Volume 2 Issue 5
TMJ osteoarthritis (degenerative joint disease)
Less common conditions
Connective tissue disorders
Approaches to acute cases may be different from chronic
Common Initial Treatments
Patient experiencing closed lock for 1 week or less.
Consider referring the patient to an oral medicine specialist
or oral and maxillofacial surgeon.
Consider attempting manual manipulation to regain the
normal disc–condyle relationship. If this is successful, then
the patient could wear an anterior positioning appliance
for the first 2–4 days followed by nighttime use only. Once
stability has occurred, a stabilization appliance may be
considered for nighttime use.
If patient’s condition is not responding to the above
recommendations, then a minimal invasive surgical
procedure (arthrocentesis/arthroscopy) could be
considered to return the disc to a normal functional
relationship with the condyle. This will need to be followed
by conservative supportive therapies.
Conservative supportive therapies:
• Advise the patient to avoid chewing/biting hard
foods, stop parafunctional habits (tooth clenching
and grinding, gum chewing, nail biting) and generally
avoid activities that aggravate the condition.
• Counsel the patient to perform gentle, controlled
jaw exercises within a pain-free range, as this may be
helpful in regaining range of opening.
• Consider application of moist heat or ice to
symptomatic preauricular area. After an acute injury
(<72 hours) heat should not be used.
• Prescribe a short course of NSAIDs for pain control
and resolution of inflammation.
• Fabricate a stabilization appliance for nighttime use.
• Involve a physical therapist knowledgeable in TMDs
to assist with pain control and regaining range of
If inflammation develops, the pain may be constant, dull
or throbbing, even at rest, and be accentuated by joint
movement and joint loading.
Patient displays concern regarding the sudden decrease in
mandibular movement as a result of the “closed lock.”
Obtain thorough medical and dental history, including
details related to pain and dysfunction.
Perform head and neck examinations (cranial nerve,
muscle and joint tenderness, joint sound, range of mo-
tion of jaw) and intraoral (teeth, gingiva, oral soft tissue)
to rule out local pathology or other sources of pain and
to assess joint function.
Downward force applied to the mandibular incisors pro-
duces minimal, if any, increase in range of opening (hard
a. Restricted mouth opening (maximum interincisal
opening) as a result of muscle disorders is usually
variable in terms of range of opening. However, mild
passive force applied to the mandibular incisors will
usually result in an increase in range of opening (soft
Loading of the involved joint is often painful.
Confirm the diagnosis on a magnetic resonance imaging
(MRI) scan of the TMJ.
a. In the maximal intercuspal position, the posterior
band of the disc is located anterior to the 11:30
position and intermediate zone of the disc is anterior
to the condylar head.
b. On full opening, the intermediate zone of the disc is
located anterior to the condylar head.
Determine whether the disc displacement without
reduction with limited opening (closed lock) is acute or
a. The clinical picture becomes less clear if disc
displacement is chronic, as the ligaments become
further elongated and the morphology of the disc
becomes altered, thus allowing a greater range of
movement. This may mistakenly be considered as a
disc displacement without reduction without limited
A diagnosis of disc displacement without reduction with
limited opening is based upon patient history, clinical exami-
nation and related tests.