TMD is also known as Temperomandibular Dysfunction.
There is a significant relationship between TMD and voice dysfunction (Amorino & Taddey, 1993) as most of the ligaments and muscles responsible for vocalisation also move the jaw.
TMD describes the misalignment of the jaw in relation to the skull, with resultant incongruent stresses on the neck and head area. This ultimately also affects posture, upright balance and vocalisation. The jaw is designed not only for chewing food but is also involved in functional activity for the pharynx, the larynx and the bony and muscular systems of the neck. Muscles associated with the jaw may create postural imbalances to cervical vertebrae, potentially leading to head, neck and facial asymmetry with concomitant skeletal side effects. It should be noted that the incorrect meeting of the upper and lower teeth also frequently leads to TMD. It is even believed that the craniosacral pump may be affected by TMD.
- Unreliable pitching
- Lower back pain
- Neck & shoulder pain
- Headaches, migraines
- Numbness or tingling of fingers and feet
- Muscle spasm around C1 and C2 vertebrae affecting the function of the atlanto-occipital joint in the neck
- Breathlessness (diaphragm spasm possible)
- Decreased confidence/performance/ability
- Forgetfulness, nervousness, worry
The symptoms above were noted in a US survey conducted in the early 90s, where singers reporting voice problems were also found to be suffering from TMD.
The Hyoid and Tongue:
Breathing, singing and speech all rely heavily upon the excursive movements of the hyoid bone, which is designed to co-ordinate with the tongue and pharynx. Other associated throat muscles are very delicately involved to function properly in synchrony. However it is known that TMD leads to the loss of symmetry in hyoid functioning, which results in spasm. This ill-function of the lower jaw leads to distress, to resultant vocal chord dysfunction and to vocal distress.
The tongue, in its natural resting position, is located against the palate and hence acquires its shape; it rests behind and away from the upper front teeth. Like this, the tongue creates a seal with the soft palate, allowing for normal nose breathing even when the mouth is open. This natural position facilitates efficient nose breathing, swallowing, well aligned jaws, proper Eustachian tube evacuation and correct functioning of the upper respiratory tract. Removal of teeth to relieve crowded situations may lead to the forward posturing of the tongue, resulting in over functioning of the masseter muscle and jaw pain. Jaw pain may then lead to poor posture and ultimately to poor singing capability and projection.
A forwardly positioned tongue may lead to the forward positioning of the head and shoulders; a highly arched palate (due to the narrow and underdeveloped upper jaw); and a higher positioned hyoid bone (thus out of tune) which is also referred to as hypertonic suprahyoid suspension. The voice is breathy, pale and lacks lower harmonics.
Structural dysfunction has been linked to the collapse of cervical vertebrae posture with resultant problems associated with forward head tilting, forward shoulder posturing and facial muscle function. Voice function may be affected by the incoherent functioning of the structures which provide attachment for the extrinsic laryngeal frame. See below:
Vocalisation may be affected by poor coordination in any of the structures below, which provide attachment for the extrinsic laryngeal frame:
- Malocclusion of teeth (or improper meeting of the teeth)
- Lack of molar support
- Tongue thrusting (forward positioning)
- Poor TMJ functioning (clicks, grinding, limited mouth opening)
- Cranial torque
- Postural imbalance and instability
- Breathing, swallowing, Eustachian tube evacuation
- Facial function
- Tongue posture
- Potential voice skills
- Deviated jaw and limited opening
The extrinsic frame supports and stabilises the hyoid bone, which acts to balance and coordinate most movements of the vocal tract.
The Styloglossus Muscle:
This muscle pulls the tongue upwards and backwards and assists in the articulation of vowels. With a poorly-developed upper jaw and a resultant highly arched palate, the tongue cannot fit and seal properly, thus breaking the rhythmic muscular coordination between the tongue and soft palate. This, in turn, leads to tongue weakness, while the styloglossus and tensor palatine muscles contribute to a poor Eustachian tube pump and efficiency. This may cause “glue-ear”.
Efficient ear and tongue synchronicity is important for the development of the voice for effortless speech and singing.
- A diagnostic tool for alignment and balance
- A reprogramming apparatus of facial muscles and for the prevention of orthodontic regression
- A developmental instrument for facial bones, posture and teeth
Inadequate craniofacial development arises in infancy. It is most commonly due to birth trauma (aided `forceps’ delivery, for example) which may compress the craniofacial development complex, leading to insufficient upper jaw (maxilla) development and resultant crowded teeth. Traditionally, overcrowding is treated by extracting some of the teeth, which further exacerbates the problem of insufficient development of the above complex. When the maxilla is halted in its normal developmental pattern, the tongue is prevented from achieving its natural resting position (Mew, 1981). Unfortunately, removal of teeth leads to disruption of proper jaw development and precludes the tongue from achieving its natural resting position, further retarding the ill-formed development of the upper jaw.
