a greater chance of developing cervical spine disorders. Our study showed no statistically significant difference in the range of motion between the two genders. These findings were similar to a study conducted by Fleckenstein et al.^[26] which revealed no significant differences in terms of gender in either the occurrence of myofascial pain or any impairment of cervical range of motion.

There is robust proof of craniocervical postural changes in established cases of myogenous TMDs. The presence of TMDs appears to considerably alter the cervical range of motion and hence, serve as a prequel to cervical spine anomalies and postural changes later in life. In line with previous studies, there is evidence toward correlating the myogenous TMDs with an altered range of motion. However, to the best of our knowledge, there is no literature evidence that correlates the involvement of individual masticatory muscles inflicting TMDs with tests for cervical range of motion. Likewise, few authors have reported the presence of spinal anomalies causing a painful TMJ.^[29] In our study, we found that the range of motion especially the tests for flexion is significantly affected in patients positive for TMDs. The masticatory muscle most commonly responsible for myogenous TMDs is the medial pterygoid followed by the masseter. Further investigations to measure muscle response or electrical activity in response to neural stimulation of the masticatory muscles involved in TMDs can be very useful. The response of cervical muscles in these tests can help us to understand the neuromechanics involved in patients with myogenous TMD and the mechanism of its influence on cervical spine musculature.

Conclusion

Neuroanatomical and neurophysiological relationships in the orofacial region and its intricate relationship with the cervical spine are well documented. In our study, we have ascertained a statistically significant association between the various cervical range of motion and masticatory muscles that cause TMDs. The present study revealed a significant association between myogenous TMDs and an impaired cervical range of motion.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Zarb GA, Carlsson GE. Temporomandibular disorders: osteoarthritis. J Orofac Pain 1999;13:295-306.
2.	Griffiths RH. Report of the president’s conference on the examination, diagnosis, and management of temporomandibular disorders. J Am Dent Assoc 1983;106:75-7.
3.	Tanaka E, Detamore MS, Mercuri LG. Degenerative disorders of the temporomandibular joint: etiology, diagnosis, and treatment. J Dent Res 2008;87:296-307.
4.	Murphy MK, MacBarb RF, Wong ME, Athanasiou KA. Temporomandibular joint disorders: a review of etiology, clinical management, and tissue engineering strategies. Int J Oral Maxillofac Implants 2013;28:e393-414.
5.	Solberg WK, Woo MW, Houston JB. Prevalence of mandibular dysfunction in young adults. J Am Dent Assoc 1979;98:25-34.
6.	Glick M. Burket’s ORAL MEDICINE. 12th edition. Shelton, Connecticut: People’s Medical Publishing House; 2015. Chapter 11. Temporomandibular joint disorders; p. 276.
7.	Peck CC, Goulet JP, Lobbezoo F et al. Expanding the taxonomy of the diagnostic criteria for temporomandibular disorders. J Oral Rehabil 2014;41:2-3.
8.	Kandel ER, Schwartz JH, Jessell TM. Principles of Neural Science, 3rd ed. New York: Elsevier Science Publication Co. 1991.
9.	Gangloff P, Louis JP, Perrin PP. Dental occlusion modifies gaze and posture stabilization in human subjects. Neurosci Lett 2000;293:203-6.
10.	Hellsing E, Mcwilliam J, Reigo T, Spangfort E. The relationship between craniofacial morphology, head posture and spinal curvature in 8, 11 and 15 years old children. Eur J Orthod 1987;9:254-64.
11.	Darlow LA, Pesco J, Greenberg MS. The relationship of posture to myofascial pain dysfunction syndrome. J Am Dent Assoc 1987;114:73-5.
12.	Braun BL. Postural differences between asymptomatic men and women and craniofacial pain patients. Arch Phys Med Rehabil 1991;72:653-6.
13.	Huggare JA, Raustia AM. Head posture and cervicovertebral and craniofacial morphology in patients with craniomandibular dysfunction. Cranio 1992;10:173-8.
14.	Kritsineli M, Shim YS. Malocclusion, body posture, and temporomandibular disorder in children with primary and mixed dentition. J Clin Pediatr Dent 1992;16:86-93.
15.	Milani RS, De Periere DD, Lapeyre L, Pourreyron L. Relationship between dental occlusion and posture. Cranio 2000;18:127-34.
16.	Darlow LA, Pesco J, Greenberg MS. The relationship of posture to myofascial pain dysfunction syndrome. J Am Dent Assoc 1987;114:73-5.
17.	Braun BL. Postural differences between asymptomatic men and women and craniofacial pain patients. Arch Phys Med Rehabil 1991;72:653-6.
18.	Zonnenberg AJ, Van Maanen CJ, Oostendorp RA, Elvers JW. Body posture photographs as a diagnostic aid for musculoskeletal disorders related to temporomandibular disorders (TMD). Cranio 1996;14:225-32.
19.	Visscher CM, De Boer W, Lobbezoo F, Habets LL, Naeije M. Is there a relationship between head posture and craniomandibular pain? J Oral Rehabil 2002;29:1030-6.
20.	Nicolakis P, Nicolakis M, Piehslinger E et al. Relationship between craniomandibular disorders and poor posture. Cranio 2000;18:106-12.
21.	Lind B, Sihlbom H, Nordwall A, Malchau H. Normal range of motion of the cervical spine. Arch Phys Med Rehabil 1989;70:692-5.
22.	De Laat A, Meuleman H, Stevens A, Verbeke G. Correlation between cervical spine and temporomandibular disorders. Clin Oral Investig 1998;2:54-7.
23.	Thorp JN, Willson J. The neck disability index is not correlated with some parameters of temporomandibular disorders: a cross-sectional study. J Oral Facial Pain Headache 2019;33:39-46.
24.	De Wijer A, Steenks MH, De Leeuw JR, Bosman F, Helders PJ. Symptoms of the cervical spine in temporomandibular and cervical spine disorders. J Oral Rehabil 1996;23:742-50.
25.	von Piekartz H, Pudelko A, Danzeisen M, Hall T, Ballenberger N. Do subjects with acute/subacute temporomandibular disorder have associated cervical impairments: a cross-sectional study. Man Ther 2016;26:208-15.
26.	Ferreira MP, Waisberg CB, Conti PCR, Bevilaqua-Grossi D. Mobility of the upper cervical spine and muscle performance of the deep flexors in women with temporomandibular disorders. J Oral Rehabil 2019;46:1177-84.
27.	Greenbaum T, Dvir Z, Reiter S, Winocur E. Cervical flexion-rotation test and physiological range of motion − a comparative study of patients with myogenic temporomandibular disorder versus healthy subjects. Musculoskelet Sci Pract 2017;27:7-13.
28.	Rollman GB, Lautenbacher S. Sex differences in musculoskeletal pain. Clin J Pain 2001;17:20-4.
29.	Fleckenstein J, Zaps D, Rüger LJ et al. Discrepancy between prevalence and perceived effectiveness of treatment methods in myofascial pain syndrome: results of a cross-sectional, nationwide survey. BMC Musculoskelet Disord 2010;11:32.