TREATING THE LOCKED TMJ
TMJs typically undergo locking when a forwardly dislocated disk, which has been clicking into place during each opening and then out again with each closing, suddenly stops clicking into place during opening. The mouth can only open to the place where it used to click or pop. If you try to open wider, the midline of your lower jawbone will veer off to the side of the lock, because the condyle of that side stops moving, (the dislocated disk is blocking its path) while the condyle of the other side keeps moving. If you use your fingers to try and open further, you'll feel immediate pain just in front of your ear on that side, because you’re stretching the ligaments that once held the TMJ disk in place and now hold it in the path of the condyle, like someone trying to touch their toes for the first time.
IF THE TMJ STAYS LOCKED, the degenerative process will run its natural course, which may not be so 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 subside. It’s difficult to say whether the process will require days or decades, but it almost always occurs by middle age. Orthopedic treatment may not unlock the TMJ, but it can certainly facilitate the adaptation. This treatment is explained in MANAGING THE ARTHRITIC TMJ.
UNLOCKING may be possible, especially if the lock is recent. However, simply unlocking the TMJ without making any changes to the situation that produced the locking rarely solves the problem, because the joint is very likely to lock up again. If you want your TMJ to stay unlocked, you need to plan on disk recapturing, as detailed in the paper on that subject.
ATTEMPTING to unlock your TMJ involves a series of progressively more invasive steps.
1) PIVOTING is accomplished by adding a small high spot (pivot) to an oral appliance on the back molar on the side of the lock in order to mechanically distract the involved condyle. The pivot must be located behind the first molar, the center of force of the jaw closing muscles, to pry down the condyle and allow it to slip over the edge of the locked out disk and back into place on the center of the disk. Even if the pivot does not unlock the TMJ, it unloads the inflamed joint, which should feel good immediately. You can use a temporary pivot, like a tongue blade, or you can use an oral appliance with a pivot that operates all night when you'll be clenching anyway. If the pivot allows you to unlock at home, you need to be careful not to bite down without a block between your teeth, or the lock will likely recur.
2) JAW MUSCLE RELAXATION facilitates all unlocking attempts, because the jaw closing muscles are aligned vertically, therefore 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, so they often need loosening. Various medications or even Intravenous (IV) sedation may be needed to calm the jaw closing muscles to stop them from pulling the jawbone up against the TMJ so tightly that it can’t allow the disk to go back into place.
3) ARTHROCENTESIS - is a minor surgery that inserts little tubes into the locked TMJ and pumps it to unlock it. Even if the surgery fails to unlock the disk, it often relieves pain and other symptoms at least temporarily by flushing out the inflammatory by-products.
4) ARTHROSCOPY - is another closed surgery that can be used to pump the locked TMJ. It uses slightly larger tubes that allow the surgeon to see the inside of the TMJ and even pull directly on the disk with a little hook or use a little cutter to remove damaged tissues.
5) OPEN SURGERY - can be used to physically manipulate the disk back in place and then suture it to mini-implants in the bone of the condyle, however it has not been shown to be predictably successful, and it can create long term problems by preventing natural adaptation from occurring, which then requires subsequent surgeries to clean out the scar tissue left by the previous surgery. Therefore open surgery must be considered a last resort.
CONCLUSION - 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. Locking is the most symptomatic stage in the natural course of a TMJ disorder. If your symptoms are minor at this stage, they will probably never become a serious problem in your life, even with your disk is permanently displaced, especially if you are willing to wear a TMJ protective oral appliance during sleep, you have a generally healthy bite, and you maintain good dental health.