The primary function of the face is to allow for nose breathing. With nose breathing occurring during one’s early years of development, the facial bones are permitted to develop normally to produce correct speech, chewing, swallowing and facial expression. Tongue posture is vital to both nose breathing and to facial balance. Mouth breathing, on the other hand, is only meant to be supplemental to the primary method of breathing, which is reserved for the nose solely. Long term mouth breathing leads to facial muscle system changes and causes detrimental dental and skeletal changes.
No one is completely balanced or perfectly symmetrical, which is not a problem when it doesn’t have a detrimental affect upon one’s quality of life. More significantly: is the adaptive range equal to the demand? Professionals such as performers and singers demand more precision and thus need to develop and maintain greater coordination and balance. Such precision is impossible to achieve if there is a misalignment of the skull, jaw or entire skeleton.
Improvements include better breathing control, wider palates to accommodate the tongue correctly, enhanced posture, upright balance, release of suprahyoid muscle tension and greater voice strength and stamina. Greater pitch range, confidence and motivation deliver joy in the musical profession.
Aspects to be aware of and look out for, but not limited to:
- Long faces, heads and convex facial profiles
- Mouth breathing, narrow nostrils
- Snoring and tension around the mouth
- Jaw aches with or without clicking or sounds during functioning
- Limited mouth opening capability (less than 5cm)
- Facial pain, eye bags, purple under the eyes, visual disturbances
- Ear disturbances – chronic ear aches (especially as kids)
- Frequent nasal congestion
- Frequent flu-like symptoms and sinusitis attacks
- Crowded or crooked teeth and cross-bites
- Forwardly positioned tongue
- Headaches, migraines, head, neck and shoulder tension
- Lower back pain
- Poor posture, unequal leg lengths with resultant swaying when standing
- Interference in vocal efficiency, rhythm, performance and confidence
It has been found that when singers’ voices didn’t sound right, no matter how hard they practiced, they wasted precious time agonising about their failure and tried to conceal the root problem, invariably compounding it! The correct approach to the problem must be multidisciplinary and look at the entire body working in synchrony from head to toe. Often the opinions and treatment of cranial osteopaths, chiropractors, voice coaches and specialised dentists is required to heal and improve the above mentioned aliments for performance and singing professionals. The individual can recover their upright posture with two feet stable and equally balanced on the ground, with minimum effort and maximum energy available.
It is important that parents are made aware of the connections between voice, posture and teeth. Encouraging activities in which voice and body act together helps to develop good tongue posture, an expansive and accommodating palate and well aligned teeth. Singing throughout school life is also recommended to train for proper muscular positioning and sinus aeration of the developing face and skull bones. A balanced tongue is correctly positioned against the hard palate and facilitates efficient nose breathing and proper vocalisation mechanics for life!
Interesting Case Studies (with permission from Angela Caine; www.voicegym.co.uk.)
Case study 1
Music student, age 21.
He had been a choir-boy treble in his Prep and Public School choirs until he was fourteen and has an AB grade 8 with distinction in double bass. He played leading roles in National Youth Music Theatre from age sixteen to eighteen and applied to Cardiff College, which specialised in the teaching of singing.
The tenor voice disappeared at nineteen after a cycle of voice loss, rest and recovery and he was unable to manage the Cardiff audition. He gained entry to the Department of Music at the University of Southampton as a double bass player and learned about our pilot study. He could no longer sing at all.
He had a narrow maxilla, the arch of upper teeth fitting inside the lower teeth: the premolars had been removed at age 10 for overcrowding and several years of orthodontic work had been carried out to even his smile. He swayed to sing. He had very small teeth and was a mouth breather due to inefficient face muscles and poor tongue posture.
His pelvis was stabilised by the chiropractor. His tongue was reprogrammed to increase breathing efficiency and exercises, using a centring board, helped him to relearn how to balance symmetrically (Caine, 1991). Light wire orthotics were fitted which did not cross the maxillary midline and an elastic pull was introduced between upper and lower teeth on one side to correct a torsion in his cranium.
