Temporomandibular joint disc displacement with reduction
Temporomandibular joint disc
displacement with reduction
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abstract
Disc displacement with reduction (DDWR) is one of the most common
intra-articular disorders of the temporomandibular joint (TMJ).
Factors related
to the etiology, progression and treatment of such condition is still a subject
of discussion
we will talk about the treatment of DDWR.
we will talk about the treatment of DDWR.
TTT
DDWR is usually asymptomatic and requires
DDWR is usually asymptomatic and requires
no treatment, since the TMJ structures adapt very well and painlessly to
different disc positions. Yet, long-term studies have shown the favorable
progression of this condition, with no pain and/or jaw locking occurring in
most of the patients
Treatment of DDWR
Clinically, DDWR can be considered in three
ways: (I) as a clinical finding, when the patient has
no complaints and the clicking is identified during
the manual professional TMJ inspection or the disc
displacement is diagnosed by an MRI examination and
only orientations to the patient are sufficient; (II) as
the main patient’s complaint, when the noise motivates
the patient to seek treatment and the treatment
plan should address options to reduce/eliminate
the clicking; (III) when the click is accompanied by
arthralgia and the treatment plan should be focused
on the amelioration of pain.
Treatment of DDWR, especially when the noise is
the complaint, is not an easy task, and for the vast
majority of individuals, an explanation of the situation,
along with avoidance of overloading activities is the
best option. As mentioned above, there is evidence for
a self-limiting tendency to this condition, without any
kind of clinical conduct or treatment.17,58 In absence
of complaints, no treatment is recommended.39 It
is important to remember that there is still no gold
standard treatment for TMJ clicking; thus, when
patients complain about the noises (clicking) and
seek treatment, conservative approaches are always
the first choice.17
Amongst conservative treatments there are:
patient education (such as the explanation about
DDWR and orientation of avoidance of excessive open
mouth), exercises, relaxation techniques, and occlusal
splints.17,59 Au and Klineberg60 (1993), used isokinetic
exercises of the jaw in 22 patients complaining about
TMJ clicking. The exercises included two movement
sequences as follows: (1) jaw opening and closing over
a distance of 15 mm, and (2) moving the jaw to the
left and right over a distance of 5 mm to each side.
Jaw movements were performed against a constant
but moderated resistance provided by the subject’s
hand. After six months of follow-up, the clicking
disappeared in approximately 82% of the patients.
Yoda, et al.61 (2003), also find a clicking reduction on
61.9% TMJ of patients with painless clicking, after
three months of therapeutic exercise (protrusion and
retrusion). Huang, et al.62 (2011), treated 59 patients
with painless clicking with a mandibular stabilization
occlusal splint (hard acrylic). After six months, there
was an elimination of TMJ clicking in 71.2% of cases.
These findings were like those previously found by
Conti, et al.63 (2006), who treated with occlusal
devices 57 patients with a complaint about TMJ pain
and clicking. The patients were divided into three
groups: bilateral balanced occlusal splints; canine
guidance occlusal splints; and, nonoccluding splint.
All subjects had a general improvement on the pain,
though subjects in the occlusal splint groups had better
results than subjects in the nonoccluding splint group.
The frequency of joint noises decreased over time, with
no significant differences among groups. In another
study, Conti, et al.64 (2015) assessed the effectiveness
of the partial use of intraoral devices and counseling
in the management of 60 patients with DDWR and
arthralgia. The patients were equally divided into three
groups: group I wore anterior repositioning occlusal
splints; group II wore NTI-tss devices, and group III
only received counseling for behavioral changes and
self-care. The first two groups also received the same
counseling. At the beginning of the study, all patients
had a TMJ click at least on one side. When joint sounds
(clicking) were investigated after 3 months, a decrease
in frequency for groups I and III were observed. On
the other hand, an increase in frequency for those in
group II was detected, although with no significance.
Even though, there is no direct scientific evidence
that impaired lubrication of TMJ is indeed responsible
for the development of a disc displacement.65
Hyaluronic acid (HA), has been suggested as an
alternative therapeutic agent for the management of
internal TMJ derangements.66 Basterzi, et al.67 (2009),
treated 20 patients with DDWR, with clicking complaint,
with intraarticular hyaluronic acid (HA) injections (at
weekly intervals for 3 weeks). After one year, there was
a significant reduction of joint noises, however, there
was no control group without intervention. Korkmaz,
et al.68 (2016), compared the effectiveness of a single
HA injection, a double HA injection, and splint therapy
for the treatment of DDWR. The results of this study
showed that HA injection and stabilization splinting
are acceptably successful modalities of treatment to
alleviate the clinical signs and symptoms of DDWR
(double HA injection seems to be superior), especially
in reducing TMJ clinking.
Invasive methods should be considered only after
failed attempts at conservative care in what concerns
persistence of complaints,9 and are rarely indicated for
DDWR, when noises are considered. These modalities
comprise TMJ arthrocentesis, arthroscopies and
surgical techniques.17 Surgical procedures always
involve some risks such as extravasation of liquid
to the surrounding tissue, lesion of the facial nerve,
optical lesion, pre-auricular hematoma, arteriovenous
fistula, trans articular perforation, intracranial
perforation, extradural hematoma and post-surgical
intra-articular problems, which justify the clinician’s
caution to recommend any of such procedures as
routine or first treatment choice
Conclusion
DDWR is the most common of the TMJ disc
displacements. It is commonly an asymptomatic
condition and no treatment is usually required,
since the structures in this region may adapt and
the progression is extremely benign for most cases.
Treatment should be done when DDWR is the patient’s
main complaint, and when the noise motivates
the patient to seek treatment and/or the click is
accompanied by pain
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