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Acupuncture compared with stomatognathic treatment for TMJ dysfunction. Part III: Effect of treatment on mobility
TSAO
because increasing hinge-to-tooth distance will increase the efficiency of hinge jaw movement. 4. Condylectomy will not only destroy the rotation and translation joint mechanism, but will also reduce hinge-to-tooth distance, even if a pseudo-hinge joint can be developed. 5. Removal of the third molar may facilitate hinge jaw movement. 6. The occlusal force in patients with long face syndrome might be reduced because of inefficient vertical vector of the hinge closure of the mandible. 7. Segmental osteotomy of the maxillae in long face syndrome may improve a patient’s cosmetic appearance as well as the mechanics of hinge movement. 8. Tooth eruption sequences are important. If the maxillary posterior teeth erupt before the mandibular teeth, interceptive procedures may be indicated to prevent supereruption of the maxillary posterior teeth and a negative orientation of the occlusal plane from developing. Early loss of the mandibular first permanent molar without replacement may also cause supereruption of the maxillary first permanent molar and result in negative orientation of the occlusal plane. 9. A small mouth may be potentially disadvantageous from a mechanical standpoint. 10. A lower cusp height with a curve of Spee should be the occlusal scheme of choice for retrognathic denture patients.
SUMMARY
has been explored by separating this rotation from translation of the mandibular hinge axis. After quantitative comparison, it appears that hinge rotation is the primary physiologic movement of the mandible, and that the Hanau quint provides compensatory factors in facilitating hinge jaw movement. However, an unguided opening and closing of the mouth usually consists of rotation and translation that are six-dimensional in nature and very difficult to solve quantitatively without idealization and differentiation. With an accurate threedimensional image-measuring system, such as computerized axial tomography, it should be possible to apply this hypothesis clinically. The author expresses his gratitude and appreciation to Mr. Nicholas Mackovak for the preparation of the illustrations.
REFERENCES Tsao DH: Graphic description of figure representation of the teeth and mandible in centric occlusion. J PROSTHETDENT 47~95, 1982. Tsao DH: A mathematical interpretation of locating the hinge axis. Bull Dept National Defense Medical Center, Taiwan, R.O.C., 13~37, 1982. Tsao DH, Kazanoglu A, McCasland JP: Measurability of radiographic images. Am J Orthod 84~212, 1983. Reprint requests to: DR. D. H. TSAO VIRGINIA COMMONWEALTHUNIVERSITY SCHOOLOF DENTISTRY Box 566, MCV STATION RICHMOND, VA 23298
On the basis of Newtonian principles of applied mechanics, rotation around the mandibular hinge axis
Acupuncture compared with stomatognathic treatment for TMJ dysfunction. Part III: Effect of treatment on mobility Aune M. Raustia, Lic.Odont.*
and Risto T. Pohjola, M.D.‘*
University of Oulu, Institute of Dentistry, and Oulu University Central Hospital, Oulu, Finland.
D
ifferent treatment methods such as counseling, occlusal splints, occlusal adjustment, prosthetic reconSupported by the Finnish Dental Society. *Assistant Teacher, Department of Prosthodontics and Stomatognathit Physiology. **Head, Department of Physical Medicine and Rehabilitation.
616
struction, and exercises of the mandible have been used to alleviate the painful symptoms of temporomandibular joint (TM J) dysfunction.‘-3 Other alternative methods have used transeutaneous nervous stimulation (TNS), which can be viewed as a western version of acupuncture,‘s5 and electromyographic biofeedback, which is similar in many ways to yoga.6 Intramuscular and NOVEMBER 1986
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Table I. Pain on movement and acupuncture (B)
PART
111
of the mandible
in patients
receiving
stomatognathic
Total Movement to left Score 1 Score 5 Total Protrusion Score 1 Score 5 Total
__--_~ 3 months after treatment
Immediately after treatment
Before treatment
Opening Score 1 Score 5 Total Movement to right: Score 1 Score 5
(A) - --~.
Sample size
Movement
treatment
A
B
A
0 lo 10
0 s 8
2 2 4
1 1;?
2 15
13 0 12 13
3
A
B
0 6 6
1 5 6
3 3 7
2 3
1 z
1 6
17
5
8
7
2 r 3 7
2 13 15
2 4 6
4 4 8
3 3 7
0 5 5
3
0
2
2
2
1
12 15
14 14
5 7
6 8
5. 7
s 6
-.-
I_
Score 1 = pain on 1 movement; score 5 = pain on 2 or more movements.
Table II. Pain on retrusion acupuncture (B)
of the mandible
in patients
receiving
stsmatognathic
treatment
(A) and
Sample size Before treatment
-
3 months after treatment
Immediately after treatment
Movement
A
B
A
B
A
B
Pain only on retrusion Pain on retrusion and other movements
2 9
1 14
0 2
3 -z
1 --!--
2 3
11
15
2
10
Total
intra-articular injections have also been prescribed,’ and a few patients with TMJ dysfunction who do not respond to noninvasive or conservative treatment may need surgical treatment.s.” Conservative treatment modalities aim in part at eliminating masticatory muscle hyperactivity assumed to be present.” An interdependence between TMJ dysfunction and symptoms or disorders originating in the musculoskeletal system has been proposed. Ideally the diverse etiqlogic features contributing to TMJ dysfunction should be identified and treated in order to achieve better neuromuscular rehabiiitation.“-‘3 The effects of acupuncture on pain, muscle spasm, and mental tension have been verified in other organ systems.14,I5 This treatment method has also been recommended as suitable for patients with TMJ dysfunction.16-19It has been established that acupuncture has a genuine treatment effect in addition to a placebo effect, which in itself is a part of any therapeutic program.20~” THE JOURNAL
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---i--.
Our short-term trial comparing the effect of acupuncture with that of stomatognathic treatment suggested that they have a similar effect.ls Indeed, no significant difference betwtyn these two types of treatment was noted except in the range of mandibular movement.19Inasmuch as the mobility of the mandible is an important fact in evaluating the e:ffect of treatment on patients with TM J dysfunction, thinspresent study sought to analyze the effect of acupuncture and stomatognathic treatment on total mobility of the mandible in such patients.
MATERIAL
AND METHODS
The series consisted of 50 patients referred to the Department of Prosthodontia and Stomatognathic Physiology, University of Oulu, for diagnosis and treatment of TMJ dysfunction. The patients were divided randomly into two groups, the first receiving acupuncture and the second standard stomatognathic treatment. The material and method of investigation, including the forms of treatment, have been described. ‘* 617
RAUSTIA
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Fig. 1. Linear regression analysis of changes in lateral mandibular movement to left. Values of i refer to stomatognathic treatment (i = 1) and acupuncture (i = 2), respectively. Parameters are (Ye= 5.33, a2 = 3.67, fil = -0.41, and & = -0.28. Two-sided p value for testing B1= /3*is 0.37.
