Semenov K.A. (Candidate of
Medical Sciences), Prof. Drohomyretska M.S. (Doctor of Medical Sciences)
The State Establishment “
of the Ministry of Health of
Department of Dentistry,
Faculty of Postgraduate Education.
STAGES OF
TREATMENT OF A PATIENT WITH CHRONIC TRAUMATIC ARTHRITIS OF TEMPOROMANDIBULAR
JOINT
Abstract
Clinical example of treatment of a patient with chronic traumatic arthritis,
which arose as a result of disorder in the occlusal relationships of the teeth
of the upper and lower jaws, is a subject of consideration.
Treatment and monitoring of the patient were carried out for three years
and included medical, surgical, therapeutic, as well as orthopedic stages, which
contributed to the elimination of pain in the temporomandibular joint and
restoration of occlusal relationships in dentitions. Treatment measures were
aimed at normalization of functional activity in the dentofacial apparatus by restoration
of uniform distribution of occlusal loads.
Keywords: Patient
treatment, chronic traumatic arthritis of
temporomandibular joint.
In recent years, the number of patients with disorders of the
temporomandibular joint (TMJ) has increased. The experts’ interest in this
pathology remains quite high, since many aspects of this problem still remain
controversial and insufficiently studied. The most common pathologies of the TMJ
are arthritis, arthrosis and musculo-articular dysfunction [Timofeev A. A., Maksimcha
S.V., Novinskyi V.P. 2012, Margunska V.A., Liudchik T.B. 2012]. [6,7]
Temporomandibular joint is a paired structure that works synchronously. Uneven
loading of the moving section of the masticatory apparatus is considered one of
the main factors of development of the TMJ dysfunction.
There are many clinical, radiographic and myographic studies, indicating
that an important role in the etiology of this disorder is played by asymmetric
contacts of antagonist teeth, which result in asymmetric function of the
muscles of the masticatory apparatus and the TMJ. [1,4,8]
Emergence of disorders in the TMJ rarely occurs in a
sudden manner, with the exception of acute trauma cases (such as hitting the
periarticular area, falling on the chin, rapid
maximum opening of the mouth). There is a certain dependence of a chronic
overload of the muscle group in cases of constrained unilateral chewing, malocclusion,
partial secondary adentium and long period of eruption of wisdom teeth. As a
result, muscle hypertrophy occurs in the working side, which causes persistent
dysfunction of the joint. The main symptoms in this case may include clacking
in the TMJ, jamming when moving the lower jaw, fatigue of muscles during
chewing, impossibility of biting off, teeth closing disorder and arthralgia [Abolmasov N.G., Riabokon Y.N., 2006; Y. Ide, Nakazawa
K., Khvatova V.A., 2001, Shuvalov S.M., Silin À.V., Mirza R.À., 2013; Mikheeva I.V.
2012; Wang Y. Edwin, Fleisher A. Kenneth, 2008]. [5, 6, 7, 8].
Emotional, physical tension and occlusive disharmony
are the main causes of disorders in the functional balance of the masticatory
apparatus and adaptive ability of the body.
As a result, there occur such clinical symptoms as
pain, tension and fatigue of the muscles, snapping and limited motility in the
temporomandibular joint, painful symptoms in the ear area, abrasion and decay
of the teeth as well as significant pressure on periodontium [1, 3, 4].
Treatment of motor dysfunction of the masticatory
system is aimed to restore its normal functionality, as well as to relieve a
patient from of his pain and other symptoms. In order to achieve this purpose,
it is necessary to adhere to the following principles:
1. Reproduction of the correct intraarticular
relationships in the TMJ, i.e. restoring the correct positioning of the
articular heads in the lower jaw as well as articular discs in the TMJ with the
maximum intercammonial contact of the teeth.
2. Restoration of normal or adapted occlusion, as well as
its stabilization by reproducing the continuity of the dentition.
3. Restoring the correct muscle function of the
masticatory apparatus. [4]
Purpose of our work. To consider a
clinical example of treatment of a patient with chronic traumatic (Occlusal)
arthritis in the temporomandibular joint.
Materials and methods of research.
Female patient G.,
born in 1983 (33 y.o.) complained about pain in the right TMJ and having difficulty
with mouth opening. The pain in the right TMJ intensified when chewing food. Concerns
about the joint appeared six months ago and at the beginning were of a repeated
nature. Currently, limitation in jaw movement and discomfort while eating
became permanent.
Patient G. underwent
a visual inspection, which revealed an asymmetry of her face due to increase in
the volume of chewing muscle on the left side of the face. Examination of the
oral cavity was difficult to carry out due to the limitation of the movement of
the lower jaw: the amplitude of mouth opening was about one and a half
centimeters. When palpating the TMJ area at the right, the patient felt
discomfort at rest and pain when moving the lower jaw.
Patient G. was
recommended to pass a “2D examination” – panoramic radiography.
