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Practical management of internal derangements of the temporomandibular joint in partially and completely edentulous patients
SECTION EDITOR
Practical m a n a g e m e n t of internal d e r a n g e m e n t s of the t e m p o r o m a n d i b u l a r joint in partially and c o m p l e t e l y edentulous patients F. C. R o b s o n , D . D . S . Tacoma, Wash. The d i a g n o s i s and t r e a t m e n t of temporomandibular disorders must focus on the specific needs of individual patients. Anecdotal reports s u g g e s t that a number of therapeutic methods can be s e l e c t i v e l y prescribed. T r e a t m e n t of partially and c o m p l e t e l y edentulous patients must also consider retention and stability of the denture base(s). (J PROSTHET DENT 1991;65:828-32.)
J[ e m p o r o m a n d i b u l a r joint disorders (TMD) are believed to affect a large segment of the population. 1-5 Denture wearers are not believed to suffer from T M D - r e lated symptoms to any great extent, 6 b u t this belief appears inconsistent with the suggested progressive nature of joint disease processes. Some reports demonstrated an increase in T M disorders with increased age or loss of teeth, 7-1° and such patients do not typically complain to dental practitioners about these dysfunctions, n13 This article reviews some current therapeutic beliefs used in the m a n a g e m e n t of some TMD. TREATMENT
OF FIBROMYALGIA
T r e a t m e n t of fibromyalgia can serve as a model for the t r e a t m e n t of T M D in general. This t r e a t m e n t involves the use of orthotics (splints) in addition to physical therapy, medications, and psychologic and medical care. The use of an orthotic in fibromyalgia has the potential of decreasing forces applied to the masticatory system by reducing muscle splinting and the level of symptoms. Functional t r e a t m e n t of the stomatognathic system has been shown to be valuable in treating m a n d i b u l a r dysfunction and headache. 14 In the t r e a t m e n t of fibromyalgia, p a r t - t i m e wear of an orthotic is usually adequate. Malocclusions have not been shown to be etiologic in T M problems, and in the t r e a t m e n t of fibromyalgia, correction of occlusal relationships will not eliminate bruxism habits. 15 The effects of occlusal t h e r a p y may be a result of correction of unequal or inappropriate loading of T M structures t h a t may worsen or propagate symptoms. Orthotics are most stable when they are tooth borne. An
Presented at the Academy of Denture Prosthetics meeting, Corpus Christi, Tex. 10/1/26090
828
edentulous ridge may not be able to resist occlusal forces as well as one t h a t is dentulous, and special care must be given to the a d a p t a t i o n of the prosthesis to the edentulous region (Fig. 1). Preliminary conditioning of the denturesupporting tissue is, of course, essential. Orthotics are frequently useful in the t r e a t m e n t of muscular splinting. T h e y may provide reduction of this muscle activity, and with their use a more relaxed m a n d i b u l a r position can be verified for dental care. The use of an orthotic over an existing complete or removable partial denture may be used to establish a mandibular position prior to prosthodontic procedures. The patient's tolerance for change can also be evaluated in this way. An occlusal scheme is considered to be efficacious if it is free of interfering centric contacts, is flat in character, allows a centric occlusal posture, and is free of protrusive and balancing interferences (Fig. 2). Physical t h e r a p y techniques, including the use of heat or cold therapies and lifestyle and diet changes are used also. These physical methods comprise the initial t r e a t m e n t plan for many patients. Electrophysical modalities, such as T E N S devices and ultrasound, may provide reduction of symptoms. Although a therapeutic effect by use of these methods has been suggested, their benefit may be palliative and useful in facilitating other t r e a t m e n t processes, such as joint distraction, an exercise program, or splint therapies. Physical therapy can be effective by itself or with other t r e a t m e n t techniques. Medical evaluation may be needed to t r e a t or to help eliminate the possibility of a systemic problem. Use of medications, alone or with other modalities, is often beneficial. Simple analgesics can be adequate in management of some pain problems. Anti-inflammatory medications, such as ibuprofen (Motrin, Upjohn, Kalamazoo, Mich.) and naproxen (Naprosyn, Syntex, Humacao, P.R.) are also of value and can substitute for aspirin. Also effective are muscle relaxants such as cyclobenzaprine (Flexer-
J U N E 1991
V O L U M E 65
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PRACTICAL MANAGEMENT OF TMD
Fig. 2. Maxillaryflatsplintfortreatmentoffibromyalgia.
