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Structural Misalignment: Postural
Changes Related
toTemporomandibular Joint
Pathology
LidiaYavich
1 Introduction
Upon patient evaluation, one must analyze not
only the cranio-cervical-mandibular system but
also the whole posture and gait. To correctly
assess the maxillomandibular relationship, one
must begin to consider the physiological rest
position of the mandible. This concept is no different from the physiological rest position of the
body but, concerning not only the hard tissue
such as teeth and bone as is usually done in dentistry, but also muscle and nerves.
The rest position of the mandible is also a
result of a combination of the posterior cervical
muscles and the muscles that are anterior to the
cervical spine. Therefore, one can appreciate the
connection from the cranium to the mandible,
from the shoulder girdle to the mandible, and
from the cervical spine to the mandible through a
muscular chain. The hyoid is the prevertebral
bone which distributes tensional forces below the
mandible and in front of the cervical spine.
The important role of the tongue during swallowing also determines the mandibular posture as
does the level of contraction of the genioglossus.
The mandible articulates with the cranium through
the temporomandibular joint. Nociceptive reexes
originating from the temporomandibular joint lead
L. Yavich (*)
SBPAT, The Brazilian Society for Diagnosis and
Treatment of Temporomandibular Joint Pathologies,
Attending, Clinica My, PortoAllege, RS, Brazil
to adaptive postural responses (craniomandibular,
head and neck, trunk, and limbs). Although not
considered a part of the joint itself, muscles are
closely related to joints. In orthopedic disorders,
muscle spasms are secondary and are the result,
not the cause, of pain. Skeletal asymmetries are a
common source of mechanical stress. Postural
stress is often a consequence of structural stress.
The vertical dimension of occlusion (VDO) is
also determined by the TMJ and its state of health.
Head and neck posture inuences the resting position of the mandible, which subsequently alters its
closure pathway for tooth–tooth contact. As mentioned in Chap. 11, one of the fundamental things to
consider in a patient’s documentation are photos of
the patient’s entire body, front, back, right, and left
prole, not only photos of the patient’s head and
neck. In the same way as panoramic radiographs in
conferences and publications are often displayed
without mandibular condyles, one often sees
patients’ photographs focused on the face only.
Analysis of photographs of the face and part
of the neck, as shown in Fig.1a–c, has a limited
view of the patient. It is important to understand
that the patient’s entire posture has to be analyzed, taking into account that interventions can
produce postural changes that may or may not be
benecial (Fig. 1d): in this frontal view image,
one can observe right and left shoulder protrusion, abdominal protrusion, forward head position, higher right nipple, and higher right
shoulder. Figure1g, h, left (g) and right (h): in
these lateral images, one can observe knee ex-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
B. C. Stack Jr. et al. (eds.), Craniofacial Pain, https://doi.org/10.1007/978-3-031-57563-1_12
205
206
L. Yavich
a b
c
de fgh
Fig. 1 Above: patient’s face in frontal, prole, and smile views. Below: patient’s posture, frontal, back, smiling, right,
and left prole
ion, pelvic anteversion, increase in spinal curvatures (lumbar hyperlordosis and dorsal
hyperkyphosis), right shoulder more protruding
than the left, cervical rectication, and forward
head position.
A photograph is only an image in time. It is a
method that allows one to see body posture alignments and misalignments. Dentists need to detect
these signs even though they are not qualied to
directly treat these conditions. Such patients
should be referred to specialists who will make
an adequate description and diagnosis of postural
problems. Dentists treat mandible tridimensional
posture, which has a fundamental relation to
body posture.
This patient suffered headaches, neck pain,
difculty swallowing liquids and solids, and nocturnal and daytime choking episodes. In this spe-
ab
ab
Structural Misalignment: Postural Changes Related toTemporomandibular Joint Pathology
207
cic example, postural comparisons will be
highlighted, as well as the patient’s prole and
vertical dimension with the orthotic (Fig.2b) and
the patient’s prole and vertical dimension at the
beginning of the treatment in habitual occlusion
(Fig.2a).
An orthotic is not a simple piece of acrylic; it
represents the position where the muscles are at
their best performance, with the limitations of
each differential diagnosis. Teeth habitual trajectory must coincide with the neuromuscular trajectory, considering mandible posture with all its
components. An improvement in cervical rectication can be observed by comparing Fig.2a with
b. Patients’ evaluation should consist of complete
records including conventional images, CT, and
MRI of the temporomandibular joints. To make
the orthotics, bioinstrumentation is utilized such
a
as surface electromyography and a computerized
jaw tracker. Patients may also be referred to a
physiotherapist and speech therapist during
treatment.
