Mandibular Manipulation Research Articles

Is the positioning guide mandatory for the virtual planning of orthognathic surgery? A randomized double-blind trial.

The aim of this study is to verify the positioning of the condyles in computed tomography (CT) scans of skeletal Class II and Class III patients in virtual surgical planning before orthognathic surgery. The secondary aim is to determine whether occlusal devices are mandatory for performing a CT examination. In this retrospective randomized double-blind study, 42 CT scans were evaluated from patients who had undergone to orthognathic surgery at the University Hospital of the University of São Paulo. Male and female patients between the ages of 25 and 40 were included. The sample consisted of skeletal Class II and III patients. The CTs were randomly selected into centric relation (CR) and maximal intercuspal position (MI). Statistical analysis was performed with R Statistical Package and was considered significant in the case of p <0.0001. A total of 504 measurements were carried out in 42 patients. Three joint spaces on each side were used. No statistically significant difference between the inter- and intraobservers was found for CR and MI. Some scores were performed to avoid the risk of gender bias. No statistically significant value was found between patients in CR and MI after mandibular manipulation. The use of a positioning guide to perform a CT scan prior to virtual planning is not absolutely necessary.

Different methods of determining centric relation – comparison with a digital mandibular motion analyser

BackgroundFinding and registering the maxillary–mandibular jaw relation is crucial in dental practice. Several comparative studies have been conducted to investigate the reproducibility and accuracy of techniques for determining the centric relation (CR) position of the mandible. The aim of our study was to determine which of seven different CR determination methods had the smallest deviation from the theoretical zero with the help of a digital mandibular motion analyser. The chosen theoretical zero position, the maximal intercuspal position (MIP), is the most reproducible and widely used position.MethodsThirty-four volunteers (24 females and 10 males) with a mean (SD) age of 29.1 (± 7.3) years with a negative history of temporomandibular disorder (TMD) participated in the study. A digital mandibular motion analyser was used to register the condylar position after the use of each technique for the determination of CR. The calibration was performed to the maximal intercuspal position (MIP) for each volunteer. The investigated techniques were (A) the gothic arch tracer, (B) the adduction field method, (C) Dawson’s bimanual manipulation, (D) the patient placing the tongue tip on the palatal rugae, (E) the patient placing the tongue tip to the border of the hard and soft palate, (F) the patient actively pulling the chin backwards, and (G) the examiner pushing the patient’s chin back.ResultsThe position of the mandibular condyle was illustrated in a three-dimensional coordinate system, where the origin represented the MIP. Among the seven methods examined, five showed significant deviations compared to the MIP. Among these, two methods resulted in posterior deviation of the condyles. Methods C and E coincided with the MIP in all directions.ConclusionsWithin the limitations of our study, we found that the smallest deviations from our theoretical zero (MIP) among the investigated centric relation determining methods were obtained with the bimanual mandibular manipulation technique derived from Dawson and the placement of the tongue tip on the border of the hard and soft palate (linguomandibular homotrophy theory).

Fratura mandibular em vítima de agressão domiciliar: relato de caso

As a consequence of its prominence on the face, the mandible is one of the bones most susceptible to fractures caused by different etiological agents. Currently, domestic violence has been a considerable factor in the appearance of facial injuries, which are mostly performed by partners of the victims. The aim of this study is to report a case of mandibular fracture caused by domestic violence. Female patient, victim of domestic aggression, attended at the Maxillofacial Service, in Bahia, with extensive submandibular hematoma, facial asymmetry, pain during physical examination and presence of atypical mobility on mandibular manipulation. The Computed Tomography exam evidenced two fracture lines in the mandible. The patient was submitted to surgery for osteosynthesis, uneventfully. Considering that the face is an aesthetic region, manipulation in those structures is an aesthetic and functional challenge, requiring specialized care.

