Thirty-year follow-up of a TMD case treated based on the neuromuscular concept

Aim:

Occlusal therapy is employed to alleviate the symptoms of a temporomandibular disorder (TMD) at times. However, the long-term effect of occlusal therapy in the masticatory system is not well understood. This case study aims to present a 30-year follow-up of a TMD case.

Methodology:

The patient developed TMD with intermittent closed lock of the left temporomandibular joint (TMJ). Chief complaints included trismus, pain, and noise of the left TMJ during function. The patient’s occlusal disharmony was assessed with use of electronic instruments and corrected based on the neuromuscular concept. A minimum-invasive and reversible approach using adhesive occlusal restorations was used.

Results:

The jaw movement and masticatory muscle activity assessed at the 7- and 23-year follow-ups revealed that the established occlusion was well adapted, and re-established the patient’s functional occlusion system. The patient has been free from TMD symptoms with the corrected occlusion for 30 years.

Conclusions:

Occlusal reconstruction based on the neuromuscular concept can be stably integrated into the patient’s functional occlusion system.     

Techniques and modifications for TMJ arthrocentesis: A literature review

Objectives: To discuss advantages and disadvantages of TMJ arthrocentesis techniques, identifying modifications as reported in the literature.

Methods: A PubMed web-based search was carried out, using the terms TMJ and arthrocentesis, to determine the scope of coverage in well-documented articles in English.

Results: Among 237 articles, 12 distinct techniques were described for TMJ arthrocentesis in 12 articles. Among 12 techniques, 5 were classified as double puncture arthrocentesis (DPA) and 7 as single puncture arthrocentesis (SPA). In total, 17 well documented articles about SPA were found in literature.

Discussion: Arthrocentesis of the temporomandibular joint (TMJ) was first described in 1991. To make the traditional procedure even less invasive, many arthrocentesis methods have been described. However, in 2015, TMJ arthrocentesis techniques were divided into two groups to limit the complexities surrounding the concepts related to TMJ arthrocentesis techniques.     

Morphological changes in the temporomandibular joint after orthodontic treatment for Angle Class II malocclusion

Objective: The aim of this study was to examine the morphological temporomandibular joint (TMJ) changes that occur after orthodontic treatment in patients with Angle Class II malocclusion.

Methods: The post-treatment changes in TMJ morphology were analyzed, based on TMJ cephalometric laminographs in 19 patients with Angle Class II malocclusion and labial inclination of the upper incisors after premolar extraction.

Results: The condylar pass angle, articular eminence to the Frankfort horizontal plane angle, and total, upper, and lower heights of the articular fossa increased significantly on both sides after treatment and retention. The anteroposterior width of the articular fossa decreased significantly on both sides after treatment and retention.

Discussion: These results suggest that adaptive bone remodeling of the TMJ occurs during the correction of occlusion with labial inclination of the upper incisors by orthodontic treatment after premolar extraction in patients with Angle Class II malocclusion.     

Expression of CD90 decreases with progression of synovial chondromatosis in the temporomandibular joint

Objectives: The aim of the present study was to investigate the factors that contribute to the progression of synovial chondromatosis in the temporomandibular joint (TMJ).

Methods: The authors investigated the expression of CD105 and CD90 in specimens from 17 patients with synovial chondromatosis in the TMJ, using immunohistochemical staining, and expression of CD105 and CD90 in cartilaginous nodules was scored semiquantitatively.

Results: The expression of CD105 and CD90 was found in almost all the cases. In particular, the expression of CD90 in cartilaginous nodules significantly decreased with the progression of synovial chondromatosis.

Discussion: The factors that determine progression of synovial chondromatosis are not fully understood. The results of this study suggest that CD90 may play an important role in the progression of synovial chondromatosis in the TMJ.     

Conservative reduction by lever action of chronic bilateral mandibular condyle dislocation

Aims:

The treatment of long-standing dislocation of the temporomandibular joint is broadly classified into open reduction and closed reduction. The current study presents a case of long-standing dislocation of the temporomandibular joint treated 3 years after dislocation. In this study, the authors evaluated the long-term outcome of conservative reduction by lever action of chronic bilateral mandibular condyle dislocation.

Methodology:

Manual repositioning of temporomandibular joint dislocation lasting for 3 years in a 31-year-old woman was attempted without success; therefore, conservative reduction by lever action was carried out because the patient declined treatment under general anesthesia.

