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Treatment of maxillomandibular constrictions
Treatment of maxillomandibular constrictions Edmundo Pinto Fonseca, C.D., D.L.*
University o/SSo Paulo, SSo Paulo, Brazil
M
axillomandibular constrictions prevent the mouth from being opened and cause disturbances that range from slight and temporary trismus to serious deformities. Limitations and mandible movements may be acute or chronic. Acute limitations cause partial lack of opening and occur more frequently than chronic limitations, which have a tendency to result in total closure of the mandible. Maxillomandibular constrictions are grouped into three different modalities according to anatomicopathologic criteria. These are constrictions that result from (I) muscular origin, (2) cicatricial origin, and (3) articular origin. The treatment for these conditions varies according to the origin. However, in most instances, mechanotherapy is of foremost importance, be it an exclusive or a complementary form of treatment. The two different phases of mechanotherapy are the stretching action and the movement of the joint.
TECHNIQUE OF MECHANOTHERAPY Once the mandible and maxillae have been separated by 12 or 13 mm. by exercise procedures, impressions of the dental arches are made with the use of irreversible hydrocolloid in individual baseplate trays. A restoration that has a stretching action due to the attachment of strong springs is constructed on the casts and is used for the initial phase of the treatment (Fig. 1). When the stretching phase is completed, jaw movements are made possible through the use of springs with reduced tension. To improve lateral movements, springs of different stiffness are alternately located on opposite sides of the jaws and are maintained for equal time intervals? In certain instances the restorations are used at night to prevent loss of the positive effect of jaw movement obtained during the day. For night use, the springs are securely attached to the restorations by means of screws (Fig. 1). Translated to English by Dioracy Fonterrada Vieira. *Assistant Professor, Faculty of Odontology.
652
Volume 22 Number 6
Treating rnaxillomandibular constructions
653
Fig. I. Mechanotherapy is accomplished by the action of interarch springs attached between maxillarg and mandibular restorations.
TREATMENT OF CONSTRICTIONS OF MUSCULAR ORIGIN A psychic treatment is commonly needed when trismus is of a psychic origin~ In trismus of myotonic origin, mechanotherapy is useful once the initial causes are removed. Contractures of a non-inflammatory cause may be treated from the beginning by mechanical means, mainly by those methods which produce a progressive and continuous stretching. Special devices to control the forces that are applied in the opening of the mouth are used. Mechanotherapy associated with chemotherapy, physical agents, and educative exercises are advisable to insure mobility3"* T h e stretching action must not be too great or prolonged, because a defensive resistance of the masticatory muscles which aggravates the situation may develop. An indication for mechanotherapy in a patient with acute arthritis of the temporomandibular joint which followed a trismus of infectious origin s is seen in Fig. 2. TREATMENT OF THE CONSTRICTIONS OF CICATRICIAL ORIGIN Treatment must be initiated as soon as possible for constrictions that are of cicatricial origin. The treatment consists mainly of movements of opening and closing of the mouth. Mechanotherapy may be used for these patients as an auxiliary treatment. The results are of relative value and the cicatricial retraction is not always avoided5 T h e stretching treatment is always indicated. However, when opening by a coi~tinuous pressure does not succeed in a few weeks, suri#cal therapy is required with mechanotherapy as a complementary treatment. T h e success of the treatment depends on the locations and resistance of the cicatricial bridges or bridles. T h e superficial cicatricial bridges may be stretched wi.th a well-applied treatment. Deep muscular constrictions are difficult to treat, espe-
654
Fonseca
J. Pros.Dent. December, 1969
Fig. 2. Acute arthritis of the temporomandibular joint. Left, the amount of opening prior to treatment. Right, the restorations with the springs attached are in place in the mouth. Center, note the increase in opening following treatment.
Fig. 3. A modified Eby restoration is used in the treatment of a constriction of cicatricial origin.
cially when they are located in the posterior part of the mouth. When the cicatricial bridges extend between the two bony attachments of the maxillae and mandible, mechanotherapy is not indicated. Successful treatment occurs in those patients where there is just one bony attachment or none at all (Fig. 3).
TREATMENT OF MANDIBULAR CONSTRICTIONS OF JOINT ORIGIN Early treatment of the temporomandibular joint usually gives good results when the joint is involved in limitations of mandibular movement. However, surgical treatment must be instituted and complemented later by mechanical means when fibrous or bony ankylosis of the temporomandibular joint has developed. Mechanotherapy as an exclusive treatment is advised in chronic arthritis and in fibrous ankylosis.
Volume22 Number 6
Treating maxillomandibular constructions
655
Fig. 4. The patient developed a unilateral fibrous ankylosis from use of forceps during obstetrical procedures. Left, the amount of opening before treatment. Right, the restorations with springs attached. Center, the amount of opening after treatment.
