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Volume 2 Issue 5







TMJ osteoarthritis (degenerative joint disease)

Temporalis tendonitis

Less common conditions

TMJ ankylosis

Coronoid hyperplasia

Tendon/muscle contracture

Synovial chondromatosis

Capsular fibrosis


Connective tissue disorders




Approaches to acute cases may be different from chronic


Common Initial Treatments

Acute cases

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

end feel).

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

end feel).


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.

Differential Diagnosis

Common conditions

Masticatory myalgia