Results:

The treatment was discontinued after 6 days because of the subluxation of the retaining tooth. The retainer was changed from tooth to screw for intermaxillary fixation, and treatment was reinstituted. Fifteen days later, reduction was achieved and retention was started and continued for 2 months. The outcome was good, with no recurrent dislocation within 24 months of the treatment.

Conclusions:

Conservative reduction by lever action, involving minimally invasive treatment and little dysfunction, should be considered an optional conservative treatment.     

Immunohistochemical analysis of IL-1 beta in the discs of patients with temporomandibular joint dysfunction

Purpose: Interleukin-1 beta (IL-1β) is a cytokine that participates in the regulation of immune responses and inflammatory reactions. It is hypothesized that IL-1 levels may be elevated in patients suffering from temporomandibular joint dysfunction. The purpose of this study was to determine the association of IL-1β expression with TMD using an immunohistochemical approach to evaluate the joint disc.

Materials and methods: A total of 39 human temporomandibular joint disc samples were collected, with 31 samples in the test group. Nineteen of the test group samples were from discs of patients with anterior disc displacement with reduction, and 12 of the samples were from patients with anterior disc displacement without reduction. Eight control samples were used in the control group. The samples were immunostained and evaluated on both quantity and intensity of staining.

Results: There was a statistically significant difference (p < 0.05) between the control and test groups for both quantity and intensity of staining.

Conclusion: IL-1β plays a role in the inflammatory process and degradation of TMJ discs in patients with TMJ dysfunctions.     

Low-level laser therapy for management of TMJ osteoarthritis

Aims:

This study investigated the efficacy of low-level laser therapy (LLLT) for the management of temporomandibular joint (TMJ) osteoarthritis.

Methodology:

In a double-blind clinical trial, 20 patients with TMJ osteoarthritis were randomly divided into laser and placebo groups. The patients in the laser group received irradiation from an 810 nm low-level laser (Peak power 80 W, average power 50 mW, 1500 Hz, 1 μs pulse width, 120 seconds, 6 J, 3·4 J/cm² per point), which was applied on four points around the TMJs and on painful muscles three times a week for 4 weeks. In the placebo group, the treatment was the same as that in the laser group, but with laser simulation. The patients were evaluated before laser therapy (T1), after 6 (T2) and 12 (T3) laser applications and 1 month after the last application (T4), and the amount of mouth opening and the pain intensity were recorded.

Results:

No significant differences were found in mouth opening either between the study groups or between the different evaluation times in each group (P>0·05). There was no significant difference in pain symptoms of the masticatory muscles and TMJ between the laser and the placebo groups (P>0·05), but some significant within-group improvements were present for Visual Analogue Scale (VAS) scores of the body of the masseter and TMJ in both groups.

Conclusions:

LLLT using the present laser parameters was no more effective than the placebo treatment for reducing pain and improving mouth opening in patients with TMJ osteoarthritis.     

Recurrent dislocation of the temporomandibular joint: a literature review and two case reports treated with eminectomy

Aims: Dislocation of the temporomandibular joint (TMJ) is a troublesome condition that occurs in a chronic or acute form. It is a distressing and highly embarrassing situation that may occur as a result of daily activities such as yawning, laughing, or during events that require keeping the mouth open for a long time. This review aims to present and discuss different conservative and surgical techniques to treat patients with a dislocated mandible, and to present two cases of surgical treatment.

Methodology: A search of the literature was completed (Medline, PubMed) using the keywords TMJ dislocation, TMJ luxation, mandibular dislocation and surgical and non-surgical methods of treatment for this condition.

Results: Eminectomy (Myrhaug’s surgery) has been used with satisfactory results. Most of reports present large series of patients with more than one year of follow-up and no recurrence of complications. Is less invasive and take a short operation time; need no bone transplantation or placing any kind of foreign body into the joint.

Conclusion: Eminectomy results in long-term resolution of recurrent TMJ dislocations, when compared with others surgical techniques.     

Personality traits are potentially associated with the presence of chronic temporomandibular joint pain in patients without effusion as determined by T-2 weighted magnetic resonance

Objective: The study aimed at investigating personality traits in chronic temporomandibular joints (TMJ) pain patients with and without joint effusion.

