What are the typical clinical features of temporomandibular joint (TMJ) subluxation and its initial conservative management?

TMJ Subluxation: Clinical Features

TMJ subluxation presents as excessive anterior condylar movement beyond the articular eminence that spontaneously reduces, often causing clicking, jaw deviation, or transient difficulty closing the mouth, and should be managed initially with conservative measures including jaw rest, soft diet, NSAIDs, and supervised physical therapy. 1, 2

Distinguishing Subluxation from Related Conditions

TMJ subluxation is frequently underrecognized and confused with disc displacement or complete dislocation, requiring careful clinical differentiation 3. The key distinction is that:

• Subluxation involves excessive anterior condylar translation that spontaneously reduces, allowing the patient to close their mouth without assistance 3, 4
• Complete dislocation involves the condyle becoming stuck anterior to the eminence, leaving the patient unable to close their mouth without manual reduction 5, 6

Importantly, anterior condylar movement beyond the fossa during maximal opening is actually a normal physiologic movement in many individuals, occurring even with openings as small as 35mm 4. The term "subluxation" should be reserved for cases where this movement becomes symptomatic or problematic 4.

Clinical Presentation

Primary Symptoms

• Clicking or popping sounds during jaw opening and closing as the condyle translates excessively 7, 3
• Transient jaw deviation or momentary difficulty returning to closed position 3
• Pain in the jaw region, though this may be absent in many cases 8, 7
• Sensation of the jaw "catching" or "slipping" during function 3

Physical Examination Findings

• Excessive anterior condylar translation palpable during mouth opening 8, 4
• Hypermobility of the condyle beyond the articular eminence 6, 9
• Jaw deviation during opening or closing movements 3
• Masticatory muscle tenderness in 45% of genuine TMD cases, as muscular factors dominate the etiology 7

Important Clinical Context

• Approximately 50% of patients presenting with TMJ-region symptoms have complications unrelated to the TMJ itself, emphasizing the need for accurate differential diagnosis 7
• Most TMJ problems are actually associated with limited condylar movement confined to the fossa, not excessive movement 4
• True intra-articular pathology represents only 5% of TMD cases 7

Initial Conservative Management Algorithm

Immediate First-Line Interventions (Start Immediately)

• Jaw rest and activity modification to minimize TMJ stress 1, 2
• Soft diet to reduce mechanical loading during the acute phase 1, 2
• Heat and/or cold therapy applied to reduce pain and inflammation 1, 2
• NSAIDs as first-line pharmacotherapy for pain relief and inflammation reduction 1, 2

Early Supervised Exercise Program (Start Within First Week)

• Jaw exercises and stretching provide approximately 1.5 times the minimally important difference in pain reduction and should be started early 2
• Postural exercises to improve head and neck alignment, reducing compensatory muscle tension 1, 2
• Manual trigger point therapy delivers one of the largest reductions in pain severity 2
• Therapist-assisted jaw mobilization provides substantial pain reduction 2

Timeline for Initial Management

• Continue conservative management for at least 4-6 weeks before considering escalation 2
• Reassess at 2-4 weeks; add second-line interventions if no improvement 2

Second-Line Interventions (If Inadequate Response at 2-4 Weeks)

• Occlusal splints may be beneficial for persistent symptoms, particularly if bruxism is present 8, 2
• Acupuncture shows moderate certainty evidence for TMJ pain relief 2
• Cognitive behavioral therapy with relaxation therapy or biofeedback provides the largest reduction in chronic pain severity 2

Minimally Invasive Procedures (Only After 8-12 Weeks of Failed Conservative Management)

• Intra-articular lavage (without steroid) may provide symptomatic relief in refractory cases and can be used safely in both growing and skeletally mature patients 8, 2
• Intra-articular glucocorticoid injections are reserved for refractory and symptomatic TMJ dysfunction in skeletally mature patients only 8, 2
• In skeletally immature patients, intraarticular glucocorticoids are not recommended as first-line management and should be used cautiously only for refractory cases 8

Critical Pitfalls to Avoid

• Never proceed to invasive procedures before exhausting conservative options, as this risks permanent changes in range of motion, facial nerve weakness, and local infection 1, 2
• Avoid combining NSAIDs with opioids, as this increases risks without clear additional benefits 2
• Do not use irreversible splints or premature surgery, which may result in permanent change in range of motion 2
• Recognize that 85-90% of TMD patients can be treated effectively with non-invasive interventions, as the underlying cause is typically muscular rather than structural 7

Special Consideration for Progression to Complete Dislocation

If subluxation progresses to complete dislocation (condyle stuck anterior to eminence, unable to close mouth):

• Manual reduction is the immediate treatment 1, 5
• Apply intermaxillary elastics to stabilize the joint for at least one week post-reduction 1
• Consider muscle relaxants if initial reduction attempts fail due to muscle spasm 1

For chronic recurrent dislocation unresponsive to all conservative measures, surgical options such as augmentation of the articular eminence may be considered, but only after exhausting all non-invasive options 5, 6, 9.