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Temporomandibular disorder (TMD) is a group of conditions involving the masticatory muscles, temporomandibular joint (TMJ), and associated structures of the head, neck, and cervical region. TMD may cause pain in the ear region and over the masseter muscle, restricted mandibular movement, and clicking or crepitus sounds in the temporomandibular joint. It may also be accompanied by cervical dysfunction, limited range of motion, pain, and postural abnormalities. Due to the close anatomical and functional relationship between the cervical region and the TMJ, disorders affecting one region are likely to influence the other. Alterations in the TMJ may lead to changes in the cervical spine and consequently affect proprioception. Head posture can be evaluated using the craniovertebral angle. Increases or decreases in this angle may reflect changes in anterior head tilt. Cervical impairments associated with TMD may also result in alterations in the craniovertebral angle. Therefore, the aim of this study is to compare cervical joint position sense, pressure pain threshold of the masticatory muscles, and craniovertebral angle values between individuals with TMD and healthy controls.
Temporomandibular disorder (TMD) is a condition affecting the temporomandibular joint (TMJ), masticatory muscles, and associated structures. Patients with TMD may present with a variety of symptoms, including pain, headache, joint locking, limited mouth opening, and joint sounds. Because the cervical vertebrae are anatomically and functionally connected to the cranium and masticatory structures through neurovascular components, muscles, and joints, alterations in one region may influence the other. Shortening of the cervical extensor muscles and the sternocleidomastoid muscle may contribute to the development of a forward head posture, which is associated with increased cervical lordosis. The primary clinical manifestation of TMD is pain related to mandibular movement limitation and joint sounds during function. In addition, TMD-related pain has been reported to be associated with increased psychological distress, autonomic dysfunction, motor impairments, balance deficits, and sleep disturbances. The craniovertebral angle is defined as the angle formed between a horizontal line and a line connecting the tragus of the ear to the spinous process of the seventh cervical vertebra . It is widely used to assess head posture. In a study evaluating cranio-cervical posture using lateral radiographs, Joy et al. reported that individuals with TMD had significantly greater craniovertebral angles than healthy individuals. Proprioception is the ability to perceive joint position and movement without visual input and plays an essential role in maintaining postural balance. Proprioceptors are particularly abundant in the cervical region. Damage or dysfunction affecting the cervical spine may disrupt proprioceptive input, leading to altered head and body position, impaired postural reflexes, and deficits in balance and gait. Based on the current literature, no previous study has simultaneously compared cervical joint position sense, craniovertebral angle, and the pressure pain threshold of the masticatory muscles between individuals with TMD and healthy controls. Therefore, this study was designed to investigate these parameters comprehensively and to contribute to the existing literature.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| temporomandibular dysfunction group | The study sample will consist of individuals with temporomandibular disorder and healthy controls from the Faculty of Health Sciences at Ankara Yıldırım Beyazıt University. Individuals who voluntarily agree to participate will be included in the study. | ||
| Healthy group | The study sample will consist of individuals with temporomandibular disorder and healthy controls from the Faculty of Health Sciences at Ankara Yıldırım Beyazıt University. Individuals who voluntarily agree to participate will be included in the study. |
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| Measure | Description | Time Frame |
|---|---|---|
