Botulinum Toxin injection for the management of temporomandibular joint clicking

Transcription

1 Botulinum Toxin injection for the management of temporomandibular joint clicking Thesis submitted to Faculty of Oral and Dental Medicine Cairo University In partial fulfillment of requirements for the Masters degree in Oral and Maxillofacial Surgery By: Aala Shoukry Ahmed Emara B.D.S 2006 Oral and Maxillofacial Surgery department Faculty of Oral and Dental Medicine, Cairo University 2012

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3 Supervisors Dr. Maha Mohamad Hakam Professor of Oral and Maxillofacial Surgery Faculty of Oral and Dental Medicine Cairo University Dr.Mohamad Abd El-Fattah Hassaan Professor of Radiology Faculty of Medicine Cairo University Dr. Mohamad Ibrahim El-Faramawey Lecturer of Oral and Maxillofacial Surgery Faculty of Oral and Dental Medicine Cairo University ii

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5 بسم هللا الرحمن الرحيم و ق ل اع م ل ىا ف س ي ر ي ه للا ع م ل ك م و ر س ىل ه و ال م ؤ م ن ىن و س ت ر د ون إ ل ع بل م ال غ ي ب و ال هشه بد ة ف ي ن ب ئ ك م ب م ب ك ن ت م ت ع م ل ىن صدق هللا العظيم سورة التوبة :501 iii

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7 Acknowledgements This work would not have been possible without the support of some very dedicated people. My deepest appreciation to Dr Maha Hakam, Professor of Oral & Maxillofacial Surgery for her continuous help and guidance. I m honored to be one of her students; she has taught me a lot on all different aspects, I will always remain grateful to her. Deep gratitude goes to Dr Mohamed Abd El-Fattah, Assistant Professor of Radiology for his utmost help and support with the radiologic part of the research. I am very thankful to Dr. Mohamed El-Faramawey, Lecturer of Oral & Maxillofacial Surgery for everything he has done to help throughout this research; he is a role model. I owe a lot to Dr Amr Maher since I started my residency till I was able to finish this work; I can never thank him enough. I would like to thank Dr Mohamed Khalifa for his unconditional help and support whenever needed. Im deeply grateful to Dr Omneya Abd ElAziz and Dr Reem Hossam for helping me throughout the clinical work and in the final stages of this research. All my colleagues in the department I thank each one of them personally especially Mounir, Marwa, Amira, Youssef, Mahmoud, Salma, Ghada and Nahla for making the department a place one looks forward to work in. Mr Hamdy the MR technician for his tremendous effort throughout the study. My patients have been very supportive and cooperative in the study, to them I owe this work. IV

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9 Dedications All thanks to Allah for all his blessings To my mum, for all her sacrifices, I hope I make her proud. To my dad for his unbounded support in every aspect possible. To my brother for teaching me a lot and being my role model since our childhood. To our martyrs and injured brothers and sisters throughout the blessed revolution, for giving us all hope that this country will and always be a free secular country. V

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11 Table of contents I. Introduction 1 II. Review of literature 2 III. Aim of the study 21 IV. Patients and Methods 22 V. Results 36 VI. Discussion 45 VII. Summary 50 VIII. Conclusions 51 IX. References 52 X. Appendix 62 XI. Arabic summary 64 VI

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13 List of figures Figure Title Page 1 Stages of production of the single click. 6 2 Stages of production of click and reciprocal click. 7 3 MR images of the temporomandibular articulation in the sagittal 17 oblique plane, T1-weighted imaging, captured in the closedmouth position A:Normal joint disc B: Anteriorly dislocated disc. 4 The seven anatomic points used for quantification of the disc 19 position on a MR image. 5 Joint examination in the closed (A) and open (B) positions Palpation of Masseter muscle for any tenderness Palpation of Masseter muscle for any tenderness Functional testing of the inferior head (A) and superior head (B) 26 of Lateral Pterygoid muscle. 9 Palpation of sternocleidomastoid during function (A) and rest (B) Palpation of the trapezius muscle Measuring MIO (A) and opening at which the click occurred (B) 27 using the Vernier caliper. 12 T2 parasagittal MR image showing anteriorly displaced disc (*) 28 before injection of BTX, in closed mouth MR image. 13 The sealed BTX vial before preparation. 30 VII

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15 Figure Title Page 14 The EMG needle attached to the insulin syringe and ready for 30 injection. 15 The surface electrodes placed on the cheek and neck BTX being injected into the Lateral Pterygoid muscle Diagrammatic presentation of the anatomic position of Injection Diagrammatic illustration (A) and MR application (B) of the 32 anatomical assessment points. 19 Assessment points in yellow drawn on the MRI images of one of 33 the studied joints pre (A) and postoperatively (B). 20 Preoperative MR image of graph drawn with the 2 points marked 34 for calibration and coordinates of the 2 points. 21 Postoperative MR image of graph drawn with the 2 points 34 marked for calibration and coordinates of the 2 points. 22 Scatter chart showing presence of click throughout the study 38 period. 23 Bar chart presenting the mean MIO along the study period Bar chart presenting the mean lateral movement throughout the 42 study period. 25 The difference between Point A (A) and Point B (B) 44 preoperatively and postoperatively VIII

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17 List of tables Table Title Page 1 Scanning parameters for the different sequences used Patients age Clinical preoperative data of the patients Presence of click along the different follow up periods MIO preoperatively and during the different postoperative 39 intervals. 6 The mean difference of MIO preoperatively and the different 40 follow up periods.. 7 Range of lateral movement preoperatively and during the different 41 postoperative intervals. 8 Range of lateral movement preoperatively and at different follow 42 up intervals. 9 The minimum, maximum, mean, standard deviation and P value 43 for the distance moved by each of the Points A and B respectively IX

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19 Introduction Introduction Temporomandibular Disorders (TMD) is a collective term used for a number of clinical problems that involve the masticatory muscles, temporomandibular joint (TMJ), and/or associated structures. It has plagued humanity throughout history, and treatment has been reported even during the time of the ancient Egyptians. Signs and symptoms of TMD include TMJ sounds, pain and functional disability. 1 TMJ sounds included the characteristic click which is a sudden snap or pop sound of short duration and found to be a symptom in 30-35% of patients 2. The click is a clinical reflection of articular disc displacement mainly anteriorly 3.The reduction of an anteriorly displaced disc (ADD R ) is a strongly supported mechanism for TMJ clicking sound production. Schellhas et al. 4 proved by video fluoroscopy that the anteriorly displaced disc recapture in coincidence with the clicking sound. Several attempts to identify the cause of discal displacement were reported. Since its upper head inserts into the disc 5, the responsibility of the lateral pterygoid muscle is one of the widely accepted theories. The upper head of the lateral pterygoid was, found to be hyperactive in cases of ADD applying an anteriorly pulling force on the disc 6, 7, 8. Bakke et al. 9 introduced the use of Botulinum Toxin injection in cases of ADD R. The results showed absence of the clinical symptom (click) four months after injection. The present study was designed to further investigate the effect of BTX-A injection in the lateral pterygoid muscle on TMJ clicking based on the theory suggesting that the hyperactivity of the lateral pterygoid muscle is an etiologic factor of the click. 1

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