Methods: Two groups of chronic TMJ pain patients were recruited. The TMJ pain control group was composed of patients showing magnetic resonance imaging (MRI) signs of TMJ effusion, while the TMJ pain test group included patients with chronic TMJ pain seemingly not justified, due to the absence of MRI-detected disorders. A third set of pain free individuals was selected as a comparison group. All patients completed a personality assessment with the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) instrument, and the between-group differences were assessed for significance by performing an analysis of variance test.

Results: Patients of the TMJ pain test group had higher scores than subjects belonging to the TMJ pain and pain-free control groups in almost all of the MMPI-2 clinical scales. A significant difference was shown for the scales related to concerns about physical health (Scale 1-Hs; F = 7.74; p = .001) and physical symptoms (Scale 3-Hy; F = 8.43; p = .001).

Conclusions: Chronic TMJ pain patients without MRI-detected TMJ effusion have a different personality profile than patients with TMJ effusion and pain-free individuals, regarding high levels of concerns about physical health and physical symptoms.

Clinical implications: This study has important clinical implications for temporomandibular disorders practitioners, providing suggestions that symptoms in the TMJ area are not only related to a physical disorder. The possible existence of a psychologically modulated condition in patients who refer pain in the TMJ area without signs of effusion should be carefully taken into consideration.     

The role of occlusal factors on the occurrence of temporomandibular disorders

Aims:

The aim of this study was to investigate the relationship between occlusal factors and temporomandibular disorders (TMD).

Methodology:

One hundred patients were selected among those who sought medical or dental care in public practice in Recife, Brazil. The presence of malocclusions and absence of five or more posterior teeth were evaluated by the clinical exam. TMD diagnosis was given using Research Diagnostic Criteria (RDC/TMD). Statistics were carried out using Fisher and Mann–Whitney methods with 5% significance level, as well as multiple logistic regression analysis.

Results:

The sample was mainly comprised of women (83%), individuals over 30 years old (57%) and singles (53%). The percentage of TMD and malocclusion in total sample was 42% and 50%, respectively, while in TMD subjects, malocclusion was present in 38·1%. There was no association between TMD and the occlusal factors studied.

Conclusion:

It can be concluded that malocclusion and loss of five or more posterior teeth does not contribute to TMD.     

Complications and post-operative sequelae of temporomandibular joint arthrocentesis

Objective: To evaluate intraoperative complications and postsurgical sequelae associated with arthrocentesis of the TMJ, including injection of Sodium Hyaluronate.

Methods: This retrospective study evaluated 433 arthrocentesis procedures performed in 315 patients between January 2009 and August 2016. The authors reviewed the complications identified during the procedure and the follow-up period.

Results: Temporary swelling of the periarticular tissues (95.1%) or the external auditory canal (23.5%), ipsilateral temporary open bite (68.8%), frontalis and orbicularis oculis paresis (65.1%), preauricular hematoma (0.4%), and a case of vertigo (0.2%) were the complications detected.

Conclusions: TMJ arthrocentesis remains a procedure with a minimum number of important complications. If present, complications are generally temporary, caused by the anesthetic effect or by the soft tissue edema created by the fluid extravasation created by the irrigation procedure, and can be managed on an outpatient basis.     

Diagnosis of retrodiscal tissue in painful temporomandibular joint (TMJ) by fluid-attenuated inversion recovery (FLAIR) signal intensity

The purpose of the present study is to analyze the fluid-attenuated inversion recovery (FLAIR) signal intensity of the retrodiscal tissue in a painful temporomandibular joint (TMJ), and to develop a diagnostic system based on FLAIR data.

Methodology:The study was based on 33 joints of 17 patients referred for MR imaging of the TMJ. Regions of interest were placed over retrodiscal tissue and gray matter (GM) on FLAIR images. Using signal intensities of GM as reference points, signal intensity ratios (SIR) of retrodiscal tissue were calculated. SIRs in painful TMJ were compared with those in painless TMJ. Wilcoxon’s Rank Sum Test was used to analyze the difference in SIRs between the painful and painless groups (P<0·05).

Results:The SIRs of retrodiscal tissue were significantly higher in painful joints than in painless joints.

Conclusion:FLAIR sequences provide a high signal in patients having painful TMJ, and it suggests that retrodiscal tissue in painful TMJ contains elements such as protein.     

