Other Pertinent Research

Ireland VE: The Problem of "The Clicking Jaw." Proceedings of the Royal Society of Medicine 1951;44:363-372

ABSTRACT: It is not many years since the treatment of lesions of the temporomandibular joint was regarded as the exclusive province of general and orthopaedic surgeons. A growing appreciation in recent years of the importance of dental factors in the etiology of many of these conditions is at least resulting in the direction of these cases to the dental surgeons. In many of the American publications on this subject the emphasis has been on the auditory symptoms which are believed to result from lesions of the temporomandibular joint. In my experiences cases in which there are auditory symptoms are rare. The only cases encountered so far have been undoubted examples of otosclerosis. The purpose of this paper is to consider more closely the symptoms which definitely accompany disorders of the temporomandibular joint, in an endeavour to show the mechanism of their production and indicate a rational approach to their prevention and treatment. Anterior repositioning appliance therapy is described and the positive clinical results that were achieved.

Brooke RI, Leeds LDS, Grainger RM. Long-term Prognosis for the Clicking Jaw. Oral Surgery Oral Medicine Oral Pathology June 1988;65:668-670

ABSTRACT: Ninety-four patients who complained of clicking of the temporomandibular joint not associated with pain were followed up for varying lengths of time. Analysis of the follow-up indicates that approximately 70% of the patients who have a painless, clicking temporomandibular joint will eventually have pain and that the use of a nonrepositioning occlusal splint does not lessen the likelihood of pain ensuing.

Lundh H, Westesson PL, Jisander S, Eriksson L: Disk-repositioning Onlays in the Treatment of Temporomandibular Joint Disk Displacement: Comparison with a Flat Occlusal Splint and with No Treatment. Oral Surgery Oral Medicine Oral Pathology August 1988;66:155-162

ABSTRACT: Sixty-three patients with an arthrographic diagnosis of disk displacement with reduction were randomly assigned to three treatment groups: (1) onlays to maintain disk repositioning, (2) flat occlusal splint, or (3) untreated controls. Guidance for construction of the disk-repositioning onlays was established during arthrography to obtain a recaptured disk position relative to the condyle. The onlays were cemented to the teeth and maintained the new intercuspal position anteriorly and inferiorly. The flat occlusal splint was used at night only and was adjusted to maintain a maximal occlusal contact in centric relation and centric occlusion. Clinical examinations were performed before and after 6 months of treatment. The disk-repositioning onlays improved joint function and reduced joint and muscle pain when compared with the flat occlusal splint and with nontreatment. The signs and symptoms in the flat occlusal splint group were no different from those in the control group.

Lundh H, Westesson PL: Long-term Follow-up After Occlusal Treatment to Correct Abnormal Temporomandibular Joint Disk Position. Oral Surgery Oral Medicine Oral Pathology January 1989;67:2-10

ABSTRACT: Fifteen patients with temporomandibular joint disk displacement in whom a normal condyle-disk relationship could be established were treated with occlusal changes to maintain the disk in a recaptured position. Occlusal changes were achieved by prosthodontics in 11 patients and by orthodontics in four patients. Follow-up after about 3 years showed that joint function was improved, intensity of pain was reduced, and joint and muscle tenderness were less frequent than before treatment. Intermittent locking, use of analgesics, sleep disturbances, and absence from work because of temporomandibular joint symptoms were also less frequent. Radiographic examination performed in 11 patients at follow-up demonstrated anteroinferior condylar position in the majority of patients, but only minor hard tissue changes. Arthrography showed the disk to be in a correct position relative to the condyle in 82% (9 of 11) of the patients. These results suggest that permanent change of the occlusion with the objective of eliminating abnormal disk position may be effective treatment for disk displacement when conventional methods of treatment have failed to alleviate the symptoms. The extent of dental treatment needed to maintain the disk in a correct position should, however, be considered relative to the severity of the symptoms.

Paesani D, Westesson PL, Hatala MP, Tallents RH, Brooks SL: Accuracy of Clinical Diagnosis for TMJ Internal Derangement and Arthrosis. Oral Surgery Oral Medicine Oral Pathology March 1992;73:360-3

ABSTRACT: This study investigated the accuracy of clinical examination in determining the status of the temporomandibular joint with respect to internal derangement and arthrosis. A series of 110 patients was given standard clinical examinations followed by bilateral imaging with arthrography and/or magnetic resonance imaging. There was agreement between the clinical diagnosis and the imaging finding in 95 joints (43%). In the other 125 joints (57%), the clinical diagnosis did not agree with imaging findings. There were false-positive clinical diagnoses in 39 joints and false-negative clinical diagnoses in 31 joints. In the other 55 joints the clinical diagnosis correctly indicated that the joint was abnormal but was incorrect about the stage of abnormality. On the basis of the overall diagnostic accuracy of 43%, it was concluded that a clinical examination is not reliable for determining the status of the joint in patients with signs and symptoms of temporomandibular joint internal derangement.

