CMD, craniomandibular dysfunction – the chameleon of dental and oral medicine

CMD (Craniomandibular Dysfunction) is the collective term for structural, functional, biochemical and psychological dysregulation of muscle or joint function of the temporomandibular joints.

These dysfunctions are so significant because the temporo‐ mandibular joint is one of the central joints in the body:

It is the connection between the brain and abdomen, and the control center for information and energy flow.

Basics of anatomy and function

There is a close anatomical relationship to the ear, the parotid gland and also the orbit via the vas‐ cular and nerve supply and the bony structures.

We find in the immediate vicinity:

• large vessels (carotid artery, durae sinus)

• lymphatic system

• connection with almost all cranial nerves

The joint and masticatory muscles are supplied by the trigeminal and facial nerves (N.V and N.VII), but the glossopharyngeus, vagus, accessorius and hypoglossus (N.IX, X, XI, XII) are also involved in coordination.

Meridians: Gallbladder, Triple Warmer, Small Intestine, Stomach with relevant points reflect the value of this zone.

The masticatory muscles and the joint are assigned to the stomach meridian. This ends next to Voll’s joint degenera‐ tion pathway at the 2nd toe.

Anatomy of the joint

The temporomandibular joint is a double joint in the double sense, because the right and left sides must always move together. An anatomical feature of this joint, namely a mov‐ able cartilaginous discus, divides the joint space into an up‐ per and lower chamber.

This discus is connected laterally to the ligamentous structures of the joint capsule, anteriorly to a masseter muscle, and posteriorly to a connective tissue structure, the bilaminar zone, which en‐ velops blood vessels, nerves, and autonomic pathways for the joint and ear.

This allows for quite differentiated three‐dimensional rotational‐sliding motion of the condyles, but this complex structure is also susceptible to pathological changes.

A diverse musculature (up to 30 muscles, reaching from the temple to the middle of the thoracic spine) ensures very finely tuned movements during chewing, swallowing and speaking.

The coordination of the masticatory and neck muscles is controlled by a complex neuromuscu‐ lar reflex system. Neurophysiologically, the temporomandibular joints can be described as po‐ sition and movement information organs.

Symptomatology of CMD

The anatomical adjacency to the ear and eye and to their supply structures, i.e. nerves, vessels, lymphatic channels and this multi‐layered muscular apparatus lead to a variety of symptoms in CMD.

CMD is a collective term for all dysregulations.

Locally, we look at the leading symptoms of pain, dysfunction, and tissue damage in the mastica‐ tory muscles, joints, jaws, teeth, ears, face, and head.

Morphologically we distinguish:

• Arthropathy

• Arthritis, arthrosis, malformation

• Discopathy (chondropathy)

• Partial/total displacement after ant/post and with/without reduction

• Cracking and rubbing, discus perforation

• Tendinopathy

• Capsulitis, capsular shrinkage, “impingement”.

• Condylopathy

• Displacement: distraction, compression, subluxation

• Hypermobility, shape change

• Myopathy

• Myalgia, myospasm, myogelosis, muscle hypertrophy

• Occlusopathy

• Disturbed static or dynamic occlusion

• Parafunction: pressing, grinding

In addition to these local symptoms, there are secondary symptoms and interactions up to the feet, because both movement patterns and end position of the condyles directly affect and are affected by the back muscles and pelvic statics.

In addition, neurological and vegetative symptoms are also possible. Neurological disorder symptoms

Paresthesias, numbness, burning sensation, and neuralgia are possible in all co‐affected body regions

• Cardiac and vegetative symptoms

• Cardiac arrhythmia, blood pressure change

The chameleon CMD masks itself in many even non‐local symptoms and often occurs as a cofactor in complex medical conditions.

In addition to the pain directly in the joint or the masticatory muscles, the patient usually only as‐ signs cracking noises and extreme changes in the mouth opening such as lockjaw or lockjaw to CMD from these symptoms.

Causes of CMD / Etiology

Structure, biochemistry and nervous system

Structural and functional triggers for disturbances in the bio‐mechanical balance of the mastica‐ tory system:

Unharmonious bite position due to jaw malpositions, after tooth loss, tooth loosening or tooth migration, due to incorrect height of fillings or dentures.

Muscular dysfunctions due to general orthopedic prob‐ lems and posture disorders, including eye‐related poor posture.

Injuries, condition after accidents, tissue damage after operations, scars, tumors, genetic malfor‐ mations or changes.

Biochemical components

Metabolic disorders and inflammations locally or systemically in general diseases, dental foci, elec‐ troplating, material intolerances, allergies, hyperacidity, hormonal factors.

Psychological factors

Bruxism for stress management, anxiety and depression due to pain.

Neurological disorders causal:

Trigeminal neuralgia, facial nerve paresis, apoplexy Energetic disturbances, meridian stresses

Importance of occlusion

The upper and lower jaw form a dynamic functional unit.

The final position of the condyles and thus of the jaw is determined by the bite. If the bite position is incorrect, dysfunction patterns of the musculature establish themselves, which can lead to CMD.

Displacement of the lower jaw leads to postural change of the head.

Not only chewing and speaking have a significant influence on the functional patterns. Here the teeth only touch each other slightly and only moderate pressure is applied.

When swallowing (approx. 2000 times a day!), there is a coordinated activation of many muscles of the lips, cheeks, tongue, soft palate, pharynx, larynx, vocal cords and esophagus. This involves biting down briefly to lock the lower jaw. This acts like a reset ‐ a neurological programming of the muscles involved which has an effect on central vegetative mechanisms.

