|Treating the Locked TMJ|
|Written by Dr. John Summer|
In some cases the transition from a disk that can be recaptured to a disk that can no longer be recaptured is accompanied by a condition known as a closed lock. The jaw is not locked in a fully closed position, but it cannot open as wide as it used to, because the disk will no longer go back into place. The jaw can only open to the place where it used to click. The opening click was previously the sound made by the disk going back into place. Now it will not click because it is no longer going back into place. If you try to open further, your chin will shift toward the side of the lock, and you’ll experience pain in front of your ear on that side, because you’re stretching the ligaments attached to the TMJ disk.
If the TMJ stays locked, the disk dislocation process will run its natural course, which may not be that bad. The disk will never go back into place, but the jaw will gradually and progressively open wider until normal or near-normal opening is achieved, and the pain will diminish. It’s difficult to say whether the process will require days or decades. The goal of treatment, if we leave the TMJ locked, is to enable your body to anatomically adapt and thereby achieve normal opening and elimination of symptoms. This treatment is explained under the heading SPECIFIC TREATMENTS in the file entitled, MANAGING THE ARTHRITIC TMJ.
If the TMJ has gone into locking recently, we may be able to unlock it.. However, the unlocking must be followed by a disk recapturing procedure (explained under the heading SPECIFIC TREATMENTS in the file entitled , RECAPTURING THE DISLOCATED DISK. Otherwise, without making any orthopedic changes, your TMJ is almost sure to lock up again, and you’ll be right back where you started before the unlocking.
The chance of unlocking your TMJ depends on the length of time it has been continuously locked. If it has only been locked for hours, we can probably unlock it quickly by manipulation. For example, if you dislocate your shoulder playing sports and your coach pops it back in right there on the field, it normalizes rapidly. If it stays locked for a day or even a week, it's still likely that it can be unlocked easily. If you wait months, it is unlikely to go back in, because the anatomy changes so unlocking becomes progressively more difficult and eventually impossible.
The process of unlocking your TMJ involves a series of progressively more invasive and expensive medical procedures starting with a removable dental appliance and various techniques to relax the jaw muscles and later progressing to measures like anaesthetizing the joint before pumping fluid into it under pressure in the oral surgeon’s office.
The first unlockng attempt usually involves manual manipulation and/or wearing a stabilization appliance with a pivot. The pivot is a small high spot in the very back of the appliance on the side of the lock. Biting against the pivot serves to pry down the condyle (the end of the jawbone) on the side of the lock. This slight downward shifting of the condyle may allow it to slip around the locked out disk. Pivoting is best used together with jaw muscle relaxation.
If you unlock at home, it’s important to know what to do, or the TMJ will just lock up again. The unlocking will be obvious, because you’ll suddenly be able to open your jaw all the way without your lower jawbone veering off to the affected side. If you've unlocked, you must not bite down on your back teeth without the appliance in your mouth, and you should also call the office right away so Dr. Summer can quickly make you a comfortable daytime appliance which will keep your TMJ unlocked and allow you to function normally. You’ll then continue with the disk recapturing process.
The second unlocking attempt involves manipulation of the lower jawbone accompanied by anesthesia. The jaw closing muscles are arranged vertically, so tight jaw muscles prevent the condyle from lowering and allowing the disk to go back into place. The jaw muscles tighten up automatically in response to pain. Anesthesia, like various relaxation techniques and medications, allows the muscles to relax and thereby stop pulling the jawbone up against the TMJ so tightly that it can’t drop down and allow the disk to go back into place.
The third unlocking attempt involves closed surgery which avoids the dangers associated with open surgery. In arthrocentesis, two little tubes are inserted into the joint, and fluid is pumped in to flush out the inflammatory by-products and push the condyle down under the disk. In arthroscopy, larger tubes are used so the surgeon can see the inside of the TMJ, cut out small adhesions, and perform some simple manipulations of the disk while still pumping fluid through the TMJ.
If closed surgery is not successful, open surgery can be used to physically manipulate the disk back in place and suture it there. Previous studies have not yet shown that the disk can be successfully sutured into place and held there over time. Recently the use of mini-implants placed into the bone of the condyle during such surgery has been employed to improve the chances that the repositioned disk will stay in place. However the danger of open surgery is that failure can be disasterous and prevent natural adaptation from ever occurring.
Finally, in choosing how far to go in attempting to unlock your TMJ, it’s important to keep the treatment proportional to the symptoms and the prognosis. The locking stage is the stage in the natural course of a TMJ disorder which is normally the most symptomatic. If your symptoms are minor at this stage, they will probably never become a serious problem in your life, even though your disk will stay dislocated, especially if you are willing to wear a TMJ protective night appliance on a long term basis and maintain good dental health.