Original Article J. Phys. Ther. Sci.

12: 97–100, 2000

Correlation of Temporomandibular Joint
Pathologies, Neck Pain and Postural
Differences

.
DENIZ EVCIK, MD1), ORKUN AKSOY, DDS, PHD2)

1)
Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Kocatepe
ˆ
¸
University: Kocatepe Üniversitesi Rektörlügü Arastirma ve Uygulama Hastanesi Fizik Tedavi
ABD, Inönü Bulvari 03200, Ankara-Turkey. TEL +90 272-2171753
2)
Section of Oral and Maxillofacial Surgery, Oral and Dental Health Center, Ministry of
Health, Dr. M.Ü. First Aid and Traumatology Hospital

Abstract. Background and purpose. The purpose of this study was to investigate the relationship between
temporomandibular joint (TMJ) pathologies, neck pain and postural differences. Subjects and Methods.
Eighteen patients referred to us with TMJ and neck pain complaints were included in the study. The control
group consisted of individuals who had no TMJ and neck pain complaints. Both groups were subjected to
cervical X-Ray and Magnetic Resonance Imaging (MRI) of TMJ. Patients were evaluated by mandibular
ROM (active-passive), and head-shoulder angles parameters. Mandibular ROM as active and passive was
measured with a ruler in milimeters between the upper and lower first incisor teeth. For measurement of
head and shoulder angles, tragus, processus spinosus of C7 cervical vertebra and acromial head on shoulder
were marked and angular measurements were taken from these three points on the patients’ photographs.
Results. There was a statistical difference in head-shoulder angles and TMJ active-passive ROM values
when both groups were compared with each other (p<0.001). Conclusion. This study supports the
hypothesis that cervical postural changes affect the muscles of the stomatognathic system and cause TMJ
dysfunction pathologies.
Key words: Temporomandibular joint, Cervical posture.

(This article was submitted Mar. 9, 2000, and was accepted Oct. 20, 2000)

INTRODUCTION head to neck and shoulder girdle and is accepted to

The influence of posture and stress on
musculoskeletal pain and dysfunction is a prime
factor that is commonly overlooked. This is
especially important when a patient with
craniofacial pain (CFP) presents without any
temporomandibular disorder (TMD) 1) . TMJ
dysfunction and postural abnormalities appear
prevalent in patients presenting at a TMJ clinic for
treatment2). In terms of anatomic concepts, the
craniomandibular system is an important
component of the upper quarter, which combines
be a major functional unit of the body3).
In humans the spinal column and musculature
system related to it are designed to support the
weight and gravitational forces that are
superimposed on it. Therefore, there is a normal
lumbar lordosis, thoracic kyphosis, mid-lower
cervical lordosis of 30 to 35 degrees and a slight
kyphosis in the suboccipital region4).
One of the most common intracapsular
dysfunctions of TMJ is internal derangement or
displacement of the articular disk, including
reducing displaced disc (DDR) and non reducing
98 J. Phys. Ther. Sci. Vol. 12, No. 2, 2000

displaced disc (DDN). This is characterized by

anterior displacement of the disk and a
posterosuperior displacement of the condyle. The
posterior attachments are highly innervated and can
be overstretched if the joint is subjected to condylar
changes. Chronic trauma in this region is caused by
repetitive microtrauma extended over long periods
of time. If this condition continues the attachments
will become elongated and the ligaments and the
muscles will be damaged5).
In the normal resting position of the mandible, the
presence of a freeway space of 2 to 4 mm is
accepted. The tongue is suspended like a sling by
its myofacial and ligamental attachments from the
styloid process of the temporal bone and the
anterior portion of the mandible1).

