Comparison of two physiotherapy programmes for rehabilitation after temporomandibular joint arthroscopy

Current thinking in physiotherapy for the management of idiopathic and postsurgical temporomandibular disorders: a narrative review

Temporomandibular disorders (TMDs) are the second most common form of orofacial pain after an odontogenic source. Despite their complex aetiopathology they are considered a musculoskeletal disorder. They can have a significant impact on the quality of life of those suffering from TMDs, but can be treated and managed through a mixture of conservative and surgical approaches. Physiotherapists specialising in musculoskeletal therapy and pain management can offer a variety of techniques to help in the treatment and management of TMDs. In this narrative review the evolution of physiotherapy practice in the United Kingdom will be outlined, along with a discussion about physiotherapeutic theoretical frameworks in the management of musculoskeletal disorders and idiopathic TMDs. Finally, a narrative review will be presented, outlining the literature exploring the use of physiotherapy post TMJ surgery, underpinned by a systematic literature search on the topic. After screening for inclusion in the narrative review, eight articles were included for narrative synthesis. The main findings were that there is a relative paucity of studies looking at the value of physiotherapy post TMJ surgery compared with the treatment of idiopathic TMDs, and there is heterogeneity in the physiotherapy programmes described in the literature, but the addition of physiotherapy post TMJ surgery seems to augment the patient's response to surgery. The article concludes by describing the domestic challenges and opportunities of integrating physiotherapy into TMD management pathways.

Temporomandibular Joint Dysfunctions: A Systematic Review of Treatment Approaches

Temporomandibular disorders (TMDs) encompass a diverse array of conditions affecting both the structure and function of the jaw. The aetiology of TMDs is multifactorial and may arise from muscular and joint disorders, degenerative processes, or a combination of various symptoms. The objective of this review was to analyse the physiotherapy treatment techniques used for the management of temporomandibular disorders. This review also aimed to compare the effectiveness of the differenttreatment methods used and identify the dysfunctions for which physiotherapy interventions are applied as the main treatment. A systematic literature review was conducted using the PubMed, ScienceDirect, Dialnet, and PEDro databases. After applying the inclusion criteria, 15 out of 656 articles were included. The application of different physiotherapy techniques, both alone and in combination, is effective in controlling the primary symptoms of TMD in patients. These symptoms include pain, functionality, and quality of life. The use of physiotherapy as a conservative intervention method for TMDs is supported by sufficient scientific evidence. The combination of different therapies within physiotherapy achieves the best results in treatment. Therapeutic exercise protocols, in combination with manual therapy techniques, are the most commonly utilized method for addressing TMDs and thus provide the best results according to the analysed studies.

Effectiveness of Physical Therapy in Orthognathic Surgery Patients: A Systematic Review of Randomized Controlled Trials

Orthognathic surgery (OS) can present many complications that affect patients' rehabilitation. However, there have been no systematic reviews that assessed the effectiveness of physiotherapy interventions in the postsurgical rehabilitation of OS patients. The aim of this systematic review was to analyze the effectiveness of physiotherapy after OS. The inclusion criteria were randomized clinical trials (RCTs) of patients who underwent OS and who received therapeutic interventions that included any physiotherapy modality. Temporomandibular joint disorders were excluded. After the filtering process, five RCTs were selected from the 1152 initially obtained (two had acceptable methodological quality; three had insufficient methodological quality). The results obtained showed that the effects of the physiotherapy interventions studied in this systematic review on the variables of range of motion, pain, edema and masticatory muscle strength were limited. Only laser therapy and LED showed a moderate level of evidence in the postoperative neurosensory rehabilitation of the inferior alveolar nerve compared with a placebo LED intervention.

Restricted Mouth Opening in Head and Neck Cancer: Etiology, Prevention, and Treatment

Restricted mouth opening or trismus is often encountered in patients with head and neck cancer. The restriction may be the presenting sign of malignancy, a sequela of tumor site or growth, an adverse effect of oncologic treatment, or a first sign of tumoral recurrence. In general, any insult to the temporomandibular joint, masticatory muscles, or their neural innervation may cause limitation in mouth opening. The etiologies leading to trismus are as follows: myospasm secondary to tumor infiltration; reflectory myospasm; radiation-induced myositis and myofibrosis; temporomandibular joint involvement with tumor; unfavorable postsurgical scarring; muscle and joint atrophy secondary to immobilization; pain; jaw fracture and hardware failure; and infection. Preventive measures should be implemented before, during, and after treatment. These measures include identification of high-risk patients, utilization of dose-sculpting radiation techniques whenever possible, performing reconstruction at the same time of resective surgery whenever feasible, and initiating mobilization exercises as early as possible. When trismus develops, treatments are often challenging and disappointing. These include physical therapy, mouth opening appliances, drug therapy, and release surgery. All medical specialties dealing with head and neck cancer should be familiar with the diagnosis and prevention of trismus and make an effort to ensure patients are referred to the appropriate care when needed. Trismus should not be considered a trivial sequela of head and neck cancer.

