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Temporomandibular disorders (TMD) is a collective term has been defined as a group of conditions that affect the temporomandibular joint (TMJ), muscle of mastication and associated structures. These disorders are common, affecting at least 30% of the population.1 TMD can severely affect individuals’ daily activities and produce varying symptoms ranging from mild discomfort to severe function disability. Patients with TMD often presents with reduced mandibular function secondary to increased pain levels, reduced ability in chewing, limited mouth opening and during excursive movement of the joint.
There are many causes of limited mandibular movement, ‘closed lock’ is the most common presentation in the clinic. Closed lock is a well recognised condition. An estimated 2% of people with TMD suffer from a closed lock. 2 It has been suggested that condylar translation is limited by the failure of the disc to reduce, with the posterior band being trapped anterior to the condylar head. It was also proposed this condition was a result of reversible restriction in gliding movements of the disc caused by its adherence to the fossa. 3 These group of patients often complaints of jaw-opening difficulties such as pain, restriction and TMJ tightness.
Macrotrauma to the structures of the joint through impact or extension injuries, and microtrauma either in the form of clenching or occlusal abnormalities may contributes in the aetiology of internal derangement with closed lock.
A various treatment options have been considered to improve the symptoms of closed lock. Non-surgical approaches may consist of anti-inflammatory medications, muscle relaxants, splint therapy, physiotherapy, exercise, moist heat, stress management and soft diet or combination of thereof. In patients whom the symptoms proved refractory to non-invasive therapy, surgical management on the TMJ is generally considered.
The aim of this dissertation is to discuss and analyse the published data to support the current management of TMJ closed lock syndrome.
There are many treatment modalities in management of TMJ closed lock. The two main approaches used are non-surgical and surgical treatment.
Treatment efforts are directed toward:
Reduction of pain using Visual Analogue Scale (VAS)
Improvement in mouth opening and lateral movement
Improvement in joint function.
For most TMD, clinicians generally agree that non-surgical and non invasive care should precede surgery. However, for TMJ closed lock, surgery has been described as preferable. 4
Non Surgical Treatment
A range of conservative treatments including physiotherapy, occlusal bite splints, NSAIDS, muscle relaxants, stress management and soft diet are available.
Minakuchi et al5 conducted a randomized controlled evaluation of non-surgical treatments for closed lock. 232 patients were randomly allocated to one of three group – control, self-care plus NSAIDs, or occlusal appliance jaw mobilization plus self-care/NSAIDs. The subjects were observed over 2 month’s period. All three experimental groups had significant improvement in their signs and symptoms with time. The self-care/ NSAIDs group showed more improvements in the daily activities limitation compared with the other two groups. However, this difference was present only for two review appointment, and during the last review at 8 weeks, there were no significant group difference. These data suggests the gradual improvement in signs and symptoms was non-specific and was not related to the type of treatment, but more to the passage of time.
Lundh et al 6 carried out a randomized controlled study on 51 patients. These patients are treated with a flat occlusal splint or to serve as an untreated control group. It is noted that at the end of 12 months period, 16% of patients in control group and 40% of patients treated with splints, the symptoms were worse than at the beginning at the study. In addition, 36% of patients in the control group improved after 1 year without treatment. This study indicates that aggressive treatment modalities should not be used in the initial phase of closed lock. Instead, counselling and adequate pain medication seems to be a reasonable treatment approach.
Surgery on the temporomandibular joint is generally only considered when non-invasive therapy proved unsuccessful. Closed lock is usually associated with permanent disc displacement, and this condition is frequently resistant to conservative treatment.
The primary role of surgery is physical debridement, repair and removal of diseased tissue that cause pain and dysfunction within the TMJ. The primary aim of surgery is to reduce the symptoms of pain and to improve joint function of individuals.
The historical perspective on temporomandibular surgery dates back to 1887 when Annadale7 reported two successful operations to reposition and secure the disc in two patients.
In 1957 Henry and Baldrige8 described the condylectomy operation. They emphasized the preservation of the disc, and limited bone reduction to increase joint space, and relieve irritation to nerve-bearing tissues. Condylectomy was formerly extensive used, but has many disadvantages 9. It often leads to ramus shortening with resultant of malocclusion and mandibular deviation to the side of the surgery.
Ward 10 in a review of 21 patients, who he followed for periods of up to three years, reported a high success rate. Banks and MacKenzie 11 in a much larger series of 211 patients reported 91% of them to be cured or improved by surgery. However, in a follow-up of patients by Lindahl 12, a high prevalence of persistent pain and dysfunction was still evident.
Temporomandibular joint arthroscopy is a new method for the management of acute, subacute, and sometimes chronic limitation of movement of the TMJ. The miniaturised arthroscopy to the TMJ first appeared by Ohnishi 13 in the Japanese literature in 1975. It is used as diagnostic and therapeutic procedure. It has been postulated that it improves limited joint movement by lysis and lavage of fibrotic adhesions, and reductions of surface adherence on articulating joint spaces.