| pain threshold | Pressure pain threshold (PPT) of the temporalis and masseter muscles will be assessed using a digital algometer (J-Tech Commander Algometer, Preston Co., USA), an objective measurement device. Participants will be instructed to lie comfortably in the supine position. To familiarize them with the sensation of pressure, pressure will first be applied to an area that is not included in the assessment. During the evaluation, participants will be instructed to raise one hand when the applied pressure first becomes uncomfortable or painful. The algometer will then be applied perpendicularly to the predetermined assessment points: bilaterally over the masseter muscle (1 cm superior and 2 cm anterior to the mandibular angle) and bilaterally over the temporalis muscle (2 cm superior to the zygomatic arch, between the lateral canthus of the eye and the anterior aspect of the ear). The value displayed on the algometer at the moment the participant reports pain will be recorded in kg/cm². A one-m | Day 1 |
| pain intensity | Pain associated with TMD will be assessed using the Visual Analog Scale (VAS). Participants will be asked to indicate the intensity of pain perceived in both temporomandibular joints (TMJs). The VAS, developed by Max Freyd, is one of the most widely used methods for pain assessment. It consists of a 100-mm horizontal line with two anchor points representing the extremes of the parameter being measured. Participants will be instructed to mark the point on the line that best reflects their perceived pain intensity. They will be informed that 0 cm represents "no pain" and 10 cm represents "the worst imaginable pain." | Day 1 |
| sense of joint position in the cervical region | Joint position sense (JPS) will be assessed using an Acumar Dual Digital Inclinometer® (Acu360, Acumar, Lafayette, IN, USA). Cervical joint position sense will be evaluated during flexion, extension, right and left lateral flexion, and right and left rotation at a target angle of 30°. This target angle was selected based on the normal range of cervical motion to minimize the influence of soft tissue tension surrounding the joint on joint position sense. First, the examiner will position the participant at the target angle, where the position will be maintained for 2 seconds to allow the participant to memorize it. The participant will then be passively returned to the neutral position and instructed to actively reproduce the target angle. Each movement will be performed three times with the participant's eyes closed, and the mean value of the three trials will be used for analysis. |
| Measure | Description | Time Frame |
|---|---|---|
| craniovertebral angle | The craniovertebral angle will be measured using digital image analysis of a lateral-view photograph obtained while each participant is seated on the same standardized chair. Participants will be instructed to sit comfortably with their thoracic and lumbar regions in contact with the backrest, their eyes facing forward, and both feet placed flat on the floor with the knees flexed at 90°. To facilitate image analysis, a reflective marker will be attached over the spinous process of the seventh cervical vertebra (C7) using adhesive tape, and the tragus of the ear will be clearly visible in the photograph. The C7 spinous process will be identified by palpation during active cervical rotation. The images will be analyzed using Kinovea software (version 0.8.15). The craniovertebral angle will be defined as the angle formed between a horizontal line passing through the C7 spinous process and a line connecting the C7 spinous process to the tragus of the ear. |
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Inclusion Criteria:
Temporomandibular dysfunction group:
Healthy group:
Exclusion Criteria:
Temporomandibular dysfunction group:
Healthy group:
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Ankara Yıldırım Beyazıt University Faculty of Health Sciences
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| Name | Affiliation | Role |
|---|---|---|
| Emine Kübra AY | Ankara Yildirim Beyazıt University | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Ankara Yıldırım Beyazıt University,Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation | Ankara | Turkey (Türkiye) |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 2755707 | Background | Ohrbach R, Gale EN. Pressure pain thresholds in normal muscles: reliability, measurement effects, and topographic differences. Pain. 1989 Jun;37(3):257-263. doi: 10.1016/0304-3959(89)90189-9. | |
| 30198391 | Background | Ozdinc S PhD, Ata H MSc, Selcuk H MSc, Can HB MSc, Sermenli N MSc, Turan FN PhD. Temporomandibular joint disorder determined by Fonseca anamnestic index and associated factors in 18- to 27-year-old university students. Cranio. 2020 Sep;38(5):327-332. doi: 10.1080/08869634.2018.1513442. Epub 2018 Sep 8. |
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Individual participant data will not be shared due to privacy and confidentiality concerns.
