The steps of treating a patient with chronic traumatic arthritis of the temporomandibular joint.

Semenov К.А., Stepanova S.V., Fesenko V.I., Ignatenko S.P.*

The State Institution “Dnipropetrovsk Medical Academy of HM Ukraine”

The Municipal Institution “Dniprodzerzhinska Dental Clinic ”DRC”*

Chronic arthritis - inflammation of the temporomandibular joint (TMJ), flowingon the background of the destructive changes in the bony structures of the temporomandibular joint [2,3,4,5].

Chronic arthritis is characterized by moderately severe pain in the TMJ, often triggered by hypothermia and developed after a lengthy speech load or during a meal (in case of solid food). The following is also noted: stiffness in the joint in the morning and at the end of the day, stiffness when chewing or talking. Limitation of mouth opening is observed, mainly in the period of exacerbation. Radiographs reveal areas of narrowing or widening of the joint space, the centers of osteoporosis and bone destruction of TMJ joint elements [4].

Abnormalities in the dentition are the starting point in the development of TMJ arthritis. Painful TMJ dysfunction is the main reason of chronic arthritis. A.Mirza explains the pathogenesis of pain dysfunction as follows [4]. In cases when during clamping dental arches individual teeth or areas of the occlusal surface come into contact before the others (premature contacts) barriers occur for clamping other teeth [1,5]. This can lead to a shift of the lower jaw in a forced position when multiple contacts are achieved at the cost of violation of coordinated functions of the masticatory muscles and changing the position of the articular heads. This leads to disruption of normal bilateral function of the masticatory muscles and temporomandibular joint elements and clinically causes painful dysfunction. Reflexively the function of masticatory muscles changes, the process of chewing rebuilds, which leads to microtraumas of joint elements and disturbance of their trophicity.

Clinical studies conducted by A. Mirza proved that with the ongoing changes in the relative position of the articular head, holes and disk the functional load is redistributed to the various sections of the joints. In areas where the load is increased, there is compression of the soft tissues, in other areas with stretches - distraction. The result is the formation of cracks, perforation, ruptures of the disc and articular cartilage, articular ligament sprains, dislocation of the diosk, trophic changes in the joint.

Consider a clinical example: the patient K. born 1989 complained on difficulties in opening the mouth (mouth opening distance was 1.5 cm). Upon visual inspection a slight asymmetry of the face on the right side was spotted. The cause was the hypertrophy of the masseter muscle, which is a characteristic of one-side chewing.

It was recommended for Patient K to do the panoramic radiography. According to the panoramic radiography and examination of dentition the following was found: changes in the shape and structure of the head of the TMJ on the left, dystopia of teeth 18 and 28, lack of space for impacted teeth 48 and 38, malocclusion in the frontal area due to reduced lower jaw. The bite was deep and prognathic (second class first subclass classification Engle). Teeth examination revealed: photopolymer restoration of teeth 17, 16, 26, 27, 36, 35, 45, 46 and 46, and endodontic treatment of a tooth 46. Established that a violation of occlusal relationship of the teeth of the upper and lower jaw, the violation of a uniform distribution of masticatory forces in the distal parts of the dentition (Fig. 1).

Based on complaints, and clinical and radiographic examination the arthritis on the left TMJ was diagnosed.

Figure 1 Panoramic radiography of patient K prior to treatment in 2008

Examination and treatment of patient K. went on for two years. Therapeutic measures have been divided into five stages, which include: medical therapy, surgical sanitation - removal of dystopic teeth, orthodontic treatment, therapeutic reorganization and orthopedic stabilization of the bite height. In the early stages of treatment a medical therapy was held in order to relieve inflammation and restore the function of the TMJ. In the scheme we developed the following products were included:

1. Restructa pro injectione C - 1 shot (i.m.), after 2 days, 2 ml syringe. 5 weeks

2. Dona - 1 amp. + Supplied solvent, i.m., 3 times a week for 4 weeks

3. Hondroksid (gel) - Lubricate the skin in the region of the joints 2 times a day.

4. Persen - 1 tab. 2 times a day.

Two month drug therapy restored the full opening of the mouth and eased movements in the left TMJ.

In the second phase of treatment, patient K was encouraged to get removed dystopic teeth 18 and 28. After surgery and analysis of diagnostic models one year orthodontic treatment was recommended.

In order to stabilize the height of occlusion after orthodontic treatment the following was recommended: therapeutic rehabilitation in the dentition, orthodontic treatment, which consisted of a counter-crowns on teeth 16 and 46, 26 and 36, the removal of impacted teeth 48 and 38 (Fig. 2).

Figure 2 Panoramic radiography of patient K after orthodontic and orthopedic treatment in 2010

At the moment, the patient K feels well, no complaints about TMJ. In case of future painful phenomena in the TMJ patient K was advised to use the standard glenoid kappa for a month for 3 hours a day.

Conclusions

1. There is no universal method or ideal scheme applied to treat the diseases of the temporomandibular joint yet. An integrated approach to pathology of the temporomandibular joint that takes into account all the factors contributing to the functional disruption of the joint allows to stabilize the development of this disease and relieve the patient's condition during periods of exacerbation.

2. Accurate diagnosis taking into account the etiological factors in the pathology of the temporomandibular joint allows to select the most efficient method of treatment and contributes to long-term remission of the disease.

3. Detection of infringements and the normalization of the occlusal relationship of the teeth in the dentition is a major challenge in the treatment of pathologies of the temporomandibular joint.

References

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