Fig. 1. Orthotic appliance retained on denture by use of ball clasp. A, Mandibular; B, maxillary.
il, Merck, Sharp & Dohme, West Point, Pa.) and chlorzoxazone (Paraflex, McNeil Pharmaceutical, Spring House, Pa.). Codeine, often in combination with analgesics, may be administered for brief periods of time. The use of more powerful narcotic medications is seldom deemed appropriate. Tricyclic antidepressant medications can be of value. Examples of such medications are desipramine (Norpramin, Merrell Dow, Cincinnati, Ohio) and amitriptyline (Elavil, Merck Sharp & Dohme). For limited periods of time, antianxiety medications such as alprazolam (Xanax, Upjohn) and lorazepam (Ativan, Wyeth-Ayerst, Philadelphia, Pa.) can be beneficial. Other medications such as antibiotics, antihistamines, and dietary supplements may have a place on an individual basis. Psychological care is needed occasionally in the basic treatment protocol. Use of biofeedback has been shown to be efficacious in the treatment of fibromyalgia. Stress can induce maladaptive behaviors for which counseling can also be useful. Bruxism, for example, is a stress-induced occlusal habit that can occur with sleep disturbance. Psychiatric abnormalities are also seen, and psychological testing as well as psychiatric evaluations are occasionally needed. This testing cannot differentiate physical prob-
THE J O U R N A L OF P R O S T H E T I C D E N T I S T R Y
lems from problems of psychological origin, but it can be useful in establishing an overall therapeutic program. Acute pain situations can develop into chronic ones and chronic pain may then be regarded as a separate disease entity. Individual response to pain seems to play an important role in creating this chronic pain situation. In chronic pain, there is often a clinical depression as well as neurosis, sleep disturbance, secondary gain, sexual disinterest, anxiety, jealousy, and other relationship problems. Doctor shopping and anger are seen frequently. Delay of nonsurgical or surgical treatment in the presence of a developing chronic pare problem may have negative longterm consequences. Reversible techniques are initially used. Counseling of patients is used initially so that they understand the problem is sometimes the only care needed. The first line of treatment should include a soft diet, mild analgesics, nonsteroidal anti-inflammatory medication, and the use of heat or cold coupled with voluntary attempts to discontinue undesirable oral habits. Initial therapeutic attempts in this manner can be part of the diagnostic process. TREATMENT
OF ARTHRALGIA
The treatment of arthralgia uses the principles of basic splint therapy as they apply to the treatment of fibromyalgia. Arthralgia patients, however, represent a separate group from fibromylgia or atypical facial pain patients and need to be treated differently. 16 This difference in treatment in many patients can be seen in the emphasis on the various facets of basic splint care. In addition, treatment of fibromyalgia may be effective with a flat orthotic. The same device may be ineffective when used in treatment of disk displacement. 17 As with all TMD care, reversible methods should be the major consideration. It is believed that specific splint situations exist in relationship to specific TMJ problems and to desired results of treatment. With early displacements normalization of disk function can be accomplished with the use of a night orthotic and muscle therapy. In more advanced situations,
829
ROBSON
Fig. 3. Anterior repositioning splint used to recapture disk displacement with reduction.
orthotic use likely will fail to provide improvement in disk or joint function even on a full-time basis. In patients with advanced degenerative joint disease (DJD), a basic muscle therapy approach is again used. Between the extremes of early disk displacement and DJD is an area of TMJ care for disk displacement with reduction and inflammatory joint problems. This area may benefit by the application of a different class of splint therapy. Although anterior repositioning therapy often has been recommended, ls-25 this form of therapy is not specifically supported. 26 Often the partially edentulous, and usually the completely edentulous, patient presents a challenge. The denture-bearing tissue must be used to absorb even more force if anterior repositioning is to be accomplished. These prosthetic devices may not allow for care that is as definitive as that for dentulous patients.
D I S K D I S P L A C E M E N T WITH REDUCTION Mechanical therapy becomes a part of TMD care when an orthotic device is used to reposition the mandible anteriorly in an attempt to normalize disk function, is, 19,23 It is important to consider disk position and function when anterior repositioning therapy is used. Arthrographic studies of disk position with these devices demonstrate that elimination of joint noise is possible without recapture of the displaced disk. 19, 26 The technique for establishing the recaptured position and the proper choice of patients for attempting recapture are important considerations but are not scientifically proven. 27, 28 If the mandible is therapeutically positioned in the splint at the point of disk displacement, there may be a greater chance of positioning in a nonreduced position. Positioning slightly forward of this position may increase chances of successful recapture (Fig. 3). With compromised posterior support in the denture patient, even more anterior positioning may be needed in the initial phase of repositioning therapy. 830
Attempts to recapture displaced disks may be inappropriate when the displacements are of a chronic nature. In many individuals, displaced disks may not be recapturable. The presence of dentures may also complicate this process and needs to be considered. Physical diagnosis and clinical judgment are important in this determination. The prognosis for treatment of disk displacements of less than 6 months duration is considered more favorable than for those of longer duration. A deflection of the mandible posteriorly when closing from a directly protruded, reduced mandibular position of 1.5 mm or less is considered favorable. The character of the closing click needs to be considered because it may give some information about the health and morphology of the disk apparatus. When a reduced mandibular position is achieved and maintained on an orthotic, it can be held for a period of time to stabilize the joint more fully. This procedure also allows the patient to experience a period of comfort. Usually 3 months is adequate. At this time, the orthotic can be reformed to a flat, basic splint to allow the mandible to assume a more retruded position, if indicated, but with maintenance of satisfactory posterior support for the TMJ. This appliance has been named a superior repositioning splint by Williamson. 29 It is similar to the basic orthotic used in fibromyalgia treatment. When this treatment is successful, a changed mandibular position can occur and therapy may be needed to restore harmonious occlusal relationships. If the disk cannot be maintained in its reduced position as the mandible is retruded in the superior repositioning splint, a reevaluation is done. If appropriate, further anterior repositioning is pursued and later a walk back is again attempted. Decisions are made at this time to determine whether the occlusion should be restored at a slightly more forward mandibular position. This decision is directed by the pain problem and by the need to maintain the mandibular condyle within the confines of the fossa without excessive anterior loading of the articular eminence. A mandibular position that is slightly more forward than centric relation may be needed especially in the completely or partially edentulous patient. For these patients, an increase in the vertical dimension of occlusion within physiological limits can be useful especially in those who may have presented originally with a reduced vertical dimension. Elimination of the reciprocal click is not always necessary for the establishment of satisfactory levels of comfort. Continuing care with the disk out of place ("off disk") is often possible and needed. Some of these patients may need surgical treatment if symptoms cannot be reduced adequately by less invasive means. Disk displacements with reduction, but which are not recapturable, are treated also with the disk out of place. Basic splint therapy may be needed and can provide a slightly more anterior mandibular position. This position may serve to unload inflamed posterior capsular tissue and can be useful in treatment of TMJ inflammation. Anti-inJ U N E 1991
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PRACTICAL MANAGEMENT OF TMD
Fig. 5. Change in mandibular position using denture with repositioning therapy. Fig. 4. Pretreatment and posttreatment cephalometric tracings demonstrate change in mandibular position with "recapture" treatment.