Fig. 2. Linear regression analysis of changes in protrusion of mandible. Values of i refer to stomatognathic treatment (i = 1) and acupuncture treatment (i = 2), respectively. Parameters are (Ye= 5.06, a2 = 3.51, fl, = -0.52, and & = -0.42. Two-sided p value for testing /31= & is 0.57.
RESULTS Both acupuncture and stomatognathic treatment relieved the pain experienced with mouth-opening, movement of the mandible to the right and left, and protrusion of the mandible (Table I). Stomatognathic treatment was clearly superior in alleviating pain associated with retrusion immediately after treatment (Table II). Lateral and mandibular protrusion movements were compared by using linear regression analysis and the 618
Student’s t-test, with the test variable (expressed in millimeters) as the change. The linear model assumed the form (expected change in the movement) = (r, + /3, (initial value), where the change equals value 3 months after treatment minus initial value. The two forms of treatment had a similar influence (p > .05) on movement to the left (Fig. 1) and protrusion (Fig. Z), but differed in their effect on movement to the right (p < .Ol)(Fig. 3). No regression line could be drawn to illustrate the material in the acupuncture group because this group NOVEMBER
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Fig. 3. Linear regression analysis of changes in lateral mandibular movement to right. Value of i refer to stomatognathic treatment (i = 1) and acupuncture (i = 2), respectively. Parameters are q = 6.73, & = -1.05, & = -0.54, and p2 =-O.Oi Two-sided p -value f&r testing /3, = & is 0.002.
Table III. Ranges of lateral mandibular movement (mm) to the right i n patients stomatognathic treatment (A) and acupuncture (B)
A
Mean SD Sample size Maximum Minimum Test score Two-sided p value
Immediately after treatment
Before treatment
-
receiving
B
A
No
3 months after treatment B
A
B
No pain
Pain
pain
Pain
pain
Pain
Pain
Pain
No pain
Pain
No pain
11.0
10.8
10.0
10.7
11.7
13.0
10.3
10.8
11.3
12.6
10.5
2.6
2.7 13 14.0 5.0
2.3
1.7 17 13.0 7.0
2.3 20 17.0
2.5 5 16.0
1.6
2.1 7 16.0
2.7 18 15.0 6.0
12 15.0 5.0
No
8 13.0 7.0
0.22 0.83'
-0.87 0.39
No
8.0 -1.17 0.25
10.0
1.8 17 13.0 7.0
1.8 8 14.0 9.0
-0.5Et 0.57
18 15.0 9.0
10.0 -1.57 0.13
Pain 9.7 2.6 7 13.0
5.0 0.66 0.52
*0.05 < p not significant
showed no clear pattern of change in the range of movement after treatment (Table III). The stomatognathic treatment group had enough uniform increase in the range of movement immediately after treatment and three months later to enable a regression line to be drawn (Table III). A comparison of the range of movement in patients in each group who had pain and those who did not is made in Tables III to VI. Statistically, the differences in range of movement between the groups with and without pain were not significant except during lateral mandibular movement to the left 3 months after treatment in the acupuncture group @ < .Ol) (Table V). In the case of mouth opening, mouth opening immediately after treatTHE JOURNAL
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ment is almost significant Cp = < .OS) (Table IV), again in the acupuncture treatment group & = < .05) (Table IV). The range of lateral mandibular movement to the left in the stomatognathic treatment group (Table V) is almost significantly larger in the patients with pain than in those without pain 0, < .05) before treatment, immediately after treatment, and 3 months after treatment. The effect of the forms of treatment on deviation in mouth opening is illustrated in Fig. 4. Most. patients in each group had a deviation to the right, but deviation to the left was more common in the stomatqrtathic treatment group. The number of patients without deviation after stomatognathic treatment nevertheless grew steadi619
RAUSTlA
Table IV. Ranges of mouth opening acupuncture
(mm) in patients
stomatognathic
treatment
POHJOLA
(A) and
(B) Immediately after treatment
Before treatment A
Mean SD Sample size Maximum Minimum Test score Two-sided p value
receiving
AND
B
A
3 months after treatment B
A
B
No pain
Pain
No pain
Pain
No pain
Pain
No pain
Pain
No pain
Pain
51.0 5.3 15 62.0 42.0
45.6 8.7 10 62.0 35.0
47.0 9.4 17 59.0 22.0
39.9 9.1 8 52.0 27.0
51.6 5.7 21 68.0 41.0
47.8 5.7 4 53.0 40.0
50.2 6.5 19 59.0 39.0
43.2 7.0 6 50.0 33.0
52.3 4.8 19 61.0 44.0
50.8 9.5 6 60.0 40.0
1.93 0.07
1.77 0.09
1.24 0.23
2.28 0.03’
No pain
Pain
49.7 43.3 7.4 6.5 18 7 60.0 52.0 33.0 32.0 2.01 0.06
0.37 0.73
*O.Ol < p Almost significant.
Table V. Ranges of lateral mandibular treatment
(A) and acupuncture
movement
(mm) to the left in patients Immediately after treatment
Before treatment A No pain Mean SD Sample size Maximum Minimum Test score Two-sided p value
10.2 1.8 13 14.0 7.0 -2.38 0.03”
receiving
stomatognathic
(B)
B
A
Pain
No pain
Pain
11.9 1.8 12 15.0 8.0
9.8 2.0 10 13.0 6.0
9.9 2.5 15 14.0 5.0 -0.07 0.94
No pain 11.3 2.3 19 16.0 8.0 -2.24 0.04’
3 months after treatment A
B Pain
No pain
Pain
13.5 1.2 6 16.0 13.0
10.8 1.8 17 14.0 7.0
10.1 1.6 8 12.0 8.0 0.87 0.39
B
No pain
Pain
11.3 1.5 18 14.0 9.0 -2.50 0.02t
13.1 2.0 7 16.0 10.0
No pain
Pain
10.9 9.0 2.4 0.7 20 5 15.0 10.0 7.0 8.0 3.09 0.005~
*O.Ol < p Almost significant. fO.001 < p 5 0.01 Significant. $p 5 0.001 Very significant.
