Mandibular manipulation of anterior disc displacement without reduction*

Transcription

1 Journal of Oral Rehabilitation. 1991, Volume 18, pages andibular manipulation of anterior disc displacement without reduction R.G. Cardiff, U.K. JAGGER Department of Prosthetic Dentistry. University of Wales College of edicine, Summary The history and clinical symptoms of anterior temporomandibular joint disc displacement without reduction are characteristic, and include limitation of mandibular movement and mandibular deviation on opening of the mouth. Twelve consecutive patients attending a clinic with such symptoms were treated by mandibular manipulation. An immediate increase in the range of mandibular movement was obtained for all patients, with a mean increase in interincisal opening of 8 mm. The method of manipulation is described, and the implications of the results for the treatment of TJ patients are discussed. Introduction Internal derangement of the temporomandibular joint (TJ) is defined as an abnormal relationship of the articular disc to the condyle. Inaccessibihty of the joint and articular tissue has made it difficult to determine the nature of the tissue response. The application of arthrography, arthrotomography and magnetic resonance imaging, and correlation of the findings of these techniques with clinical and surgical observations has led to an improved understanding of internal derangements of the TJ (Katzberg et al, 1980; Bronstein, Tomasetti & Ryan, 1981; Donlon & oon, 1987). Although posterior disc displacement and partial lateral displacement have been described, the disc is usually antero-medially or anteriorly displaced (Westesson & Rohlin, 1984). Anterior disc displacement (ADD) has been classified functionally as displacement with or without reduction. ADD with reduction implies normalization of the disc position on opening of the mouth, and subsequent anterior displacement when the mouth is closed again. This is associated with reciprocal clicking, i.e. clicking both on opening and on closing the mouth. ADD without reduction implies that the relationship between the disc and the condyle is not normalized, the disc remaining displaced at all times. The condition is characterized by a distinctive combination of signs and symptoms, which are listed in Table 1 (Schwartz & Kendrick, 1984). Although surgical procedures to correct ADD without reduction have been shown to yield good results (ccarty Jr & arrar, 1979), few data are available on conservative Presented at a British Society for the Study of Prosthetic Dentistry eeting, anchester, April 1990, Correspondence; r R.G, Jagger, Department of Prosthetic Dentistry, University of Wales College of edicine, Dental School, Heath Park, Cardiff C4 4XY, U.K. 497

2 498 R.G. Jagger treatment. iddleton (197) reported a 75% success rate using manipulation of the mandible under general anaesthesia, but did not describe details of patient selection, the manipulative technique or criteria for evaluation of success. urakami et al. (1987) described mandibular manipulation for disc displacement after inereasing the intraarticular pressure of the TJ by 'pumping" fluid into the upper joint compartment. arrar (1978) has described a teehnique of manipulation to recapture the disc, but considered that the method that he used was useful only if the disc had been displaced for less than 3 4 weeks. The aim of the present study was to investigate the use of a method of mandibular manipulation to treat a group of patients who presented at a clinic with signs and symptoms of ADD without reduction. aterials and methods Subjects were seleeted from patients who were referred to the TJ Clinic at the Department of Prosthetic Dentistry, Cardiff Dental School. Twelve consecutive patients (8 women and 4 men, of mean age 1-8 years) with a history of TJ dise displacement without reduction, as described in Table 1, were included in the study. The duration of these symptoms was recorded, and the mean duration was found to be 3 months (range 1 9 mouths). All patients were examined for signs of TJ dysfunction. All patients with signs and symptoms listed in Table 1 were included in the investigation. aximal interincisal opening (without taking into account overbite) was noted. A simple explanation of the probable cause of the limitation was given to the patients, and the proposed manipulation proeedure was described. The mandible was depressed by pressing with the index fingers on the patient's lower molar teeth. Leverage was obtained by placing the thumbs on the upper teeth (ig. 1). The patient was asked to attempt to reproduce the clicking noise which he had experienced in the affeeted joint before the limitation had occurred, whilst pressure was applied to the lower molars. andibular movement eapacity was reassessed after manipulation. Results An immediate improvement in inter-incisal opening was observed for all 1 patients (mean improvement 8mm, range 5-1mm). The results are shown in Table. Deviation on opening was no longer present, and alj patients were able to perform unrestricted lateral excursions. Table 1. Signs and symptoms of disc displacement without reduction 1, Joint previously clicked, Clicking stops followed immediately by limitation of mouth opening 3, On examination: Limitation of mouth opening Pain in joint on opening mouth Tenderness of joint to palpation Deviation of mandible to affected side on opening Limited lateral excursion possible away from affected side