METHODS
A total of 18 patients referred to our clinic with
complaints of TMJ pain, were included in the study.
The average age of the patients was 28.50 ± 12.93
(14–52). All of the patients received a detailed
physical examination. The patients who had pain in
TMJ with palpation, symmetrical mandibular
movements, joint sounds, crepitation and clicking
were among the eighteen. Those having movement
deficiency of an excessive level, symptoms for less
than a 6-month period, inflammatory-tumoral
specifications and traumatic problems were
excluded from the study. The patients were asked if
they had neck pain or not, and evaluated in terms of
neck Range of motion (ROM) and cervical spasm as
well. The control group consisted of the individuals
who had no TMJ and neck pain complaints. Both
groups were subjected to cervical graphy in four
directions and magnetic resonance imaging (MRI),
and evaluation of mandibular ROM (active-passive)
and head-shoulder angles parameters. Mandibular
ROM as active and passive was measured with a
ruler in milimeters between the upper and lower
first incisor teeth6). Both groups were requested to
adopt the most comfortable posture for head -
shoulder angles. Subjects were seated and
photographs were taken from the aside from 2
meters distance. Tragus, processus spinosus of C7
cervical vertebra and acromial head on shoulder
were marked and angular measurements were taken
as shown in Fig. 12).
Student’s t test was used to compare the age, head-
shoulder angles and the active-passive mandibular
Fig. 1. The measurement of head and
shoulder angles.
ROM of both groups. The Chi-square test was used
to evaluate the differences in gender.
RESULTS
The demographic properties of patient and
control groups are shown in Table 1.
In the first group 78% of the patients had
unilateral, and 22% had bilateral TMJ complaints.
Physical examinations determined that 50% of
patients had cervical spasm, 30% neck pain and
20% ROM limitation in the neck. MRI
investigation confirmed DDR, DDN and
degenerative changes in 50%, 30% and 20% of
patients, respectively. No pathology existed in the
control group. There were no statistical differences
in age and gender.
There were statistical differences in head and
shoulder angles and TMJ active-passive ROM
values between the two groups (p<0.001). The
results are shown in Table 2.
DISCUSSION
Postural anomalies producing muscular
hyperactivity can alter the normal anatomic
relationship between the head, neck and shoulder
girdle and frequently become a prime source of
CMP and dysfunction1).