ly with time, whereas no such change could be seen in the acupuncture group. TMJ sounds (clicking and crepitation) appeared in both groups (Figs. 5 and 6). Clicking was more frequent in the right joint of the stomatognathic treatment group before treatment (Fig. 5), whereas patients in the acupuncture group demonstrated locking phenomena more often in both joints (Fig. 6). Crepitation was more common in the left joint in both groups. The effects of acupuncture and stomatognathic treatment on TMJ pain are indicated in Table VII. The joints were palpated laterally and posteriorly by the dentist in the clinical examinations. The effect of the treatment on joint pain was similar in both groups, except for the left joint immediately after acupuncture, which was probably irritated further by the treatment. 620
DISCUSSION This short-term trial suggests that acupuncture and stomatognathic treatment appear to have a similar effect on painful movement of the mandible immediately after treatment and 3 months after treatment (Table I). Retrusion movement immediately after treatment was an exception to this observation (Table II). It is noteworthy that neither group included patients who had pain only on mouth opening before treatment (Table I). We therefore stress the importance of a patient’s examination, including the recording of all jaw movements. Acupuncture and stomatognathic treatment appeared to act differently on painful retrusion movement of the mandible. Stomatognathic treatment, which included occlusal adjustment, was clearly superior in its immediate effect (Table II). This difference highlights the NOVEMBER
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Fig. 4. Deviation in mouth-opening movement with stomatognathic and acupuncture treatment. (A = before treatment; B = immediately after treatment; C = 3 months after treatment).
importance of interference in a retruded position (RP) of the mandible. Analysis of the factors influencing the long-term effect of stomatognathic treatment on TMJ dysfunction suggests significant correlations between RP interferences, for example, unilateral contact in the RP and lateral slide between the RP and intercuspal position (IP), and reported pain on jaw movement, reported facial pain, and clinically recorded pain on lateral jaw movement.22 Residual interferences could still be detected at reexamination because they may also reappear after occlusal adjustment.23 The difference between the two forms of treatment was no longer discernible after 3 months (Table II). Further occlusal adjustment could be expected to be easier and less time-consuming to accomplish in the acupuncture treatment group because these patients did not seem to need occlusal splints so often. This could support the use of acupuncture as an early form of therapy for some patients with TMJ dysfunction.‘“, I9 In addition to oeclusal adjustment, the stomatognathic treatment group was given muscular coordination exercises for the lower jaw. ‘* The influence of this therapy on the deviation in mouth opening movement was clearly visible (Fig. 4). Before treatment 96% of the patients in the acupuncture group and 92% in the stomatognathic group had deviation either to the right or to the left on mouth opening, whereas 3 months after treatment 88% in the acupuncture group and 68% in the stomatognathic group had deviation either to the right or left on mouth opening. The forms of treatment also differed in their effect on the range of mandibular movement, as could be seen in analyzing the components of the dysfunction index.19 In the first component of the Helkimo index, all of the THE JOURNAL
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Fig. 5. TMJ sounds and locking phenomena in patients receiving stomatognathic treatment. (A = before treatment; B = immediately after treatment; C = 3 months after treatment).
RlGHT
LEFT
Fig. 6. TMJ sounds and locking phenomena in patients receiving acupuncture. (A = before treatment; B = immediately after treatment; C = 3 months after treatment).
ranges of mandibular movement are grouped together (opening, lateral, and protrusive). The treatment modalities differed in their influence on mouth-qening movement, with acupuncture emerging as slightly better with small initial values.‘* This tends to supprt the view that either form of treatment has its own bi&gic basis.19 Compared with stomatognathic treatment, acupuncture is effective in patients with functional disorders, whereas it cannot repair gross organic changes. Ac~rdiig to de la Fuye, 25 “in acupuncture, needles are itiserted into exactly determined points on the skin which are spontaneously sensitive or sensitive to pressure in fmWiona1, reversible illnesses or disorders for therapeutic and/or diagnostic purposes.” Figs. 1 and 2 show that the two forms of treatments had a similar effect on the ranges of lateral mandibular 621
RAUSTIA AND POHJOLA
Table VI. Ranges of protrusion (A) and acupuncture
of the mandible
(mm) in patients
B
A
Sample size Maximum Minimum Test score Two-sided p value
stomatognathic
Immediately after treatment
Before treatment
Mean SD
receiving
treatment
(B) 3 months after treatment
A
B
A
B
No pain
Pain
No pain
Pain
No pain
Pain
No pain
Pain
No pain
Pain
9.6 2.4 10 15.0 6.0
9.3 2.1 15 14.0 6.0
6.6 1.9 11 9.0 3.0
7.6 1.9 14 11.0 4.0
9.4, 1.9 18 15.0 7.0
10.9 3.0 7 16.0 8.0
7.6 1.7 17 10.0 5.0
7.9 1.1 a 9.0 6.0
9.7 1.7 18 13.0 8.0
9.3 1.5 7 12.0 8.0
0.37 0.72
-1.32 0.20
Table VII. Effect of stomatognathic
-1.47 0.15
-0.34 0.74
(A) and acupuncture
(B) treatment
No pain
Pain
7.6 1.8 19 11.0 5.0 -0.47 0.64
0.59 0.56
8.0 1.1 6 9.0 6.0
on TMJ pain
Sample size Right TMJ Immediately after treatment
Before treatment
Left TMJ 3 months after treatment
Immediately after treatment
Before treatment
3 months after treatment
Response
A
B
A
B
A
B
A
B
A
B
A
B
TMJ pain when palpated laterally TMJ pain when palpated posteriorly Subtotal No pain Total
2
3
0
3
1
2
2
1
1
3
1
1
5
12
3
5
4
6
6
2
2
3
1
0
7 18 25
15 10 25
3 22 25
8 17 25
5 20 25
8 17 25
8 17 25
3 22 25
3 22 25
6 19 25
2 23 25
1 24 25
movement to the left and protrusion movement, but differed in their influence on lateral mandibular movement to the right (Fig. 3); the acupuncture treatment group included more patients with locking phenomena and locking was more usual in the left TM J (Fig. 6). No clear change could be seen in the range of lateral mandibular movement to the right, however (Table III, Fig. 3). Locking is generally caused by erroneous positioning of the disk, which can be dislocated either totally anteriorly, anterolaterally, or anteromedially,26~27 whereupon lateral mandibular movement to the contralateral side is often restricted, as has been noted in recent studiesz8and in our own unpublished studies on patients with disk dislocation. The ranges of lateral mandibular movement to the left were almost significantly larger among the patients in the stomatognathic treatment group who experienced pain on attempting this movement. The reporting of pain is by nature subjective, and patients tend to report pain on every movement of the jaw.29 There was an almost significant difference in results 622
(p < .05) between the forms of treatment in the TMJ pain component of the Helkimo dysfunction index (initial score O),” and it is noteworthy that acupuncture had an irritating effect on the left TMJ immediately after treatment (Table VII), with the stimuli apparently overshooting the pain detectors. Muscle pain or tenderness is common and widespread, especially in patients with TMJ dysfunction resulting from psychogenic factors.‘O Muscle pain and spasms are also associated with TM J dysfunction, which is believed to result from occlusal interferences and damage of the TMJ. In our short-term trial, the two treatment modalities used here, which obviously differ in their rationale, had similar effects on muscle pain.19 The correlation of occlusal disturbances with muscle pain and damage of the TMJ needs to be studied. This could explain why acupuncture, and probably other forms of physical therapy that cannot possibly remove organic causes (for example, occlusal interferences), can be so successful in helping some patients with TMJ dysfunction. NOVEMBER 1986
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SUMMARY The purpose of this study was to compare the effects of acupuncture and stomatognathic treatment on the mobility of the mandible in random szimples of patients with TMJ dysfunction. One group of 25 patients was treated with acupuncture performed by a specialist in physical medicine and rehabilitation and a second similar group received standard stomatognathic treatment. All of the patients were evaluated in terms of the Helkimo dysfunction index by a dentist before treatment, within 1 week of treatment, and 3 months after treatment. No significant differences could be detected in painful movement of the mandible except in retrusive movement, wherein stomatognathic treatment was clearly superior immediately afterward. Acupuncture seems to be a useful early form of therapy in patients with TM J disorders that are expected to be largely functional and reversible and with evidence of psychophysiologic or neuromuscular disturbances but not of any marked occlusal interference or joint damage. Acupuncture could well be complementary to stomatognathic treatment, either preceding or following it, to achieve full neuromuscular rehabilitation, to ease the treatment (for example, occlusal splints), or to eliminate other possible contributory factors.