Comparing Fig. 3a with b: in these frontal
images, note the improved shoulder positioning,
right shoulder, and right iliac crest more aligned
and improved knee alignment. Comparing Fig.3
(c, e) with (d, f): in these lateral images, note the
improved head and shoulder positioning,
decreased abdominal protrusion, improved spine
curvature alignment, knee bending no longer
apparent, and pelvic anteversion correction.
It may be easier to understand what a threedimensionally misaligned mandible can cause if
one considers the mandible as the rst girdle of
the body (Fig.4). The mandible is connected to
the vertebral spine. TMJ pathologies not only
b
a
ba b
ab
Fig. 2 Photographs and lateral radiographs including C7 of the patient with and without an orthotic appliance
208
a
ef
b
cd
L. Yavich
Fig. 3 Comparison of the patient’s postural changes at the beginning and during the treatment
disturb the masticatory apparatus but also alter
the deglutition and speech systems among others. Primary pathologies of the TMJ can affect
teeth positions; sometimes, this wrong position
is a consequence and not the cause of
dysfunction.
TMD is not a problem of modern society; it is
not the product of a single etiological factor.
Occlusion is a compounding factor of TMD.The
point is how occlusion is dened. A healthy
occlusion requires that the TMJs are healthy and
working properly and that the muscles are healthy
and working correctly. Therefore, if there is any
variation of a TMJ-related disorder, then, by denition, there must be a malocclusion. Upon considering the TMJ, one must analyze its structures:
the mandibular condyle and the articular disc,
especially in growing patients, where the condyle
must be protected by the disc. Ligaments, and
synovial space in three-dimensional, frontal, sagittal, and axial views, must also be analyzed. Any
modication in the joint structures will cause distortions in its vertical, horizontal, and axial
dimensions.
Structural Misalignment: Postural Changes Related toTemporomandibular Joint Pathology
209
Fig. 4 Girdles on the human body, considering the mandible as the rst girdle
2 Some Considerations When
Dealing withTMJ
Pathologies
• Can the TMJ be healed?
• Can the TMJ be improved or can TMD be pre-
vented from worsening?
• Can TMJ articular discs be recaptured?
The rst question must be: What is the problem? And only after that, the second should be:
How can it be xed? For this, a differential diagnosis must be carefully elaborated. Consider that
central relation is not a dental terminology; it is a
terminology that relates to the concept of stability of synovial joints. Basically, it refers to the
congruency of joint surfaces. When it relates to
the temporomandibular joint, it is a synovial
joint. If the joint attens, if the articular disc is
displaced, the joint is no longer stable regardless
of the occlusion or molar class. If there are degen-
erative processes affecting the mandibular condyle, if the mandibular condyle presents growth
axis modication, and if the temporomandibular
joint presents effusions caused by different etiologies, then there is articular pathology and resultant joint instability.
Even though there are aligned teeth and correct molar class in both patients in the top and
bottom images, the articular discs shown with
open mouth are dislocated and only on the
right side of Fig.5a, there is a recapture. The
bottom images (c) and (d) show that the teeth
are aligned and in the correct molar class, but
both in the open-mouth MRI have irreducible
articular disc dislocations; furthermore, the left
side has an anatomic distortion. This condition
can happen at any age without pain and is frequently undiagnosed. It implies that the system
is compromised. Joint stability presupposes the
correct functioning of ligaments, tendons, and
muscular structures for the proper mechanics
210
a
b
L. Yavich
c
Fig. 5 Top: a slice of TMJ MRI (a, b) with intraoral photographs of the same patient. Bottom: a slice of TMJ MRI (c,
d) with intraoral photographs of another patient
of the joint. Images of beautiful occlusions as
shown in image Fig.5 are not a guarantee of
TMJ health.
Analyzing the TMJ in sequence, the rst piece
of information about the mandibular condyle can
be obtained from the panoramic radiograph, but
pathology may or may not be visible. The next
comes from the TMJ plain lm, and the third and
most accurate for hard tissues can only be seen in
the CT where shape, positioning, and bone alterations are evident. To be able to observe discs,
soft tissues, bone edema, and effusions, among
other changes, one must obtain an MRI of the
TMJs. What is important when requesting a magnetic resonance image of the TMJs, apart from
the knowledge to interpret the image, is the question of what can be done with that information.
This is an exam that should be requested by colleagues who can apply this information to the
treatment of the patient’s TMJ pathology.
functional dysfunction of the temporomandibular
joint (TMJ). It is important to know that this type
of fracture can produce growth disturbances.
Changes in the orientation of the condyle axis are
common in patients who have suffered blows to
the chin region, whether they are anteroposterior,
vertical, or lateral.