3 andibular manipulation of anterior disc displacement 499 ig. 1. ethod of obtaining leverage on mandible; index fingers pressing on mandibular mt)lar teeth, thumb on opposing maxillary teeth. Table. Results of manipulatton Inter-ineisal distanee(tnni) Patient Sex Age (years) Pro-manipulation Post-manipulation Duration of limitation (tnonths) 1 RT SD 3 C 4 WW 5 JD 6 L 7 C.P 8 RD 9 H 10 SJ 11 RR 1 K cs ! 4 3« "Not recorded. Discussion The manipulation procedures in this study were applied only to patients who presented with the symptom complex characteristic of ADD without reduction. The author had previously attempted manipulation for patients with reciprocal clicking, without success. All patients included in the study experienced an immediate improvement in mandibular movement capacity. The most striking finding after manipulation was the increased inter-incisal opening (Table ). Also notable was the absence of mandibular

4 500 R.G. Jagger deviation on opening of the mouth, and the ability of the patient to make unrestricted lateral excursions. The manipulation technique described here differs from that reported by arrar (1978). It would be interesting to test his statement that his method might only be of value for locking of short duration (3 4 weeks). The present study suggests that even longer-term ADD without reduction may be treated by the manipulation technique described here. The intra-articular effect of the manipulation procedure is uncertain, and arthrography or magnetic resonance imaging would be necessary to establish whether the disc is completely repositioned. On only one occasion (patient 6) was a loud snap heard on manipulation, as described by arrar (1978). Although all the patients who participated in the study benefited from manipulation, when ADD without reduction is chronic, the condyle has been shown to push the disc forward and stretch the posterior ligaments, sometimes resulting in perforation. It would be most unlikely that a perforated disc could be manipulated successfully. This study provides support for the view that mandibular manipulation may reduce ADD without reduction, and demonstrates that such a procedure may be successful even for long-standing displacement. arrar (1978) has recommended that an interocclusal bite-raising appliance be placed immediately following successful manipulation, in order to retain the recaptured disc. urther studies should include an assessment of the long-term results of manipulation, and also investigate the need for post-manipulation conservative treatment in order to maintain the benefits of the manipulation procedure. References BRONSTEtN, S.L., ToASETtt, B.J. & RYAN, D.E. (1981) Internal derangements of the temporomandibular joint: correlation of arthrography with surgical findings. Journal of Oral Surgery, 39, 57. DoNLON, W.C. & OON, K.L. (1987) Comparison of tnagnetic resonance imaging, arthrotomography and clinical and surgical findings in temporomandibular joint internal derangements. Journal of Oral Surgery, 64,. ARRAR, W.B. (1978) Characteristics of the condylar path in intcmal derangements of the TJ. Journal of Prosthetic Dentistry, 39, 319. KATZBERG, R.W.. DoLwtcK,.., HELS, C.A., HOPENS, T., BALES, D.J. & COGGS, G.C. (1980) Arthrotomography of the tetnporomandibular joint. American Journal of Roentgenologv, 134, 995. CCARTY, Jr., W.L. & ARRAR, W.B. (1979) Surgery for internal derangements of the temporomandibular joint. Journal of Prosthetic Dentistry, 4, 191. tddleton, D.S. (197) Chnical approach to derangement of the mandibular joint. Journal of the Royal College of Surgeons of Edinburgh, 17, 87. ury\kai, K-I., itzuka, T., ATSUKt,. & TAKATOKJ, O. (1987) Recapturing the persistent anteriorly displaced disc by mandibular manipulation after pumping and hydrauhc pressure to the upper cavity of the temporomandibular joint. Journal of Craniomandibular Practice and acial Pain, 5, 17. SCHWARTZ, H.C. & KENDRtCK, R.W. (1984) Internal derangements of the temporomandibular joint: description of clinical syndromes. Journal of Oral Surgery, 58, 4. WESTESSON, P-L. & ROHLIN,. (1984) Internal derangement related to osteoarthrosis in temporomandibular joint autopsy specimens. Journal of Oral Surgery, 57, 17.

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