Clinical and magnetic resonance imaging findings in patients with and without improvement after mandibular manipulation and conservative physical therapy for temporomandibular joint disorders

This study compared clinical and magnetic resonance imaging (MRI) findings in patients with anterior disk displacement without reduction (ADDWOR) who improved to anterior disk displacement with reduction (ADDWR) vs. patients who did not improve after mandibular manipulation (MM) and conservative self-administered physical therapy (CSAPT). Of 15 patients diagnosed with ADDWOR by MRI, 7 improved to ADDWR (WOR-WR) and 8 did not improve (WOR-WOR). The clinical and MRI findings before and after therapy were compared in each group. Significant differences between the groups included age, period of awareness of trismus, and maximum mouth opening (MMO). The MRI findings revealed significant differences in the degree of ADD and morphology of the disk and condyle. MMO significantly improved in the WOR-WR group between initial and follow-up visits. Patients who were successfully treated with MM and CSAPT tended to be <30 years old, with a longer period of awareness of trismus, MMO <40 mm, a slight or moderate degree of ADD, no deformity of the disk, and no morphologic change in the condyle. Patients with ADDWOR who are treated with MM and CSAPT require an accurate clinical examination and MRI before treatment.

The Equine Temporomandibular Joint: Comparisons Between Standard and Needle Arthroscopic Examination of Cadaver Specimens and Standing Horses.

Background:Definitive diagnosis of equine temporomandibular joint osteoarthritis (TMJ-OA) may require advanced diagnostic imaging. Arthroscopy is a modern, minimally invasive, diagnostic, and treatment modality. Standing arthroscopic treatment of joint disease is a relatively recent advance in equine surgery, despite which there are few published comparisons between the available arthroscopic systems.ObjectiveTo compare and contrast two arthroscopic systems for assessing the equine temporomandibular joint compartments in cadavers and standing horses.Study designExperimental study.MethodsPhase I involved the assessment of the discotemporal joint (DTJ) and discomandibular (DMJ) joint compartments of both temporomandibular joints (TMJ) of 14 cadaveric equine heads using a caudally placed arthroscopy portal. Joints were initially examined using the needle arthroscope and the results compared to the findings of examination using a 2.5 mm 30° arthroscope system (standard). Three healthy horses were subsequently examined to determine the validity of the procedure in live animals in Phase II.ResultsNeedle and standard arthroscopy, in combination with mandibular manipulation, allowed evaluation of the caudal aspects of both joint compartments of the TMJ in Phase I. However, the extreme margins of the joint were more commonly visualized using standard arthroscopy. Live horses in phase II were restrained in stocks and both the rostral and caudal aspects of the DTJ and DMJ compartments of both TMJs were examined successfully understanding sedation and local analgesia. The use of a modified Guenther speculum allowed the mandible to be manipulated and offset, which facilitated a complete examination of the joint compartments. Despite adverse behavior encountered during the procedure in one horse, no surgical complications ensued.Main LimitationsNot blinded—bias; learning curve.ConclusionsThe needle arthroscope system is a relatively inexpensive diagnostic tool, which can be used to evaluate the TMJ in the absence of advanced diagnostic imaging such as computed tomography or magnetic resonance imaging. However, if arthroscopic treatment is required after advanced imaging and pre-operative diagnosis, superior image quality and ease of manipulation may favor the use of the standard equipment.

Arthroscopic approach and intra-articular anatomy of the equine discomandibular joint compartment of the temporomandibular joint.

To develop an arthroscopic approach to the discomandibular joint (DMJ), the ventral compartment of the temporomandibular joint (TMJ) of the horse. Experimental study. Nine cadaveric equine heads and two live horses. A 2.5-mm 30° arthroscope was used to explore the DMJ after joint distension. The first portal was created caudally, allowing placement of a rostral portal under visual guidance. Nasotracheal intubation of the live horses allowed mandibular manipulation, which is required for complete visualization of the joint. A novel injection technique allowed consistent arthrocentesis of the DMJ. The joint could be completely explored by using both portals and manipulation of the mandible. Variations in the medial joint capsule were observed between horses along with a cyst of the mandibular condyle in one horse. The only complication consisted of damage to the parotid salivary gland, which occurred in three cadaver heads. No communication was found between the joint compartments of the TMJ. Correct portal placement and intraoperative manipulation of the mandible were critical and allowed complete exploration and debridement of the DMJ. Determining the independence of the TMJ joint compartments has clinical ramifications for the diagnosis and treatment of clinical disorders. Most TMJ pathology, notwithstanding sepsis, is identified within the DMJ. Arthroscopic exploration of the DMJ is possible and may help manage these conditions.

