Craniomandibular Dysfunction

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Classification according to ICD-10
K07 Dentofacial abnormalities
(including improper occlusion)
K07.6 Craniomandibular Dysfunction (CMD)
Diseases of the temporomandibular joint
ICD-10 online (WHO version 2019)

Craniomandibular dysfunction or craniomandibular dysfunction ( CMD ), English Temporomandibular joint dysfunction ( TMJD ) , is an umbrella term for structural, functional, biochemical and psychological dysregulation of the muscle or joint function of the temporomandibular joints . These dysregulations can be painful or cause dizziness , headaches , sensitivity to light , panic attacks (racing heart) and stress in everyday life. Craniomandibular dysfunction can be both a cause and a consequence of stress. The German Society for Functional Diagnostics and Therapy defines CMD as a collective term for a number of clinical symptoms of the masticatory muscles and / or the temporomandibular joint and the associated structures in the mouth and head area. The exact diagnosis differentiates between: disorder of the chewing surfaces ( occlusopathy ), disorder of the masticatory muscles ( myopathy ) and disorder of the temporomandibular joint ( arthropathy ). In the narrower sense, it concerns pain in the masticatory muscles ("myofascial pain"), displacement of the cartilage disc in the temporomandibular joint ("disc displacement") and inflammatory or degenerative changes in the temporomandibular joint (" arthralgia , arthritis and arthrosis ").


In Germany, the term craniomandibular dysfunction has become established, a collective name for various musculoskeletal complaints in the craniomandibular system (chewing system), as well as cranio-vertebral dysfunction (CVD). In Switzerland the term myoarthropathy is preferred, in the English-speaking world Temporomandibular Disorders or Temporo-mandibular-Joint-Disease (TMDs, TMJ). The old name Costen Syndrome is outdated. The main point of contact for these symptoms is the dentist or the orthodontist , but many medical specialties are affected.

Classification systems

There are various classification systems, the Research Diagnostic Criteria for Temporomandibular Disorders (RDC / TMD) from 1992 having the greatest international distribution. Accordingly, a distinction is made between the following two areas ("axes"):

Axis I and axis II; Patient A: severe somatic complaints; Patient B: severe psychological complaints with minor somatic complaints
AXIS I (physical diagnoses)

Area I: Painful complaints in the area of ​​the masticatory muscles (especially mouth-opener and mouth- closing muscles )

  • Ia: Myofascial pain
  • Ib: Myofascial pain with restricted jaw opening

Area II: Anterior displacement of the articular disc

  • IIa: Anterior disc displacement with reduction with jaw opening
  • IIb: Anterior disc displacement without reduction when the jaw is opened, with limited jaw opening.
  • IIc: Anterior disc displacement without reduction when the jaw is opened, without restricted jaw opening.

Area III: arthralgia , activated arthrosis, arthrosis

  • IIIa: arthralgia
  • IIIb: activated osteoarthritis of the temporomandibular joint
  • IIIc: osteoarthritis of the temporomandibular joint
AXIS II (psychosocial diagnoses)
  • Pain-related impairments in daily activities
  • Depressive mood
  • Nonspecific somatic symptoms

In January 2014, an international group of experts published an extended classification of craniomandibular dysfunction. This includes the 12 diagnoses of the Diagnostic Criteria for Temporomandibular Disorders and also includes 25 less common diagnoses.


The incidence of CMD is around 8% of the total population, with only around 3% requiring treatment because of these complaints. Symptoms of CMD are rare in infancy, but the incidence increases until puberty. As with other pain disorders, women of childbearing age are affected significantly more often than men. After the menopause, symptoms often subside and CMD is relatively rare in old age.


A variety of symptoms can make diagnosis difficult. The jaw muscles or the jaw joints are often painful when chewing. Other symptoms can include:

  • Limited jaw opening
  • Cracking or rubbing of the temporomandibular joints when opening or closing the jaw
  • Radiating pain in the teeth, mouth, face, head, neck, shoulder or back, neck, spine and shoulder problems, restricted head rotation, headache
  • Sudden problems with the fit of the teeth.
  • uncomfortable earache
  • Tinnitus
  • dizziness
  • Cardiac arrhythmias
  • Chest pain (stinging in the chest caused by tension in the back)
  • difficulties swallowing
  • Eyes / visual impairment
  • migraine


The pathogenesis of craniomandibular dysfunction is based on ascending and descending symptoms. In the ascending chain z. B. Lateral deviation of the spine is transferred to the cervical spine and then to the temporomandibular joint. In the descending symptomatology, dental problems such as B. too high a crown, a wrong bite or a misaligned teeth on the temporomandibular joint, then transferred from there to the neck, the shoulder and the spine.

Since in most cases the causes are unclear, a multifactorial origin is suspected . Predisposing, triggering, and entertaining factors include biological, psychological, and social elements. Some of them are listed below, whereby new aspects will always arise in clinical and research:


The following procedure is currently recommended for diagnosing the CMD:

  1. A detailed consultation with a doctor using standardized questionnaires.
  2. A somatic examination of the jaw opening, masticatory muscles and temporomandibular joints (functional status).
  3. An instrumental functional analysis (API / CPI)
  4. An x-ray of the entire jaw (panoramic slice image) to rule out dental and oral surgical causes of the disease.
  5. Questionnaires for the identification of psychosocial impairments.

