Ross Hauser, MD
The forward head posture has many negative effects on the body, but it is especially harmful to the TMJ and upper cervical spine. Forward Head Posture is both a cause and a symptom of ligament weakness in the neck. Weakness of the neck ligaments commonly occurs because most people spend a good portion of their days looking down at phones (text neck) and hunched over while working. Their work may consist of typing on a computer or being constantly tethered to their mobile devices for many hours per day, as well as the huge surge in computer gaming. Increasing numbers of patients have suffered from “text neck.” All of these tech activities precipitate the head-forward position and put the cervical vertebral ligaments in a stretched position. Over time, these ligaments weaken and cause pain (creep). The ligament laxity causes an even more head-forward position, as the ligaments can no longer keep the cervical vertebrae in their proper posterior alignment. The paracervical muscles (the neck muscles) tighten to stabilize the joints and head. As the muscles tighten, they create more pain.
What are we seeing in this image?
A forward head posture shows one mechanism by which passive tension (the ligaments and muscles have a “stretched” resting position) in selected suprahyoid and infrahyoid muscles alters the resting posture of the mandible. The mandible is pulled inferiorly and posteriorly, changing the position of the condyle within the temporomandibular joint. Also, in this image, note the relationship between the cervical spine and the shoulder.
The above also explains why forward head posture is so damaging to the TMJ. Habitual head forward posture is a well-known etiological cause or contributing factor of craniofacial, craniocervical, and craniomandibular syndromes. As the head goes forward with habitual sitting and looking at a computer screen or down at a smartphone, the anterior muscles of the neck tighten. This causes a shortening of the inferior hyoid muscles, pulling the hyoid bone inferior. This causes a lot of stretching or tension on the suprahyoid bone to keep the hyoid bone in place.
This tension on the suprahyoid bone causes the mandible to retract, which forces the mandibular to condyle posteriorly (backward). Remember from above that the poor lateral pterygoid muscle, as the main protractor of the mandible, has to go against the powerful temporalis and masseter muscles that retract the mandible. So, in addition to this, the habitual forward head posture, also retracts the mandible, further causing a “stretching” or contraction of the lateral pterygoid, and the articular disc is again forced anteriorly by the posterior moving condyle. To counter the pull on the disc, the lateral temporomandibular ligament stretches. Eventually, it gets stretched out too much, resulting in TMJ instability.
As a person loses cervical lordosis in the lower cervical vertebrae because of a forward head posture or trauma-inducing posterior ligament complex injury, the C1-C2 vertebrae become more lordotic or have too much inward curve.
Forward head posture research
In April 2021, doctors in China published their findings (1) on the investigation of the differences in forward head posture between patients with temporomandibular disorders and healthy people. These researchers found that compared with healthy people, TMD patients present more forward heads with abnormal head and neck posture.
A January 2023 paper in the Clinical Oral Investigations (2) examined whether forward head posture contributes to TMD symptoms. Findings, they suggest, remain unclear. The researchers assessed 145 patients diagnosed with TMD. Patients were divided into either the forward head posture group or the non-forward head posture group. Differences in the masseter and temporalis muscle pressure pain thresholds between the two groups were analyzed.
- No significant difference in masseter and temporalis muscle pressure pain thresholds was found between the two groups.
- No correlation was found between forward head posture and masticatory muscle pressure pain thresholds. (Forward head posture did not put pressure on the masticatory muscles.)
- A significant association was found between the neck muscle and masticatory muscle pressure pain thresholds.
- Conclusion, the presence of neck pain, not the degree of forward head posture, in patients with TMD is of significance.
It should be pointed out that the above research is questioning forward head posture as the main factor for TMD problems. In many patients we see, they suffer from many problems and for many, it is the neck pain that is the “ground zero.” A December 2023 study (3) from Chile which suggests other problems can first lead to forward head posture. “Bad habits, such as poor posture during the use of technological devices, poor abdominal control and oral breathing pattern can lead to a forward head position, which has important implications for the entire future of the individual, especially at the stomatognathic system. There is a strong association between temporomandibular disorders and forward head syndrome. Where the muscular component is the main affected, with the appearance of more trigger points at the level of the sternocleidomastoid muscles (head tilt muscles in the neck), upper trapezius (common neck muscle injury), rectus capitis posterior (neck muscles that allow head forward and backward movement) and upper oblique capitis (helps maintain position of head).”