in evaluation of the temporomandibular joint. Phys Ther 62597. 1982. 12. Danzig WN, Van Dyke AR: Physical therapy as an adjunct to temporomandibular joint therapy. J PROSTMET DcN.~ 49:96, 1983. 13. Graham MM, Buxbaum J, Staling LM: A study of occlusal relationships ,md the incidence of myofacial pain. .J PROSTHEY DENT 4’13549, 1982.
14. Jayasuriya A Fernando F: Principles and Practice of Scientific Acupuncture. Sri Lanka, 1978, Lake House Illvestments Ltd, pp 47-60. Ordnungstherapie. 3 ,\ufl.. 15. Bachman G: Die Akupunktur-eine I Band, 1980 Haug Verlag Heidelberg, pp .?O-21. 16. McNeil1 C: Craniomandibular (TM J) disorders--The state of the art. Part II: Accepted diagnostic and trcalment modalities. J PROSTHET DE,NT 49:393,
17.
18.
19.
20.
We are grateful to Heikki Laaksama, M.Sc., and Pekka Vasari, B.Sc., for their assistance with the statistical analysis of the results.
21.
REFERENCES
22.
1.
2.
3. 4.
5.
6.
7.
8.
9. 10.
11.
Zarb GA, Speck JE: The treatment of mandibular dysfunction. In Zarb GA, Carlsson GE, editors: Temporomandibular Joint and Dysfunction. Copenhagen, 1979, Munksgaard, pp 373396. Magnusson T, Carlsson GE: Treatment of patients with functional disturbances in the masticatory system. A survey of 80 consecutive patients. Swed Dent J 4~145, 1980. Mongini F, editor: The Stomatognathic System. Chicago, 1984, Quintessence Publishing Co, pp 233-286. Hellsing G: Transkutan nervstimulering (TNS) vid kronisk smirta hos patienter med klkledsbesvHr. Tandlikartidningen 68:789, 1976. Ihalainen U, Perkki K: The effect of transcutaneous nerve stimulation (TNS) on chronic facial pain. Proc Finn Dent Sot 74~86, 1978. Dahlstrijm L, Carlsson SG: Treatment of mandibular dysfunction: The clinical usefulness of biofeedback in relation to splint therapy. J Oral Rehabil 11:277, 1984. Kopp S, Wenneberg B: Effects of occlusal treatment and intra-articular injections on temporomandibular joint pain and dysfunction. Acta Odontol Stand 39~87, 1981. McCarty Jr WL, Farrar WB: Surgery for internal derangements of the temporomandibular joint. J PROSTHET DENT 42191, 1979. Carlsson GE, Kopp S, Lindstram J, Lundqvist S: Surgical treatment of TMJ disorders. Ear Nose Throat J 61:42, 1982. Moss RA, Carrett JC: Temporomandibular joint dysfunction syndrome and myofascial pain dysfunction syndrome: A critical review. J Oral Rehabil 11:3, 1984. Friedman WH, Weisberg J: Application of orthopedic principles
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24 25 26
27
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Pohjola RT, Raustia AM, Virtanen KK ,\kupunktur her mandibulotemporaler Gelenksdysfunktion (ThlJ). In Bischko J, editor: Weltieangress fiir wissenschaftlichr Akupunktur, Kongressband, Tcil 2. In Series, Handbuch fiir Akupunktur und Auriculotherapie. Heidelberg, 1985, Haug Verlag, pp 76-83. Raustia AM, Poh.jola RT, Virtanen KK: Acupuncture compared with stomatognathic treatment for TMJ dysfunction. Part I: A randomized study J PROSTHETDENT .54:5X1 1985. Raustia AM, Pohjola RT, Virtanen KK: Acupuncture effect on motion capacity in TMJ dysfunction. J Dent Res 64(Special issue):232, 1985 (Abstr No. 518). Junnila SYT: Akupunktuuri kivunhoitomenetelminS terveyskeskuksessa. English summary: Acupuncture lor Pain Treatment in a Finnish Health Centre. Turku, 1981, KansanelZkelaitoksen julkaisuja, Al,: 15 (Monograph Series ‘AL: Ii The National Pension Institute). Williams NE: Current views of the pharmacological management of pain In Swerdlow M, editor: Thr Therapy of Pain. Lancaster, England, 1981, MTP Press Limlred, p 87. Mejersjii C, Carlsson GE: Analysis of factors influencing the long-term efIect of treatment of TM J-pain dysfunction. J Oral Rehabil 11:289, 1984. Magnusson T, Carlsson GE: Occlusal adjustment in patients with residual or recurrent signs of mandibular dysfunction. J PROSTHETDENT 49~706, 1983. Magnusson 1‘: Patients referred for stomatognathic treatmentA survey of 1:82 patients. Swed Dent J 8~191, 1984. de la Fuye R: Traiti d’Acupuncture. Paris. 1056, Librairie de Francois. Thompson JR, Christiansen E, Hasso AN. Hinshaw Jr DB: Temporomandibular joints: High-resolution computed tomographic evaluation. Radiology 150~105, 1984. Raustia AM, Pyhtinen J, Virtanen KK: E,xamination of the temporomandibular joint by direct sagittal c,omputed romography. Chin Radio1 36~291, 1985. Roberts CA, Tallents RH, Espeland MA, Handelman SL, Katzberg RW: Mandibular range of motion vs arthographic findings in 205 patients. J Dent Res 64(Spec1al Issue):231, 1985 (Abstr No. 51 I). Helkimo M: Studies on function and dysfuncrion of the masticatory system. II. Index for anamnestic and climcal dysfunction and occlusal state. Swed Dent J 62101, 1074.