Clinical protocol for managing acute disc displacement without reduction: a magnetic resonance imaging evaluation

This study investigated the efficacy of a sequential combination of arthrocentesis, mandibular manipulation, and anterior repositioning splint (ARS) in the management of acute temporomandibular joint (TMJ) disc displacement without reduction (DDwoR). Twenty-one consecutive patients diagnosed with acute DDwoR by Diagnostic Criteria for Temporomandibular Disorders and magnetic resonance imaging (MRI) were recruited and managed with this method. Clinical and MRI data were obtained before and at 1 week after treatment. The disc–condyle relationship was determined by disc–condyle angle measurement. Condyle/disc positions were described as x–y coordinates with the summit of the articular fossa as the coordinate origin. Statistical analyses including independent/paired samples t-tests were conducted; significance was set at P<0.05. Clinical success was observed in 95.2% of patients (20/21) with 22 joints affected by acute DDwoR. After combined treatment and ARS insertion, TMJs with DDwoR showed (a) normal disc–condyle relationships with substantial forward and downward condyle movement and significant disc reduction in closed position, and (b) discs with an intermediate zone located between the condylar head and articular eminence in open position. The combined approach was highly effective in ‘unlocking’ acute TMJ DDwoR and achieving spatial full disc reduction and a normal disc–condyle relationship. The duration of acute DDwoR appears to be critical for success.

Condylar repair and regeneration in adolescents/young adults with early-stage degenerative temporomandibular joint disease: A randomised controlled study.

Anterior repositioning splint (ARS) can facilitate regenerative condylar remodelling. To determine the effect of ARS on osseous condylar changes in adolescents/young adults with early-stage degenerative joint disease (DJD). Sixty-nine patients with early-stage temporomandibular joint (TMJ) DJD based on the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) and cone beam computed tomography (CBCT) imaging were recruited and randomly allocated to two treatment groups: (a) conservative therapy with ARS and (b) conservative therapy without ARS. Subjects with acute TMJ closed-lock had their displaced discs physically reduced by mandibular manipulation prior to ARS therapy. Clinical and CBCT data of 59 patients (86.4% females, mean age 17.95±4.53years, 67 joints) were attained pre- and at 6 or 12months post-treatment. Osseous changes after treatment were categorised into (a) progressed, (b) unchanged, (c) repaired (remodelled without new bone formation) and (d) regenerated (remodelled with new bone formation). Statistical analysis including chi-square test, independent samples t test or Mann-Whitney U test was conducted. About 85.5% of patients (59/69) completed the study, with 28 subjects (32 joints) in the splint group and 31 (35 joints) in the control group. The occurrence of condylar repair and regeneration was significantly higher with ARS (78.1%/[25/32] of joints) when compared to control group (48.6%/[17/35]) (P<0.05). Moreover, condylar regeneration was exclusively observed in 50%/(16/32) of joints with ARS. For the 14 joints in splint group that received physical TMJ closed-lock reduction, 85.7%/(12/14) exhibited condylar regeneration. The splint group (3.1%/[1/32]) also had significantly lower incidence of progressive TMJ degeneration than the control (37.1%/[13/35]) (P<0.001). Condylar repair and regeneration in early-stage TMJ DJD are possible, and ideal spatial disc-condyle relationship appears important. The possibility of restoring TMJ form/structure by ARS therapy presents an attractive area of new basic science and clinical research (Bone defect repair in early osteoarthrosis of temporomandibular joint by joint distraction therapy: A randomized controlled trial/ChiCTR-TRC-14005172).