Table 1. Demographic properties of patients and control
groups
Patients group (n=18) Control group (n=20)
Age 28.50 ± 12.93 29.70 ± 9.76
Sex (F/M) 15/3 15/5
The facet joints and capsules of the atlas and axis,
as well as their related ligamental stabilization,
contain a significant number of mechanoreceptors.
It is well known that mechanoreceptors control the
balance, equilibrum and the proprioceptive input7, 8).
When normal head and neck posture changes, this
resu lts in shortening or contraction of th e
suboccipital musculature. The central nervous
system (CNS) input from this region becomes
nociceptive, which can result in nystagmus or
vertigo. The prime muscular source of
proprioceptive input relative to the orientation of
the head in space is the sternocleidomastoid muscle
(SCM). The upper trapesius muscle is also a
common source of pain referral to the temporal and
retro-orbital region as well as the angle of the
mandible1).
Postural abnormalities that result from acute or
cumulative microtrauma which compromise the
normal propioceptive, vascular and neural interplay
o f t h e s u b o c c i p it a l r e g i o n c a n t h u s c a u s e
craniofacial pain (CFP) and associated symptoms.
Head-forward posture mostly occurs by the
weakness of the anterior cervical neck flexor
muscles which results in tightening of the SCM9).
Specifically, various upper quarter postural
abnormalities are associated with CFP and can also
contribute to TMD1).
Ideal posture according to Sharmann10) is that
state of muscular and skeletal balance which
protects the supporting structures of the body
against injury or progressive deformity irrespective
of the attitude (erect, lying, squatting, stooping) in
which these structures are working or resting.
Kendall and Kendall gave a definition of a good
side-view head posture, according to which the
head is erect and back, the chin is above the notch
between the collar bones with a slight forward curve
in neck and shoulders in line with the ear. They also
gave the definition of good frontal-view head
posture, according to which the head is held erect,
not turned or tilted to one side and the shoulders are
level11). Kendall, et al. also describe posture as “a
99
Table 2. Head and shoulder angles, and mandible ROM
(active-passive) measurements of both groups
Patients group Control group P
Head angle 39.00 ± 5.96 59.00 ± 11.72 <0.001
Shoulder angle 119.83 ± 10.47 96.90 ± 13.47 <0.001
ROM (active) 39.39 ± 8.81 55.95 ± 4.13 <0.001
ROM (passive) 43.50 ± 7.39 62.50 ± 5.18 <0.001
composite of the position of all the joints of the
body at any given moment” and state that faulty
posture results in muscular imbalance with
concomitant muscle shortening and/or elongation12).
A muscle that functions inefficiently over a
prolonged period is susceptible to strain and spasm
and can produce pain and poor postural
relationships2, 13, 14). According to some researchers
poor cervical posture affects the posture of the
mandible and the functional demands of the
stomatognathic system4, 15–17). The muscles of the
stomatognathic system are subjected to strain as a
result of inefficient use and are likely to suffer
spasm. Thus, muscular connection between the
head, neck and jaw becomes responsible for the
development or perpetuation of TMJ dysfunction2).
Several studies have also been performed
correlating the position of the head with the activity
of the masticatory musculature condyle position
and jaw dysfunction15).
Darlow, et al. found no significant difference
when they studied TM disorders in related
posture 18) . However, other studies support the
hypothesis that there is a definite relationship
between changes in head posture and positioning of
the mandible19).
Kritsineli and Shim also support the hypothesis of
a significant relationship between many of the
occlusal conditions, TMJ dysfunctions and head
posture that does not affect facial musculature at a
very young age, but with long and repeated bad
posture can cause muscular imbalance which results
in various signs of TM disorders15).
Darling et al. investigated the relationship of head
posture and the rest position of the mandible. Head
angle was assessed, in similar way to ours, as 50–60
degrees normally. They indicated that there is a
correlation between head posture and the position of
the mandible17).
Lee et al. reported a result similar to ours, that
there is a statistically significant relationship
100 J. Phys. Ther. Sci. Vol. 12, No. 2, 2000
between forward head posture and temporo-
mandibular disorders20).
Other authors have also reported that changes in
the activity of masticatory muscles with changes in
head position also change the vertical and
horizontal positions of the mandible which causes
forward head posture; and related to forward head
posture the posterior cervical muscles are shortened
iso me tric ally resulting in mu sculosk eletal
imbalance11).
CONCLUSION
The results of this study determined that cervical
postural changes affect the stomatognathic system.
Muscles stain and musculoskeletal spasm especially
in the suprahyoid area, contract the mandible
causing DDR and DDN TMJ disk displacements.
In conclusion, it is recommended that patients with
TMJ problems be examined in terms of cervical
postural changes.
REFERENCES
1) Mannheimer JS, Rossenthal RM: Acute and chronic
postural abnormalities as related to craniofacial pain
and temporomandibular disorders. 1991, Dental
Clinics North America, 35 (1): 185–207.
2) Braun LB: Postural differences between asymptomatic
men and women and craniofacial pain patients. 1991,
Arch Phys Med Rehabil, 72: 653–656.
3) Shaffer WG, Hine MK, Levy BM: A textbook of oral
pathology. Fourth edition. 1983, Saunders Company,
pp. 702–717.
4) Pal GP, Sherk WH: The vertikal stability of the
cervical spine. 1988, Spine, 13 (5): 447.
5) Rocabado M: Arthrokinematics of temporomandibular
joint. 1983, Dent Clin North Am, 27: 573–594.
6) Solberg WK: Temporomandibular disorders: physical
tests in diagnosis. 1986, British Dental Journal, 19:
273–278.
7) Bogduk N: The clinical anatomy of the cervical dorsal
rami. 1982, Spine, 7 (4): 319–330.
8) Driscoll D: Anatomical and biomechanical
characteristics of upper cervical ligamentous
structures. 1987, J Manip Physiol Therap, 10 (3): 107–
110.
9) Silverman JL, Rodriquez AA, Agre JC: Quantitive
cervical flexor strength in healty subjects and in
subjects with mechanical neck pain. 1991, Arch Phys
Med Rehabil, 72: 679–681.
10) Sharmann S: Course Notes: Diagnosis and treatment of
muscle imbalance. 1989, Atlantic City, NJ.
11) Kendall H, Kendall F: Developing and maintaining
good posture. 1968, Physical Therapy 48: 319–336.
12) Kendall FP, McCreary EK, Provance PG: Muscles, 4th
edition. 1993, Baltimore: Williams Wilkins, pp. 3–8.
13) Williams KS: Temporomandibular disorders:
masticatory myalgia and its management. 1986, Br
Den J, 160: 351–356.
14) Griegel-Morris P, Larson K, Mueller-Klaus K, Oatis
CA: Incidence of common postural abnormalities in
the cervical, shoulder, and thorasic regions and their
association with pain in two age groups of healthy
subjects. 1992, Physical Therapy, 72: 425–431.
15) Kritsineli M, Shim YS: Malocclusion, body posture
and temporomandibular disorder in children with
primary and mixed dentition. 1992, J Clin Pediatr
Dent, 16 (2): 86–93.
16) Ayub E, Glasheen-Wray MB, Kraus S: Head posture:
a case study of effects on rest position of mandible.
1984, J Orthop Sports Phys Ther, 5: 179–183.
17) Darling DW, Kraus S, Glasheen-Wray MB:
Relationship of head posture and rest position of
mandible. 1984, J Prosthet Dent, 52: 111–115.
18) Darlow L, Pesco J, Greenberg M: The relationship of
posture to myofacial pain dysfunction syndrome.
1987, JADA 114: 73–75.
19) Urbanoicz M: Alteration of vertical dimension and its
effect on head and neck posture. 1991, J Craniomand
Prac, 9: 174.
20) Lee WY, Okeson JP, Lindroth J: The relationship
between forward head posture and temporomandibular
disorders. 1995, J Orofac Pain, 9 (2): 161–167.