Bruxism can have an even more precarious effect than a malocclusion, as when pressing or grind‐ ing, up to 30 times the normal chewing pressure is often generated for hours.

In the case of bruxism, it becomes clear that symptoms and cause cannot always be neatly sepa‐ rated, as it is often a self‐reinforcing process.

Pressing and grinding leads to damage to the tooth structure, hypersensitivity or pain, tooth mi‐ gration or loosening, possibly even tooth loss. The resulting occlusion disorder intensifies CMD, as the increased muscle activity during bruxism leads to lactate formation, ischemia, and tone in‐ crease, even as far as spasticity in the muscle.

Recent studies confirm bruxism as a compensation pattern for coping with stress, as the muscle hyperactivity contributes to lower cortisol levels.

Here we find all 3 categories of etiological factors gathered together: structure, biochemistry, psy‐ che.

We see the tooth substance destroyed by abrasion, but also by acid erosion, tooth loss and loss of contact of the posterior teeth. It results in a massive lowering of the bite, and on the extraoral pic‐ ture, muscle hypertrophy of the masseter. This is a sign of permanent tension of a person who cannot let go at all.

If left untreated, it usually does not remain with local symptoms in the long term. Often a de‐ scending disorder develops from this change in the bite position with a change in the entire body statics and can lead to adjustment disorders as far as the ankles.

In the same way, we also find ascending disturbances:

Orthopedic misalignments with postural changes and shifting of the body planes promote head malposition and can trigger or exacerbate muscular dysfunctions in the craniomandibular system.

In addition to the typical knee and back pain, pelvic misalignment can also be associated with shoulder pain, neck pain and headaches.

Collaboration with orthopedic surgeons and physical therapists is important to address these causal patterns.

Dental diagnostics

After a thorough anamnesis, dental diagnostics includes an assessment of the functional status, with manual and instrumental functional analysis of the patient and models, OPG X‐ray, MRI, CT or DVT if necessary. The OPG X‐ray often provides clear indications of pathologies and should be viewed by all practitioners.

CMD Mini Check

This brief examination can be performed by all therapists and is suitable for detecting CMD, albeit without precise differentiation.

Anamnesis: Access pain level and modalities: location, time, radiation Inspection of the bite: tooth status, bite position, Palpation of joint, musculature,

Mobilization of the jaw movement, mobility of the upper cervicals Bite test according to Meersseman ft. Wolschner

Findings of the overall statics, if necessary manual tests for pelvic position, leg length

Meersseman test

Record the change of functional findings due to the bite whilst deblocking with cotton rolls. Indication of bite disorder, indication of ascending / descending disorder.

Modified Meersseman test ft. Wolschner

Testing of the latissimus dorsi muscle on both sides one after another in a standing position.

Each side once without and once with biting and, if possible, with use of a therapeutic bite block by the therapist. While the test muscle is held tense, the examiner makes contact with the second hand to the temporomandibular joint, then to the occiput, followed by descending to the upper cervicals, subsequent vertebrae, the sacrum and the ISG.

Interpretation:

• Comparison of findings without and with bite

• The temporomandibular joint gives an indication of whether a bite disorder is present

• Look at the other areas too, and whether a bite‐associated disorder is present there

• Change in findings due to probationary or therapeutic bite blocks

• Confirms the indication of the disorder and indicates the direction of therapy

• Occurrence of weakening of the test muscle in the tested areas

• Should be eliminated with a therapeutic bite

• If partial findings, especially in the lower spine, remain with a balanced bite, this indicates an additional disorder from below (a so‐called ascending pattern).

Extended Meersseman test

Includes some functional tests of the pelvis and upper cervical joints to differentiate descend‐ ing/ascending symptom patterns.

CMD treatment

Dental therapy

• Elimination of acute pain, inflammation triggers and local disturbance factors (if necessary support with bioresonance)

• Splint therapy

Repositioning of the lower jaw, thereby relieving the jaw joints, teeth and periodontium, muscular relaxation, harmonization of the masticatory plane and body axes‐restoration of a stable bite position.

Interdisciplinary co‐treatment

Orthopedics, physiotherapy, osteopathy, physical measures, psychotherapy with guidance on re‐ laxation techniques, self‐observation, feedback, changing stressful situations, movement patterns and postural habits.

This interdisciplinary treatment is rightly always demanded in the case of complex disorders, but is often difficult to implement in practice because appointments can often not be coordinated at short notice, especially in the case of acute complaints. Therefore, it makes sense to focus on the most comprehensive therapy that is possible from the main practitioner.

Supportive holistic healing methods

Acupuncture, Bioresonance, Craniosacral therapy / Osteopathy, Electroacupuncture, Homeopa‐ thy, Oral acupuncture, Neural therapy, Kinesiology, Orthomolecular medicine, Phytotherapy.

Bioresonance offers both the general therapist and the dentist very good possibilities for both causal and symptom‐related supportive therapy for acute pain conditions and chronic degenera‐ tive changes.

Another very helpful application is bioresonance for muscular relaxation before bite registration during prosthetic work.

Proven bioresonance programs for CMD

The classic 530 and 570, both H + Di, 52 kHz, with several indications Joints: 321, 391, 530, 531, 536

Metabolism: 530

Inflammation: 570

Nutrient points: 391, 530, 570, 801

Allergies: 530, 945, 977, 984, 997

Organs and tissues: 321, 391, 530, 531, 535, 921

Veg. & neurol. disorders: 535, 570, 571, 801, 921

At 52 kHz there are quite a few more programs, this frequency obviously has a profound and com‐ prehensive effect in the organism.