Efficacy of mandibular manipulation technique for temporomandibular disorders patients with mouth opening limitation: a randomized controlled trial for comparison with improved multimodal therapy

PurposeManual therapy has been used for the treatment of patients with temporomandibular disorders (TMD) with mouth-opening limitations. However, the curative effect of manipulation differs among researchers, and its necessity remains controversial. The purpose of this study was to confirm the efficacy of manipulation using a randomized controlled trial (RCT). MethodsA total of 61 TMD patients who had mouth-opening limitation (upper and lower middle incisor distance ≤35mm) were selected. They were divided into two treatment groups: conventional treatment (n=30) and conventional treatment plus manipulation (n=31). The conventional treatment included two types of self-exercise: cognitive behavioral therapy for bruxism and education. Mouth-opening limitation, orofacial pain, and temporomandibular joint (TMJ) sounds were recorded from baseline to 18 weeks after baseline. These parameters were statistically compared between the two treatment groups by using analysis of variance (ANOVA) and Scheffe’s test to assess mouth opening distance and pain; TMJ sounds were compared using Mann–Whitney U test. ResultsNo statistical difference was observed between the two treatment groups except for mouth-opening limitation after treatment at the first visit. Subgroup analyses, stratified according to the pathological type of TMD, indicated a similar trend. ConclusionsThe efficacy of manipulation seems to be limited, in contrast to our expectations, and improved execution of therapeutic exercises has a similar effect to that of manipulation during long-term observation. The advantage of manipulation was observed only during the first treatment session. The RCT was registered in the University Hospital Medical Information Network in Japan (UMIN-CTR: 000010437).

Clinical effect of mandibular manipulation combined with comprehensive physical therapy for treatment of acute anterior disc displacement without reduction

Clinical effect of mandibular manipulation combined with comprehensive physical therapy for treatment of acute anterior disc displacement without reduction

The Basic Conservative Treatment of Temporomandibular Joint Anterior Disc Displacement Without Reduction--Review.

Temporomandibular joint derangement is acommon disorder of the stomatognathic system. One type of these disorders is disc displacement without reduction with limited mouth opening, characterized by pain in affected TMJ and adecreased range of mouth opening. The natural course of closed lock is self-limiting. However, if there is no significant improvement after 12 weeks of following natural course of disc displacement without reduction, this is an indication that the therapy should be implemented. The article presents areview of the most commonly applied methods of basic conservative closed lock treatment. The most commonly applied methods of closed lock conservative management are: education and counseling, mandibular manipulation, splint therapy, exercise therapy and pharmacotherapy. The first choice method of treatment should be minimally invasive. The surgical management should be considered after unsuccessful conservative therapy. All presented methods of closed lock treatment seem to be effective in decreasing pain and reestablishing physiological range of motion.

Evaluation of condylar position by CBCT after static and dynamic registration in edentulous patients

ObjectivesThe aims of this study are to: compare the condylar position in articular fossa after static and dynamic registration; analyze symmetry between right and left condyles and examine the relationship between articular eminence and condylar position. MethodsTwenty completely edentulous patients were included in this study, after signing a written informed consent. Static registration was obtained by mandibular manipulation and dynamic registration was performed by Gothic Arch Tracing. Patients were submitted to one cone beam in static registration, followed by another with dynamic registration. Radiographic image measurements in lateral and frontal cuts were made. ResultsNo statistically significant differences between the two methods were found. In dynamic registration all the distances were smaller, more consistent and equidistant. Condyles stayed in a closer position to the articular fossa and in a centred position. For this registration a higher symmetry between left and right condyle exists, revealed by homogeneous results. Static registration had a higher heterogeneity of results, due to the fact that it is dependent upon a number of factors. ConclusionsDynamic registration seems a reliable and an accurate method to use. With the higher condylar symmetry and the centred position in articular fossa, it seems that this registration reproduces a physiologic condylar position.

