Man Holding His Temporomandibular Joint (TMJ) Before Applying a Manipulation and Mobilization Treatment

TMJ Manipulation & Mobilization Treatments

Man Holding His Temporomandibular Joint (TMJ) Before Applying a Manipulation and Mobilization Treatment

Open Locking TMJ Manipulation

This procedure is done to reduce open locking or open dislocation of the TMJ, and it can be done in one of two ways.

One method includes grasping the jaw with both hands and placing the molars on the posterior molar teeth and the fingers of the hands more anteriorly under the inferior border of the jaw.  By applying downward pressure on the molars and upward pressure on the inferior border of the jaw, this would distract the condyle down so it can move back over the eminence and allow it to return to the fossa.

Another simple method that can be used to get the anteriorly, “stuck,” condyle back behind the eminence and into the fossa, is to identify the lateral pole of condyle beneath the zygomatic bone, and apply posterior, and slightly downward finger pressure, to the anterior lateral pole of the condyle.

Note: usually the condyle is easily palpated when it is in its most anterior position.

Related Reading: TMJ Assessment: Jaw Range of Motion, Noise, and Tenderness

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TMJ Manipulations if Patients Experience Pain

In some cases the jaw has been locked open for quite a while and the joint is to painful to allow manipulation motions, so it is necessary to inject anesthetic solution into the superior space of the TM joint.

This anesthetic will reduce pain and allow either of the above two manipulation procedures to work.  The advantage of this method is that once the condyle has been relocated, the patient is not sedated or compromised in any fashion.

TMJ Manipulations if Patients Experience a Trismus or Spasm

If the jaw has been locked open for quite a while and the jaw closers have developed a very powerful trismus or spasm, it will keep the condyle in its locked open position.  No amount of manipulation will overcome this spasm.

It is necessary to have the patient take a rapidly acting muscle relaxer, assuming they can swallow or inject either intramuscularly or intravenously.  The spasm can be reduced and this will allow the above described manipulation motions to work.

The disadvantage of this method is that once the condyle has been relocated, the patient is sedated and recovery may take quite a bit of time.  They will need a companion with them to help and provide care.

The diagnoses that would link with this treatment procedure or protocol includes:

  1. Open locking
  2. Open dislocation

 

TMJ Mobilization Treatment

This treatment differs from the stretch therapy provided in the Myofacial Pain protocol in that its purpose is to mobilize a joint where you suspect DDNR.  Sometimes the mobilization can be done using vapocoolant spray, but if the mobilization requires a joint injection to mobilize, then it is more likely that you are dealing with a DDNR.  Confirmation of this diagnosis is easily achieved with an MRI.

An aid to stretching is a cooling spray that is applied to the skin in the stretch region.  The vapocoolant spray chills the skin and does not leave a residual film after it vaporizes.  This sensory barrage of cold works to block pain during the procedure, making it easier to achieve better mobilization.

Related Reading: How to Diagnose Masticatory Muscle Disorders

 

Anesthetization

Another way to block pain and achieve TMJ motion is to anesthetize the TMJ.  Once the anesthetic is in effect, the jaw is manually mobilized (stretched open gently) to increase mobility, and the patient is taught TMJ stretching exercises to be performed at home.

If the problem is pain induced trismus and the pain source is the joint, the opening will improve immediately.  If the problem is a sticky disc, mobilizing the joint will improve immediately.  If the disk is folded over and not reducing, this method will not yield full opening.

In the specific cases of acute DDNR, anesthesia-assisted mobilization is appropriate.  It has become clear with research that once a TMJ disc is displaced from its normal position it is highly unlikely that any current procedure will “unstretch the ligaments” and return the disc in a normal position.  The fact is that “you-can’t-put-it-back-and-keep-it-there” applies to open surgery (i.e. disc placation), arthroscopy, mandibular repositioning, and any occlusal therapy.

For this reason, the primary method of treating a disc displacement without reduction (DDNR) is called anesthesia-assisted mobilization.  The method is best applied when the patient has evidence of an acute onset loss of jaw opening, jaw pain while opening the restricted joint, the radiographs show limited or no osteoarthrotic changes, or the passive stretch manipulation with vapocoolant did not substantially increase the jaw opening.

The diagnoses that would link with this treatment procedure or protocol includes:

  1. Acute limitation of opening due to pain related trismus or spasm
  2. Acute limitation of opening due to DDNR (folded disk)
  3. Acute limitation of opening due to suspected joint adherence (a.k.a. a stuck disc)
  4. Substantial muscular contracture or fibrosis

Related Reading: Arthritic Temporomandibular Joint Disorders

 

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About Dr. Glenn Clark

Glenn Clark, DDS, MS is an expert on sleep apnea, orofacial pain and oral medicine, and Temporomandibular Joint Disorder (TMJ). Dr. Clark serves as the Director for the Advanced Program in Orofacial Pain and Oral Medicine at the Herman Ostrow School of Dentistry of USC.