T r e a t m e n t , by m e a n s of a p p l y i n g pressure to create opening, must be c o n t i n u e d for several months. After surgical t r e a t m e n t to free the m o v 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, the function of the m e c h a n i c a l o p e n i n g m e c h a n i s m is t h a t of m o d e l i n g the new a r t i c u l a r surfaces of the joint, strengthening of the m a n d i b u l a r muscles which h a d a t r o p h i e d , a n d a v o i d i n g a reccurrence of the lesion. 7 T h e results of using m e c h a n o t h e r a p y for m a n d i b u l a r constriction of joint origin are seen in Fig. 4.
SUMMARY M a x i l l o m a n d i b u l a r constrictions are classified as muscular, cicatricial, or articular (joint) in origin. T h e n a t u r e of the t r e a t m e n t r e q u i r e d for these three forms was discussed. T h e m e t h o d of use of m e c h a n o t h e r a p y in t r e a t m e n t of m a x i l l o m a n d i b u l a r constrictions was described.
References 1. Fonseca, E. Pi: Constric~o Mandibular, Rev. Ass. Paul. Cir. Dent., S~o Paulo 13: 297-316, 1959. 2. Fonseca, E. P.: Trismo, Rev. Bras. Odont., Rio de Janeiro 16: 313-319, 1958. 3. Newlands, C.: Diatermia, ed. 2, Rio de Janeiro, 1946, Cientifica, p. 52. 4. Parker, D. B.: Synopsis of Traumatic Injuries of the Face and Jaws, St. Louis, 1942, The C. V. Mosby Company, p. 206. 5. Fonseca, E. P.: Artrites Agudas Temporo-Mandibulares, Rev. Ass. Paul. Cir_ Dent., S+io Paulo 12: 222-229, 1958.
656
Fonseca
j. Pros. Dent.
December, 1969
G. Fry, W. K., and Ward, T.: The Dental Treatment of Maxillo-facial Injuries, ed. 2, Springfield, Ill., 1956, Charles C Thomas, Publisher, p. 315. 7. Dufourmentel, L.: Chirurgie de l'articulation temporo-maxillaire, Paris, 1929, Masson et Cie, p. 135. UNIVERSITY OF SAO PAULO FACULTY OF DENTISTRY C. POSTAL 8216 S~o PAULO, BRAZIL
University o/SSo Paulo, SSo Paulo, Brazil
M
axillomandibular constrictions prevent the mouth from being opened and cause disturbances that range from slight and temporary trismus to serious deformities. Limitations and mandible movements may be acute or chronic. Acute limitations cause partial lack of opening and occur more frequently than chronic limitations, which have a tendency to result in total closure of the mandible. Maxillomandibular constrictions are grouped into three different modalities according to anatomicopathologic criteria. These are constrictions that result from (I) muscular origin, (2) cicatricial origin, and (3) articular origin. The treatment for these conditions varies according to the origin. However, in most instances, mechanotherapy is of foremost importance, be it an exclusive or a complementary form of treatment. The two different phases of mechanotherapy are the stretching action and the movement of the joint.
TECHNIQUE OF MECHANOTHERAPY Once the mandible and maxillae have been separated by 12 or 13 mm. by exercise procedures, impressions of the dental arches are made with the use of irreversible hydrocolloid in individual baseplate trays. A restoration that has a stretching action due to the attachment of strong springs is constructed on the casts and is used for the initial phase of the treatment (Fig. 1). When the stretching phase is completed, jaw movements are made possible through the use of springs with reduced tension. To improve lateral movements, springs of different stiffness are alternately located on opposite sides of the jaws and are maintained for equal time intervals? In certain instances the restorations are used at night to prevent loss of the positive effect of jaw movement obtained during the day. For night use, the springs are securely attached to the restorations by means of screws (Fig. 1). Translated to English by Dioracy Fonterrada Vieira. *Assistant Professor, Faculty of Odontology.
652
Volume 22 Number 6
Treating rnaxillomandibular constructions
653
Fig. I. Mechanotherapy is accomplished by the action of interarch springs attached between maxillarg and mandibular restorations.