When analyzing
panoramic radiography, the following was detected: Included defect of the lower
jaw in the area of 45–48 teeth, chronic periodontitis and complete destruction
of the crown part of the 45th tooth, dystopia and retention in the
48th tooth, crowding of the teeth at the frontal area of the lower
jaw, absence of the 13th tooth, disorder of occlusal relationships
of the teeth in the upper and lower jaws; as well as narrowing of the joint
space on the right, asymmetrical arrangement of the joint heads in the left and
right sides, anatomical difference in the size of TMJ heads at the left and
right sides.
On the basis of
complaints and analysis of panoramic radiography patient G. was diagnosed with
the right-sided chronic traumatic (occlusive) arthritis of the TMJ.
In order to relieve
pain syndrome and restore the motility of the lower jaw the following treatment
was prescribed:
-
Sinarta or (Dona) 1 ampoule + included solvent, intramuscularly, 3 times a week
during 4 weeks, in the morning after eating;
-
Incena 10 drops 3 times a
day, 1 hour after eating, 30 days;
-
Chondroxide (gel). Apply on skin in the area of
joints 2 times a day, 30 days;
- Persen 1 pill 2 times a day, 30 days.
Rational
nutrition:
Technique of food introduction into the oral cavity
with diseases of the temporomandibular joint is as follows: the patient is
allowed to eat the usual food, but at the same time laying it into the mouth in
small uniform pieces, to avoid overloading the ligament apparatus of the joint
when opening the mouth. The obligatory condition is not to use the usual hand
when doing so. For example: if the person is right handed, then he / she should
do it with his / her left hand, and if the person is left-handed, then he / she
should do it with his / her right hand. At this point, a knife and fork are
there to help: knife makes small comfortable pieces of food, and fork is there
to introduce them into the oral cavity according to the etiquette. When fork is
brought to the mouth with an unusual hand, an unconditioned reflex activates, due
to which the mouth opens parallel to the median line of the body and thus a
more uniform load distribution over the muscle and ligament components of the
temporomandibular joint occurs. Coordination of movements in the human body is
carried out by concerted action of the cortex of the cerebral hemispheres, cerebellum
and vestibular apparatus. The leading organ of coordination of movements is the
cerebellum, which regulates muscle tone as well. [2] When a piece of food is brought to the mouth with an
unusual hand there occurs a synchronization of the muscular component of the
maxillofacial apparatus, as the hand tends to the tip of the nose ( finger-nose test) [2]. If liquid food is
taken, then a dessert spoon is required; it is introduced into the oral cavity
in the usual way, but at the same time a patient should try not to open his /
her mouth too much. When food is brought into the mouth by hand (bread, fruits,
slices of vegetables, seeds, nuts, etc.), it is necessary to make small
comfortable pieces and introduce them with an unusual hand, trying to
distribute them evenly across the left and right sides of the dentoalveolar apparatus
when chewing.
A month after the symptomatic treatment and the implementation
of recommendations on how to eat food, a re-examination was recommended to
patient G. in order to design a diagnostic model and a plan fro dental
treatment aimed at the restoration of the integrity of the dentition and to
create conditions for even distribution chewing pressure in the dentoalveolar apparatus.
Results
and
discussion
A month after the symptomatic treatment and following
the recommendations on the peculiarities of nutrition the condition of patient
G. got normalized, painful seizures in the TMJ area began to appear less often
and with a lower intensity of manifestation, the amplitude of mouth opening was
A diagnostic model was designed for the analysis of
occlusal interrelations of the teeth in the upper and lower jaws.
Patient G. was recommended an oral dental sanitation, which
included surgical, therapeutic and orthopedic aspects, aimed at restoring the
integrity of dentition and stabilization of the occlusion height. Specifically:
Removal of a dystopic and impacted tooth 48, removal of a broken tooth 45 with
chronic periodontitis, Implant placement in the area of 45 – 47 teeth; endodontic
training of the teeth 16, 25, 26, 35, 36, 37 for their subsequent use in
orthopedic normalization of occlusal relationship between upper and lower jaw
teeth with stabilization of the occlusion height. After the treatment,
panoramic radiography and scheduled examinations 2 times a year are recommended.
At the moment, patient G. feels satisfactory, does not
complain about the TMJ, food intake and movement of the lower jaw when talking
and chewing do not cause pain or discomfort.
The patient is warned that at the maximum opening of
the oral cavity pain and dysfunction of the TMJ may occur. Therefore, she is
recommended to open her mouth within a comfortable distance, which causes no
painful sensations.
Currently there is still no universal treatment method
or a perfect scheme, used for diseases of the temporomandibular joint. Complex
approach to the problem of pathology of the temporomandibular joint taking into
account all the factors, that lead to disorders in the functioning of the joint,
allows achieving stabilization in the development of this pathology and
alleviating the patient’s condition during periods of exacerbation.
Conclusions
1.
Making
a correct diagnosis taking into account etiological factors in case of
pathology of the temporomandibular joint allows choosing the most rational
method of treatment and contributes to the long-term remission of the disease.
2. Detection of abnormalities and normalization of
occlusal relationships of teeth in the dentoalveolar system is the main task in
the treatment of temporomandibular joint diseases.
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