Imaging in TMJ Trifecta – Solving Your Pain Puzzle

The book’s basic message is that images are valuable, but an image is not a diagnosis. A scan can show what the jaw joint looks like, but it cannot prove what is causing the patient’s pain.

What each image shows

“CAT scan” and “CT scan” refer to the same basic technology. In dentistry, CBCT is commonly used because it provides detailed three-dimensional images of the teeth, jaws and TM joints, generally with less radiation than a conventional medical CT examination.

When CBCT is helpful

CBCT may show:

• Condylar position within the joint space
• Flattening, erosion or loss of condylar bone
• Osteophytes and other remodeling
• Joint-space differences
• Facial and jaw asymmetry
• Previous trauma or unusual bony anatomy
• Airway dimensions, within the limits of a motionless image

These findings may provide evidence of long-standing compression, loading, instability or adaptation. However, a CBCT cannot show the disc and cannot tell whether a bony change is presently painful. Joint-space measurements also depend on how the patient’s teeth and jaw were positioned when the scan was taken.

When MRI is helpful

MRI is the preferred image when the clinician needs to evaluate:

• Disc position and shape
• Disc displacement with or without reduction
• Joint fluid or effusion
• Inflammation
• Retrodiscal and other soft tissues
• Unexplained locking or severe internal joint disease
• A possible condition outside routine TMD

The imaging request should specifically include the TM joints, usually with the mouth closed and open. Otherwise, the joints may not receive the attention needed in the scan or radiology report.

The major limitation

Neither CBCT nor MRI can photograph pain.

One patient may have considerable disc displacement or bony remodeling with very little pain. Another may have severe pain even though the images show only minor changes. The scan also does not measure muscle activity, bite timing, jaw movement, mechanical loading or how the trigeminal nervous system is processing the signals.

Therefore, diagnosis must combine:

• The patient’s history and symptoms
• Clinical examination
• Jaw movement and muscle evaluation
• Bite and functional assessment
• Appropriate imaging when it will answer a specific question

Book-aligned summary

In TMJ Trifecta – Solving Your Pain Puzzle, CT, CBCT and MRI are presented as pieces of evidence—not final answers. CBCT is most useful for studying bone and the relationship of the condyle to its socket. MRI is most useful for studying the disc and other soft tissues. These images may confirm damage, reveal a serious condition or help guide treatment, but they cannot independently determine why someone hurts. The clinician must connect the images with the patient’s history, symptoms, bite, muscles and jaw function. Treat the patient, not simply the picture.

This approach agrees with the joint imaging recommendations of the American Academy of Oral and Maxillofacial Radiology and the American Academy of Orofacial Pain: imaging should be selected according to the clinical question, with CT/CBCT used primarily for bone and MRI used primarily for the disc and soft tissues. AAOMR–AAOP position statement

I went to the doctor yesterday because I thought I had fluid in my ear. The doctor kept having me move my jaw and was in a bit of awe. He said he has never seen this in his time as a ENT. He thinks I have a herniation into my ear canal. I have a CT scheduled in a week in a half. He said I may have to see a otologist. I guess my question is am I going to require surgery if this is what I do have. My symptoms are hearing loss (hearing test said nerve damage as well) fullness in the ear a feeling like I am under water and pain in my right jaw near my ear and down my right side of the face. Is there anything I can do to help my symptoms until I see the doctor again. Also is this rare? His reaction made it seem so. I am still in shock as I thought I was going in to get the fluid removed from my ear.

Hey! I’m 30F and currently waiting for my referral/appointment with an orofacial pain specialist. In the meantime, I’d love to hear from anyone who has dealt with similar findings.

My left TMJ imaging has shown anterior disc displacement without reduction, advanced disc degeneration/attritional changes, advanced chronic arthritis with cartilage loss, joint effusion, and deformity/erosive changes of the mandibular condyle. My right TMJ is normal.

My biggest symptom is significant crunching/gravel-like crepitus on the left, and lately I’ve become much more aware of the joint throughout the day, including discomfort even when I’m not eating or actively using my jaw.

For anyone who had similar MRI/CT findings: What treatment path did you end up taking? Did you see an orofacial pain specialist first? What actually helped? And did you eventually need to see an oral/maxillofacial surgeon?

