Temporomandibular joint disorders in patients referred for third molar extraction

The Role of Supraerupted and Distoverted Maxillary Third Molars in the Treatment of Temporomandibular Disorder: A Randomised Controlled Trial

Objective Temporomandibular disorder (TMD) is a multifactorial disease that is classified into muscular and joint disorders. The etiology of TMD is unknown but it is related to various factors such as bruxism, uncorrected high dental restorations, and occlusal prematurities. This study aims to provide treatment modalities for TMD patients with supraerupted and/or distoverted maxillary third molars that have premature contact with the opposing arch. Methods A total of 430 subjects diagnosed with TMD were included in the study and randomized into study and control groups based on their treatment needs. A detailed case history was taken, and findings of intra and extra oral examination were recorded along with other investigations such as study model analysis, orthopantomogram (OPG), cone-beam computed tomography (CBCT), and MRI. The multiphase treatment included counseling in phase I, extraction in phase II (only for the study group), and oral appliance in the third phase. The final phase involved the restoration of edentulous areas or reduced vertical dimension. Results Extraction of supraerupted and/or distoverted maxillary third molars in the study group during phase II showed a 96% reduction in TMD when compared to the control group who did not undergo extraction. Conclusion TMD is a repetitive motion disorder, and the success of treatment relies on the elimination of causative factors, the type of appliance used, and the establishment of ideal occlusion. This study suggests that the extraction of supraerupted and/or distoverted maxillary third molars is a prerequisite for treating TMD patients.

Temporomandibular joint arthrocentesis: a single-center experience and review of the literature

BACKGROUND

The aim of this paper was to report our experience and to review the literature of arthrocentesis focusing on protocols and results.

METHODS

Arthrocentesis with supplemental hyaluronic acid was performed in patients with TMDs between January 2017 and December 2020 at the Division of Maxillofacial Surgery. The maximum interincisal opening (MIO) and pain score were recorded preoperatively (T0), 2 months postoperatively (T1), and 6 months postoperatively (T2). A literature search was performed to analyze the same parameters in patients with TMDs. Patient demographic, characteristics and treatment protocols used were also recorded.

RESULTS

This retrospective analysis enrolled 45 patients. Twenty-two patients (20 females, 2 males) with mean age of 37.13 years with internal derangement were included in study group A. Study group B included 23 patients with degenerative joint disease (19 females and 4 males) with mean age of 55.73 years. The outcomes trend of MIO and pain during the follow-up period showed a gradual improvement. Fifty articles meeting the proposed scientific criteria were selected for the literature revision. A range of clinical and procedural variables were analyzed by grouping the studies into two broad categories based on the diagnosis of TMD.

CONCLUSIONS

Based on our experience and on the basis of the most accredited scientific studies in the literature, intra-articular injections of HA are beneficial for the improvement of the pain and/or functional symptoms of TMDs.

Mischievous mandibular third molars camouflaging temporomandibular joint disorders

Objectives

The aim of this study was to observe the relationship between impacted mandibular third molars and development of temporomandibular joint (TMJ) disorders. Knowledge of the factors that have an adverse effect on the TMJ is necessary for proper diagnosis, treatment, and prognosis of TMJ disorders.

Materials and Methods

The study was performed on 80 patients aged between 20 and 60 years with impacted mandibular third molars, over a period of two months. The patients were examined clinically and radiologically to determine the type of impaction and detect the associated TMJ symptoms or disorders.

Results

In the 80 patients, 63.8% (51/80) of TMJ disorders were found in the horizontal group, 46.3% (37/80) in the mesioangular group, 42.5% (34/80) in the distoangular group, and 30.0% (24/80) in the vertical group of impacted mandibular third molars.

Conclusion

The study concluded that type of impacted mandibular third molar is factor in the development of temporomandibular disorders.

Upregulation of FosB/ΔFosB in limbic circuits after tooth exodontia-induced occlusal instability in an experimental model of unpredictable chronic stress