Keprzntrequest311,: DR. AUNE M. RAIJSTIA UNIVERSITYOF OLILU INSTITUTEOF DENTISTRY AAPISTIE 3 SF-90220 OULU 22 FINLAND
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because increasing hinge-to-tooth distance will increase the efficiency of hinge jaw movement. 4. Condylectomy will not only destroy the rotation and translation joint mechanism, but will also reduce hinge-to-tooth distance, even if a pseudo-hinge joint can be developed. 5. Removal of the third molar may facilitate hinge jaw movement. 6. The occlusal force in patients with long face syndrome might be reduced because of inefficient vertical vector of the hinge closure of the mandible. 7. Segmental osteotomy of the maxillae in long face syndrome may improve a patient’s cosmetic appearance as well as the mechanics of hinge movement. 8. Tooth eruption sequences are important. If the maxillary posterior teeth erupt before the mandibular teeth, interceptive procedures may be indicated to prevent supereruption of the maxillary posterior teeth and a negative orientation of the occlusal plane from developing. Early loss of the mandibular first permanent molar without replacement may also cause supereruption of the maxillary first permanent molar and result in negative orientation of the occlusal plane. 9. A small mouth may be potentially disadvantageous from a mechanical standpoint. 10. A lower cusp height with a curve of Spee should be the occlusal scheme of choice for retrognathic denture patients.
SUMMARY
has been explored by separating this rotation from translation of the mandibular hinge axis. After quantitative comparison, it appears that hinge rotation is the primary physiologic movement of the mandible, and that the Hanau quint provides compensatory factors in facilitating hinge jaw movement. However, an unguided opening and closing of the mouth usually consists of rotation and translation that are six-dimensional in nature and very difficult to solve quantitatively without idealization and differentiation. With an accurate threedimensional image-measuring system, such as computerized axial tomography, it should be possible to apply this hypothesis clinically. The author expresses his gratitude and appreciation to Mr. Nicholas Mackovak for the preparation of the illustrations.
REFERENCES Tsao DH: Graphic description of figure representation of the teeth and mandible in centric occlusion. J PROSTHETDENT 47~95, 1982. Tsao DH: A mathematical interpretation of locating the hinge axis. Bull Dept National Defense Medical Center, Taiwan, R.O.C., 13~37, 1982. Tsao DH, Kazanoglu A, McCasland JP: Measurability of radiographic images. Am J Orthod 84~212, 1983. Reprint requests to: DR. D. H. TSAO VIRGINIA COMMONWEALTHUNIVERSITY SCHOOLOF DENTISTRY Box 566, MCV STATION RICHMOND, VA 23298
On the basis of Newtonian principles of applied mechanics, rotation around the mandibular hinge axis
Acupuncture compared with stomatognathic treatment for TMJ dysfunction. Part III: Effect of treatment on mobility Aune M. Raustia, Lic.Odont.*
and Risto T. Pohjola, M.D.‘*
University of Oulu, Institute of Dentistry, and Oulu University Central Hospital, Oulu, Finland.
D
ifferent treatment methods such as counseling, occlusal splints, occlusal adjustment, prosthetic reconSupported by the Finnish Dental Society. *Assistant Teacher, Department of Prosthodontics and Stomatognathit Physiology. **Head, Department of Physical Medicine and Rehabilitation.
616
struction, and exercises of the mandible have been used to alleviate the painful symptoms of temporomandibular joint (TM J) dysfunction.‘-3 Other alternative methods have used transeutaneous nervous stimulation (TNS), which can be viewed as a western version of acupuncture,‘s5 and electromyographic biofeedback, which is similar in many ways to yoga.6 Intramuscular and NOVEMBER 1986
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Table I. Pain on movement and acupuncture (B)
PART
111
of the mandible
in patients
receiving
stomatognathic
Total Movement to left Score 1 Score 5 Total Protrusion Score 1 Score 5 Total
__--_~ 3 months after treatment
Immediately after treatment
Before treatment
Opening Score 1 Score 5 Total Movement to right: Score 1 Score 5
(A) - --~.
Sample size
Movement
treatment
A
B
A
0 lo 10
0 s 8
2 2 4
1 1;?
2 15
13 0 12 13
3
A
B
0 6 6
1 5 6
3 3 7
2 3
1 z
1 6
17
5
8
7
2 r 3 7
2 13 15
2 4 6
4 4 8
3 3 7
0 5 5
3
0
2
2
2
1
12 15
14 14
5 7
6 8
5. 7
s 6
-.-
I_
Score 1 = pain on 1 movement; score 5 = pain on 2 or more movements.
Table II. Pain on retrusion acupuncture (B)
of the mandible
in patients
receiving
stsmatognathic
treatment
(A) and
Sample size Before treatment
-
3 months after treatment
Immediately after treatment
Movement
A
B
A
B
A
B
Pain only on retrusion Pain on retrusion and other movements
2 9
1 14
0 2
3 -z
1 --!--
2 3
11
15
2
10
Total
intra-articular injections have also been prescribed,’ and a few patients with TMJ dysfunction who do not respond to noninvasive or conservative treatment may need surgical treatment.s.” Conservative treatment modalities aim in part at eliminating masticatory muscle hyperactivity assumed to be present.” An interdependence between TMJ dysfunction and symptoms or disorders originating in the musculoskeletal system has been proposed. Ideally the diverse etiqlogic features contributing to TMJ dysfunction should be identified and treated in order to achieve better neuromuscular rehabiiitation.“-‘3 The effects of acupuncture on pain, muscle spasm, and mental tension have been verified in other organ systems.14,I5 This treatment method has also been recommended as suitable for patients with TMJ dysfunction.16-19It has been established that acupuncture has a genuine treatment effect in addition to a placebo effect, which in itself is a part of any therapeutic program.20~” THE JOURNAL
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---i--.
Our short-term trial comparing the effect of acupuncture with that of stomatognathic treatment suggested that they have a similar effect.ls Indeed, no significant difference betwtyn these two types of treatment was noted except in the range of mandibular movement.19Inasmuch as the mobility of the mandible is an important fact in evaluating the e:ffect of treatment on patients with TM J dysfunction, thinspresent study sought to analyze the effect of acupuncture and stomatognathic treatment on total mobility of the mandible in such patients.
MATERIAL
AND METHODS
The series consisted of 50 patients referred to the Department of Prosthodontia and Stomatognathic Physiology, University of Oulu, for diagnosis and treatment of TMJ dysfunction. The patients were divided randomly into two groups, the first receiving acupuncture and the second standard stomatognathic treatment. The material and method of investigation, including the forms of treatment, have been described. ‘* 617
RAUSTIA
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POHJOLA
Fig. 1. Linear regression analysis of changes in lateral mandibular movement to left. Values of i refer to stomatognathic treatment (i = 1) and acupuncture (i = 2), respectively. Parameters are (Ye= 5.33, a2 = 3.67, fil = -0.41, and & = -0.28. Two-sided p value for testing B1= /3*is 0.37.