Timing interventions in relation to temporomandibular joint closed lock duration: a systematic review of ‘locking duration’

Temporomandibular joint (TMJ) 'closed lock' (CL) is a clinical condition causing TMJ pain and limited mouth opening (painful locking) that is mostly attributed to disc displacement without reduction (DDwoR), or less commonly to anchored disc phenomenon (ADP). Both conditions are described clinically as CL that can be 'acute' or 'chronic' depending on the duration of locking. There is, however, no consensus about the duration of locking that defines the acute state and its effect on the success of interventions. This review paper, therefore, aims to provide: (i) a narrative review of the pathophysiological need for early intervention in DDwoR and the clinical implications of acute/chronic CL stages on the management pathway; (ii) a systematic review investigating the effects of locking duration on the success of interventions for CL management. Electronic and manual searches until mid-August 2013 were conducted for English-language studies of any design investigating the effects of non-surgical and surgical interventions for acute or chronic CL (DDwoR or ADP). A total of 626 records were identified, and 113 studies were included. Data extraction and quality assessment were completed for all included studies. Included studies were, however, heterogeneous and mostly of poor-quality leading to contradictory and inconsistent evidence on the effect of the duration of locking on treatment outcomes. Future high-quality trials investigating the effect of CL duration on treatment outcome are needed. At present, early intervention by 'unlock' mandibular manipulation seems to be the most practical and realistic approach that can be attempted first in every CL patient as an initial diagnostic/therapeutic approach.

Mandibular Manipulation for the Treatment of Temporomandibular Disorder

The aim of this study was to conduct a systematic review to identify the randomized clinical studies that had investigated the following research question: Is the mandibular manipulation technique an effective and safe technique for the treatment of the temporomandibular joint disk displacement without reduction? The systematic search was conducted in the electronic databases: PubMed (Medical Publications), LILACS (Latin American and Caribbean Literature in Health Sciences), EMBASE (Excerpta Medica Database), PEDro (Physiotherapy Evidence Database), BBO (Brazilian Library of Odontology), CENTRAL (Library Cochrane), and SciELO (Scientific Electronic Library Online). The abstracts of presentations in physical therapy meetings were manually selected, and the articles of the ones that meet the requirements were investigated. No language restrictions were considered. Only randomized and controlled clinical studies were included. Two studies of medium quality fulfilled all the inclusion criteria. There is no sufficient evidence to support the effectiveness of the mandibular manipulation therapy, and therefore its use remains questionable. Being minimally invasive, this therapy is attractive as an initial approach, especially considering the cost of the alternative approaches. The analysis of the results suggests that additional high-quality randomized clinical trials are necessary on the topic, and they should focus on methods for data randomization and allocation, on clearly defined outcomes, on a priori calculated sample size, and on an adequate follow-up strategy.

Residents' journal review

Residents' journal review

Condylar remodeling accompanying splint therapy: a cone-beam computerized tomography study of patients with temporomandibular joint disk displacement

The aim of this study was to evaluate osseous changes accompanying anterior repositioning splint (ARS) therapy in patients with temporomandibular joint disk displacement. Cone-beam computerized tomography (CBCT) data of 36 patients with intermittent or permanent closed-lock were used; 23 patients with permanent closed-lock had their displaced disks physically reduced by mandibular manipulation before ARS therapy. CBCT was performed before and ≈ 6 months after ARS therapy. The presence and location of "double contour" images suggesting condylar bone remodeling were statistically analyzed. The "double contour" images after ARS therapy were observed in ≈ 80% of patients, more frequently in joints with signs of displaced disks. The "double contour" appeared more often on the posterior bevel as well as the medial and middle part of condyles (P < .01). ARS therapy can facilitate regenerative remodeling of condyles. CBCT is a useful tool for monitoring osseous changes in condyles.

Is there a role for arthrocentesis in recapturing the displaced disc in patients with closed lock of the temporomandibular joint?

