current recommendations for the diagnosis of temporo ...6)_no2/2008_vol3(… · the principles of...

Mædica A Journal of Clinical Medicine, Volume 3 No.2 2008130

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Mædica - a Journal of Clinical Medicine

ABSTRACTThe present paper reviews current literature on evidence-based treatment guidelines for TMJ disorders.

Treatment of TMJ disorders may be non-invasive and/or surgical.

Key words: TMJ disorders, treatment guidelines, conservative treatment, surgical treatment

Current recommendations for thediagnosis of temporo-mandibularjoint disorders – Review paperPart twoHerve REYCHLERa, MD, PhD; Serban Tovarub, DDS, PhDaDepartment of Stomatology and Maxillo-Facial Surgery, Catholic University ofLouvain, Bruxelles, BelgiumbDepartment of Oral Medicine Oral Pathology,Faculty of Dental Medicine, “Carol Davila“ University of Medicine andPharmacy, Bucharest, Romania

Address for correspondence:Serban Tovaru, DDS, MD, Department of Oral Medicine-Oral Pathology, Faculty of Dental Medicine, “Carol Davila“ University ofMedicine and Pharmacy, 19 Calea Plevnei, Zip Code 010221, Bucharest, Romaniaemail address: [email protected]

INTRODUCTION

T he disorders of the temporo-mandibular joint (TMJ) form aspecial group of problems, with alarge number of symptoms whichcause complex painful syndromes,

characterized by a developing self-limiting stageof stable ostheoarthrosis, with a powerfulpsychological component (1), a special pathologyand therapeutic measures which should befocused on the patient’s own situation.

The present diagnostic recommendationsare mainly based on clinical evidence, because

the complementary examinations only have alimited value due to the obvious lack ofsensitivity and specificity. An MRI can be usedto provide information, being the onlytechnique which is able to show abnormalitiesof position and especially of mobility of theintra-articular disc.

The part played by dental occlusion,previously controversial, has been settled as anethiologic factor favoring but certainly not adetermining element. This fact is cruciallyimportant for the therapeutic measures.

The question that must be answered priorto any form of treatment is: what should be

Mædica A Journal of Clinical Medicine, Volume 3 No.2 2008 131

CCCCCURRENT RRRRRECOMMENDATIONS FOR THE DDDDDIAGNOSIS OF TTTTTEMPORO-MMMMMANDIBULAR JJJJJOINT D D D D DISORDERS – R R R R REVIEW P P P P PAPER. P P P P PART TTTTTWO

done and especially what should not be done?The different forms of treatment, ranging fromdrug treatment, behavioral and kinetictreatments, to orthopedic and/or mechanicaltreatments by occlusal bite-guards and surgicaltreatment, should be taken into account.

MEDICAL TREATMENTS

Several drugs can be prescribed with goodresults, for their antialgic or muscular relaxing

effects.Whereas analgesics are useful in the acute

stages, the non-steroid antiinflammatory drugs,especially COX-2 (Celocoxib) (2) have provento be particularly efficient in acute arthralgias.

Muscle relaxant drugs have a certain, thoughlimited, effect: in case of a chronic stage or of arelapse, the relaxing effect of anxiolytics will bebeneficial.

For the same reasons, some specialistsrecommend antidepressants in the abovementioned situations; nevertheless, these drugsare certain to have some effects on the patient’sbehaviour, all risks and benefits must be clearlyexplained.

Local infiltrations are equally recommendedin parallel with the general use of drugs. If theintra-joint infiltrations are excluded (especiallybecause of the risk of cartilage lesions and ofinfections of the joint), recent literatureemphasizes more often the excellent effect ofintramuscular infiltrations of botulinic toxin. Therecommended doses are, most commonly, 30U in the lateral pterygoid muscle or in themasseter and temporal muscles, depending onthe pain and/or the contraction. Due to suchinfiltrations, two cases (thus anecdotic) ofsuppression of a slipped disc for one year (5)have been reported. This treatment breaks acycle (3) and seems useful in diminishingbruxism (66% of the patients reported animprovement) (4).

Along with other non-invasive treatment, thismedication has the main goal of alleviating thepatient’s pain, breaking the cycle of pain-contractions-functional disability, as well as allowingthe patient to complete other treatments –kinesitherapy, occlusal bite-guards, for example.In any case, the use of such drugs should be limitedto as short a period as possible.

BEHAVIORAL TREATMENT

Self-management of the therapeutic schemataby the patient is of critical importance: as

far as the therapist is concerned, it requires aclear and accurate explanation of thesymptoms, reassurance concerning the benigncharacter of and the spontaneous improvementin his or her disorder, advice concering joint andmuscle relaxation, awareness of the patient’sbad habits, as well as relaxation of the muscle-joint apparatus.