Fig. 2. Linear regression analysis of changes in protrusion of mandible. Values of i refer to stomatognathic treatment (i = 1) and acupuncture treatment (i = 2), respectively. Parameters are (Ye= 5.06, a2 = 3.51, fl, = -0.52, and & = -0.42. Two-sided p value for testing /31= & is 0.57.
RESULTS Both acupuncture and stomatognathic treatment relieved the pain experienced with mouth-opening, movement of the mandible to the right and left, and protrusion of the mandible (Table I). Stomatognathic treatment was clearly superior in alleviating pain associated with retrusion immediately after treatment (Table II). Lateral and mandibular protrusion movements were compared by using linear regression analysis and the 618
Student’s t-test, with the test variable (expressed in millimeters) as the change. The linear model assumed the form (expected change in the movement) = (r, + /3, (initial value), where the change equals value 3 months after treatment minus initial value. The two forms of treatment had a similar influence (p > .05) on movement to the left (Fig. 1) and protrusion (Fig. Z), but differed in their effect on movement to the right (p < .Ol)(Fig. 3). No regression line could be drawn to illustrate the material in the acupuncture group because this group NOVEMBER
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Fig. 3. Linear regression analysis of changes in lateral mandibular movement to right. Value of i refer to stomatognathic treatment (i = 1) and acupuncture (i = 2), respectively. Parameters are q = 6.73, & = -1.05, & = -0.54, and p2 =-O.Oi Two-sided p -value f&r testing /3, = & is 0.002.
Table III. Ranges of lateral mandibular movement (mm) to the right i n patients stomatognathic treatment (A) and acupuncture (B)
A
Mean SD Sample size Maximum Minimum Test score Two-sided p value
Immediately after treatment
Before treatment
-
receiving
B
A
No
3 months after treatment B
A
B
No pain
Pain
pain
Pain
pain
Pain
Pain
Pain
No pain
Pain
No pain
11.0
10.8
10.0
10.7
11.7
13.0
10.3
10.8
11.3
12.6
10.5
2.6
2.7 13 14.0 5.0
2.3
1.7 17 13.0 7.0
2.3 20 17.0
2.5 5 16.0
1.6
2.1 7 16.0
2.7 18 15.0 6.0
12 15.0 5.0
No
8 13.0 7.0
0.22 0.83'
-0.87 0.39
No
8.0 -1.17 0.25
10.0
1.8 17 13.0 7.0
1.8 8 14.0 9.0
-0.5Et 0.57
18 15.0 9.0
10.0 -1.57 0.13
Pain 9.7 2.6 7 13.0
5.0 0.66 0.52
*0.05 < p not significant
showed no clear pattern of change in the range of movement after treatment (Table III). The stomatognathic treatment group had enough uniform increase in the range of movement immediately after treatment and three months later to enable a regression line to be drawn (Table III). A comparison of the range of movement in patients in each group who had pain and those who did not is made in Tables III to VI. Statistically, the differences in range of movement between the groups with and without pain were not significant except during lateral mandibular movement to the left 3 months after treatment in the acupuncture group @ < .Ol) (Table V). In the case of mouth opening, mouth opening immediately after treatTHE JOURNAL
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ment is almost significant Cp = < .OS) (Table IV), again in the acupuncture treatment group & = < .05) (Table IV). The range of lateral mandibular movement to the left in the stomatognathic treatment group (Table V) is almost significantly larger in the patients with pain than in those without pain 0, < .05) before treatment, immediately after treatment, and 3 months after treatment. The effect of the forms of treatment on deviation in mouth opening is illustrated in Fig. 4. Most. patients in each group had a deviation to the right, but deviation to the left was more common in the stomatqrtathic treatment group. The number of patients without deviation after stomatognathic treatment nevertheless grew steadi619
RAUSTlA
Table IV. Ranges of mouth opening acupuncture
(mm) in patients
stomatognathic
treatment
POHJOLA
(A) and
(B) Immediately after treatment
Before treatment A
Mean SD Sample size Maximum Minimum Test score Two-sided p value
receiving
AND
B
A
3 months after treatment B
A
B
No pain
Pain
No pain
Pain
No pain
Pain
No pain
Pain
No pain
Pain
51.0 5.3 15 62.0 42.0
45.6 8.7 10 62.0 35.0
47.0 9.4 17 59.0 22.0
39.9 9.1 8 52.0 27.0
51.6 5.7 21 68.0 41.0
47.8 5.7 4 53.0 40.0
50.2 6.5 19 59.0 39.0
43.2 7.0 6 50.0 33.0
52.3 4.8 19 61.0 44.0
50.8 9.5 6 60.0 40.0
1.93 0.07
1.77 0.09
1.24 0.23
2.28 0.03’
No pain
Pain
49.7 43.3 7.4 6.5 18 7 60.0 52.0 33.0 32.0 2.01 0.06
0.37 0.73
*O.Ol < p Almost significant.
Table V. Ranges of lateral mandibular treatment
(A) and acupuncture
movement
(mm) to the left in patients Immediately after treatment
Before treatment A No pain Mean SD Sample size Maximum Minimum Test score Two-sided p value
10.2 1.8 13 14.0 7.0 -2.38 0.03”
receiving
stomatognathic
(B)
B
A
Pain
No pain
Pain
11.9 1.8 12 15.0 8.0
9.8 2.0 10 13.0 6.0
9.9 2.5 15 14.0 5.0 -0.07 0.94
No pain 11.3 2.3 19 16.0 8.0 -2.24 0.04’
3 months after treatment A
B Pain
No pain
Pain
13.5 1.2 6 16.0 13.0
10.8 1.8 17 14.0 7.0
10.1 1.6 8 12.0 8.0 0.87 0.39
B
No pain
Pain
11.3 1.5 18 14.0 9.0 -2.50 0.02t
13.1 2.0 7 16.0 10.0
No pain
Pain
10.9 9.0 2.4 0.7 20 5 15.0 10.0 7.0 8.0 3.09 0.005~
*O.Ol < p Almost significant. fO.001 < p 5 0.01 Significant. $p 5 0.001 Very significant.
