Braz J Oral Sci. July/September 2004 - Vol.

3 - Number 10

Temporomandibular disorder and

dysfunctional breathing

Eliane C. Rodrigues Corrêa 1

Fausto Bérzin 2 Abstract
1
Professor of Physiotherapy Department in
This article studied the relationship among respiratory, masticatory
the Federal University of Santa Maria – RS
and cervical muscles and the factors that contribute for TMD. It
2
DDS, PhD, Professor of Piracicaba Dental
School, State University of Campinas consists in a review of studies approaching dysfunctional breathing
and TMD, enclosing mouth breathing syndrome, anxiety, respiratory
mechanics changes, diaphragmatic muscular dystonia and overuse of
accessory inspiratory muscles. It also stresses the importance of
breathing evaluation and the multiprofessional intervention in the TMD
patients.
Received for publication: January 30, 2004
Accepted: March 2, 2004
Key Words:
temporomandibular disorder, temporomandibular joint, breathing,
respiratory muscles.

Correspondence to:
Eliane C. Rodrigues Corrêa
Physiotherapy Department Federal
University of Santa Maria – RS
Rua Tuiuti 2462/803,
Santa Maria, RS, CEP 97050420
e-mail: [email protected]

498
Braz J Oral Sci. 3(10): 498-502 Temporomandibular disorder and dysfunctional breathing

Introduction The accessory inspiratory muscles, as integrants of the

The ventilatory function involves more than thoracic and anterior cervical chain, are also linked with the stomatognatic
abdominal movements and this should be understood as an system. The hyperactivity of the sternocleidomastoideus
integrated system, with muscular actions significantly (SCM) muscle determines a posterior cranial rotation with
affected in no-physiologic conditions. Hruska1 studied the mentum anteriorization, tension in the muscles supra and
influence of breathing pattern in the rest mandibular position infra-hyoid, lowering of the tongue and posterior rotation of
and the alignment craniocervical, demonstrating that the jaw.
alterations of body posture, upper thoracic breathing pattern The relationship among the masticatory and cervical muscles
and mouth breathing constitute causal factors for the has being studied, by means of electromyography. Boyd et
overuse of the accessory inspiratory musculature, that al.4 verified an increase of the masseter muscle activity and
generates hyperactivity and, consequently, alteration of reduction of the temporal (anterior portion) muscle activity
head position, and mandibular traction. during flexion of the head and, the opposite during the
The causes for the overuse of this musculature can be related extension. Zuniga et al. 5 demonstrated, that the
to body posture, upper thoracic breathing pattern, mouth sternocleidomastoid (SCM) and trapezius muscles became
breathing and neuro-psychological stress. more actives with the occlusion in retrusive contact. The
In the present article, we will discuss each one of these topics SCM muscle became inactive during the deep nasal
and their relationship with Temporomandibular disorder inspiration in individuals with diaphragmatic breathing
(TMD), besides the relationship among the cervical, pattern and active during nasal and oral inspiration in
masticatory and respiratory muscles. individuals with thoracic breathing pattern6. The increased
electric activity of the SCM muscle is considered the main
Cervical, Masticatory and Respiratory Muscles decisive factor for head forward posturing,
The stomatognatic system muscles are part of the temporomandibular disorder and craniofacial pain.
cervical muscular chain, being an integrant part of the The diaphragm, the most important inspiratory muscle, has
postural system. The tongue and the jaw are integrated its function dependent on its morphology, that is, dome-
into the anterior muscular chain and the maxila is tied shaped, which position influences the thorax mechanics and
up to the posterior muscular chain. The hyoid bone is the posture in the lumbar and cervical areas. Its cylindrical
the pivot among the anterior and posterior muscular aspect, that opposes to the lower rib cage, constitutes the
chains 2 . apposition zone. Accessory respiratory muscle overuse is
TMD occurs due to an unbalance between the extensor and also influenced by the diaphragm position and changes in
flexor muscles of the head and the masticatory, supra and the zone of apposition. When the zone apposition decreases
infrahyoid muscles (Fig.1). due to reduction of the intra-abdominal pressure, there is an
alteration of the anterior cervical muscles and fascia alignment
as a result of the forward, outside and upward displacement
of the anterior rib cage. This situation contributes to the
development of the forward head posturing and posterior
cranial rotation1.