Does arthroscopic lysis and lavage in subjects with Wilkes III internal derangement reduce pain?

PURPOSE

The aim of this study was to determine the efficacy of arthroscopic lysis and lavage on pain in patients with unilateral Wilkes stage III derangement of the temporomandibular joint. Authors retrospectively evaluated whether the arthroscopic lysis and lavage has an impact on pain decrease in patients with moderate osteoarthritis.

METHODS

Patients with unilateral Wilkes III of temporomandibular joint were included in this study. All patients underwent arthroscopic lysis and lavage (ASC-L), assessed pain before and after the procedure (primary outcome variable), maximal interincisal opening (MIO) was recorded as secondary outcome variable. The patients also subjectively assessed whether they were satisfied with the outcome of the arthroscopy or whether their condition required further interventions. The disc position was evaluated by magnetic resonance imaging (MRI) 24 months after the arthroscopy and compared with the disc position on the MRI prior to the arthroscopy. The R Project for Statistical Computing 3.4.1 and the Gretl Pro programs were used for statistical analysis. In addition to the descriptive statistics methods, the Shapiro-Wilk normality test was used to verify data normality and the two sample t test used to test the hypotheses themselves.

RESULTS

The sample consisted of 62 patients who underwent arthroscopic lysis and lavage (ASC-L) in 2015 and 2016. It included 6 men and 56 women with an average age of 34.37. Pain and MIO were recorded during regular check-ups 1, 3, 6, 12, and 24 months. A therapeutic effect (MIO over 34 mm, VAS score 0-1) was recorded in 69% of cases 24 months after the ASC-L. Nonetheless, the work demonstrated the importance of subjective assessment, as 87% of patients perceived their condition as satisfactory after 24 months and not requiring further intervention, while 8 patients (13%) perceived it as unsatisfactory. Disc reposition 24 months following the ASC-L was recorded in only 44% of patients who assessed their condition as satisfactory. Patients with persistent disc dislocation 24 months after the arthroscopy were older, had a lower average maximal interincisal opening value before the ASC-L and a longer duration of mandibular movement restriction before the ASC-L (evaluated as a statistically significant difference).

CONCLUSION

In this study, the authors confirmed that ASC-L is an effective therapeutic method in patients with WIII, from both clinical and subjective perspectives. This work demonstrated that improvement in patients with Wilkes stage III is not related to disc reposition. Postoperative physiotherapy is an integral component of ASC-L and is reflected in the final results.

Novel guide device for temporomandibular joint arthroscopy

Operative arthroscopy of the temporomandibular joint requires the insertion of an arthroscope and a working cannula. The surgical instruments are introduced into the joint space via the working cannula, and are visualized by the arthroscope. While the insertion of the arthroscope is relatively easy as anatomical landmarks such as the tragus-canthus line aid the surgeon, the insertion of the working cannula requires the use of advanced techniques and demands higher levels of surgical expertise. Following is a description of a novel guide device that enables the surgeon to introduce the working cannula into the desired location relative to the arthroscope, and maintains optimal spatial relations between them throughout the procedure.

Three-Dimensional Orofacial Changes Occurring After Proportional Condylectomy in Patients With Condylar Hyperplasia Type 1B (Unilateral Hemimandibular Elongation)

PURPOSE

To evaluate 3-dimensional orofacial changes that occurred after proportional condylectomy that was not followed by orthognathic surgery in patients with condylar hyperplasia type 1B (unilateral hemimandibular elongation).

MATERIALS AND METHODS

This retrospective analysis used the medical records of 14 skeletally mature patients. Transverse, vertical, and horizontal cephalometric analyses of photographs and radiographs were undertaken. A comparison of preoperative and postoperative measurements was conducted.

RESULTS

After proportional condylectomy, transverse chin position and vertical lip cant improved to various degrees, whereas ramus and condyle height and mandibular lower border discrepancy worsened to different extents. The prominence of the gonial angle of the affected (operated) side increased in all patients after surgery, and this contributed to better symmetry only when the preoperative prominence was small (flat), whereas the opposite occurred when the preoperative prominence was large (bulky). After condylectomy, there was posterior displacement of the pogonion point (setback), which was favorable in cases with a preoperative concave profile and unfavorable in cases with a preoperative convex profile.

CONCLUSION

Proportional condylectomy can successfully arrest the hyperplastic growth of the affected condyle; however, it rarely achieves perfect symmetry of the face. Although it improves some facial features, other facial traits are worsened. Surgeons should have a full understanding of the 3-dimensional changes occurring after proportional condylectomy and should be able to predict, based on preoperative findings, the anticipated improvement or worsening of different facial features.