ly with time, whereas no such change could be seen in the acupuncture group. TMJ sounds (clicking and crepitation) appeared in both groups (Figs. 5 and 6). Clicking was more frequent in the right joint of the stomatognathic treatment group before treatment (Fig. 5), whereas patients in the acupuncture group demonstrated locking phenomena more often in both joints (Fig. 6). Crepitation was more common in the left joint in both groups. The effects of acupuncture and stomatognathic treatment on TMJ pain are indicated in Table VII. The joints were palpated laterally and posteriorly by the dentist in the clinical examinations. The effect of the treatment on joint pain was similar in both groups, except for the left joint immediately after acupuncture, which was probably irritated further by the treatment. 620
DISCUSSION This short-term trial suggests that acupuncture and stomatognathic treatment appear to have a similar effect on painful movement of the mandible immediately after treatment and 3 months after treatment (Table I). Retrusion movement immediately after treatment was an exception to this observation (Table II). It is noteworthy that neither group included patients who had pain only on mouth opening before treatment (Table I). We therefore stress the importance of a patient’s examination, including the recording of all jaw movements. Acupuncture and stomatognathic treatment appeared to act differently on painful retrusion movement of the mandible. Stomatognathic treatment, which included occlusal adjustment, was clearly superior in its immediate effect (Table II). This difference highlights the NOVEMBER
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Fig. 4. Deviation in mouth-opening movement with stomatognathic and acupuncture treatment. (A = before treatment; B = immediately after treatment; C = 3 months after treatment).
importance of interference in a retruded position (RP) of the mandible. Analysis of the factors influencing the long-term effect of stomatognathic treatment on TMJ dysfunction suggests significant correlations between RP interferences, for example, unilateral contact in the RP and lateral slide between the RP and intercuspal position (IP), and reported pain on jaw movement, reported facial pain, and clinically recorded pain on lateral jaw movement.22 Residual interferences could still be detected at reexamination because they may also reappear after occlusal adjustment.23 The difference between the two forms of treatment was no longer discernible after 3 months (Table II). Further occlusal adjustment could be expected to be easier and less time-consuming to accomplish in the acupuncture treatment group because these patients did not seem to need occlusal splints so often. This could support the use of acupuncture as an early form of therapy for some patients with TMJ dysfunction.‘“, I9 In addition to oeclusal adjustment, the stomatognathic treatment group was given muscular coordination exercises for the lower jaw. ‘* The influence of this therapy on the deviation in mouth opening movement was clearly visible (Fig. 4). Before treatment 96% of the patients in the acupuncture group and 92% in the stomatognathic group had deviation either to the right or to the left on mouth opening, whereas 3 months after treatment 88% in the acupuncture group and 68% in the stomatognathic group had deviation either to the right or left on mouth opening. The forms of treatment also differed in their effect on the range of mandibular movement, as could be seen in analyzing the components of the dysfunction index.19 In the first component of the Helkimo index, all of the THE JOURNAL
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Fig. 5. TMJ sounds and locking phenomena in patients receiving stomatognathic treatment. (A = before treatment; B = immediately after treatment; C = 3 months after treatment).
RlGHT
LEFT
Fig. 6. TMJ sounds and locking phenomena in patients receiving acupuncture. (A = before treatment; B = immediately after treatment; C = 3 months after treatment).
ranges of mandibular movement are grouped together (opening, lateral, and protrusive). The treatment modalities differed in their influence on mouth-qening movement, with acupuncture emerging as slightly better with small initial values.‘* This tends to supprt the view that either form of treatment has its own bi&gic basis.19 Compared with stomatognathic treatment, acupuncture is effective in patients with functional disorders, whereas it cannot repair gross organic changes. Ac~rdiig to de la Fuye, 25 “in acupuncture, needles are itiserted into exactly determined points on the skin which are spontaneously sensitive or sensitive to pressure in fmWiona1, reversible illnesses or disorders for therapeutic and/or diagnostic purposes.” Figs. 1 and 2 show that the two forms of treatments had a similar effect on the ranges of lateral mandibular 621
RAUSTIA AND POHJOLA
Table VI. Ranges of protrusion (A) and acupuncture
of the mandible
(mm) in patients
B
A
Sample size Maximum Minimum Test score Two-sided p value
stomatognathic
Immediately after treatment
Before treatment
Mean SD
receiving
treatment
(B) 3 months after treatment
A
B
A
B
No pain
Pain
No pain
Pain
No pain
Pain
No pain
Pain
No pain
Pain
9.6 2.4 10 15.0 6.0
9.3 2.1 15 14.0 6.0
6.6 1.9 11 9.0 3.0
7.6 1.9 14 11.0 4.0
9.4, 1.9 18 15.0 7.0
10.9 3.0 7 16.0 8.0
7.6 1.7 17 10.0 5.0
7.9 1.1 a 9.0 6.0
9.7 1.7 18 13.0 8.0
9.3 1.5 7 12.0 8.0
0.37 0.72
-1.32 0.20
Table VII. Effect of stomatognathic
-1.47 0.15
-0.34 0.74
(A) and acupuncture
(B) treatment
No pain
Pain
7.6 1.8 19 11.0 5.0 -0.47 0.64
0.59 0.56
8.0 1.1 6 9.0 6.0
on TMJ pain
Sample size Right TMJ Immediately after treatment
Before treatment
Left TMJ 3 months after treatment
Immediately after treatment
Before treatment
3 months after treatment
Response
A
B
A
B
A
B
A
B
A
B
A
B
TMJ pain when palpated laterally TMJ pain when palpated posteriorly Subtotal No pain Total
2
3
0
3
1
2
2
1
1
3
1
1
5
12
3
5
4
6
6
2
2
3
1
0
7 18 25
15 10 25
3 22 25
8 17 25
5 20 25
8 17 25
8 17 25
3 22 25
3 22 25
6 19 25
2 23 25
1 24 25
movement to the left and protrusion movement, but differed in their influence on lateral mandibular movement to the right (Fig. 3); the acupuncture treatment group included more patients with locking phenomena and locking was more usual in the left TM J (Fig. 6). No clear change could be seen in the range of lateral mandibular movement to the right, however (Table III, Fig. 3). Locking is generally caused by erroneous positioning of the disk, which can be dislocated either totally anteriorly, anterolaterally, or anteromedially,26~27 whereupon lateral mandibular movement to the contralateral side is often restricted, as has been noted in recent studiesz8and in our own unpublished studies on patients with disk dislocation. The ranges of lateral mandibular movement to the left were almost significantly larger among the patients in the stomatognathic treatment group who experienced pain on attempting this movement. The reporting of pain is by nature subjective, and patients tend to report pain on every movement of the jaw.29 There was an almost significant difference in results 622
(p < .05) between the forms of treatment in the TMJ pain component of the Helkimo dysfunction index (initial score O),” and it is noteworthy that acupuncture had an irritating effect on the left TMJ immediately after treatment (Table VII), with the stimuli apparently overshooting the pain detectors. Muscle pain or tenderness is common and widespread, especially in patients with TMJ dysfunction resulting from psychogenic factors.‘O Muscle pain and spasms are also associated with TM J dysfunction, which is believed to result from occlusal interferences and damage of the TMJ. In our short-term trial, the two treatment modalities used here, which obviously differ in their rationale, had similar effects on muscle pain.19 The correlation of occlusal disturbances with muscle pain and damage of the TMJ needs to be studied. This could explain why acupuncture, and probably other forms of physical therapy that cannot possibly remove organic causes (for example, occlusal interferences), can be so successful in helping some patients with TMJ dysfunction. NOVEMBER 1986
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SUMMARY The purpose of this study was to compare the effects of acupuncture and stomatognathic treatment on the mobility of the mandible in random szimples of patients with TMJ dysfunction. One group of 25 patients was treated with acupuncture performed by a specialist in physical medicine and rehabilitation and a second similar group received standard stomatognathic treatment. All of the patients were evaluated in terms of the Helkimo dysfunction index by a dentist before treatment, within 1 week of treatment, and 3 months after treatment. No significant differences could be detected in painful movement of the mandible except in retrusive movement, wherein stomatognathic treatment was clearly superior immediately afterward. Acupuncture seems to be a useful early form of therapy in patients with TM J disorders that are expected to be largely functional and reversible and with evidence of psychophysiologic or neuromuscular disturbances but not of any marked occlusal interference or joint damage. Acupuncture could well be complementary to stomatognathic treatment, either preceding or following it, to achieve full neuromuscular rehabilitation, to ease the treatment (for example, occlusal splints), or to eliminate other possible contributory factors.