If such a treatment is familiar to anytherapist, it is, nevertheless, clear, that thekinesitherapist is the specialist best prepared tomanage it. The kinesitherapist’s advice will havea favourable impact during other forms oftreatment, which are mentioned in the followingparagraph.

KINETHIC TREATMENT

The principles of kinesytherapy used in thetreatment of TMJ disorders are the

following: a muscle relaxation (throughthermotherapy and manual therapy: massage –stretching – trigger point) of the masticatorymuscles as well as the muscles of the neck andthe backside of the neck, the muscular chainsthat are further away but connected to theagonist and antagonist muscles, active andpassive exercises (kinetic, noises, propriocep-tors, re-programming, paradoxical breathing,lingual dysfunctions), exercises to correctcervical posture, teaching relaxation and self-relaxation techniques.

The effects of kinesytherapy are particularlybeneficial in cases of miofascial pains throughconsiderable reduction in the level of pain and aclear improvement in movement (6, 8). In caseof non-reducible meniscal displacement thepatient has less pain and a wider open mouth.In case of reducible displacement of the disc, animprovement in function was obtained (in 11%of cases, noises disappeared after 6 months) (9).The effect of kinesytherapy on the accufenes israndom, hard to foresee and has no guaranteeof success in the long run.

OCCLUSAL BITE-GUARDS

The aims of so-called mechanical therapyby means of occlusal bite-guards are the

following: mandibular relaxation, suppression of



control of the intermaxillary relations throughthe existing dental occlusion, suppresion ofmuscular contraction, disappearance of jointpain and rehabilitation of the position of themandible (10, 11, 12).

For this particular type of treatment, rigidor soft bite-guards can theoretically be used.

Soft bite-guards are hardly ever used inthe treatment of TMJ disorders becauseof their potential to change shape,difficulty of being polished, difficulty ingetting an even, constant pressure andof the unconscious tensions they causedetermined by fragility of the occlusal bite;on the other hand, they are frequentlyrecommended in the treatment of night-time bruxism.Rigid bite-guards have all the features forbeneficial treatment of TMJ disorders.There are several types, only the mostimportant will be discussed further – theso-called Michigan bite-guards, themeniscal reduction guards and the retro-incisive guide.

The so-called Michigan bite-guard, placedon all the teeth on the upper maxilla, is madeof hard, translucent resin, having neat occlusalsurfaces and allows lateral and frontal canineguidance, but no incisive guidance; it mustensure good occlusal stability, with a minimumvertical size of the occlusion and a minimumoral crowding, for the patient’s comfort; its onlydisadvantage is the fact that it must be madeon an articulator (Figure 1).

The guards for the repositioning of themandible are different, according to thereducibility or non-reducibility of the meniscus.

The guards for the repositioning of themandible in the case of a reducible displacedmeniscus (Figure 2) can be placed on the uppermaxilla or on the mandible, in a therapeuticposition on the TMJ level so as to obtain a morefrontal and lower position of the condylecapitulum, which means an edge to edge incissor

bite, with a consequent posterior inocclusionsupported by the guard. The occlusal surfacesare indented. This type of guard must be wornpermanently for 4 to 6 months. It results, atthe end of the treatment, is a posterior dentalinocclusion; its compensation is obtained inmost of cases by prosthetic and rarely byorthodontic or by surgical means.

Guards for repositioning the mandible incase of a non-reducible meniscal displace-ment disc is known “decompression guard”,which reduces the symptoms of a recent and/or acute displaced disc. In theory, the posteriorocclusal obstacle allows decompression ofunilateral TMJ, which should, in turn, enablethe disc to return to its correct position. Due tothe lack of tissue elasticity which is characteristicof this stage, it must be admitted that the discwill most often remain in an incorrect anteriorposition and that the disc-ligament apparatuscan be reshaped, leading to near-normalfunctioning of the mandible and to anasymptomatic stage.

The retro-incissive guide (Figure 3) is an inter-occlusal device, conceived as a retroincisive planfrom one upper canine connect to another,allowing only lower incisives and canines to haveconnection to the guide. This plan must beparallel to the bipupil ligne and the Campertreatment; it also creates a disocclusion of theposterior teeth. It is generally worn around theclock and adjustment is achieved by adding orremoving resin in the lateral zones.Figure 1. The Michigan byte-guard

Figure 2. Repositioning bite-guard in case ofreducible condylar luxation



All the above mentioned non-surgicaltreatments have an 89% success rate after 10months; success being measured in terms ofpain, joint mobility, and buccal opening (6).

Patients who do not respond to theseconservative treatments have as a characteristica painless limited buccal opening, of under 30mm, also known as “stuck disc“ (7).

