Read more: Anatomy of the Temporomandibular Joint →

Clinical Challenges

🔹 Imaging difficulty — 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.

🔹 Relaxation therapy — Relaxation therapy may be indicated in some conditions to help calm spastic and tight muscles. J5 Dental 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.

🔹 Patient understanding of disc displacement — It is imperative that the patient understand that their disc is displaced (wrongly positioned inside 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.

Methods Used to Reduce the Displaced Disc

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

🔹 Gagging techniques — used to create an automatic mouth opening response to unlock the joints

🔹 Pivot appliances — placed over the back molars unilaterally or bilaterally as an attempt to decompress the joints

🔹 Injection therapy — into the joint compartment to reduce inflammation

🔹 Anti-inflammatory medications — prescribed to reduce inflammation

🔹 Surgical intervention under sedation — to manipulate the jaw open (for patients who are anxious and want something done immediately)

🔹 Combination approach — muscle relaxation therapy with low frequency J5 Dental TENS combined with decompression techniques to increase condylar space and reduce the disc (the latter is done non-surgically), which takes cooperation, understanding and patience on the part of both patient and dentist to slowly unravel the hyperactive muscles that are doing a tug-of-war on the cranio-mandibular joint and occlusal system.

Depending on the philosophy of the dentist or surgeon, 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 understanding, 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 — such 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 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 be required. (Note: Disc reduction non-surgically is not a one-stop visit; it may require multiple visits to reduce the problem.)

Referral can certainly 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 has the jaw been restricted? — Recent occurrence, or has this been the case 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 what approach you want 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.

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Frequently Asked Questions

Does the GNM dentist need full range of motion to do all testing?

No. It is impossible to do full range of motion testing if the jaw is restricted. GNM acknowledges that the temporomandibular joints are synovial joints. 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 reposition the mandible 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, multiple visits will be required to accommodate the displaced ligamentous disc and slowly regain normalized range of mouth opening. An initial “emergency” visit will be required to assist in helping increase the deficient vertical dimension of the jaw (in most cases) that is contributing to the disc entrapment problem.

Does GNM work for disc issues?

Yes — it does work when the trained clinician follows “optimization” of the condyle and disc protocols. Discs that are identified as non-reducing, where the patient is still able to move and open their jaw, may be good candidates for the Optimization of the Bite protocol. Diagnostic tests are recommended. Training, skill and understanding by the OC GNM dentist is required.

However, GNM 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 restricted jaw problems are muscle-related and disc displacement problems are involved. Patience with your GNM dentist is required, along with your cooperation and understanding of the underlying anatomical and physiologic issues involved. It is not just a mechanical problem.

For a fuller account of the objective measurement and clinical evidence behind these protocols, see The Evidence Behind GNM: Objective Measurement and Clinical Outcomes.

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