What is the best treatment for Temporomandibular Joint (TMJ) locking?

Treatment for Temporomandibular Joint (TMJ) Locking

The best treatment for TMJ locking involves a stepped approach starting with conservative measures including jaw rest, physical therapy, and occlusal splints, with more invasive procedures like arthrocentesis reserved for refractory cases. 1

Initial Conservative Management

First-Line Treatments

• Education and self-management strategies:
  • Jaw rest and behavioral modifications
  • Soft diet
  • Avoiding wide mouth opening and aggravating activities
  • Application of heat and/or cold 1

Physical Therapy Interventions

• Manual therapies (strongly recommended):

  • Therapist-assisted mobilization
  • Manual trigger point therapy
  • Manipulation 1

• Exercise-based interventions:

  • Supervised postural exercise
  • Supervised jaw exercise with stretching 1

Occlusal Splint Therapy

• Stabilization splints have shown effectiveness for TMJ closed lock, with benefits including:
  • Increased interincisal distance
  • Decreased dysfunction indices 2
  • Fewer complications compared to anterior repositioning splints 2

Intermediate Interventions for Persistent Locking

Manipulation Techniques

• For acute open lock: Pumping manipulation technique can be effective to reduce the displaced articular disk 3
• For closed lock: Manipulation combined with stabilization splint, moist heat, and exercise should be considered before more invasive options 2

Pharmacological Management

• Note: The American College of Physicians conditionally recommends against using NSAIDs alone, acetaminophen, gabapentin, benzodiazepines, and strongly recommends against NSAIDs with opioids for TMJ pain 1
• Glucosamine sulfate has shown effectiveness (71% improvement) compared to ibuprofen (61%) 1

Advanced Interventions for Refractory Cases

Arthrocentesis

• Indicated when conservative measures fail
• Success rate of 77% for chronic closed lock 4
• Procedure involves washing the joint to:
  • Remove inflammatory mediators
  • Break intra-articular adhesions
  • Change intra-articular pressure 5
• Significantly improves jaw opening and mandibular function 6
• Low complication rate (8%) with complications resolving within 2 weeks 4

Arthroscopy

• For chronic closed lock unresponsive to conservative therapy
• Arthroscopic lysis and lavage has shown:
  • Increased mouth opening from mean 27mm to 38mm
  • 77% success rate (defined as ≥35mm opening)
  • Short hospital stay (mean <1 day) 4

Surgical Management

• Total TMJ replacement should be reserved for cases where:
  • Joint collapse or fusion has occurred
  • Other treatments have failed to provide adequate symptomatic control
  • Caution: Consider metal hypersensitivity, particularly in females (10-15% of population may exhibit allergy to metals used in implants) 1

Treatment Algorithm

1. Start with conservative management (4-6 weeks):

   • Self-management strategies
   • Physical therapy
   • Stabilization splint

2. If no improvement, proceed to:

   • Manipulation techniques
   • Consider glucosamine sulfate

3. For persistent symptoms:

   • Arthrocentesis (minimally invasive, high success rate)
   • Arthroscopy for chronic closed lock

4. Last resort:

   • Surgical interventions only after exhausting all conservative options 1

Important Considerations

• Infection risk: While rare (0.7%), surgical site infections following TMJ replacement can have significant consequences 7
• Multidisciplinary approach: Involve oral and maxillofacial surgeons, oral medicine specialists, physiotherapists, and maxillofacial prosthetists 1
• Regular reassessment: Monitor treatment effectiveness and adjust as needed 1