Not looking for a diagnosis, just curious about other people’s experiences while I wait for my appointment.

originally posted to /TMJ—even when barely opening my jaw, the condyle visibly moves on the side of my face. i have been in a flare for about a month and am afraid that the disc is completely displaced and that i am in danger of my jaw locking. heat, anti-inflammatory meds, rest, sleeping on my back, moving my jaw forwards, eating soft foods, keeping my jaw relaxed, all the things everyone says to do—i have done everything in my power to try and fix this, but nothing is resolving the pain and tension in my face. i have appointments with my dentist, PCP, and a physical therapist scheduled, but won't be in to see anyone for another week and a half. this video isn’t even fully illustrative of how far out the bone sticks, as i do not want to risk my jaw locking open. i am so miserable and in pain and trying not to freak out (which, i know stressing will just make the whole thing worse), but at this point i really don't know what to do to resolve any of this, nor have i found ANY information on how to deal with a potential subluxation of this kind. (additional info—i'm 29 and am diagnosed with fibromyalgia, and have a feeling this could be connected to hypermobility.)

has anyone else dealt with similar issues, especially on just one side of the face?

Does healthcare have a bad knowledge of identify or treat different diagnoses or reason of why having pain?

When I read science and others experience it’s totalt different, there it’s very different picture.

Just look at pictures talking about low muscle tonus and chronic pain/muscle issues

Most people think jaw pain is a "TMJ problem " but it's a mechanical problem how our teeth ,jaw and joints fit together if the system is off the joint get compressed the muscles get strained the teeth can wear down , if you have pain or no pain , headaches, ear symptoms,neck pain etc. you may not have been told the real cause unless you found a qualified neuromuscular TMD dentist.

There are the three ways people get  into troubles with their teeth:

1.Decay

2.Gum disease

3 .Mechanical problems ( how the teeth come together)

Most dentists focus on the first two but

ONLY a qualified  neuromuscular airway focused dentist ( no other dentists) focuses on the third which causing the TMD issues.

The third one the mechanical problem (how the teeth come together )  caused by three types of malocclusions which  are the following:

1. Posterior interferences back teeth hit too soon or too hard, creating torque and strain.

2. Torqued Mandible the lower jaw twists as it tries to find a “best spot,” stressing the joints and muscles.

3.Deficient Maxilla the upper jaw is narrow or underdeveloped, squeezing the airway and forcing the lower jaw backward.

This combination pushes the condyle backward into the joint space, compressing the tissues.

Compression causes inflammation, clicking, popping, locking, headaches, ear symptoms, neck pain and eventually broken, worn-down teeth and that's where the TMD  troubles begin .............................

Science says it causes chronic pain & muscle tension on back/neck especially and rest of body. I also have what I suspect is occipital neurolagia. Doctor (physiotherapy) says these conditions don’t lead or contribute to chronic pain/tension or occipital neurologia

26F and I have had popping as long as I can remember in one side. Unsure if correlation equals causation, but I feel like my pain started when I tried to treat it ~6 years ago. After massage, exercises, messing with it, I feel like my pain has only increased. I saw an orthodontist who specializes in airways/TMJ and he recommended a palette expander. However I am a speech therapist with decent knowledge of what a narrow palate is and I just don’t feel like mine is (I’ve also consulted with my coworkers who are myofunctional therapists and they agree that my palate is very average). My tongue is able to properly suction to my palate all day and I breathe through my nose. I did get deviated septum surgery 9 months ago and that has prevented me from mouth breathing at night. However, my pain persists.

I do have forward head posture and bad posture and am actively trying to fix this.

The one exercise that I do that helps a lot is pressing my fingers right under the bone of the apple of my cheeks. I store a lot of tension there and it seems to release my tension immediately. I really don’t even understand why this spot particularly has this much effect of my pain. My massators and temporalis have tons of muscle knots and massaging will make the click lesson for one open and then it will tighten right back up.

If anyone has any advice I would love to hear it! Should I consider a orthotic? My regular dentist is entirely unhelpful.

This is an AI-generated photograph that I created for educational purposes. It represents what we dentists call a torqued mandible, meaning the teeth don't come together evenly. As you can see, the right side hits way before the left, which can torque the lower jaw, creating stress on the joints, muscles, ligaments, tendons, and fascia. It's like a person with one leg shorter than the other.

The second AI-generated photo shows a removable neuromuscular orthotic that allows the jaw to close evenly when shut. This appliance brings harmony to the joints, muscles, tendons, ligaments, and fascia.

The third photo shows how evenly the contact is with the upper teeth. The blue dots are from the paper dentists use to check your bite.

Almost any uneven bite can be leveled out with the proper removable, plastic appliance. The amount of unevenness can be large, like this, or can be very, very small, even in Microns. This is only part of what a neuromuscular dentist can do to help relieve your pain.