patients can be difficult because many chronic degenerative changes typically take place in the joints. SURGICAL
flammatory medications are also helpful in these situations. Anterior positioning of at least 1.5 mm may be needed in these patients. The partially and completely edentulous patient may need more anterior positioning and may have difficulty with trauma to the edentulous ridge. The standard protocol for basic splint care is followed in these patients. They usually experience a good reduction of symptoms. Surgical care is again reserved pending results of nonsurgical treatment.
DISK DISPLACEMENT REDUCTION
WITHOUT
Disk displacement without reduction can be divided into acute and chronic displacement. The acute phase is typically easy to diagnose and treatment is more dramatic. In this phase, range of motion of the affected joint is restricted severely. In chronic displacement, joint noise may be absent and some patients show a hypermobility. Several methods to reduce an acute disk displacement have been suggested. With these methods, the mandibular condyle is moved inferiorly and anteriorly to allow the disk to resume a more normal relationship between the condyle and posterior slope of the articular eminence. The method of Farrat is perhaps the most useful.* After reduction is achieved, the disk displacement is treated as a displacement with reduction. Total compliance with full-time appliance wear is needed to maintain the disk in a reduced position. Treatment is compromised greatly in the completely edentulous ridge, which may interfere with successful treatment. Chronic displacements without reduction can be treated with basic splint therapy or as a disk displacement with reduction that cannot be recaptured. Management for these *Farrar WB. Personal communication, 1982. THE J O U R N A L OF PROSTHETIC D E N T I S T R Y
CARE
Surgical TMJ care is recommended for specific joint problems that significantly interfere with a patient's quality of life and do not respond adequately to reversible therapeutic techniques. If adequate pain reduction cannot be established in a reasonable amount of time, surgery may be considered. Excessive delay in making a surgical decision may allow the continuation of a disease process and a less desirable surgical resolution may ensue. Prolonged care with orthotic devices that may lead to permanent changes in tooth position and adaptive remodeling of joint structures is not recommended. The psychologic aspects of chronic pain creation and propagation by long-term nonsurgical therapies also should be considered in the surgical decision. Delay of more definitive therapies in the presence of the development of a chronic pain situation may have negative long-term effects. TREATMENT FOLLOWING TEMPOROMANDIBULAR CARE Disk repositioning by surgical or nonsurgical means can create a change in position of the mandible and alteration of dental occlusal relationships (Figs. 4 and 5). The treatment of fibromyalgia can alter muscle splinting and result in a clinically changed mandibular position. Dental care to provide dental support for the TMJ is frequently needed after these treatments. Although the presence of a malocclusion is not known to be etiologic in TMJ problems, the modification of occlusal relationships in patients with TMJ problems may provide increased comfort and improved function. Unsatisfactory dentures, for example, have been reported to result in an increase in recurrent headache and mandibular dysfunction.16' 2o This effect is seen with such occlusal problems as decreased vertical dimension, posterior occlusion collapse, and lack of anterior protected 831
ROBSON
occlusion. Reversible alteration of these occlusal problems with occlusal splints is often adequate in reduction of pain and dysfunction in the edentulous or partially edentulous patient. The dental restoration of the more accepted occlusal patterns by use of a dental equilibration, restorative dental care, prosthodontics, orthodontics, orthognathic surgery, or a combination of these techniques may be indicated. At completion of active TMJ care, long-term night devices can be u s e d . 24 They are recommended in all postsurgical treatment. Usually, a neutral mandibular position is used for these orthotics. The use of these night guards may be indicated also in situations of occlusal trauma to help protect the dental health of the patient.
13.
SUMMARY
17.
Splint therapy, including the use of orthotics, physical therapy, medication, and psychologic and medical care are regarded as important aspects of TMD care and are modified to fit the specific needs of each patient. Partially and completely edentulous patients present a special challenge because the lack of stability of the complete or partial denture may also complicate care.