TREATMENT OF CONSTRICTIONS OF MUSCULAR ORIGIN A psychic treatment is commonly needed when trismus is of a psychic origin~ In trismus of myotonic origin, mechanotherapy is useful once the initial causes are removed. Contractures of a non-inflammatory cause may be treated from the beginning by mechanical means, mainly by those methods which produce a progressive and continuous stretching. Special devices to control the forces that are applied in the opening of the mouth are used. Mechanotherapy associated with chemotherapy, physical agents, and educative exercises are advisable to insure mobility3"* T h e stretching action must not be too great or prolonged, because a defensive resistance of the masticatory muscles which aggravates the situation may develop. An indication for mechanotherapy in a patient with acute arthritis of the temporomandibular joint which followed a trismus of infectious origin s is seen in Fig. 2. TREATMENT OF THE CONSTRICTIONS OF CICATRICIAL ORIGIN Treatment must be initiated as soon as possible for constrictions that are of cicatricial origin. The treatment consists mainly of movements of opening and closing of the mouth. Mechanotherapy may be used for these patients as an auxiliary treatment. The results are of relative value and the cicatricial retraction is not always avoided5 T h e stretching treatment is always indicated. However, when opening by a coi~tinuous pressure does not succeed in a few weeks, suri#cal therapy is required with mechanotherapy as a complementary treatment. T h e success of the treatment depends on the locations and resistance of the cicatricial bridges or bridles. T h e superficial cicatricial bridges may be stretched wi.th a well-applied treatment. Deep muscular constrictions are difficult to treat, espe-
654
Fonseca
J. Pros.Dent. December, 1969
Fig. 2. Acute arthritis of the temporomandibular joint. Left, the amount of opening prior to treatment. Right, the restorations with the springs attached are in place in the mouth. Center, note the increase in opening following treatment.
Fig. 3. A modified Eby restoration is used in the treatment of a constriction of cicatricial origin.
cially when they are located in the posterior part of the mouth. When the cicatricial bridges extend between the two bony attachments of the maxillae and mandible, mechanotherapy is not indicated. Successful treatment occurs in those patients where there is just one bony attachment or none at all (Fig. 3).
TREATMENT OF MANDIBULAR CONSTRICTIONS OF JOINT ORIGIN Early treatment of the temporomandibular joint usually gives good results when the joint is involved in limitations of mandibular movement. However, surgical treatment must be instituted and complemented later by mechanical means when fibrous or bony ankylosis of the temporomandibular joint has developed. Mechanotherapy as an exclusive treatment is advised in chronic arthritis and in fibrous ankylosis.
Volume22 Number 6
Treating maxillomandibular constructions
655
Fig. 4. The patient developed a unilateral fibrous ankylosis from use of forceps during obstetrical procedures. Left, the amount of opening before treatment. Right, the restorations with springs attached. Center, the amount of opening after treatment.
T r e a t m e n t , by m e a n s of a p p l y i n g pressure to create opening, must be c o n t i n u e d for several months. After surgical t r e a t m e n t to free the m o v 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, the function of the m e c h a n i c a l o p e n i n g m e c h a n i s m is t h a t of m o d e l i n g the new a r t i c u l a r surfaces of the joint, strengthening of the m a n d i b u l a r muscles which h a d a t r o p h i e d , a n d a v o i d i n g a reccurrence of the lesion. 7 T h e results of using m e c h a n o t h e r a p y for m a n d i b u l a r constriction of joint origin are seen in Fig. 4.
SUMMARY M a x i l l o m a n d i b u l a r constrictions are classified as muscular, cicatricial, or articular (joint) in origin. T h e n a t u r e of the t r e a t m e n t r e q u i r e d for these three forms was discussed. T h e m e t h o d of use of m e c h a n o t h e r a p y in t r e a t m e n t of m a x i l l o m a n d i b u l a r constrictions was described.
References 1. Fonseca, E. Pi: Constric~o Mandibular, Rev. Ass. Paul. Cir. Dent., S~o Paulo 13: 297-316, 1959. 2. Fonseca, E. P.: Trismo, Rev. Bras. Odont., Rio de Janeiro 16: 313-319, 1958. 3. Newlands, C.: Diatermia, ed. 2, Rio de Janeiro, 1946, Cientifica, p. 52. 4. Parker, D. B.: Synopsis of Traumatic Injuries of the Face and Jaws, St. Louis, 1942, The C. V. Mosby Company, p. 206. 5. Fonseca, E. P.: Artrites Agudas Temporo-Mandibulares, Rev. Ass. Paul. Cir_ Dent., S+io Paulo 12: 222-229, 1958.
656
Fonseca
j. Pros. Dent.
December, 1969
G. Fry, W. K., and Ward, T.: The Dental Treatment of Maxillo-facial Injuries, ed. 2, Springfield, Ill., 1956, Charles C Thomas, Publisher, p. 315. 7. Dufourmentel, L.: Chirurgie de l'articulation temporo-maxillaire, Paris, 1929, Masson et Cie, p. 135. UNIVERSITY OF SAO PAULO FACULTY OF DENTISTRY C. POSTAL 8216 S~o PAULO, BRAZIL