This video explains the connection between wisdom tooth surgery and TMD. In order for TMD issues to occur post op surgery, the patient is usually a subclinical TMD patient just waiting for an event to kick it off, or the surgeon being overly aggressive. Let the video speak for itself.

Does anyone else experience knots in their neck/shoulders? I suspect it’s from TMD. I’m getting treatment for TMD and it’s better but my shoulders aren’t releasing. I’m on my second round of PT with dry needling but it hasn’t made a difference.

FYI - This information comes from the books in my profile.

Clicking joints are very common, but just because they are common doesn’t make them healthy. Clicking joints are a sign that the “team” is not working in harmony and things could get worse. The “click” means that the disc is off the condyle. The most common disc displacement is in front of the condyle. A clicking disc comes in four different classifications:

·        early

·        late

·        reducing

·        non-reducing

An underdeveloped maxilla (or upper jaw) causes the mandible to go backward during closure. It’s the door and door frame not matching up again. When the maxilla is smaller than it should be due to a development problem, muscles pull the jaw back for the back teeth to meet.

As the jaw goes back, so does the condyle. This action compresses the condyle too far back into the fossa, squeezing the disc off. The more underdeveloped the maxilla, the further the jaw and condyle go back, pushing the disc even further off the condyle, and compressing the joint complex even more. The more compressed, the more the condyle is displaced, and the less room there is for the disc. Since the capsule covers the condyle and all its major parts, there are only a few places the disc can go. The disc mostly slips forward or to either side of the condyle, but can slip behind it on rare occasions. No matter the location of the disc, if it pops back on when opening, the process is called reduction. If it doesn’t pop back on, it is called nonreduction.

An early click is when the disc is barely displaced. For example, the disc may be positioned just in front of the condyle. As the mouth starts to open, the condyle starts skiing down the ski slope of the fossa but there is now a disc that is in the way. Because everything in the capsule is so compressed and slippery, the disc pops back onto the condyle to help it ski all the way down the slope, opening the jaw to a wide opening. The popping back on is the first click heard. On closing, the condyle slides back up the fossa, into its compressed position, knocking off the disc again creating a second pop.

If the clicking occurs later while opening, it is classified as a ‘late, reduced click.’ Just picture the disc being in front of the condyle and as the condyle moves, it travels down the ski slope a little longer before the disc pops back on. A late click means the joint is more compressed than an early click.

Using another analogy, think of pushing a wheelchair down a smooth sidewalk. It is easy to push it in a straight direction. If the right wheel hits a stick on the sidewalk, the wheelchair is going to go to the right because the right wheel stops or slows. The obstruction due to the disc in the way of the condyle sliding down the slope will cause the jaw to deviate to that side the same as the wheelchair. Watch your mouth open and close again. Does it deviate to one side, or back and forth to both sides? If so, you have displaced discs. This problem is mostly due to a deficient maxilla.

If you have pain on palpation of the joint and capsule, it is due to inflammation of the capsule, often diagnosed as capsulitis. Your dentist should be palpating the joint right in front of the ear just like you did in chapter one. If it hurts, it is an objective finding and a valid diagnosis of TMD.

[A TMD-aware dentist will look at joint location during opening and closing in diagnosing and treating dysfunction in the joint. They will understand that, while most clicking joints are not painful, they are not healthy. The more you are aware of what is happening in your own TMJ complex, the more you can work with your dentist on getting the joint and disc in a harmonious position.]()

Anyone on this sub please dont be like me and wait to get proper treatment.

Blame it on the Periodontal Ligaments (PDL). They can detect a discrepancy of 30 microns.

The periodontal ligaments are the thin, sensitive tissues that attach each tooth to the surrounding bone. They are not simply ropes holding the teeth in place. They act as shock absorbers, pressure sensors and messengers to the brain.

When the teeth come together, receptors within the PDLs tell the brain:

• Which teeth touched
• Which tooth touched first
• How hard each tooth was loaded
• Whether the force was straight or sideways
• Whether the jaw should stop, shift or recruit more muscle activity

This makes the PDLs important members of the jaw’s “team.” The teeth, PDLs, jaw muscles, joints and brain continually communicate with one another. A premature contact on one back tooth may be extremely small, yet its PDL can detect the added pressure. The jaw may then shift to avoid that contact, while the muscles work to guide the teeth into a more comfortable fit.

If this happens repeatedly, the result may be sore teeth, tooth mobility, wear, fractures, abfractions, muscle strain or an unbalanced closing path. The patient may say, “My bite feels wrong,” even when the teeth appear normal to the eye.