Result so far
After fifteen months chiropractic treatment, five months with a dental appliance and eighteen months of singing lessons. The tenor voice has returned. After audition he has now been accepted on the performance course at Southampton as a singer. He will perform in his first recital in three months time, wearing the light wire appliance. The maxilla has widened to change his whole face shape and all of the upper teeth have wide gaps. Work will begin soon to move the teeth into place and the extraction spaces will be bridged. Voice range and resonance are increasing in direct relation to the maxillary widening and reprogramming of the tongue and articulation.
Case Study 2
Singer, age 27.
She had been offered a scholarship to the Royal College of Music, but decided to train at Guildhall as a performer after winning a county music award for singing. She had received advanced ballet training and gained Grade 8 piano. Glandular fever took her out of college for a year but she returned to obtain a GGSM with a qualification to teach singing.
The voice was getting smaller and thinner; limited in range and arrhythmic. She could not open her mouth very far and her pitch range was gradually decreasing. She experienced jaw pain and clicking joints and could only sing at all with great effort, constantly running out of breath. She had no confidence in her voice or in her musical ability and apologised all the time.
The maxilla was too narrow for a natural tongue resting position, having had four premolars removed at age twelve. Her articulation had been programmed with the tongue lying in the floor of the mouth. She was assessed by the chiropractor as a category II.
The pelvis was stabilised, bringing an immediate improvement to the breathing. Her tongue was reprogrammed using exercises (see Caine, 1991) to prioritise vowels, stretch ligaments and relieve jaw pain. She was fitted with a light wire appliance to widen the maxilla.
Results after 2 years
Her tongue is now resting against roof of her mouth. The back of her mouth opens wider and the jaw pain has gone. Her face shape has changed from long and doleful to smiling with well-toned muscles. The range and resonance of the voice has extended; she now sings across an octave and a half without effort and her range is expected to extend further with continued maxillary widening.
Case study 3
Music Student, age 19.
She had AB grade 8 in singing and a grade 8 in piano. She is a former member of the National Youth Chamber Choir of Great Britain, completing two world tours between the ages of sixteen and eighteen.
The voice lacked pitch range and resonance. No matter how hard she practiced, her voice was breathy and did not develop any personal qualities. The only available pitch was very low and with her good sight reading and ability to hold a vocal line she was always made to sing alto. On auditioning for singing lessons at age seventeen she had been declared to be a contralto and trained as such. She did not feel that this was her natural voice.
Contralto was definitely not her natural voice. The pressure required to produce it was now causing huskiness in both speech and singing. She had her premolars removed at the age of twelve and then had three years of a fixed brace which crossed the roof of her mouth. An excessively narrow maxilla and difficulty with balancing indicated a pelvic and cranial misalignment, particularly as she always fell off a balance board to the right (Caine, 1991).
It was difficult for her parents to accept the assessment since she had already gained two advanced music certificates and a place on a University degree course in music. They were given the relevant information and could then see that their daughter was not improving musically, however hard she worked. Treatment will begin during this semester. The voice will be carefully maintained well within adaptive range until a treatment protocol can be set up.
Case study 4
Counter tenor, age 27.
He had an illustrious career as a chorister, winning the RSCM St Nicholas Award. After University he worked extensively as a counter tenor with five different choirs. He is a biology teacher in a private school.
He had recurring voice loss, tightness in the chest, limited range and discomfort which has increased over the last four years. He found it difficult to make anyone take his voice problem seriously because he is not a professional singer.
He had a very narrow palate following the removal of four premolar teeth. His tongue rested in the floor of the mouth. He did not correctly understand the mechanics of the tongue, the soft palate, the face muscles and the breathing. He still sang like a treble. He had a TMD problem and an unstable pelvis. The two temporal bones of his cranium were seriously out of alignment.
A “Cranio Group” chiropractor near his home stabilized the pelvis. He then returned to the Voice Workshop to re-educate his tongue and face muscles to assist the cranial treatment to align his temporal bones. Once a good state of cranial symmetry has been achieved, a dentist working with the chiropractor will fit a light wire appliance to realign his jaw and expand the maxilla.
Results after 4 months
His pelvis is now stable. His singing is getting stronger and has gained in both pitch and resonance. He has been taught how to roll on the floor while singing to reduce vocal effort and loosen his “choirboy legs”.
Dr Amir Kamburov qualified as a Dentist from WITS University in Johannesburg in 1998. His extensive post graduate training in Cosmetic Dentistry, Facial Aesthetics, Implantology, Orthopaedic Orthodontics and Functional Jaw Development has positioned him as one of the top dentists who is widely popular with patients in London. Amir keeps abreast with modern Dental Techniques and Treatments in order to provide excellence to his patients with their best interests in mind.
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