40
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Volume2 Issue5
S
upporting
Y
our
P
ractice
•
TMJosteoarthritis (degenerative joint disease)
•
Temporalis tendonitis
Less commonconditions
•
TMJ ankylosis
•
Coronoidhyperplasia
•
Tendon/musclecontracture
•
Synovial chondromatosis
•
Capsular fibrosis
•
Polyarthritides
•
Connective tissuedisorders
•
Neoplasm
•
Trauma/fracture
Treatment
Approaches toacutecasesmaybedifferent fromchronic
cases.
Common InitialTreatments
Acutecases
•
Patient experiencingclosed lock for 1weekor less.
•
Consider referring thepatient toanoralmedicine specialist
or oral andmaxillofacial surgeon.
•
Consider attemptingmanualmanipulation to regain the
normal disc–condyle relationship. If this is successful, then
thepatient couldwear ananterior positioningappliance
for thefirst 2–4days followedbynighttimeuseonly. Once
stabilityhasoccurred, a stabilizationappliancemaybe
considered for nighttimeuse.
•
If patient’s condition isnot responding to theabove
recommendations, thenaminimal invasive surgical
procedure (arthrocentesis/arthroscopy) couldbe
considered to return thedisc toanormal functional
relationshipwith thecondyle. Thiswill need tobe followed
byconservative supportive therapies.
•
Conservative supportive therapies:
• Advise thepatient to avoid chewing/bitinghard
foods, stopparafunctional habits (tooth clenching
andgrinding, gum chewing, nail biting) andgenerally
avoid activities that aggravate the condition.
• Counsel thepatient toperformgentle, controlled
jawexerciseswithin apain-free range, as thismaybe
helpful in regaining rangeof opening.
• Consider applicationofmoist heat or ice to
symptomaticpreauricular area. After an acute injury
(<72hours) heat shouldnot beused.
• Prescribe a short courseof NSAIDs for pain control
and resolutionof inflammation.
• Fabricate a stabilization appliance for nighttimeuse.
• Involve aphysical therapist knowledgeable inTMDs
to assistwithpain control and regaining rangeof
opening.
•
If inflammationdevelops, thepainmaybeconstant, dull
or throbbing, evenat rest, andbeaccentuatedby joint
movement and joint loading.
•
Patient displays concern regarding the suddendecrease in
mandibularmovement as a result of the “closed lock.”
Investigation
1.
Obtain thoroughmedical anddental history, including
details related topain anddysfunction.
2.
Performhead andneck examinations (cranial nerve,
muscle and joint tenderness, joint sound, rangeofmo-
tionof jaw) and intraoral (teeth, gingiva, oral soft tissue)
to ruleout local pathologyor other sources of pain and
to assess joint function.
3.
Downward force applied to themandibular incisorspro-
ducesminimal, if any, increase in rangeof opening (hard
end feel).
a. Restrictedmouthopening (maximum interincisal
opening) as a result ofmuscledisorders is usually
variable in terms of rangeof opening. However,mild
passive force applied to themandibular incisorswill
usually result inan increase in rangeof opening (soft
end feel).
4.
Loadingof the involved joint is oftenpainful.
5.
Confirm thediagnosis on amagnetic resonance imaging
(MRI) scanof theTMJ.
a. In themaximal intercuspal position, theposterior
bandof thedisc is located anterior to the11:30
position and intermediate zoneof thedisc is anterior
to the condylar head.
b. On full opening, the intermediate zoneof thedisc is
locatedanterior to thecondylar head.
6.
Determinewhether thediscdisplacementwithout
reductionwith limitedopening (closed lock) is acuteor
chronic.
a. Theclinical picturebecomes less clear if disc
displacement is chronic, as the ligamentsbecome
further elongated and themorphologyof thedisc
becomes altered, thus allowing agreater rangeof
movement. Thismaymistakenlybe considered as a
discdisplacementwithout reductionwithout limited
opening.
Diagnosis
Adiagnosisof discdisplacementwithout reductionwith
limitedopening isbaseduponpatient history, clinical exami-
nationand related tests.
DifferentialDiagnosis
Commonconditions
•
Masticatorymyalgia
•
Myositis