10. 11. 12.
14.
15. 16.
18. 19. 20. 21. 22.
T h e editorial assistance of Drs. Vincent Kokich, Fuertel Paris, and David W a n d s is gratefully acknowledged.
23.
REFERENCES
24.
1. Helkimo M. Studies on function and dysfunction of the masticatory system. I. An epidemiological investigation of symptoms of dysfunction in Lapps in the north of Finland. Proc Finn Dent Soc 1974;70:37-49. 2. Williamson EH. Temporomandibular joint dysfunction in pretreatment adolescent patients. Am J Orthod 1977;72:429-33. 3. Bush FM, Butler JH, Abbott DM. The relationship of TMJ clicking to palpable facial pain. J Cranio Pract 1983;1:45-8. 4. Nilner M. Prevalence of functional disturbances and diseases of the stomatognathic system in 15-18 year olds. Swed Dent J 1981;5:189-97. 5. Owen III AH. Orthodontic/orthopedic treatment of craniomandibular pain dysfunction. Part 1: Diagnosis with transcranial radiographs. J Cranio Pract 1984;2:238-49. 6. Loiselle RJ. Relation of occlusion to temporomandibular joint dysfunction: the prosthodontic viewpoint. J Am Dent Assoc 1969;79:145-6. 7. Agerberg G, Osterberg T. Maximal mandibular movements and symptoms of mandibular dysfunction in 70-year-old men and women. Swed Dent J 1974;67:147-64. 8. Serfaty V, Nemcovsky CE, Friedlander D, Gazit E. Functional disturbances of the masticatory system in an elderly population group. J Cranio Pract 1989;7:46-51. 9. Rieder CE, Martinoff JT, Wilcox SA. The prevalence of mandibular
832
25. 26.
27.
28.
29.
dysfunction. Part 1: sex and age distribution of related signs and symptoms. J PROSTHET DENT 1983;50:81-8. Agerberg G. Mandibular function and dysfunction in complete denture wearers--a literature review. J Oral Rehabil 1988;15:237-49. Choy E, Smith DE. The prevalence of temporomandibular joint disturbances in complete denture patients. J Oral Rehabil 1980;7:331-52. Magnusson T. Prevalence of recurrent headaches and mandibular dysfunction in patients with unsatisfactory complete dentures. Community Dent Oral Epidemiol 1980;8:159-64. Bergman B, Carlsson GE. Review of 54 complete denture wearers, patients opinions one year after treatment. Acta Odontol Scand 1972;30:399-414. Magnusson T. Changes in recurrent headache and mandibular dysfunction after treatment with new complete dentures. J Oral Rehabil 1982;9:95-105. Kydd WL, Daly C. Duration of nocturnal tooth contacts during bruxing. J PROSTHET DENT 1985;53:717-21. Magnusson T. Changes in recurrent headaches and mandibular dysfunction in patients with unsatisfactory complete dentures. J Oral Rehabil 1982;9:95-105. Westesson P-L, Lundh H. Temporomandibular joint disk displacement: arthrographic and tomographic follow-up after 6 months treatment with disk-repoeitioning onlays. Oral Surg 1988;66:271-8. Eversole LR, Stone CE, Matheson D, Kaplan H. Psychometric profiles and facial pain. Oral Surg 1985;60:269-74. Fox CE, Abrams BL, Williams B, Doukoudakis A. Protrusive positioners. J PEOSTHETDENT 1985;54:258-62. Keller DC. Anterior maxillary appliance for treating TMJ dysfunction. J Cranio Pract 1985;3:251-66. Clark GT. The TMJ repositioning appliance: a technique for construction, insertion, and adjustment. J Cranio Pract 1986;4:37-46. Clark GT. A critical evaluation of orthopedic interocclusal appliance therapy: effectiveness for specific symptoms. J Am Dent Assoc 1984;108:364-8. Farrar WB. Diagnosis and treatment for anterior dislocation of the articular disk. N Y State Dent J 1971;41:348-57. Farrar WB., McCarty WL. The TMJ dilemma. J Alabama Dent Assoc 1979;63:19-26. Owen III AH. Orthopedic/orthodontic therapy for anterior disk displacement: unexpected treatment findings. J Cranio Pract 1989;7:33-45. Griffith RH. Report of the President's conference on the examination, diagnosis, and management of temporomandibular disorders. J Am Dent Assoc 1983;106:75-7. Manzione JV, Tallents R, Katzberg RW, Oster C, Miller TL. Arthrographically guided splint therapy for recapturing the temporomandibular joint meniscus. Oral Surg 1984;57:235. Tallents RH, Katzberg RW, Miller TL, Manzione JV, Oster C. Evaluation of arthrographically assisted splint therapy in treatment of TMJ disk displacement. J PROSTHETDENT 1985;53:836-8. Williamson EH, Sheffield JW. The treatment of internal derangement of the temporomandibular joint: a survey of 300 cases. J Cranio Pract 1987;5:119-24.