Distraction of the temporomandibular joint condyle in patients with unilateral non-reducing disc displacement: Fact or fiction?

Objectives: This study investigated the distractive effect of a unilateral pivot splint on patients with unilateral disc displacement without reduction.

Methods: The study group was comprised of 18 patients who had no history of treatment with removable prosthetic restorations of molars, premolars, or canine teeth, and no previous treatment for temporomandibular disorder. Joint spaces measurements made on magnetic resonance images indicated the affected side to be narrower than the healthy side. Unilateral distraction splints were made for all patients. An ultrasonic motion analyzer was used to measure the vertical shift occurring on the affected side as patients closed their mouths with maximal force with the splint in their mouths.

Results: Closing with maximal force on the unilateral distraction splint led to a noticeable downward movement of the affected condyle.

Discussion: The findings of this study indicate that the TMJ condyle of patients with unilateral disc displacement without reduction may be unilaterally distracted if the articular space is narrowed.     

Features and management of intracranial mandibular condyle dislocation after trauma

Background:

Dislocation of the mandibular condyle into the middle cranial fossa is rare in clinics. It often occurs when the mouth is open wide during the injury. It causes restriction of mandibular motion, lower facial asymmetry, pain in the temporomandibular joint (TMJ), etc.

Objective:

To introduce the features of intracranial mandibular condyle dislocation and discuss the management to this kind of trauma.

Major findings:

In this paper, the authors present two cases, describing the diagnosis, surgical management, and 1-year follow-up evaluation. The results of the authors' treatment to intracranial mandibular condyle dislocation were satisfactory and stable, and no surgical complications were detected.

Conculsion:

Advanced imaging studies are mandatory for exact diagnosis and successful treatment of intracranial mandibular condyle dislocation, and individualized management is recommended.     

Quantitative measurements of the articular areas of mandibular condyles with temporomandibular joint disorders using magnetic resonance imaging

Objective: The authors sought to clarify the variation in the condylar anterior functional surface (AFS) of patients with temporomandibular joint (TMJ) disorders using quantitative measurements by magnetic resonance imaging (MRI).

Methods:MR images of 68 joints (2 males, 32 females) were used. The subjects were classified into three groups: with/without defects of cortical bone groups and a combination group without defects. The AFS was measured as the length between the protrusive point and the apex of the condyle on MRI (4-mm-thick slices), and the quad value of the length was defined as the area on the slice. The summed quad values of all slices were used as the AFS area. Differences in the areas among the three groups were compared by one-way analysis of variance (ANOVA).

Results:The non-defect group had significantly larger AFS areas than the defect group.

Conclusions:Quantitative measurement on MR images clarified the changes in the condylar sagittal appearance.     

Could different TMJ disc positions observed in MRI cause different sounds? Analysis on a group of subjects with ADD with reduction: a pilot study

Aims:

Magnetic resonance imaging (MRI) is the method of choice for examining soft-tissue pathology of the temporomandibular joint (TMJ). MRI shows a high spatial resolution with accuracy for the identification of internal derangement. Tasaki developed a classification system for disc displacement in the TMJ, identifying eight different types of disc displacements in addition to the superior disc position. This study aims to test the ability of electrosonography (ESG) in discriminating different kinds of disc displacement according to the disc position criteria proposed, comparing the ESG results with those obtained by MRI.

Methodology:

Twenty-seven patients were selected from an initial group of 50 patients with articular disc displacement, selected by means of clinical examinations, according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) and who had both MRI and ESG studies performed. For each patient and for each peak in ESG, both in the opening and closing movements, three different parts of the sound were analyzed. The frequency (Hz) and the mean amplitude (μV) of the sounds were calculated in the three analyzed windows. Afterwards, gathering the data for the Tasaki’s classes and dividing opening and closing sounds, the number of peaks was calculated, as well as average and standard deviations for both the Hz and µV.

Results:

The peak frequency shows significant differences between different disc positions during the first and second third of the opening phase and during the first third of the closing phase. The peak amplitude shows significant differences between different disc positions during all of the opening and closing phases.

Conclusions:

Although limited by sample size, the present study shows the presence of different sounds with different Hzs and μVs associated with different disc positions that were recorded with ESG.     