Dysfunctional Breathing Pattern

The respiratory dysfunctional mechanics, with excessive use
of the breathing musculature accessory contributes to
craniofacial pain. The decisive factors of this condition can be:

a)Tension/anxiety
The stress increases the neuro-muscular tonus and it tends
to increase the shortening and the stiffness of the breathing
muscles.
The thorax blocked in inspiratory position is a body attitude
of nervous individuals, with emotional and organic
instability 7-8. This situation reduces the thorax and the
diaphragm mobility.
In the oriental culture, the human being, due to breathing
Fig. 1: Muscular balance of head and neck. M, masseter muscle; E,
neck extensors muscle; SCM, sternocleidomastoideus muscle; T, tem- control, the individual has higher domain of the body,
poral muscle; IH, infrahyoid muscles. (From Friedman and Weisberg3) emotions and vital energy. In the western culture, breathing

499
Braz J Oral Sci. 3(10): 498-502 Temporomandibular disorder and dysfunctional breathing

is responsible for the psyco-physical balance. The mouth the thorax to relax through out and it limits the amplitude of
and superficial breathing, as an anxiety symptom, is a the diaphragm movements.
controllable phenomenon in the psychomotor instability There is also a direct relationship among facial musculature
moments9. Emotional alterations can cause rapid breathing and clavicular breathing, because this breathing pattern
and reduction in the amplitude of diaphragmatic movement. provokes cervical contractions that dissipate to face, causing
The muscular tensions accumulated progressively block the hypertonia of chewing muscles, muscle pain and alterations
diaphragmatic action, according to Campignion8, because in temporomandibular joint function13.
this is one of the first muscles affected by emotions, as
melancholy, fear, anguish cholera. Only happiness can
liberate it.

b) Upper thoracic breathing pattern (breathing effort

increased)
The upper thoracic breathing pattern occurs due to an
increased inspiratory effort, with higher activity of the SCM
muscle, which produces a posterior cranial rotation. This
change in head posturing intensifies the inspiratory effort,
settling down a vicious cycle of dysfunctional breathing.
Several authors have investigated the breathing pattern in
the evaluation of TMD. It happens mainly due to the intense
action of accessory inspiratory muscles. When the SCM
muscle acts in inspiration, it stops exercising its primary
function of flexor of the head, causing protrusion of this and
decrease of the neck movements. There is also more energy
waste with reduction of mechanical work, when exercising a
secondary function10.
The accessories inspiratory muscles are spinal, thoracic, neck
and scapular. The spinal muscles (scalene, intercostal,
superior and medium trapezius, minor pectoral, mayor
pectoral) are anti-gravity tonic muscles. A length loss in these Fig. 2: Diaphragm tendon shortening with diaphragmatic
hyperlordosis, short nape and forward head (Souchard 11)
muscles modifies the position of the nape, shoulders and
dorsal column and, in the same way, the incorrect posturing
of cervical column, scapular waist and spine favors their c) Mouth Breathing Syndrome
stiffness and this promotes an inspiratory deficit11. The head extension, characteristic of mouth breathers,
involves the jaw lowering and the tongue descent to the
The inspiratory pattern produces thoracic deformities, with mouth floor, what is an ethyological factor of dental
elevation of the lower ribs due to diaphragm shortening. malloclusion due to superior maxillary compression.
This pattern can be caused by biomechanical factors, as Oral breathing is associated with anterior movement of the
mouth breathing. Besides, the thoracic deformities cause tongue and forward movement of the hyoid bone. The
breathing anxiety with use of the accessory breathing position of hyoid bone affects facial characteristics by means
muscles, as described by Farah and Tanaka12. These authors of neuromuscular compensations14.
reported a decreases thoracic expansibility in individuals with The nasopharynx changes causes posturing modifications
myofunctional oral changes, that can be related to the in the tongue rest position in order to open the airway and to
posterior chain, sternocleidomastoideus and scalene muscle allow a normal breathing function. This, therefore, provokes
shortening, including the breathing and the antero-medial dysfuntion in the associated actions as the mandibular
of the hip muscles chains, due to cervico-thoracic-abdomino- position, swallowing and articulation proficiency. The hyoid
pelvic fascia muscles commitment (Fig.2). bone controls tongue function, as its normal position is related
The SCM and scalene hypertonia “ flattens “ the cervical to the cervical column, infra-hyoid muscles and scapular
column and it pulls the mastoid processes forward, provoking waist and their relationship with the airway permeability. The
the forward head with short nape, when the thorax is tongue interposition has as deformant effetct the overjet,
immobile. If the nape is immobile, The SCM and scalene frequently found in mouth breather children due to the
contraction cause an elevation of the thorax11. decrease in the nasopharyngeal space15.
The inspiratory chain retraction elevates the thorax. It hinders Solow et al.16 observed that the obstruction or narrowing of