SURGICAL TREATMENT

These involve arthrocentesis or jointrinsing, arthroscopy or arthrotomy with

discpexis or discectomy. Unfortunatelly,literature is not very rigorous in the analysis ofsurgical results, so there are very few “evidence-based” scientific facts. Nevertheless, there areevaluation questionnaires which allow the

comparison of results in patiens from differentcountries and cultures (British, German,Japanese). Culture seems to play an importantpart in the way patients report symptoms ofTMJ disfunctions: an even more important roleseems to be the patients’ response to conser-vative treatment.

There are some reports in literatureemphasizing the correlation between thecomposition of synovial fluid (collected duringsurgery) and clinical TMJ disfunction. Thus,clinical symptoms are correlated with cytokins(15) (IL-1, TNF-alfa), Beta-glucorodinase (16),values of IgG and IgA.

Arthrocentesis or joint rinsing (Fig. 4), isefficient in 90% of the patients after one year(17), but only in 26% of patients after 5 years(20). The procedure must be done under highpressure: the high pressure ensures betterresults than lower pressure (18). Threehundreed (300) ml are necessary to removethe inflammation products (19). The mainindication remains non-responsiveness toconservative treatment (21).

Surgical treatments (22) is only recommendedin cases with the following pathologic situations:if and only if, severe pain is present after havingtried, for at least 6 months, well controlledconservative treatment; if and only if functionaldisability persists; if and only if organic intra-articulary or peri-articulary pathology is alsopresent.

At present there is no consensus on the useof a particular articular prosthesis. If TMJresection becomes necessary following nondisfunctional pathology but of an organic nature,reconstruction with a chondro-costal graft is themethod of choice.

Unfortunately, there are no random studieson surgical treatments of TMJ disorders and, atthe same time, all the studies that have alreadybeen published have a low methodologicalstandard; by the end of 2006, 32 studies,reporting results for 11 to 237 patients can bereviewed; only 54% of these studies areprospective, with a follow-up period of 2 to 111months for surgery performed for reducible andnon-reducible disc displacements, as well assurgery performed for temporal-mandibularostheoarthrosis sequellae. Analyzing the entirerange of reported results, it can be pointed outthat arthroscopy has the same results as acondylectomy, a discectomy better than a

Figure 3. Retroincisive guide

Figure 4. Left TMJ arthrocentesis



discopexy (23), except for a slight advantagebecause of mandible mobility (24).

In case of non reducible disc displacement,a maximum of 10% of cases become reduciblethrough surgery, although the disc generallyremains stuck on the temporal structures (theroof of the glenoid cavity or the anteriortemporal tubercle), which MRI results show verywell bearing in mind that 60% of patients haveno symptoms (25).

In case of discectomy, the results after 5 yearsare encouraging: 85% (26) to 87% (27) goodresults given by the disppearance of pain, bettermobility and a buccal opening of 40 mm.

OUR THERAPEUTICRECOMMENDATIONS

In view of recent specific literature, which wasbriefly reviewed in this article the findings of

which were supported by our experience ofmore than 25 years, we consider that thefollowing therapeutic recommendations can beproposed:

in case of myalgia: kinesytherapy,prescription of mio-relaxing drugs, andinfiltrations with botulinic toxine. If thepatient is not satisfied, our suggestion is aretro-incissive occlusal guard;in case of arthralgy: prescription of non-steroid anti-inflammatory drugs alongwith kinesytherapy. If this treatmentproves unsuccessful (less than 10% ofcases), the mechanical treatment – retro-incissive occlusal guard – is introduced;

in case of reducible disc displacement:kinesytherapy is extremely efficient. Theguard is not recommendable in ouropinion;in case of non-reducible disc displacement:kinesytherapy is very efficient for treatmentof pain and mandible mobility. The occlusalguard is only the second choice;in case of osteoarthrosis: non-steroidanti-inflamatory drugs are prescribed,followed by kinesytherapy; in case oftreatment failure, the occlusal guard canefficiently alleviate the patient’s discom-fort. At the same time, the long term effectof guards on dental occlusion generallyshould be remebered at all times.

Only after failure of well-controlledconservative treatment for at least 6 months issurgery recommended:

in case of arthralgy: arthrocentesis underhigh pressure will relieve the patient, butits effect is limited over time (often 6 to12 months);in case of reducible disc displacement: adiscopexy can have good results after 5and even after 10 years;in case of non-reducible disc displacement:an arthrocentesis, a discopexy, or even adiscectomy can be suggested with caution;in case of osteoarthrosis: an arthro-centesis is chosen first. If symptomsreappear and cannot be controlledthrough conservative treatment, wesuggest an arthrotomy and, most often,a temporal muscular flap.

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