Reprint requests to: DR. FARRANDCORYROBSON 1950 SOUTHCEDAR, STE. B TACOMA,WA 98405
JUNE 1991
VOLUME 65
NUMBER 6
Practical m a n a g e m e n t of internal d e r a n g e m e n t s of the t e m p o r o m a n d i b u l a r joint in partially and c o m p l e t e l y edentulous patients F. C. R o b s o n , D . D . S . Tacoma, Wash. The d i a g n o s i s and t r e a t m e n t of temporomandibular disorders must focus on the specific needs of individual patients. Anecdotal reports s u g g e s t that a number of therapeutic methods can be s e l e c t i v e l y prescribed. T r e a t m e n t of partially and c o m p l e t e l y edentulous patients must also consider retention and stability of the denture base(s). (J PROSTHET DENT 1991;65:828-32.)
J[ e m p o r o m a n d i b u l a r joint disorders (TMD) are believed to affect a large segment of the population. 1-5 Denture wearers are not believed to suffer from T M D - r e lated symptoms to any great extent, 6 b u t this belief appears inconsistent with the suggested progressive nature of joint disease processes. Some reports demonstrated an increase in T M disorders with increased age or loss of teeth, 7-1° and such patients do not typically complain to dental practitioners about these dysfunctions, n13 This article reviews some current therapeutic beliefs used in the m a n a g e m e n t of some TMD. TREATMENT
OF FIBROMYALGIA
T r e a t m e n t of fibromyalgia can serve as a model for the t r e a t m e n t of T M D in general. This t r e a t m e n t involves the use of orthotics (splints) in addition to physical therapy, medications, and psychologic and medical care. The use of an orthotic in fibromyalgia has the potential of decreasing forces applied to the masticatory system by reducing muscle splinting and the level of symptoms. Functional t r e a t m e n t of the stomatognathic system has been shown to be valuable in treating m a n d i b u l a r dysfunction and headache. 14 In the t r e a t m e n t of fibromyalgia, p a r t - t i m e wear of an orthotic is usually adequate. Malocclusions have not been shown to be etiologic in T M problems, and in the t r e a t m e n t of fibromyalgia, correction of occlusal relationships will not eliminate bruxism habits. 15 The effects of occlusal t h e r a p y may be a result of correction of unequal or inappropriate loading of T M structures t h a t may worsen or propagate symptoms. Orthotics are most stable when they are tooth borne. An
Presented at the Academy of Denture Prosthetics meeting, Corpus Christi, Tex. 10/1/26090
828
edentulous ridge may not be able to resist occlusal forces as well as one t h a t is dentulous, and special care must be given to the a d a p t a t i o n of the prosthesis to the edentulous region (Fig. 1). Preliminary conditioning of the denturesupporting tissue is, of course, essential. Orthotics are frequently useful in the t r e a t m e n t of muscular splinting. T h e y may provide reduction of this muscle activity, and with their use a more relaxed m a n d i b u l a r position can be verified for dental care. The use of an orthotic over an existing complete or removable partial denture may be used to establish a mandibular position prior to prosthodontic procedures. The patient's tolerance for change can also be evaluated in this way. An occlusal scheme is considered to be efficacious if it is free of interfering centric contacts, is flat in character, allows a centric occlusal posture, and is free of protrusive and balancing interferences (Fig. 2). Physical t h e r a p y techniques, including the use of heat or cold therapies and lifestyle and diet changes are used also. These physical methods comprise the initial t r e a t m e n t plan for many patients. Electrophysical modalities, such as T E N S devices and ultrasound, may provide reduction of symptoms. Although a therapeutic effect by use of these methods has been suggested, their benefit may be palliative and useful in facilitating other t r e a t m e n t processes, such as joint distraction, an exercise program, or splint therapies. Physical therapy can be effective by itself or with other t r e a t m e n t techniques. Medical evaluation may be needed to t r e a t or to help eliminate the possibility of a systemic problem. Use of medications, alone or with other modalities, is often beneficial. Simple analgesics can be adequate in management of some pain problems. Anti-inflammatory medications, such as ibuprofen (Motrin, Upjohn, Kalamazoo, Mich.) and naproxen (Naprosyn, Syntex, Humacao, P.R.) are also of value and can substitute for aspirin. Also effective are muscle relaxants such as cyclobenzaprine (Flexer-
J U N E 1991
V O L U M E 65
NUMBER S
PRACTICAL MANAGEMENT OF TMD
Fig. 2. Maxillaryflatsplintfortreatmentoffibromyalgia.