A February 2025 study in the Journal of Oral Rehabilitation (4) looked at how temporomandibular dysfunctions could cause changes in cervical muscle strength, muscle endurance and position sense. Specifically, the study focuses on the changing muscle activation patterns of forward head posture and looks at the effects of Temporomandibular dysfunctions have on cervical joint position sense (the ability to make adjustments in neck position to help remain balanced and reduce fall risk) and head posture which remain controversial.
Findings in 84 test subjects showed people with Temporomandibular dysfunctions exhibited higher angular deviation in cervical joint position sense (this is a miscommunication between where the brain thinks the neck is in space and where the neck actually is, the cause of balance and fall issues) during flexion and extension of the neck. Additionally, individuals with TMDs demonstrated higher TMJ pain, limitation and dysfunction severity, as well as a more limited TMJ range of motion.
Progressive TMJ osteoarthritis, Forward Head Posture, Reduced Airway dimensions
A December 2020 study published in the Journal of Oral and Maxillofacial Surgery (5) sought to investigate associations among progressive temporomandibular joint osteoarthritis, airway dimensions, and head and neck posture. In this study, 114 temporomandibular disorders patients were examined.
- Among the 114 patients:
- No TMJ osteoarthritis – 28 patients had no pathologic bony changes (bone spurs) in the TMJ condyles
- 45 had progressive TMJ osteoarthritis
- 41 had TMJ osteoarthritis which had not progressed for 12 months.
The finding here was that forward head posture seemed to be worsening more in the progressive TMJ osteoarthritis than in either the No TMJ or TMJ osteoarthritis had stopped progressing group. (Side note: If you stop TMJ osteoarthritis progression this can help stop forward head posture.)
The problems with breathing
The researchers found: The volume (size opening) change of the oropharynx (the back part of the throat) in a supine (lying face up) position was more prominent in the progressive TMJ osteoarthritis than in the TMD no osteoarthritis patient but no significant differences in changes in the pharyngeal airway (that part of the pharynx that regulates airflow) while in an upright position was detected. – Meaning: Progressive TMJ osteoarthritis may have associations with retrognathia (the improper position of the mandible) and decreased oropharyngeal airway volume in the supine (laying down) position but not in the upright position. Progressive TMJ osteoarthritis may be related to altered head posture in the upright position to compensate for reduced airway dimensions. (The TMJ is changing your head posture so you can breathe.)
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Our published research
Lockerman LZ, Hauser R. The association between mandibular position to cervical spine and internal jugular vein diameters in upright position. Have we been ignoring critical generators of head and neck pathology? Cranio. 2023 Sep;41(5):403-406. [Google Scholar]
References
1 Tang Y, Xu LL, Fan S. Control study of forward head posture between patients with temporomandibular disorders and healthy people. Shanghai kou qiang yi xue= Shanghai journal of stomatology. 2021 Apr;30(2):173-6. [Google Scholar]
2 Yao Y, Cai B, Fan S, Yang HX, Zhang YX, Xu LL. The association between forward head posture and masticatory muscle pressure pain thresholds in patients with temporomandibular joint dissorders: a cross-sectional observational study. Clinical Oral Investigations. 2023 Jan;27(1):353-60. [Google Scholar]
3 Tomás J, Castillo C, Villarroel G, Giner Á, Felipe N. Effect of the forward head syndrome in the development of temporomandibular disorders. Revista Cientifica Odontologica (Universidad Cientifica del Sur). 2023 Oct 1;10(4):e133-. [Google Scholar]
4 Yüzbaşıoğlu Ü, Kaynak BA, Taş S. Assessment of Cervical Joint Position Sense and Head Posture in Individuals With Myogenic Temporomandibular Dysfunctions and Identifying Related Factors: A Case‐Control Study. Journal of Oral Rehabilitation. 2025 Feb;52(2):160-8. [Google Scholar]
5 Kang JH. Associations Among Temporomandibular Joint Osteoarthritis, Airway Dimensions, and Head and Neck Posture. Journal of Oral and Maxillofacial Surgery. 2020 Dec 1;78(12):2183-e1. [Google Scholar]
6 Tariq M, Fatima K, Khan SF, Mahmood W, Mahmood T, Khurshaid S, Khalid M, Khoosa M, Babur MN. Efficacy of massage versus massage with post isometric relaxation in temporomandibular disorders: a randomized controlled trial. BMC Sports Science, Medicine and Rehabilitation. 2024 May 16;16(1):110. [Google Scholar]