In the case of complex clinical pictures, complex apparatus, radiological or psychological procedures can be used in diagnostics and therapy, as well as other disciplines.

Differential diagnostics

Due to the large number of causes of pain in the head area, an interdisciplinary diagnosis is useful if the diagnosis is unclear. Diseases from a wide variety of medical specialties must be excluded and an intensive consultative assessment is then essential.


Bite splint for the upper jaw for the treatment of CMD (craniomandibular dysfunction)

The basic idea behind the treatment of CMD is a gentle and reversible approach. Scientifically recognized therapy concepts are used depending on the severity and individually tailored to the patient.

  1. Informing the patient about the context of the disease and making a correct diagnosis is the first and most important step in positively influencing the disease process. A cracking of the temporomandibular joint did not lead to pain in the temporomandibular joint, according to a study with 454 patients.
  2. Advice on self-treatment, such as soft food, stretching exercises , heat or cold applications, relaxation exercises or stress management , can help.
  3. An occlusion splint ( bite aid ) is often used by the dentist and can relax the chewing and head muscles and relieve the jaw joints. However, the benefit of the occlusion splint in CMD treatment has not been scientifically proven. Depending on the study, the effectiveness is proven or refuted.
  4. Sometimes pain-relieving, anti-inflammatory, muscle-relaxing or sleep -inducing drugs are necessary to stop the pain becoming chronic and to improve the quality of life.
  5. Transcutaneous electrical nerve stimulation (TENS) can help by relaxing the muscles and reducing pain.
  6. It is discussed whether trigger point infiltration of the muscles with various substances is useful and can bring lasting relief.
  7. Extensive dental restorations, orthodontic or surgical measures should only be used under the strictest indications.
  8. Targeted physiotherapy is used to regulate the muscle tone in the jaw and shoulder / neck muscles. The effects of posture deficits on the temporomandibular joint are corrected. The patient learns self-exercises to relax and prevent the increased muscle tone.

Botulinum toxin

The use of botulinum toxin for the treatment of bruxism ( grinding of teeth), craniomandibular dysfunction and for the optical thinning of the face is warned as it can lead to massive damage to the jawbone . Botulinum toxin is injected into the masseter muscle to reduce muscle tension. A period of three months between injections, which is usually observed, is not enough to regenerate the lost bone. In some cases, the results show that the jawbone no longer regenerates even in the long term. The bone loss can lead to tooth loosening - up to and including loss of teeth - and increases the risk of fracture of the jawbone.

See also


  • Jürgen Dapprich: Interdisciplinary functional therapy , temporomandibular joint and spine . Deutscher Zahnärzte Verlag, Cologne 2016, ISBN 978-3-7691-2320-3 .
  • Paul Ridder: Craniomandibular Dysfunction. Interdisciplinary diagnosis and treatment strategies . Elsevier, Urban & Fischer, Munich 2011, ISBN 978-3-437-58630-9 .
  • Rainer Schöttl: CMD: No fate! Get a grip on the CMD . MediPlus, 2011, ISBN 978-3-9812738-5-4 .
  • James P. Boyd, Wesley Shankland et al. a .: Taming of muscle forces that threaten daily dentistry. Muscle relaxation through trigeminal inhibition . Postgraduate Dentistry, 2000 ( [PDF] translation from the American).
  • Christian Larsen, Bea Miescher: Relaxed jaw: simply train away complaints. The best exercises from spiral dynamics . TRIAS, 2010, ISBN 978-3-8304-3833-5 .
  • Wolfgang Stelzenmüller, Jan Wiesner: Therapy of temporomandibular joint pain. A treatment concept for dentists, orthodontists and physiotherapists . 2nd Edition. Thieme, 2010, ISBN 978-3-13-131382-9 .
  • Siegfried Leder: Recognize and treat functional disorders . Spitta, 2010, ISBN 978-3-941964-17-4 .
  • Sylvana Skorna: CMD - the craniomandibular dysfunction. Interdisciplinary collaboration between physiotherapists and dentists in the treatment of patients with CMD . Publishing house Dr. Müller, 2010, ISBN 978-3-639-25911-7 .
  • Heike Höfler: Relaxation training for the jaw, neck and shoulders. 10 programs to let go and relax . TRIAS, 2010, ISBN 978-3-8304-3541-9 .
  • Christian Köneke: Craniomandibular Dysfunction. Interdisciplinary diagnostics and therapy . Quintessence, 2009, ISBN 978-3-938947-78-4 .
  • Rainer Schöttl: The Cranio-Mandibular Orthopedics . MediPlus, 2009, ISBN 978-3-9812738-0-9 .
  • Erich Wühr, Hardy Gaus, Holger Hüttermann, Gregor Pfaff, Ulrich Randoll, Martin Simmel: Craniofacial Orthopedics. An interdisciplinary concept for the diagnosis and therapy of patients with muscle and joint pain inside and outside the craniomandibular system . Systemische Medizin AG, 2008, ISBN 978-3-927344-89-1 .
  • Horst Kares, Hans Schindler, Rainer Schöttl: The slightly different headache and facial pain: Craniomandibular dysfunction CMD . Schlütersche, 2006, ISBN 978-3-89993-778-7 .
  • Horst Kares: Innovations in CMD treatment . In: Practice and Science . 13th year, (April). GZM, 2008 ( [PDF]).
  • Major M. Ash (Ed.): Splint Therapy. Evidence-based diagnosis and therapy for TMD and CMD . 3. Edition. Urban & Fischer, 2006, ISBN 3-437-05031-1 .
  • A. Hugger, H. Göbel, M. Schilgen: Facial and headache from an interdisciplinary perspective. Evidence on pathophysiology, diagnosis and therapy . Springer, 2005, ISBN 3-540-23052-1 .
  • Harry JM von Piekartz (Ed.): Jaw, face and cervical region. Neuromusculoskeletal examination, therapy and management . Thieme, 2005, ISBN 3-13-139231-2 .
  • Jürgen Dapprich: Functional therapy in the dental practice . Quintessence, 2004, ISBN 3-87652-348-6 .
  • Axel Bumann, Ulrich Lotzmann: Functional diagnostics and therapy principles (=  color atlases of dentistry . Volume 12 ). Thieme, 1999, ISBN 3-13-787501-3 .