Expression of MMP-13 in human temporomandibular joint disc derangement and osteoarthritis

Objective: MMP-13 performs digestion of collagen, which is a primary component of the temporomandibular joint (TMJ) articular disc. This study evaluated the expression of MMP-13 in patients with anterior disc displacement with (ADDwR) and without reduction (ADDwoR), and in the presence of TMJ osteoarthrosis.

Methods: Thirty-nine human temporomandibular joint disc samples were collected and divided in two ways: ADDwR (21 samples), ADDwoR (10 samples), and a control group (8 samples); and with osteoarthrosis (10 samples) and without osteoarthrosis (29 samples). Immunostaining of the TMJ discs was statistically compared between the groups.

Results: There was no statistically significant difference for the area of MMP-13 immunostaining between the control group, ADDwR, and ADDwoR, nor between groups with and without osteoarthrosis.

Conclusion: This study suggests MMP-13 is not significantly involved in collagen degradation in human TMJ disc displacement or osteoarthrosis.     

Patterns of cervical and masticatory impairment in subgroups of people with temporomandibular disorders–an explorative approach based on factor analysis

Objectives: To identify clinical patterns of impairment affecting the cervical spine and masticatory systems in different subcategories of temporomandibular disorder (TMD) by an explorative data-driven approach.

Methods: For this observational study, 144 subjects were subdivided according to Research Diagnostic Criteria for TMDs into: Healthy controls, temporomandibular joint (TMJ) signs without symptoms, TMJ affected, temporomandibular muscles affected, or TMJ and muscles affected. Factor analysis and linear regression were applied to cervical spine and masticatory data to identify and characterize clinical patterns in subgroups.

Results: Factor analysis identified five clinical dimensions, which explained 59% of all variance: Mechanosensitivity, cervical movement, cervical and masticatory dysfunction, jaw movement, and upper cervical movement. Regression analysis identified different clinical dimensions in each TMD subgroup.

Conclusion: Distinct clinical patterns of cervical spine and masticatory function were found among subgroups of TMD, which has clinical implications for therapeutic management.     

Frequency of temporomandibular arthralgia among myofascial pain patients with pain on palpation of ipsilateral masseter

Aims:

The masseter muscle is a common source of referred pain to the temporomandibular joint (TMJ), with a possibility of false positive diagnoses for arthralgia when diagnosed by research diagnostic criteria for temporomandibular disorders (RDC/TMD) clinical examination. The current study investigated the distribution of arthralgia diagnoses among individuals with myofascial pain, with or without pain on masseter palpation.

Methodology:

The study was conducted with 255 outpatients. Clinical data and questionnaires were directly entered into software that deploys algorithms based on the diagnostic criteria of the RDC/TMD, and automatically classifies and stores the diagnosis of each patient evaluated. An association between diagnostic subgroups was verified by calculating the odds ratio (OR), and the statistical significance was tested using the Chi-square test.

Results:

A higher frequency of concordance (about three times greater) between myofascial pain and arthralgia occurred when there was pain on palpation in the region of the ipsilateral masseter muscle, and the association was statistically significant.

Conclusions:

The results of this study revealed a threefold increase in the risk for the presence of temporomandibular arthralgia in cases of myofascial pain combined with pain on palpation in the region of the ipsilateral masseter muscle.     

Association of bone marrow edema with temporomandibular joint (TMJ) osteoarthritis and internal derangements

Purpose: This study reviewed the dental literature in order to determine the association of bone marrow edema with osteoarthritis and temporomandibular joint (TMJ) internal derangement disorders.

Methods: A literature search was performed using electronic databases PubMed/Medline (National Library of Medicine, Bethesda, Maryland) and Cochrane for articles published during the last 15 years (January 2000–December 2014). A predetermined inclusion and exclusion criteria were used for filtering the scientific papers. Research articles fulfilling the basic inclusion criteria were included in the review.

Results: The reviewed studies showed that bone marrow edema is found in painful joints with osteoarthritis in a majority of cases. A few cases with no pain or significant degenerative changes are reported to have a bone marrow edema pattern as well.

Conclusions: Bone marrow edema, increased fluid level, and pain are associated with osteoarthritis in the majority of patients reporting TMJ arthritis. Degenerative and disc displacement conditions are multifactorial and require further investigations. Magnetic resonance imaging can be employed to detect bone marrow edema even in the absence of pain and clinical symptoms in the patients of internal derangements.