Fig. 1. Orthotic appliance retained on denture by use of ball clasp. A, Mandibular; B, maxillary.
il, Merck, Sharp & Dohme, West Point, Pa.) and chlorzoxazone (Paraflex, McNeil Pharmaceutical, Spring House, Pa.). Codeine, often in combination with analgesics, may be administered for brief periods of time. The use of more powerful narcotic medications is seldom deemed appropriate. Tricyclic antidepressant medications can be of value. Examples of such medications are desipramine (Norpramin, Merrell Dow, Cincinnati, Ohio) and amitriptyline (Elavil, Merck Sharp & Dohme). For limited periods of time, antianxiety medications such as alprazolam (Xanax, Upjohn) and lorazepam (Ativan, Wyeth-Ayerst, Philadelphia, Pa.) can be beneficial. Other medications such as antibiotics, antihistamines, and dietary supplements may have a place on an individual basis. Psychological care is needed occasionally in the basic treatment protocol. Use of biofeedback has been shown to be efficacious in the treatment of fibromyalgia. Stress can induce maladaptive behaviors for which counseling can also be useful. Bruxism, for example, is a stress-induced occlusal habit that can occur with sleep disturbance. Psychiatric abnormalities are also seen, and psychological testing as well as psychiatric evaluations are occasionally needed. This testing cannot differentiate physical prob-
THE J O U R N A L OF P R O S T H E T I C D E N T I S T R Y
lems from problems of psychological origin, but it can be useful in establishing an overall therapeutic program. Acute pain situations can develop into chronic ones and chronic pain may then be regarded as a separate disease entity. Individual response to pain seems to play an important role in creating this chronic pain situation. In chronic pain, there is often a clinical depression as well as neurosis, sleep disturbance, secondary gain, sexual disinterest, anxiety, jealousy, and other relationship problems. Doctor shopping and anger are seen frequently. Delay of nonsurgical or surgical treatment in the presence of a developing chronic pare problem may have negative longterm consequences. Reversible techniques are initially used. Counseling of patients is used initially so that they understand the problem is sometimes the only care needed. The first line of treatment should include a soft diet, mild analgesics, nonsteroidal anti-inflammatory medication, and the use of heat or cold coupled with voluntary attempts to discontinue undesirable oral habits. Initial therapeutic attempts in this manner can be part of the diagnostic process. TREATMENT
OF ARTHRALGIA
The treatment of arthralgia uses the principles of basic splint therapy as they apply to the treatment of fibromyalgia. Arthralgia patients, however, represent a separate group from fibromylgia or atypical facial pain patients and need to be treated differently. 16 This difference in treatment in many patients can be seen in the emphasis on the various facets of basic splint care. In addition, treatment of fibromyalgia may be effective with a flat orthotic. The same device may be ineffective when used in treatment of disk displacement. 17 As with all TMD care, reversible methods should be the major consideration. It is believed that specific splint situations exist in relationship to specific TMJ problems and to desired results of treatment. With early displacements normalization of disk function can be accomplished with the use of a night orthotic and muscle therapy. In more advanced situations,
829
ROBSON
Fig. 3. Anterior repositioning splint used to recapture disk displacement with reduction.
orthotic use likely will fail to provide improvement in disk or joint function even on a full-time basis. In patients with advanced degenerative joint disease (DJD), a basic muscle therapy approach is again used. Between the extremes of early disk displacement and DJD is an area of TMJ care for disk displacement with reduction and inflammatory joint problems. This area may benefit by the application of a different class of splint therapy. Although anterior repositioning therapy often has been recommended, ls-25 this form of therapy is not specifically supported. 26 Often the partially edentulous, and usually the completely edentulous, patient presents a challenge. The denture-bearing tissue must be used to absorb even more force if anterior repositioning is to be accomplished. These prosthetic devices may not allow for care that is as definitive as that for dentulous patients.
D I S K D I S P L A C E M E N T WITH REDUCTION Mechanical therapy becomes a part of TMD care when an orthotic device is used to reposition the mandible anteriorly in an attempt to normalize disk function, is, 19,23 It is important to consider disk position and function when anterior repositioning therapy is used. Arthrographic studies of disk position with these devices demonstrate that elimination of joint noise is possible without recapture of the displaced disk. 19, 26 The technique for establishing the recaptured position and the proper choice of patients for attempting recapture are important considerations but are not scientifically proven. 27, 28 If the mandible is therapeutically positioned in the splint at the point of disk displacement, there may be a greater chance of positioning in a nonreduced position. Positioning slightly forward of this position may increase chances of successful recapture (Fig. 3). With compromised posterior support in the denture patient, even more anterior positioning may be needed in the initial phase of repositioning therapy. 830
Attempts to recapture displaced disks may be inappropriate when the displacements are of a chronic nature. In many individuals, displaced disks may not be recapturable. The presence of dentures may also complicate this process and needs to be considered. Physical diagnosis and clinical judgment are important in this determination. The prognosis for treatment of disk displacements of less than 6 months duration is considered more favorable than for those of longer duration. A deflection of the mandible posteriorly when closing from a directly protruded, reduced mandibular position of 1.5 mm or less is considered favorable. The character of the closing click needs to be considered because it may give some information about the health and morphology of the disk apparatus. When a reduced mandibular position is achieved and maintained on an orthotic, it can be held for a period of time to stabilize the joint more fully. This procedure also allows the patient to experience a period of comfort. Usually 3 months is adequate. At this time, the orthotic can be reformed to a flat, basic splint to allow the mandible to assume a more retruded position, if indicated, but with maintenance of satisfactory posterior support for the TMJ. This appliance has been named a superior repositioning splint by Williamson. 29 It is similar to the basic orthotic used in fibromyalgia treatment. When this treatment is successful, a changed mandibular position can occur and therapy may be needed to restore harmonious occlusal relationships. If the disk cannot be maintained in its reduced position as the mandible is retruded in the superior repositioning splint, a reevaluation is done. If appropriate, further anterior repositioning is pursued and later a walk back is again attempted. Decisions are made at this time to determine whether the occlusion should be restored at a slightly more forward mandibular position. This decision is directed by the pain problem and by the need to maintain the mandibular condyle within the confines of the fossa without excessive anterior loading of the articular eminence. A mandibular position that is slightly more forward than centric relation may be needed especially in the completely or partially edentulous patient. For these patients, an increase in the vertical dimension of occlusion within physiological limits can be useful especially in those who may have presented originally with a reduced vertical dimension. Elimination of the reciprocal click is not always necessary for the establishment of satisfactory levels of comfort. Continuing care with the disk out of place ("off disk") is often possible and needed. Some of these patients may need surgical treatment if symptoms cannot be reduced adequately by less invasive means. Disk displacements with reduction, but which are not recapturable, are treated also with the disk out of place. Basic splint therapy may be needed and can provide a slightly more anterior mandibular position. This position may serve to unload inflamed posterior capsular tissue and can be useful in treatment of TMJ inflammation. Anti-inJ U N E 1991
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Fig. 5. Change in mandibular position using denture with repositioning therapy. Fig. 4. Pretreatment and posttreatment cephalometric tracings demonstrate change in mandibular position with "recapture" treatment.