in evaluation of the temporomandibular joint. Phys Ther 62597. 1982. 12. Danzig WN, Van Dyke AR: Physical therapy as an adjunct to temporomandibular joint therapy. J PROSTMET DcN.~ 49:96, 1983. 13. Graham MM, Buxbaum J, Staling LM: A study of occlusal relationships ,md the incidence of myofacial pain. .J PROSTHEY DENT 4’13549, 1982.
14. Jayasuriya A Fernando F: Principles and Practice of Scientific Acupuncture. Sri Lanka, 1978, Lake House Illvestments Ltd, pp 47-60. Ordnungstherapie. 3 ,\ufl.. 15. Bachman G: Die Akupunktur-eine I Band, 1980 Haug Verlag Heidelberg, pp .?O-21. 16. McNeil1 C: Craniomandibular (TM J) disorders--The state of the art. Part II: Accepted diagnostic and trcalment modalities. J PROSTHET DE,NT 49:393,
17.
18.
19.
20.
We are grateful to Heikki Laaksama, M.Sc., and Pekka Vasari, B.Sc., for their assistance with the statistical analysis of the results.
21.
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22.
1.
2.
3. 4.
5.
6.
7.
8.
9. 10.
11.
Zarb GA, Speck JE: The treatment of mandibular dysfunction. In Zarb GA, Carlsson GE, editors: Temporomandibular Joint and Dysfunction. Copenhagen, 1979, Munksgaard, pp 373396. Magnusson T, Carlsson GE: Treatment of patients with functional disturbances in the masticatory system. A survey of 80 consecutive patients. Swed Dent J 4~145, 1980. Mongini F, editor: The Stomatognathic System. Chicago, 1984, Quintessence Publishing Co, pp 233-286. Hellsing G: Transkutan nervstimulering (TNS) vid kronisk smirta hos patienter med klkledsbesvHr. Tandlikartidningen 68:789, 1976. Ihalainen U, Perkki K: The effect of transcutaneous nerve stimulation (TNS) on chronic facial pain. Proc Finn Dent Sot 74~86, 1978. Dahlstrijm L, Carlsson SG: Treatment of mandibular dysfunction: The clinical usefulness of biofeedback in relation to splint therapy. J Oral Rehabil 11:277, 1984. Kopp S, Wenneberg B: Effects of occlusal treatment and intra-articular injections on temporomandibular joint pain and dysfunction. Acta Odontol Stand 39~87, 1981. McCarty Jr WL, Farrar WB: Surgery for internal derangements of the temporomandibular joint. J PROSTHET DENT 42191, 1979. Carlsson GE, Kopp S, Lindstram J, Lundqvist S: Surgical treatment of TMJ disorders. Ear Nose Throat J 61:42, 1982. Moss RA, Carrett JC: Temporomandibular joint dysfunction syndrome and myofascial pain dysfunction syndrome: A critical review. J Oral Rehabil 11:3, 1984. Friedman WH, Weisberg J: Application of orthopedic principles
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Pohjola RT, Raustia AM, Virtanen KK ,\kupunktur her mandibulotemporaler Gelenksdysfunktion (ThlJ). In Bischko J, editor: Weltieangress fiir wissenschaftlichr Akupunktur, Kongressband, Tcil 2. In Series, Handbuch fiir Akupunktur und Auriculotherapie. Heidelberg, 1985, Haug Verlag, pp 76-83. Raustia AM, Poh.jola RT, Virtanen KK: Acupuncture compared with stomatognathic treatment for TMJ dysfunction. Part I: A randomized study J PROSTHETDENT .54:5X1 1985. Raustia AM, Pohjola RT, Virtanen KK: Acupuncture effect on motion capacity in TMJ dysfunction. J Dent Res 64(Special issue):232, 1985 (Abstr No. 518). Junnila SYT: Akupunktuuri kivunhoitomenetelminS terveyskeskuksessa. English summary: Acupuncture lor Pain Treatment in a Finnish Health Centre. Turku, 1981, KansanelZkelaitoksen julkaisuja, Al,: 15 (Monograph Series ‘AL: Ii The National Pension Institute). Williams NE: Current views of the pharmacological management of pain In Swerdlow M, editor: Thr Therapy of Pain. Lancaster, England, 1981, MTP Press Limlred, p 87. Mejersjii C, Carlsson GE: Analysis of factors influencing the long-term efIect of treatment of TM J-pain dysfunction. J Oral Rehabil 11:289, 1984. Magnusson T, Carlsson GE: Occlusal adjustment in patients with residual or recurrent signs of mandibular dysfunction. J PROSTHETDENT 49~706, 1983. Magnusson 1‘: Patients referred for stomatognathic treatmentA survey of 1:82 patients. Swed Dent J 8~191, 1984. de la Fuye R: Traiti d’Acupuncture. Paris. 1056, Librairie de Francois. Thompson JR, Christiansen E, Hasso AN. Hinshaw Jr DB: Temporomandibular joints: High-resolution computed tomographic evaluation. Radiology 150~105, 1984. Raustia AM, Pyhtinen J, Virtanen KK: E,xamination of the temporomandibular joint by direct sagittal c,omputed romography. Chin Radio1 36~291, 1985. Roberts CA, Tallents RH, Espeland MA, Handelman SL, Katzberg RW: Mandibular range of motion vs arthographic findings in 205 patients. J Dent Res 64(Spec1al Issue):231, 1985 (Abstr No. 51 I). Helkimo M: Studies on function and dysfuncrion of the masticatory system. II. Index for anamnestic and climcal dysfunction and occlusal state. Swed Dent J 62101, 1074.
Keprzntrequest311,: DR. AUNE M. RAIJSTIA UNIVERSITYOF OLILU INSTITUTEOF DENTISTRY AAPISTIE 3 SF-90220 OULU 22 FINLAND
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