500
Braz J Oral Sci. 3(10): 498-502 Temporomandibular disorder and dysfunctional breathing

pharyngeal airway space were associated with larger cranium- must be coordinated in order to normalize the biomechanical
cervical and cranium-vertical angle, which confirmed the relationship of these structures.
strong relationship between the position of the head and Research Diagnostic Criteria (RDC) includes in the evaluation
the airway adaptation. The effects of the forward cephalic of TMD the question no. 20 (r): do “ you breathe well “?21.
position for a long period are: alterations of proprioceptive Recent studies on TMD evaluated the ventilattory pattern
pulses (with space disorientation, dizzyness, nauseas and (mist, thoracic, diaphragmatic) and breathing mode (nasal or
vertigo) due to sternocleidomastoideus hyperactivity and mouth)22-23.
shortening, which commits nervous structures, cephalic pain,
occlusal alteration, more posterior dental contact, more Physiotherapy Intervention
compression of TMJ due to mandibular replacement, with The physiotherapy intervention in Cervico-craniomandibular
consequent cranium-facial pain. It is concluded that TMD, disorders is an important factor due to the close relationship
as well as cephalic pain, dizzyness, vertigos, nistagmo and with tension situations, anxiety and stress. Many patients,
the swalowing difficulty, can have extrinsic origin in the in these conditions, develop or manifest pain in the
system stomatognatic. temporomandibular joint, whose main causal factor is the
Sartor17 described a sequence of biological events that starts muscular unbalance and/or tension muscular. Besides, the
with the nasal obstruction and produces cranium-cervical dysfuntional breathing (upper thoracic breathing) can
and mandibular physiological posture adaptations for easier influence cranium-cervical posturing and alignment, breaking
breathing. out a painful situation. The physiotherapist has been
Ribeiro et al.18 verified that mouth breathing children present integrated to the multiprofessional team (dentists, speech
higher electromyographic activity in the therapists, psychologists, physicians, etc), contributing to
sternocleidomastoideus and trapezius muscles during nasal the evaluation and treatment of cervico-craniomandibular
inspiration than nasal breathing children. The authors disorders with the goal of alleviating the pain, reducing the
concluded that this hyperactivity is attributed to the highest level of muscular tension, improving the function of
resistance of the airway, which results in larger effort of the stomatognatic system (responsible for speech, mastication),
accessory muscles breathing. re-educating breathing musculature, controlling ventilation
Infections of the superior airways in asthmatic children, and correcting cervical posture.
according to Chaves et al.19, determine nasal obstruction The diaphragmatic muscular re-education promotes a
with development of mouth breathing. Consequently, it physiologic pattern, with less energy expense. It also
establishes significant cranium-facial alterations. These provides an improvement of lung ventilation and correction
authors evaluated the incidence of cranium-mandibular of thorax mechanical changes, caused by the incorrect use
dysfunction (CMD) in 20 asthmatic children with mouth of the muscular groups involved10. The physiotherapeutic
breathing, where all children presented CMD, 55% of children methods indicated in the treatment of the syndrome of mouth
with severe dysfunction, 15% moderate and 30% light. breather, are described by Marins 24: RPG, Iso-stretching,
Hydrokinesiotherapy, GDS, conventional Kinesiotherapy and
Respiratory Mechanics Evaluation Posturology. The author still recommends an integrated work
The symptoms related to changes in cranium-cervical of interdisciplinar team and preventive measures as breast-
biomechanics and maxillo-mandibular relationship, according feeding, observation of vicious habits, stress control,
to Rocabado20, include: pain, alterations in dental occlusion, ergonomic orientation and professional ability. It is this
in postural relationship of head-neck, in the muscular and associated action that guarantees the therapeutic success.
respiratory system and psychological factors. In the In the Ribeiro and Soares’25 study with spirometric evaluation
breathing aspect, the superior, short and insufficient costal of mouth breathing children, it was demonstrated an
breathing, that causes hyperactivity of improvement of the lung function after physiotherapy
sternocleidomastoideus muscle and occasional mouth treatment. The authors concluded that postural correction
breathing are referred in the symptomatology of TMD20. and diaphragmatic re-education promoted improvement of
Voice modification, swallowing difficulty and breathing ventilatory mechanical and muscular diaphragmatic work,
changes are referred by patients with disturbances in the with reduction of breathing effort. Besides, they also
anterior neck region. Therefore, Rocabado 20 recommends reccomended environmental control with measures for
analysis of the hyoid system and airways as a factor of reducing the exposition to allergic factors, as the passive
possible cranium-mandibular dysfunction due to posturing tabagism.
changes. He concluded that, after several clinical studies of Chaves et al.19 suggests breathing exercises, in the correction
DTM patients, the cranium-mandibular, cervical, hyoid region of the mouth breathing, that also causes cranium-mandibular
biomechanical relationship and airways are an indivisible dysfunction, in order to improve the quality of the asthmatic
unit. The two approaches (dentist and physical therapist) children’s life.

