Page 10 - GP Spring 2020

there was a definite “clicking” noise in his Therapy Related to Temporomandibu- disc disorders that have failed non-surgical
right TMJ. However, when he chewed on lar Disorders management can be successfully treated
his left side, no clicking noise was elicited. While the patient in this case had no symp- with arthrocentesis with joint manipulation
The patient declined any further treatment, toms of TMJ pain following the dental or arthroscopy. The goal of intervention
citing that he had become asymptomatic fractures and attending occlusal changes, it includes increasing function and decreas-
other than occasional clicking, and was is valuable to note some of the treatment ing pain. Success for arthrocentesis and ar-
now completely free of any discomfort. modalities typically employed to treat the throscopy is high and results in decreased
broad category of TMDs in general, and of reported pain as well as increased function
Discussion TMJOA in particular. and maximum incisal opening. 25,26 Open
There is a significant prevalence of tem- joint surgery is considered when the joint
poromandibular changes among elderly The therapeutic approach to temporoman- space has been either obliterated or fi-
patients. These anomalies commonly in- dibular joint disease is a multi-step process brosed by the degenerative processes and
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clude disc displacement and osteoarthritis, beginning with appropriate clinical and functional impairment is significant. The
both of which can be observed through radiographic evaluation to determine the decision to insert a prosthetic joint is based
MRI study. The signs and symptoms of most accurate process underlying the pre- on severity of functional impairment, and
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temporomandibular joint disorders include sentation and subjective symptoms. The again, not on the level of pain. 21
joint noises, locking pain, muscle tender- majority of TMJ disorders are myofascial
ness and tinnitus. Bony changes are rare- in nature, occurring outside of the joint Conclusion
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ly observed in only one condyle, and was articulation itself – or extracapsular. 19,20 A A case of bilateral condylar osteoarthritis
more severe in the right condyle in this in- much smaller subset will be directly relat- was presented; the case was diagnosed de-
stance. ed to an intracapsular process; more spe- finitively via a CBCT scan of the temporo-
cifically, degenerative disease of the artic- mandibular joints. It is interesting to note
In this case, diagnosed via CBCT, advanced ular surface of the mandibular condyle, the that the patient had developed a left-side
osteoarthritic changes were noted in the temporal bone or articular fossa, and/or the open bite, which led him to seek treatment,
right condyle. While it is possible that with articular disc – of which derangements of even in the absence of other symptoms.
time the condition may have presented the articular disc are the most common. 19,20
more symmetrically, the left side was the The treatment algorithm for the extra- and The CBCT scan revealed severe articular
less affected condyle. Hence, the evidence intracapsular TMJ disorders may overlap attrition with broad lack of cortication of
suggests that the most recent episode of and include classic orthopedic treatments the right condyle, suggestive of osteoar-
OA was unilateral, while prior changes to including joint or muscle rest, ice and/or thritic changes. There were cystic cavities
the left TMJ represented a typical accu- heat therapy, NSAIDS, physical therapy, in both condyles and eburnation of the right
mulation of changes over the patient’s life. identifying and discontinuing parafunc- glenoid fossa . The right temporomandibu-
Despite the bilateral bony changes and the tional habits; and less frequently medica- lar space was diminished, which may have
extreme changes on the right side, the pa- tions to address muscular spasm/injury or led to an attendant lateral rotation of the
tient was asymptomatic aside from demon- acute inflammatory processes. 21-23 mandible, causing an open bite on the left
strating a unilateral open bite. Ironically, side of the patient’s mouth.
this was the only concern that caused the In addition to the clinical evaluation and
patient to seek treatment at the time. history, identification of the underlying na- A two-month follow-up of the case revealed
ture of TMJ disease will likely include pan- that the patient had fractured the incisal
It is interesting to note that the patient ex- oramic radiography, and additional radiog- edges of #6 and #7, and the buccal cusps of
perienced a fracture of the occluding upper raphy such as open and closed view MRI of #4 and #5, resulting in re-establishment of
right lateral incisor, cuspid and first bicus- the TMJ region, as well as CT scan. The occlusion on his left side, and an attendant
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pid before therapy could be initiated, and as panoramic radiographic is easily accessi- complete absence of subjective symptoms.
a result, the left side posterior teeth ceased ble and interpretable in the dental office
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to be held out of occlusion. It seems and may reveal degenerative disease of the A six-month follow-up on the case re-
counterintuitive that what would otherwise TMJ or history of trauma to the mandible vealed that the patient now exhibited an
be thought of as a catastrophic occlusal or condyle. MRI allows evaluation of the anterior incisal Class III malocclusion. In
change should bring the patient comfort, soft tissues including the articular disc and addition, he had developed an occasional
but it is not inconsistent with previous re- its ability to function; while the CT scan unilateral clicking in his right TMJ. This
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search. For instance, an orthodontic study will reveal in detail any degeneration of the may well have been caused by the contin-
suggested that unilateral TMJOA is related hard tissues of the joint. ued advancement of pathologic changes
chiefly to dento-facial morphology, result- of the condylar head on the right ramus of
ing in a mandibular midline shift to the af- Therapy routinely begins with the afore- the mandible. (Figures 5-7) He remained
fected side and only associated with pain mentioned non-surgical management fol- asymptomatic.
usually as a result of masticatory muscle lowing proper diagnosis. Surgical inter-
imbalance. 17 vention is considered when function or References
quality of life is significantly limited. Pain 1. Wang XD(1), Zhang JN(1), Gan YH(2),
Similarly, it should be stressed that cone alone is not an indication for surgery. The Zhou YH(1). Current understanding of patho-
beam studies of patients with painful TM- hierarchy of surgical treatment includes genesis and treatment of TMJ osteoarthri-
JOA have shown that there is a poor cor- arthrocentesis and aggressive joint ma- tis. J Dent Res. 2015 May;94(5):666-73. doi:
relation between condylar changes on nipulation under anesthesia, arthroscopy, 10.1177/0022034515574770. Epub 2015 Mar.
CBCT images and pain or other clinical open joint surgery or arthroplasty, and total 2. Talaat W, Al Bayatti S, Al Kawas S. CBCT
symptoms of TMJOA. 18 joint reconstruction/replacement. The ma- analysis of bony changes associated with tem-
jority of degenerative TMJ disorders and poromandibular disorders.Cranio. 2015 Feb

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