TMJ Disease Progression
Nobody wakes up one day and says, “Wow, today I think I’d like to go get a new hip or knee or tmj.” Like any part of the human body, if a system is not healthy and stable, then it’s slowly and surely degenerating. Just as a hip or knee can degenerate to the point where they eventually require total replacement, so does the temporomandibular joint.
The earlier your condition falls on the continuum of degeneration, the easier it is to resolve, the better the prognosis, the less time and effort involved to recovery, the greater the stability of the tissues and the more complete the healing. The later your condition falls on the continuum of degeneration the worse the prognosis, the more time and effort involved to recovery, etc. The earlier treatment is pursued, the greater the chance for recovery.
Just the hard facts
Presented below are the facts. They’re presented here not to scare you or convince you to pursue treatment, as we believe everyone should and can make their own choices regarding their life, health and finances. At the Atlanta Center for TMJ we only choose to work with patients we believe we can help and who have the means and desire to get better. Only you can decide if this is the right time and the right place for you.
The facts are presented here to help you understand what is actually going on in your joints. The TMJ is arguably the most complex joint in the human body. It is the only joint where both the left and right joints have to function simultaneously in complete harmony. It is the only joint that does not just purely rotate. It is a gliding, sliding rotating joint. It is the only joint in the human body where the end point in the range of motion is not dictated by muscle. In the TMJ, the end point of our range of motion is dictated by when and where the teeth come together with our bite. If our bite forces the joint into a less than optimal position, problems can develop.
It starts innocently enough
Temporomandibular joint disease starts innocently enough with only muscle incoordination (dyskenesia) caused by muscle fatigue or atrophy. As the disease progresses, actual morphologic physical changes to the hard tissues (the condyle, the fossa and the disk) and the soft tissues (the tendons, the ligaments and muscles) occur.
Clicks or pops indicate that the disk in the joint is displaced forward out of place. The click is the sound made when the condyle temporarily pops back on the displaced disk. The second click upon closing, if felt at all, is the sound made by the condyle popping back off the disk again.
Your muscles play a huge role in the problem
Throughout the entire continuum of dysfunction, the muscles that affect the positioning of the TMJ, our jaw, our bite and whole upper body posture are majorly involved in the process. If the bite and joint are not working together properly, the muscles will be sore and fatigued causing pain. To put it simply:
Muscles are muscles. Hold your jaw in the wrong position for an hour, and it’s like chewing gum non-stop for twelve hours. Either way, you end up with tired, sore muscles. Your muscles don’t care. They’ll just produce pain if you abuse them.
Headaches, facial pain, neck pain, shoulder pain and limited range of motion can all be the result of muscle dysfunction. As stated previously, over 90% of the pain and dysfunction starts and ends with the muscles.
The progression of temporomandibular joint disease continuum:
You can probably make an educated guess of where you fall on this continuum. We can determine precisely where you are and what your likely prognosis is.
1. Muscle soreness and tenderness. There is occasional pain around the joint when opening or chewing.
2. Occasional clicks or pops in the joint when opening. The sooner the click occurs upon opening, the better the prognosis for recapturing the displaced disk. Clicks are classified into three categories; early opening click, mid opening click and late opening click.
The early opening click occurs early in the opening cycle. In other words you feel a click almost as soon as you open your mouth. This means the condyle is not displaced far posteriorly and the disk is still close by in front of the condyle. Since the distance traveled by the condyle to get back on the disk isn’t far, the click occurs quickly when we open.
The mid opening click occurs about half way between when your mouth is fully closed versus fully open. The condyle is displaced further posteriorly and the disc is further away in front, therefore it takes more time for the condyle to reach the disk and get back on it. This click has a more guarded prognosis for recapturing the disk (getting you back on your disk permanently), stabilization and healing.
The late opening click occurs late in the opening cycle. In other words your mouth is pretty wide open before you feel the click. The condyle is retruded significantly posteriorly and the disk is displaced far in front as the ligament that tethers the disk back in place is now more damaged, stretched and fatigued. Therefore it takes even more time for the condyle to reach the displaced disk and get back on it when opening. This click has a poor prognosis for complete recapture, stabilization and healing.
3. Intermittent clicking and popping. The sounds occur more frequently. There may now be multiple sounds when opening or closing the jaw. The jaw may begin to deviate to one side when opening slowly. It does not open perfectly straight up and down any more.
4. First episode of closed lock. You try to open your mouth normally but you are unable to open as wide as normal. What has happened is the condyle was unable to get back up on the disk at all, so the disk acts as a ‘roadblock’ preventing the condyle from sliding down and forward, so you can’t open fully.
5. Intermittent closed lock. Two or three episodes have now occurred, possibly over an extended period of time, where you were unable to open your mouth fully. Each time it eventually went away. Unfortunately all the while the disk is further deforming, the ligament that tethers the disk in place is fatiguing or tearing and the degeneration is progressing.
6. Completely locked out, anteriorly displaced disk. The disk is now permanently displaced in front of the condyle and the condyle is unable to get back on the disk at all. At this point the clicking or popping ceases. The click was the sound made by the condyle when it rode back onto the disk. Now that the disk is too far displaced and deformed, the condyle cannot get back onto it, hence there is no more click or pop.
At this point you are functioning on the posterior collateral ligament and retro-discal tissues.
7. Degeneration and thinning of the retro-discal tissue. Unfortunately these tissues were not designed to be functioned on by the condyle, so they degenerate and perforate quickly.
8. Perforation of the retro-discal tissue, the posterior collateral ligament and/or the lateral collateral ligament leading to further instability in the joint.
9. Crepitis. Clicking and popping has ceased. The disk is stuck out front. The ligament that was acting as a shock absorber in the absence of the actual disk, is now perforated, so for the first time there is now bone rubbing on bone. The condyle and the fossa (the ball and socket) are rubbing against each other. There’s no cushion or shock absorber in between them any more.
The sound made by the bone rubbing on bone is a sandy, gravelly, crackling, grinding type of sound. This is called crepitis.
10. Accelerated degeneration of the condyle and fossa. The bones of the TMJ ball and socket joint break down from the pressure and compression. There’s a loss of vertical height in the joint. The muscles that position the joint shorten and atrophy.
11. Compensation begins in the contra-lateral joint (the other TMJ joint) due to the dysfunction in the original joint.
12. The degenerative process repeats in the other joint.
13. Bi-lateral closed lock. Severe degeneration in both joints. Unable to function, open or chew properly.
During this entire process, the muscles are compensating for the incorrect position of the condyle/fossa and they fatigue and spasm causing many varied pain symptoms.
The main point for you to understand is that TMJ dysfunction is a degenerative disease that slowly but surely progresses from normal function to muscle in-coordination, to disc movement, to disc displacement, to early joint degeneration, to advanced joint degeneration.
Regardless of where you choose to receive treatment, get help. Don’t ignore symptoms. They will progressively worsen over time and the underlying structures will degenerate. Don’t mask symptoms.
What they call ‘symptomatic relief’ only gets you so far. After that, it’s pain again from the muscles and joints until you mask it again. Bring that approach seven days a week for 10 years and you actually might wake up one day and be looking for a new joint.