Schellhas KP, Pollei SR, Wilkes MD: Pediatric Internal Derangements of the Temporomandibular Joint: Effect on Facial Development. American Journal of Orthodontics and Dentofacial Orthopedics January 1993;104:51-9

ABSTRACT: To evaluate the relationship between internal derangement(s) of the temporomandibular joint(s) (TMJ) and disturbed facial skeleton growth (dysmorphogenesis), 128 consecutive children (103 girls, 25 boys), who were 14 years of age or younger and had undergone combined radiographic and magnetic resonance (MR) imaging studies of both TMJs, were retrospectively analyzed. Imaging studies had been performed to investigate suspected TMJ derangement because of symptoms that included, either individually or in various combinations, pain, mechanical TMJ dysfunction, and facial skeleton abnormalities, such as mandibular deficiency (particularly retrognathia) and lower facial (mandibular) asymmetry, manifested by chin deviation from the midline. Of these patients, 112 were found to have at least one internally deranged TMJ on imaging studies; in 85 patients, both TMJs were abnormal. Of the 60 retrognathic patients 56 were found to have TMJ derangement, generally bilateral and often of advanced stage. In cases of lower facial asymmetry, the chin was uniformly deviated toward the smaller or more degenerated TMJ. Both TMJs were normal in 16 patients, most of whom had normal facial structure. We conclude that TMJ derangements are both common in children and may contribute to the development of retrognathia, with or without asymmetry, in many cases.

Freidman MH: Closed Lock, A Survey of 400 Cases. Oral Surgery Oral Medicine Oral Pathology April 1993;75:422-7

ABSTRACT: Four hundred consecutive classic closed lock cases were examined. Of these, 301 were treated. Mandibular range of motion was restored by condylar distraction during jaw opening, anterior, and lateral movements. Mandibular appliances were used to prevent complete closure during healing. Of the 45 males and 355 females examined, almost all reported jaw restrictions, but 38% reported little or no pain. Secondary disorders of temporomandibular joint inflammation, muscle spasm, trigger points, and cervical dysfunction were seen on patients with temporomandibular joint pain. Of the 301 conservatively treated patients, 209 were successfully treated, 55 were moderately successful, and 37 failed. Occlusal factors did not appear as primary etiologic factors. Because all locks were preceded by clicking, treatment is recommended for clicking temporomandibular joints that lock, however briefly, to prevent future locking. Conservative closed lock treatment is successful in many cases.

Sondhi A: Current Concepts in the Orthodontic Management of Patients with TM Disorders. Orthodontic Dialogue, American Association of Orthodontists, Volume Eight, Number Two, Spring 1996

ABSTRACT: Orthodontic Management: Transitioning from Phase I to Phase II Treatment. Once a careful differential diagnosis has been completed, and the temporomandibular disorder stabilized, careful thought should be given to the advisability of orthodontic treatment in the overall management of the patient’s treatment. Orthodontic treatment has been identified as a specific treatment option in the management of occlusal discrepancies in patients with temporomandibular disorders. The patient continues to wear the modified splint until posterior vertical stops are established, at which time the orthotic can be discontinued. It is our experience that once the posterior contacts are established, the patient generally preserves the modified condylar position, and the orthodontic finishing can then be completed in a routine fashion.

Summer JD, Westesson PL: Mandibular Repositioning Can Be Effective in Treatment of Reducing TMJ Disk Displacement. A Long-term Clinical and MR Imaging Follow-up. Journal of Craniomandibular Practice April 1997;15:107-120

ABSTRACT: In order to evaluate the long term clinical and morphologic results of recapture of a displaced TMJ disk, we recalled for follow-up MR imaging 75 patients who had been treated by attempted disk recapture based on pre-treatment MR imaging 1-6 years earlier. The treatment included a day appliance with inclines to guide the mandible into the therapeutic position and a telescopic night appliance which prevented retrusion of the mandible during sleep. Appliance treatment was followed by rebuilding or resurfacing the posterior teeth of one arch to permanently support the mandible in the therapeutic position. After treatment of 115 joints with displaced disks, 52% of the disks were normally positioned, 23% were improved in position, and 25% showed persistent disk displacement. Symptom relief was 92% in patients with normalized (recaptured) disks, 84% in patients with improved disk position, and 49% in patients with persistent disk displacement. Failure to improve disk position occurred in 7% of the joints with anterior disk displacement and in 44% of the joints with a transverse (sideways) component to the displacement. Forty-five percent of the recaptured disks improved in contour. We concluded that anterior mandibular repositioning was effective in the treatment of patients with reducing displaced disks primarily when the disks were displaced only in an anterior direction. This treatment can be recommend in anterior disk displacements if the patient has failed more conservative treatment measures, permanent occlusal reconstruction can be justified, and the patient understands that long-term use of a night appliance may be necessary. Anterior mandibular repositioning appears much less effective in cases with a transverse component to the disk displacement.

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