1. When the mouth doesn’t open all the way it is difficult to nearly impossible to get normal intra oral x-rays of the teeth.  An extra oral panoramic screening film or tomograms of the TM joints can be taken to document the existing condylar restriction when the mouth is held open to its limited opening position as well as the habitual CO position prior to any treatment.
2. Relaxation therapy may be indicated in some conditions to help calm spastic and tight muscles.  (TENs, massage or physical therapy may be used to help reduce the strains, but often these will not resolve the problem alone since most often disc restrictions and displacement problems are more involved).  It may require a few visits to help calm and reduce a disc.
3. It is imperative that the patient must understand that their disc is displaced (wrongly positioned in side the glenoid fossa causing the bite/occlusion to be off and imbalanced and the muscles are straining internally and externally. When the disc is displaced anterior/medially the mouth is “stuck” or restricted causing limited range of mandibular/jaw movement since the disc is in the wrong place blocking the lower jaw to open.  It is painful!

To unlock this problem various methods have been used to reduce (unlock, recapture, normalize) the disc over the condyles.

• Direct manipulation mechanically in an attempt to unlock jaw restrictions.
• Some have used to gagging techniques to create an automatic mouth opening response to unlock the joints.
• Pivot appliances over the back molars unilaterally or bilaterally have been used as an attempt to decompress the joints.
• Injection therapy into the joint compartment to reduce inflammation.
• Anti inflammatory medications can also be prescribed.
• Surgical intervention under sedation to manipulate the jaw open (for patients who are anxious and want something done immediately).
• Combination approach – muscle relaxation therapy (low frequency TENS combined with decompression techniques to increase condylar space to reduce the disc (the later is done non surgically), but takes cooperation, understanding and patience on the part of both patient and dentist to slowly unravel the hyperactive muscles that doing a tug and war on the cranio-mandibular joint and occlusal system.

Depending on the philosophy of the dentist or surgeons some may even recommend surgery of the joints in severely damaged disc problems to “repair disc damage” and reposition it.  (Remember there are always risks to any surgical procedure).

Disc Reduction (Recapture) Considerations:

Reducing a disc (recapture or repositioning) is not an easy simple procedure to do for most dentists.  It takes understand, skill and technique to unravel a muscular problem where the lateral pterygoid muscles are pulling on the connected disc in one direction while other muscles that close the jaw as the temporalis anterior and masseter muscles are responding by closing the jaw.  Digastric/suprahyoid muscles want to help open the mouth, but find a mechanical ligamentous restriction of the disc that is not displaced internally contributing to severe pain behind the eyes and around the temporomandibular joint regions.

Emergency in office protocols may be implemented in the best interest of patient care:  Multiple appointment visits may required.  (Note: Disc reduction non surgically is not a one stop visit, it may require multiple visits to reduce the problem).

Referral certainly can be considered to any oral surgeon if that is the desire and philosophy of the dentist and patient recognizing that surgical intervention is an option.

Other Considerations:

• How long as the jaw been restricted?
  • Recent occurrence or
  • has this been like this for more than 1-2 years?
• By what philosophy and approach do you want this problem resolved?
  • Surgically or
  • non surgically?

It is very important that you decide on what approach you want to your dentist to take. It is important to develop trust and confidence in your dentist.  If you feel you don’t have the trust or confidence in your dentist then it is best you find a dentist or surgeon you can trust, because without trust and confidence the treatment will never be successful.

Once the limited mouth opening problem has been resolved a more comprehensive evaluation can be considered with your dentist.  A comprehensive examination should uncover why this type of problem has occurred and what can be done in the short and long run to prevent further incidences of restricted mouth opening.  It can re-occur if not treated properly.

Q & A:

1. Does all GNM dentist have to have full range of motion to do all testing?

• No.  It is impossible to do a full range of motion testing if the jaw is restricted.  GNM acknowledges that tempormandibular joints are a synovial joint.  The TM joint functions best when the condyles are not compressed up and back within the glenoid fossa.  Muscle relaxation therapy must be involved to help calm spastic muscles that help further the reposition of the mandibles and condyles back into a physiologic position.  It is impossible to get full range of motion immediately.  In order for the jaws to unlock (reposition) and gain sufficient space within the glenoid fossa visits will be required to accommodate the displaced ligamentous disc to slowly regain back normalized range of mouth opening.  An initial “emergency” visits will be required assist in helping increase the deficient vertical dimension of the jaw (in most cases) that is contributing the disc entrapment problem.

1. Does GNM work for disk issues?

• Yes, it does work when the trained clinician follows “optimization” of the condyle and disc protocols.  Disc that are often identified and non reducing and the patient is able to move and open their jaw may be good candidates for the Optimization of the Bite protocol.  Tests will are recommended.  Training, skill and understanding by the OC GNM dentist is required.
• No, it does not work for every case.  Each case has a different level of needs and severity. Most restricted jaw problems can be resolved by GNM protocols since most of the restricted jaw problems are muscle related and disc displacement problems are involved. Patience with your GNM dentist is required and your cooperation and understanding of the underlying issues of both the anatomical and physiologic issues are involved.  It is not just a mechanical problem.

Other Symptoms:

• MRI Disc Reduction Using GNM Optimization Protocols 
• Retro Orbital Pain – Pain Behind the Eyes
• Ear Congestion Feelings
• Tinnitus (Ringing in the Ears)