Psychological stress and occlusal alterations are contributing etiologic factors for temporomandibular and muscular disorders in the orofacial area. The neural modulation recruited for this relationship, however, is not elucidated. The aim of this study was to investigate potential central mechanisms involved in the exodontia-induced occlusal instability associated with unpredictable chronic stress (UCS). Male adult Wistar rats were submitted to occlusal instability (unilateral molar teeth extraction) and/or to a UCS protocol and treated with diazepam or vehicle. The anxiety-like behavior was evaluated by elevated plus maze (EPM) and open field (OF) tests. Limbic structures such as the central nucleus of the amygdala (CeA), paraventricular nucleus of the hypothalamus (PVN), dorsal periaqueductal gray matter (dPAG) and nucleus accumbens core (NAc) were analyzed for expression of FosB/ΔFosB (immediate early genes) by immunohistochemistry. Exodontia and/or UCS decreased the time spent in the open arms at the EPM and the distance travelled at the OF, and increased the immobility time at the OF, suggesting anxiety-like behavior. In addition, exodontia induction resulted in an upregulation of FosB/ΔFosB in the CeA, PVN and dPAG, while UCS and exodontia + UCS upregulate FosB/ΔFosB immunoreactivity in the CeA, PVN, dPAG and NAc. Treatment with diazepam decreased the expression of FosB/ΔFosB in all analyzed structures of animals subject to UCS and exodontia + UCS, while promoted a reduction in the FosB/ΔFosB expression in the CeA, PVN and dPAG in animals subject to exodontia. Our findings showed an anxiogenic effect of exodontia and UCS, which is correlated with intranuclear neuron activation of limbic structures in a spatially dependent manner and that is prevented by the administration of diazepam.

Is the extraction of third molars a risk factor for the temporomandibular disorders? A systematic review

BACKGROUND

The aim of this study was to evaluate through a systematic review the extraction of third molars as a risk factor for temporomandibular disorders (TMDs).

TYPES OF STUDIES REVIEWED

Randomized and nonrandomized controlled clinical trials where patients underwent third molar extraction and with qualitative evaluation of TMDs before and after extraction were included.

RESULTS

After applying the inclusion criteria, seven nonrandomized clinical studies were included. QUIPS tool showed that four articles presented a moderate and three a high risk of bias (RoB). Six studies reported that TMDs presented higher level after removal of third molars ranging from OR, 1.81 to 2.15/RR, 2.1. However, one study showed no significant association. GRADE showed heterogeneity in relation to general results, which means that confidence in the estimated effects varied from low to moderate GRADE. The quality of clinical recommendations decreased especially due to the risk of bias in some of the included studies evaluated with the QUIPS tool.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Third molar extraction can be associated with the development of TMD signs and symptoms. Furthermore, TMD can be aggravated according to the third molar location, the degree of impaction and surgical difficulty, age, and gender. This systematic review highlights the need to perform randomized clinical trials with diagnostic criteria and standardized surgical procedures.

Are third molars associated with orofacial pain? Findings from the SHIP study

OBJECTIVES

To examine the association between third molars and orofacial pain. We hypothesized that impacted third molars are a cause of orofacial pain.

METHODS

Magnetic resonance images of 1808 participants from two population-based cohorts from Northeastern Germany were analysed to define the status of third molars according to the Pell and Gregory classification. A self-reported questionnaire and a clinical dental examination were used to detect chronic and acute complaints of orofacial pain, masticatory muscle pain, migraine and other types of headache. Logistic regression models were used to analyse the associations between third molar status and orofacial pain.

RESULTS

Individuals with impacted third molars in the maxilla had a higher chance of chronic orofacial pain than those with erupted third molars (odds ratio 2.19; 95% CI 1.19-4.02). No such association was detected for third molars in the lower jaw. Third molars were not associated with masticatory muscle pain, migraine or other types of headache.

CONCLUSIONS

Impacted maxillary third molars might be a cause of chronic orofacial pain. Thus, physicians should consider the eruption/impaction status of third molars in their decision-making process when treating patients who complain of orofacial pain.

Pain Sensitivity Modifies Risk of Injury-Related Temporomandibular Disorder

This study evaluates contributions of jaw injury and experimental pain sensitivity to risk of developing painful temporomandibular disorder (TMD). Data were from the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) nested case-control study of incident painful TMD. Injury and subsequent onset of painful TMD were monitored prospectively for ≤5 y in a community-based sample of 409 US adults who did not have TMD when enrolled. At baseline, thermal-pressure and pinprick pain sensitivity, as potential effect modifiers, were measured using quantitative sensory testing. During follow-up, jaw injury from any of 9 types of potentially traumatic events was determined using quarterly (3-monthly) health update questionnaires. Study examiners classified incident painful TMD, yielding 233 incident cases and 176 matched controls. Logistic regression models, estimated incidence odds ratios (IORs), and 95% confidence limits (CLs) were used for the association between injury and subsequent onset of painful TMD. During follow-up, 38.2% of incident cases and 13.1% of controls reported 1 or more injuries that were 4 times as likely to be intrinsic (i.e., sustained mouth opening or yawning) as extrinsic (e.g., dental visits, whiplash). Injuries due to extrinsic events (IOR = 7.6; 95% CL, 1.6–36.2), sustained opening (IOR = 5.4; 95% CL, 2.4–12.2), and yawning (IOR = 3.4; 95% CL, 1.6–7.3) were associated with increased TMD incidence. Both a single injury (IOR = 6.0; 95% CL, 2.9–12.4) and multiple injuries (IOR = 9.4; 95% CL, 3.4,25.6) predicted greater incidence of painful TMD than events perceived as noninjurious (IOR = 1.9; 95% CL, 1.1–3.4). Injury-associated risk of painful TMD was elevated in people with high sensitivity to heat pain (IOR = 7.4; 95% CL, 3.1–18.0) compared to people with low sensitivity to heat pain (IOR = 3.9; 95% CL, 1.7–8.4). Jaw injury was strongly associated with elevated painful TMD risk, and the risk was amplified in subjects who had enhanced sensitivity to heat pain at enrollment. Commonly occurring but seemingly innocuous events, such as yawning injury, should not be overlooked when judging prognostic importance of jaw injury.