The aim of this study was to evaluate the effectiveness of arthrocentesis in releasing acute and chronic closed lock of the temporomandibular joint, improving function, reducing pain and recapturing the displaced disc. We performed arthrocentesis and mandibular manipulation (MM) as an initial treatment in 33 patients (unilateral involvement) with a variable duration of closed lock and magnetic resonance imaging (MRI) evidence of anterior disc displacement without reduction (ADDWR). Duration of locking ranged from 1 week to 2 years. After the procedure, soft diet, physiotherapy, and an interocclusal appliance (IA) were prescribed. Postoperative MRI images were obtained at 1 month. A clinical examination with analysis of maximal mouth opening (MMO), a visual analog scale (VAS), and a self-administered questionnaire were used for evaluation of pain, jaw dysfunction, and activities of daily living (ADL). The follow-up period was 1 year. At 1-year follow-up, MMO had increased significantly from a mean of 24.7 +/- 5.9 mm to 39.6 +/- 6.2 mm (P < .05). Functional improvement was associated with a significant reduction in VAS (from 6.2 +/- 2.3 to 2.8 +/- 3.4), pain (from 11.7 +/- 7.1 to 4 +/- 3.8), dysfunction (from 8.6 +/- 4.9 to 3.2 +/- 2.8), and ADL scores (from 13.9 +/- 12 to 4.4 +/- 5), with P < .05. The overall success rate was 72.7%; it was higher in acute patients (87.5%) than in chronic patients (68.0%). The disc was recaptured (the disc was interposed between the condyle and the eminence on closed and open MRI images) in 3 cases in which the duration of locking was less than 1 month (acute patients). The results indicate that arthrocentesis, in association with MM and IA, could be effective in improving function and reducing pain in patients with closed lock. Better results were obtained in terms of MMO, VAS, and questionnaire scores in acute closed lock cases than in chronic ones. Recapturing the anteriorly displaced disc is possible only in patients with acute closed lock.

Extraluminal tissue pressure: what does it mean?

In this issue of the Journal of Applied Physiology , Kairaitis et al. ([9][1]) examine the control of pharyngeal extraluminal tissue pressure by mandibular advancement and jaw position. Utilizing a novel approach for measuring peripharyngeal tissue pressures, they demonstrated that mandibular

Simple Manipulation Therapy for Temporomandibular joint Internal Derangement with Closed Lock

Objective: To evaluate the effectiveness of immediate simple mandibular manipulation therapy at initial presentation of patients with chronic temporomandibular joint closed lock.Patients and Methods: 305 consecutive patients (76 men and 229 women; age range, 18 to 74 years) were selected based on a clinical diagnosis of temporomandibular joint disc displacement without reduction, otherwise known as closed lock. Patients were randomly divided into 2 groups of 204 study patients who received immediate jaw manipulation and non-steroidal anti-inflammatory drug therapy and 101 controls who received drug therapy only. Treatment success was determined by set criteria for closed lock that included achievement of 36 mm mouth opening and 6 mm lateral excursion.Results: For patients undergoing manipulation in the 18 to 19 years age range, the success rate for treatment given on the day of diagnosis was 100.0%. In the 20 to 49 years age range, the success rate for manipulation was 87.5%, and in the 50 to 59 years age range, the success rate was 78.2%.Treatment given within 1 to 2 days of the onset of closed lock symptoms resulted in 100.0% success and was more than 90.0% if treatment was initiated within 3 weeks of the onset of symptoms. Treatment by manipulation was unsuccessful if given 2 months or more after the onset of symptoms.Conclusions: Simple jaw manipulation for the treatment of closed lock can be useful if applied early after the onset of symptoms, especially for younger patients. Lower success rates correlated with increasing age, and the likelihood of treatment success tended to decrease when the interval between the onset of symptoms and initial treatment increased.

Longitudinal MRI follow-up of temporomandibular joint internal derangement with closed lock after successful disk reduction with mandibular manipulation

We present a case of bilateral temporomandibular joint (TMJ) internal derangement with closed lock, which was followed over 11 years using serial MRI after successful disk reduction with mandibular manipulation. MRI of the bilateral TMJs before and after mandibular manipulation followed by anterior repositioning splint showed that the disk improved from non-reducible to reducible, and that the reducing disk persisted for 11 years, although minor changes in configuration and position of the disk occurred. These MRI findings suggest that non-surgical treatment with successful mandibular manipulation prevents progressive changes in the TMJ. This case report complements observations regarding the longitudinal course of TMJ internal derangement with closed lock after non-surgical treatment.