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| ID | Term |
|---|---|
| D013705 | Temporomandibular Joint Disorders |
| D010146 | Pain |
| ID | Term |
|---|---|
| D017271 | Craniomandibular Disorders |
| D008336 | Mandibular Diseases |
| D007571 | Jaw Diseases |
| D009140 | Musculoskeletal Diseases |
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| Day 1 |
| Day 1 |
| Background | Akbaş, E., Erdem, E. U., & Ünver, B. (2019). Depresyon düzeyinin boyun ağrısı, eklem hareket açıklığı ve servikal eklem pozisyon hissine etkisi. Sağlık Bilimleri ve Meslekleri Dergisi, 6(3), 555-563. |
| Background | Zárate-Tejero, C. A., Rodríguez-Rubio, P. R., Brandt, L., Krauss, J., Hernández-Secorún, M., Hidalgo-García, C., & Lucha-López, O. (2024). Measuring Craniovertebral Angle Reference Values in Adults Using Kinovea Software. Applied Sciences, 14(19), 8639. https://doi.org/10.3390/app14198639 |
| 25883964 | Background | Wieckiewicz W, Wozniak K, Piatkowska D, Szyszka-Sommerfeld L, Lipski M. The diagnostic value of pressure algometry for temporomandibular disorders. Biomed Res Int. 2015;2015:575038. doi: 10.1155/2015/575038. Epub 2015 Mar 26. |
| Background | Iunes, D. H., Carvalho, L. C. F., Oliveira, A. S., & Bevilaqua- Grossi, D. (2009). Craniocervical posture analysis in patients with temporomandibular disorder. Brazilian Journal of Physical Therapy, 13, 89-95. 13-) Oliveira, S. S. I., Pannuti, C. M., Paranhos, K. S., Tanganeli, J. P. C., Laganá, D. C., Sesma, N., |
| 31516098 | Background | Joy TE, Tanuja S, Pillai RR, Dhas Manchil PR, Raveendranathan R. Assessment of craniocervical posture in TMJ disorders using lateral radiographic view: A cross-sectional study. Cranio. 2021 Sep;39(5):391-397. doi: 10.1080/08869634.2019.1665227. Epub 2019 Sep 13. |
| 19142553 | Background | Cuccia A, Caradonna C. The relationship between the stomatognathic system and body posture. Clinics (Sao Paulo). 2009;64(1):61-6. doi: 10.1590/s1807-59322009000100011. |
| 32872670 | Background | Cuenca-Martinez F, Herranz-Gomez A, Madronero-Miguel B, Reina-Varona A, La Touche R, Angulo-Diaz-Parreno S, Pardo-Montero J, Del Corral T, Lopez-de-Uralde-Villanueva I. Craniocervical and Cervical Spine Features of Patients with Temporomandibular Disorders: A Systematic Review and Meta-Analysis of Observational Studies. J Clin Med. 2020 Aug 30;9(9):2806. doi: 10.3390/jcm9092806. |
| 32813383 | Background | Balthazard P, Hasler V, Goldman D, Grondin F. Association of cervical spine signs and symptoms with temporomandibular disorders in adults: a systematic review protocol. JBI Evid Synth. 2020 Jun;18(6):1334-1340. doi: 10.11124/JBISRIR-D-19-00107. |
| 36277551 | Background | Wadhokar OC, Patil DS. Current Trends in the Management of Temporomandibular Joint Dysfunction: A Review. Cureus. 2022 Sep 19;14(9):e29314. doi: 10.7759/cureus.29314. eCollection 2022 Sep. |
| 35339331 | Background | Tran C, Ghahreman K, Huppa C, Gallagher JE. Management of temporomandibular disorders: a rapid review of systematic reviews and guidelines. Int J Oral Maxillofac Surg. 2022 Sep;51(9):1211-1225. doi: 10.1016/j.ijom.2021.11.009. Epub 2022 Mar 23. |
| 25822556 | Background | Gauer RL, Semidey MJ. Diagnosis and treatment of temporomandibular disorders. Am Fam Physician. 2015 Mar 15;91(6):378-86. |
| D007592 |
| Joint Diseases |
| D009135 | Muscular Diseases |
| D009057 | Stomatognathic Diseases |
| D009461 | Neurologic Manifestations |
| D012816 | Signs and Symptoms |
| D013568 | Pathological Conditions, Signs and Symptoms |