An evaluation of referrals requesting third molar tooth removal: clinical diagnosis and treatment outcome

Introduction To determine the reasons why patients are referred requesting removal of third molar teeth.Method Prospective evaluation of referrals requesting removal of third molar teeth only. Following review of symptoms, clinical, and if appropriate, radiographic findings, a diagnosis according to pre-defined criteria was made, and verified by a senior member of staff.Results 662 individual referrals were received requesting removal of 1,117 individual third molar teeth, of which 73% were for mandibular teeth. A total of 195 teeth (17.6%) were not removed as there was no disease process or insufficient symptoms. In 124 cases (11.1%) a diagnosis of temporomandibular disorders was made with no dental surgery being required. Other reasons for patients not proceeding to surgery were: no symptoms or sign of disease; symptoms were from an adjacent tooth; only single episode of pericoronitis; late incisor crowding; and cervical sensitivity.Conclusion While most patients referred did proceed to have removal of third molar teeth, a significant proportion had symptoms related to chronic orofacial pain that would not have been influenced by removal of third molar teeth. The overall incidence of temporomandibular disorders within the patient sample, either as a primary, secondary or tertiary diagnosis was 18.7%.

[Relations between extraction of wisdom teeth and temporomandibular disorders: a case/control study]

The aim of this study was to assess the impact of extraction of third molars on the occurrence of temporo-mandibular disorders (TMD). A review of the literature and a case-control study have been conducted. The case-control study compares the frequency of extraction of third molars between the sample with TMD (case) and the sample without TMD (control). The proportion of patients who had undergone extractions of wisdom teeth was higher in the case group than in the control group. The difference was statistically significant when patients had undergone extraction of all four wisdom teeth or when the extraction of four wisdom teeth underwent in one sitting or under general anesthesia. The study of patients in case sample shows that all signs of TMD were more common in patients who had undergone extractions in several sessions and under local anesthesia. The temporomandibular joint sounds are significantly more frequent with local anesthesia. In the case group, 85 to 92% of patients have parafunctions and 5 to 11% have malocclusion. This demonstrates the multifactorial etiology of temporomandibular disorders.

Recurrent condylar luxation after third molar extraction: an uncommon condition treated by eminectomy

INTRODUCTION: Extraction of third molars can rarely provoke post-operative complications, such as temporomandibular joint disorders (TMDs). OBJECTIVE: Although the literature presents a series of discussions of the clinical evidence related to this subject, in this report, we present an uncommon case of a patient submitted for the extraction of third molars who presented, in postoperative monitoring, with recurrent bilateral condylar luxation. CONCLUSION: Due to this critical condition, the patient was successfully treated by bilateral eminectomy.

What are the risks of operative intervention?

PURPOSE

The purpose of this article is to conduct a literature review, identify the studies with the highest level of evidence, and summarize the complications associated with operative treatment of impacted third molars (M3s).

MATERIALS AND METHODS

To address the research purpose, a search of PubMed, Scopus, and the Cochrane Database was performed, using the Medical Subject Headings search terms "third molars" or "wisdom teeth," "complications," "periodontal complications," "temporomandibular joint," "nerve involvement," "sinus communication," and "mandibular fracture." Individual case reports and anecdotal reports were excluded from review.

RESULTS

Relevant studies for the following complications were identified and are reported: 1) periodontal, 2) temporomandibular joint, 3) nerve injury, 4) sinus, and 5) other.

CONCLUSIONS

Quality-of-life studies have indicated that around 10% of patients undergoing M3 removal may have a complication. However, most complications are mild and self-limited and undergo complete resolution. Most patients are back at work or school after 2 to 3 days, and long-term complications are rare. Clinicians advocating M3 removal should review in detail the risks of operative intervention in conjunction with the benefits of removal and should be prepared to prevent, anticipate, and manage these complications.