  • Jeffrey P. Okeson: Management of Temporomandibular Disorders and Occlusion . 7th, revised edition. Mosby, 2012, ISBN 978-0-323-08220-4 .
  • Edward F. Wright: Manual of Temporomandibular Disorders . 2nd Edition. Wiley-Blackwell, 2008, ISBN 978-0-8138-1324-0 .
  • Andrew Blumenfeld, Steven D. Bender, Barry Glassman, Andres Pinto: Patterns of Use for an Enhanced Nociceptive Trigeminal Inhibitory Splint . No. 7 (December). AEGIS Communications, Inside Dentistry, 2011 ( [PDF]).

Web links

Individual evidence

  1. M. Oliver Ahlers: functional diagnostics - systematics and evaluation. ( Memento from April 13, 2012 in the web archive ) In: zm. 2/2004.
  2. ^ Lange, Ahlers, Ottl: Craniomandibular Dysfunction. ( Memento from July 24, 2012 in the web archive ) German Society for Functional Diagnostics and Therapy
  3. CC Peck, JP Goulet et al. a .: Expanding the taxonomy of the diagnostic criteria for temporomandibular disorders. In: Journal of oral rehabilitation. Volume 41, Number 1, January 2014, pp. 2-23, ISSN  1365-2842 . doi: 10.1111 / joor.12132 . PMID 24443898 .
  4. E. Schiffman, R. Ohrbach u. a .: Diagnostic Criteria for Temporomandibular Disorders (DC / TMD) for Clinical and Research Applications: recommendations of the International RDC / TMD Consortium Network * and Orofacial Pain Special Interest Group? In: Journal of oral & facial pain and headache. Volume 28, Number 1, 2014, pp. 6-27, ISSN  2333-0384 . PMID 24482784 .
  5. ^ D. Raab: Toothache and tube dysfunction simulated by craniomandibular dysfunction - a case report. In: Military Medical Monthly. 59 (12), 2015, pp. 396-401. (on-line)
  6. Specialist blog for dentistry
  7. Liverpool woman chewed gum for 4 hours a day and needs an operation to fix jaw | Daily Mail Online. April 2, 2017, Retrieved April 11, 2017 (The article reports that a medical specialist diagnosed a woman who consumed chewing gum for 5-7 hours a day).
  8. ^ Greg J. Huang, Tessa C. Rue: Third-molar extraction as a risk factor for temporomandibular disorder. In: Journal of the American Dental Association . Vol 137, No 11, Nov 2006, pp. 1547-1554. (abstract) ( Memento from July 11, 2012 in the web archive )
  9. DR Reissmann, MT John: Is temporomandibular joint cracking a risk factor for temporomandibular joint pain? In: pain. Volume 21, Number 2, pp. 131-138. (on-line)
  10. H. Forssell, E. Kalso, P. Koskela, R. Vehmanen, P. Puukka, P. Alanen: Occlusal treatments in temporomandibular disorders: a qualitative systematic review of randomized controlled trials. In: Pain. Volume 83, Issue 3, pp. 549-560. (on-line)
  11. KG Raphael, A. Tadinada u. a .: Osteopenic consequences of botulinum toxin injections in the masticatory muscles: a pilot study. In: Journal of Oral Rehabilitation. 41, 2014, p. 555, doi: 10.1111 / joor.12180 .
  12. Is Botox Safe and Effective for TMD? The TMJ Association, Retrieved June 13, 2016.