patients can be difficult because many chronic degenerative changes typically take place in the joints. SURGICAL
flammatory medications are also helpful in these situations. Anterior positioning of at least 1.5 mm may be needed in these patients. The partially and completely edentulous patient may need more anterior positioning and may have difficulty with trauma to the edentulous ridge. The standard protocol for basic splint care is followed in these patients. They usually experience a good reduction of symptoms. Surgical care is again reserved pending results of nonsurgical treatment.
DISK DISPLACEMENT REDUCTION
WITHOUT
Disk displacement without reduction can be divided into acute and chronic displacement. The acute phase is typically easy to diagnose and treatment is more dramatic. In this phase, range of motion of the affected joint is restricted severely. In chronic displacement, joint noise may be absent and some patients show a hypermobility. Several methods to reduce an acute disk displacement have been suggested. With these methods, the mandibular condyle is moved inferiorly and anteriorly to allow the disk to resume a more normal relationship between the condyle and posterior slope of the articular eminence. The method of Farrat is perhaps the most useful.* After reduction is achieved, the disk displacement is treated as a displacement with reduction. Total compliance with full-time appliance wear is needed to maintain the disk in a reduced position. Treatment is compromised greatly in the completely edentulous ridge, which may interfere with successful treatment. Chronic displacements without reduction can be treated with basic splint therapy or as a disk displacement with reduction that cannot be recaptured. Management for these *Farrar WB. Personal communication, 1982. THE J O U R N A L OF PROSTHETIC D E N T I S T R Y
CARE
Surgical TMJ care is recommended for specific joint problems that significantly interfere with a patient's quality of life and do not respond adequately to reversible therapeutic techniques. If adequate pain reduction cannot be established in a reasonable amount of time, surgery may be considered. Excessive delay in making a surgical decision may allow the continuation of a disease process and a less desirable surgical resolution may ensue. Prolonged care with orthotic devices that may lead to permanent changes in tooth position and adaptive remodeling of joint structures is not recommended. The psychologic aspects of chronic pain creation and propagation by long-term nonsurgical therapies also should be considered in the surgical decision. Delay of more definitive therapies in the presence of the development of a chronic pain situation may have negative long-term effects. TREATMENT FOLLOWING TEMPOROMANDIBULAR CARE Disk repositioning by surgical or nonsurgical means can create a change in position of the mandible and alteration of dental occlusal relationships (Figs. 4 and 5). The treatment of fibromyalgia can alter muscle splinting and result in a clinically changed mandibular position. Dental care to provide dental support for the TMJ is frequently needed after these treatments. Although the presence of a malocclusion is not known to be etiologic in TMJ problems, the modification of occlusal relationships in patients with TMJ problems may provide increased comfort and improved function. Unsatisfactory dentures, for example, have been reported to result in an increase in recurrent headache and mandibular dysfunction.16' 2o This effect is seen with such occlusal problems as decreased vertical dimension, posterior occlusion collapse, and lack of anterior protected 831
ROBSON
occlusion. Reversible alteration of these occlusal problems with occlusal splints is often adequate in reduction of pain and dysfunction in the edentulous or partially edentulous patient. The dental restoration of the more accepted occlusal patterns by use of a dental equilibration, restorative dental care, prosthodontics, orthodontics, orthognathic surgery, or a combination of these techniques may be indicated. At completion of active TMJ care, long-term night devices can be u s e d . 24 They are recommended in all postsurgical treatment. Usually, a neutral mandibular position is used for these orthotics. The use of these night guards may be indicated also in situations of occlusal trauma to help protect the dental health of the patient.
13.
SUMMARY
17.
Splint therapy, including the use of orthotics, physical therapy, medication, and psychologic and medical care are regarded as important aspects of TMD care and are modified to fit the specific needs of each patient. Partially and completely edentulous patients present a special challenge because the lack of stability of the complete or partial denture may also complicate care.