In these cases (Fig. 6), a deformation of the
head of the condyle with respect to curvature is
seen with an anterior concavity. In some cases,
the deformity can be so signicant that it produces compression of the retrodiscal region, producing severe symptoms. This pathology may
even be present with an apparently healthy
condyle- disc relationship in those patients in
whom the articular disc structures have not been
obviously affected by the trauma.
Traumas are classied as direct and indirect.
Direct traumas are those that have their impact upon
different sectors of the mandible. Indirect traumas
d
are those that are a result of sudden and strong dislocation of the mandible. We were taught that
3 Greenstick Fractures
occlussion is guided in harmonic order, determined
by the axis of rotation of the joint, and joint position
Mandible and condylar process fractures are well
and plentifully described in the bibliography
except for greenstick fractures of the condylar
process which are rarely described. The name is
by analogy with green (i.e., immature) wood,
which similarly breaks on the outside when bent.
These fractures provoke deformation of the mandibular condyle, which in turn creates a morpho-
in so-called centric relationship. Perhaps this is the
case in ideal patients without joint pathologies. The
condyle should not be a reference in patients with
assymmetries, modication in the growth axis,
degenerative processes, autoimmune diseases,
inammatory processes, metabolic diseases, and
other conditions that affect the head of the mandible/TMJ.
Structural Misalignment: Postural Changes Related toTemporomandibular Joint Pathology
a
b
211
Fig. 6 Laminography (a) and MRI (b) of right and left
TMJ in open and closed mouth. Pathologic mandible
head. Deformity caused by traumatism in childhood.
4 Which TMJ Side Has aCentric
Relationship?
Which side is chosen to determine the centric
relationship in any one of the patients in Fig.7,
all of them with different arthropathies? The
right condyle and the right glenoid fossa or the
left condyle and left glenoid fossa? When guided
only by cephalometry, there is an assumption that
the mandibular heads are in a physiologic position and that the patients do not present any
pathology within the temporomandibular joint.
Cephalometry is traced on craniometric points in
a maximal intercuspation position ignoring muscles or presupposing that they are in balance.
How can muscles be in balance when they
are twisted because of structural failures? The
patient’s existing habitual occlusion is often a
relation of the mandible to the skull, which is
very far from optimal. Therefore, the diagnosis
made in intercuspal models, or simply in a radio-
Normal growth axis (1), fracture location (2), and pathological growth axis (3). The arrow marks the compression
site
graphic cephalometry in this position, reects the
pathological accommodation of the patient’s
muscles. Imaging is not an isolated tool and
should be requested after a thorough history and
a meticulous clinical examination.
Figure 8a: 3D reconstruction of a condyle in the
closed mouth of a patient with a history of trauma
and Staphylococcus aureus infection; Fig. 8b:
MRI of close mouth of a patient with anterior disc
displacement and a history of sudden trauma;
Fig.8c: CT patient with the change of growth axis
of the condyle, history of trauma in infancy, and a
retro-position of the condyle after orthodontic
treatment; Fig.8d: patient with psoriatic arthritis,
change of growth axis condyle, and retro-position
of the condyle after orthodontic treatment; Fig.8e:
patient with a history of rheumatic fever; Fig.8f:
patient with rheumatoid arthritis. These images
help uncover etiological agents that cause the
pathology that affects patients. The patient may
present one of these conditions or several concom-
212
L. Yavich
a
b
c
Fig. 7 Different images of occlusions of patients with the respective MRI images in closed and open mouth with color
highlights
itant ones, which modies the degree of complexity of the disease.
How is a better relationship between muscles,
jaws, teeth, and temporomandibular joints
achieved when several components of the stomatognathic system may be injured with different types and degrees of lesions? In the section,
TMJ Pathology Treatment (Chap. 13), four clin-
ical cases are presented with the therapeutic
resources utilized. Even though the importance
of full-body photographs has been emphasized
heretofore, for brevity and convenience, they are
not included. The focus in the third section is
TMJ structural and functional changes.
bc
ef
Structural Misalignment: Postural Changes Related toTemporomandibular Joint Pathology
a
d
Fig. 8 Images of different patients with diverse pathologies
213
5 Summary
Can the TMJ be healed? Yes, in many cases, as
soon as the problem is diagnosed and the structures have not undergone permanent and extensive alterations.
Can the TMJ be improved or prevented
from worsening? Yes, in many cases, when
positioning problems are treated and compressive mandible postures are avoided.
Can dislocated articular discs be recaptured? Yes, in many cases, the physiological rela-
tionship of the head of the mandible with the
articular disc can be recovered.
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