501
Braz J Oral Sci. 3(10): 498-502 Temporomandibular disorder and dysfunctional breathing

Campignion8 affirms that the breathing should not be taughet, 23. Pedroni CR. O efeito da mobilização cervical em portadores de
but indeed it should liberate the body tensions and to obtain disfunção temporomandibular [dissertation]. São Carlos: UFSC;
2003.
a larger mobility in the thoracic joints. The author mentions 24. Marins RS. Síndrome do respirador bucal e modificação posturais
Mézieres that said “ it is so absurd to teach somebody to em crianças e adolescentes: a importância fisioterápica na equipe
breathe as to want to teach to do to circulate the blood in multidisciplinar. Rev Fisioter Mov. 2001; 14: 45-52.
her/his veins “. 25. Ribeiro EC, Soares LM. Avaliação espirométrica de crianças
portadoras de respiração bucal antes e após intervenção
fisioterapêutica. Fisioter Bras. 2003; 4: 163-7.
References
1. Hruska RJ Influences of dysfunctional respiratory mechanics on
orofacial pain. Dent Clin North Am.1997; 41: 211-7.
2. Bricot B. Posturology. São Paulo: Ícone; 1999.
3. Friedman MH, Weisberg J.Temporomandibular joint disorders:
dagnosis and treatment. Chicago: Quintessence Publishing; 1985.
4. Boyd CH, Slagle WF, Boyd CM, Bryant RW, Wiygul JP. The
effect of head position on electromyographic evaluations of
representative mandibular positioning muscle groups. Cranio,
1987; 5: 50-4.
5. Zuniga C, Miralles R, Mena B, Montt R, Moran D, Santander H
et al. Influence of variation in jaw posture on
sternocleidomastoid and trapezius electromyographic activity.
Cranio. 1995;13: 157-62.
6. Costa D, Vitti M, Tosello DO, Costa RP. Participation of the
sternocleidomastoid muscle on deep inspiration in man. An
eletromyographic study. Rev Brás Fisioter. 1997; 2: 43-7.
7. Dennys-Struyf G. Cadeias musculares e articulares. São Paulo:
Summus Editorial; 1995.
8. Campignion P. Respir-Ações; São Paulo: Summus Editorial; 1998.
9. Tribastone F. Tratado de exercícios corretivos: aplicados à
reeducação motora postural. São Paulo: Manole; 2001.
10. Costa D. Fisioterapia respiratória básica. São Paulo: Atheneu;
1999.
11. Souchard PHE. Respiração. São São Paulo: Summus Editorial; 1989.
12. Farah EA, Tanaka C. Postura e mobilidade da coluna cervical e
do tronco em portadores de alterações miofuncionais orais. Rev
Assoc Paul Cir Dent. 1997; 15: 171-5.
13. Felício CM. Fonoaudiologia nas DTM. São Paulo: Pancast; 1994.
14. Takahashi S, Ono T, Ishiwata Y, Kuroda T. Effect of changes in
the breathing mode and body position on tongue pressure with
respiratory-related oscillations. Am J Orthod Dentofacial Orthop.
1999; 115: 239-46.
15. Rocabado M. Analisis biomecanico cranio cervical a traves de
una teleradiografia lateral. Rev Chil Ortod. 1984: 1-11.
16. Solow B, Siersbaek-Nielsen S, Greve E. Airway adequacy, head
posture, and craniofacial morphology. Am J Orthod. 1984; 86:
214-23.
17. Sartor AP. Inter-relação entre espaço oro-naso-faringeano, padrão
respiratório e mandíbula [monograph]. Rio De Janeiro: Associação
Brasileira de Ortopedia dos Maxilares; 1995.
18. Ribeiro EC, Marchiori SC, Silva AMT. Electromyographic
analysis of trapezius and sternocleidomastoideus muscles during
nasal and oral inspiration in nasal and mouth breathing children.
J Electromyogr Kinesiol. 2002; 12: 305-16.
19. Chaves TC, Aguiar DN, Costa D, Bevilacqua-Grossi D. Aplicação
do Índice de Disfunção Crânio-mandibular (IDCM) em crianças
asmáticas. Rev Bras Fisioter. 2002; 6(Supl.): 67.
20. Rocabado M. Cabeza y cuello - tratamiento articular. Buenos
Aires: Intermédica; 1979.
21. Pereira Jr FJ, Huggins KH, Dworkin SF. Critérios de diagnóstico
em pesquisa das Desordens Temporomandibulares RDC/DTM.
Available from: URL: http: //rdc-tmdinternational.org/
translations/RDC-Portuguese.pdf [2004 Aug 10].
22. Oliveira AS. Caracterização multifatorial de uma população de
portadores de desordens temporomandibulares [thesis].
Piracicaba: FOP/UNICAMP; 2002

502