10. 11. 12.
14.
15. 16.
18. 19. 20. 21. 22.
T h e editorial assistance of Drs. Vincent Kokich, Fuertel Paris, and David W a n d s is gratefully acknowledged.
23.
REFERENCES
24.
1. Helkimo M. Studies on function and dysfunction of the masticatory system. I. An epidemiological investigation of symptoms of dysfunction in Lapps in the north of Finland. Proc Finn Dent Soc 1974;70:37-49. 2. Williamson EH. Temporomandibular joint dysfunction in pretreatment adolescent patients. Am J Orthod 1977;72:429-33. 3. Bush FM, Butler JH, Abbott DM. The relationship of TMJ clicking to palpable facial pain. J Cranio Pract 1983;1:45-8. 4. Nilner M. Prevalence of functional disturbances and diseases of the stomatognathic system in 15-18 year olds. Swed Dent J 1981;5:189-97. 5. Owen III AH. Orthodontic/orthopedic treatment of craniomandibular pain dysfunction. Part 1: Diagnosis with transcranial radiographs. J Cranio Pract 1984;2:238-49. 6. Loiselle RJ. Relation of occlusion to temporomandibular joint dysfunction: the prosthodontic viewpoint. J Am Dent Assoc 1969;79:145-6. 7. Agerberg G, Osterberg T. Maximal mandibular movements and symptoms of mandibular dysfunction in 70-year-old men and women. Swed Dent J 1974;67:147-64. 8. Serfaty V, Nemcovsky CE, Friedlander D, Gazit E. Functional disturbances of the masticatory system in an elderly population group. J Cranio Pract 1989;7:46-51. 9. Rieder CE, Martinoff JT, Wilcox SA. The prevalence of mandibular
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dysfunction. Part 1: sex and age distribution of related signs and symptoms. J PROSTHET DENT 1983;50:81-8. Agerberg G. Mandibular function and dysfunction in complete denture wearers--a literature review. J Oral Rehabil 1988;15:237-49. Choy E, Smith DE. The prevalence of temporomandibular joint disturbances in complete denture patients. J Oral Rehabil 1980;7:331-52. Magnusson T. Prevalence of recurrent headaches and mandibular dysfunction in patients with unsatisfactory complete dentures. Community Dent Oral Epidemiol 1980;8:159-64. Bergman B, Carlsson GE. Review of 54 complete denture wearers, patients opinions one year after treatment. Acta Odontol Scand 1972;30:399-414. Magnusson T. Changes in recurrent headache and mandibular dysfunction after treatment with new complete dentures. J Oral Rehabil 1982;9:95-105. Kydd WL, Daly C. Duration of nocturnal tooth contacts during bruxing. J PROSTHET DENT 1985;53:717-21. Magnusson T. Changes in recurrent headaches and mandibular dysfunction in patients with unsatisfactory complete dentures. J Oral Rehabil 1982;9:95-105. Westesson P-L, Lundh H. Temporomandibular joint disk displacement: arthrographic and tomographic follow-up after 6 months treatment with disk-repoeitioning onlays. Oral Surg 1988;66:271-8. Eversole LR, Stone CE, Matheson D, Kaplan H. Psychometric profiles and facial pain. Oral Surg 1985;60:269-74. Fox CE, Abrams BL, Williams B, Doukoudakis A. Protrusive positioners. J PEOSTHETDENT 1985;54:258-62. Keller DC. Anterior maxillary appliance for treating TMJ dysfunction. J Cranio Pract 1985;3:251-66. Clark GT. The TMJ repositioning appliance: a technique for construction, insertion, and adjustment. J Cranio Pract 1986;4:37-46. Clark GT. A critical evaluation of orthopedic interocclusal appliance therapy: effectiveness for specific symptoms. J Am Dent Assoc 1984;108:364-8. Farrar WB. Diagnosis and treatment for anterior dislocation of the articular disk. N Y State Dent J 1971;41:348-57. Farrar WB., McCarty WL. The TMJ dilemma. J Alabama Dent Assoc 1979;63:19-26. Owen III AH. Orthopedic/orthodontic therapy for anterior disk displacement: unexpected treatment findings. J Cranio Pract 1989;7:33-45. Griffith RH. Report of the President's conference on the examination, diagnosis, and management of temporomandibular disorders. J Am Dent Assoc 1983;106:75-7. Manzione JV, Tallents R, Katzberg RW, Oster C, Miller TL. Arthrographically guided splint therapy for recapturing the temporomandibular joint meniscus. Oral Surg 1984;57:235. Tallents RH, Katzberg RW, Miller TL, Manzione JV, Oster C. Evaluation of arthrographically assisted splint therapy in treatment of TMJ disk displacement. J PROSTHETDENT 1985;53:836-8. Williamson EH, Sheffield JW. The treatment of internal derangement of the temporomandibular joint: a survey of 300 cases. J Cranio Pract 1987;5:119-24.
Reprint requests to: DR. FARRANDCORYROBSON 1950 SOUTHCEDAR, STE. B TACOMA,WA 98405
JUNE 1991
VOLUME 65
NUMBER 6