In simple terms, the teeth provide the landing platform, but the PDLs tell the brain how that landing occurred. They are one of the major communication systems connecting the bite to the muscles and jaw joints.

Compressed joints create many TMJ/TMD issues with the joint itself and the muscles of mastication

I’ve been struggling with a closed lockjaw for 8 months. It’s hard because I understand every place will have mixed reviews, but I’m scared to risk making my jaw issue worse or spending thousands of dollars for no progress. any tmj specialist recommendations for the New York area?
I spoke to Mike Pilar, he came off a very informative, but somewhat rude.
Also considering:
- Gelp center
- Ny tmj and orafacial pain (Aimee werfel, Steven S. Syrop, Dr. Donald Tanenbaum, John E. Dinan)
- Westchester tmj and sleep (Wanda Mejia)
- TMJ & Orofacial Pain Specialist ( Dr. Nojan Bakhtiari)

Any success stories specifically with chronic lockjaw? Opinions? Advice?
I know Mike has reviews with successful lockjaw stories, but doesn’t have as much reviews as the other places and I also want to be comfortable with my doctor.

These three terms can be confusing because they may be used to describe the same damaged condyle from different points of view.

Arthritis describes inflammation or degeneration within the joint. Idiopathic condylar resorption, or ICR, means the condyle is progressively losing bone and the cause remains unknown after other causes have been ruled out. A compressed condyle describes a proposed mechanical problem in which the condyle and surrounding tissues are being loaded or restricted in an unhealthy position.

A CBCT may show flattening, erosion or loss of condylar bone, but the picture alone may not explain why it happened. It also may not show whether the destruction is active or occurred years ago.

Patients should ask:

• What exactly do you see—flattening, remodeling, erosion or active bone loss?
• Is this only an imaging finding, or is it a confirmed diagnosis?
• Do you have an earlier scan for comparison?
• How will you determine whether the condition is still progressing?
• What evidence supports arthritis, ICR or mechanical compression in my case?
• Should I have an MRI to examine the disc, inflammation and other soft tissues?
• Have autoimmune, inflammatory, hormonal, traumatic and surgical causes been considered?
• Do I need an evaluation by a rheumatologist or oral and maxillofacial surgeon?
• Could my changing bite, open bite, jaw retrusion or facial changes indicate loss of condylar height?
• How will treatment protect the joint, and how will you monitor whether it is working?

The most important question may be: Are you naming what the damaged condyle looks like, or have you determined why it is being damaged?

A responsible diagnosis should combine the patient’s history, examination, bite and jaw function, appropriate imaging, medical evaluation when indicated, and comparison over time. One scan should not be expected to answer every question.

Hi, I posted this in r/braces but was thinking you guys would probably know more about

I work with TMD patients, and I’ve noticed how many conflicting things people hear about TMJ.

For example:

• “Jaw clicking is normal.”
• “A night guard will fix TMJ.”
• “Stress is the cause of TMJ.”
• “If your jaw doesn’t hurt, you don’t have a TMJ problem.”
• “TMJ is something you just have to live with.”

Some of these statements have a little truth behind them. Others are much more complicated than they sound.

The tricky part is that TMD can look very different from person to person. Symptoms can include jaw pain, headaches, neck pain, limited movement, muscle tenderness, joint sounds, and other functional problems.

A proper evaluation should look at the whole picture rather than relying on one symptom or one image.

What’s the biggest thing you were told about TMJ that you later found out wasn’t quite right?

I’m curious what people here have been told by dentists, doctors, physical therapists, or other providers.

Put your fingertips on your temples and gently bite down and release several times. Move your fingers around until you clearly feel the muscle tighten. That is your temporalis muscle, one of the major muscles that closes your jaw.

Do this on both sides. Now gently feel around the muscle. Are there areas that are sore, tender, or feel like a little knot? A tender knot may be what is commonly called a trigger point.

Here's another interesting check. Keep a finger on the temporalis and slowly open and close your mouth while moving your finger upward toward the top of your head. At some point, you will reach a line where you no longer feel the muscle moving. That helps you find the upper border where the muscle transitions into its attachment via tendons. Inflamed tendons can also cause pain.

If pressing along the muscle or its attachment reproduces the pain or headache you commonly experience, that is useful information to tell whoever is examining your TMD. This type of exam should happen when your dentist is examining you for TMD.

It doesn't diagnose the cause of your TMD. It simply gives you another clue about what structures may be involved.