Sanders et al 14 conducted 40 arthroscopic procedures on 25 patients during the mid 1980s in management of closed lock. All patients showed improvement and eventually asymptomatic after the procedures. They have good range of opening and have little preauricular pain after.
Moses et al 15 did a retrospective studies on 237 patient with 419 TMJ joints. 63% of patients reported to have an increase in opening and in these 73% having an interincisal opening of 40mm or greater after 1 year post treatment. 97% of these patients thought their surgery was successful and 82% stated that would undergo the procedure again. The results of this study appear that the arthroscopic procedure has a definite value in the treatment of TMJ internal derangement.
White et al 16 undertook a similar study on 66 patients with 100 TMJ joints. The overall postoperative increase in maximal incisor opening was 38.4%. 85.7% of the patients rated their postoperative pain and function greatly and moderately improved and 100% of the patients stated they would have the arthroscopic surgery again. However, a failure rate of 7.5% was noted by the objective criteria.
Clark et al 17 also reported decreased in mean pain score value by 57%, also an improvement of 67% jaw function in 18 patients after 2 years postarthroscopic surgical treatment.
Davis at al 3 evaluated 51 patients, with 80 joints with closed lock that were treated with arthroscopic surgery. Results showed that an immediate improvement after the treatment and followed by a more gradual improvement during the next 6 months, with a plateau in improvement thereafter.
Kurita et al 18 also evaluated the correlation between preoperative mouth opening and surgical outcome after arthroscopic surgery. 12 of the 14 patients (86%) showed good reduction in pain and improved range of jaw movement. However, 2 patients showed no improvement after the treatment and require open surgical procedures. The 2 failed cases had 10 and 19mm opening respectively before the treatment. The author concluded that limitation of mouth opening less than 22mm may be a relative contraindication to arthroscopic treatment. The main disadvantage of this study is that the number of patients in this study is very small.
Abd-Ul-Salam et al 19 conducted a retrospective study to investigate the incidence of reoperation after TMJ arthroscopic surgery in 315 consecutive patients (488 patients). He documented a 22% incidence of further surgery arthroscopy or open surgery after TMJ arthroscopic surgery.
TMJ arthrocentesis was first described by Nitzan et al 20 in 1991 for the treatment of temporomandibular joint pain and movement restriction.
Nitzan et al 20 described this technique as irrigation on the upper joint compartment with Ringer’s solution. The injected fluid enables the disc to slide and thereby re-establishes normal maximal opening in closed lock. The treatment was shown to be effective, providing significant improvement in maximal mouth opening and lateral movement, and decreased in pain level and disturbance in jaw function involved 17 joints in 17 patients. The overall success rate is 91%. Nitzan et al 21 conducted another study in 1997 on 39 patients with 40 joints with severe closed lock. The overall improvement, as expressed in pain and dysfunction levels, was about 95%, with no recurrence of severe closed lock.
A prospective study done by Dimitroulis 22 using the same technique on 46 patients with acute limitation of mouth opening, showed significant improved in pain, jaw opening and function.
Hosaka et al 23 evaluated the outcome of arthrocentesis for TMJ with closed lock at a 3 years follow-up in 20 patients. The success rate was 70% at 6 months follow-up and increase to 78.9% over the 3 years of follow-up. The literature showed stable good outcome at 3 years follow-up as compared to 6 months.
Alpaslan et al 24 conducted a 5 year retrospective to evaluate the long-term outcome of TMJ arthrocentesis on 34 patients with 48 joints. There was a significant (P < 0.001) increase in the maximal mouth opening. Pain and dysfunction levels were significantly (P < 0.001) lower than pre-operative values. 26% of patients were pain free and 88% of patients had less pain than before.
An alternative surgical approach to the treatment of closed lock of the temporomandibular joint is eminectomy. The surgery involves reduction of the articular eminence of the TMJ, provides greater freedom of movement between the condyle disc and the reduced articular eminence.
Stassen et al 25 conducted a pilot study of the use of eminectomy in the treatment of closed lock in 18 patients. Results show significant increase in mouth opening and a decrease in pain. Both the improvement in inter incisal distance and reduction of symptoms were found to be statistically significant (P<0.001). There is a high individual level of patient satisfaction with the outcome of the surgery.
Comparison between Different Surgical Techniques
A few studies were performed to compare the efficacy of different surgical technique for the management of TMJ closed lock.
A comparative study designed on a prospective basis evaluated the benefits of non-surgical therapy versus surgical treatment of TMJ closed lock. Murakami et al 26 reported 55.6% success rate in the non-surgical treated group, 70% in the arthrocentesis group, and 91% in the arthroscopy group. Arthroscopy showed the most reliable success rate.
Further prospective, randomized study was undertaken to compare arthroscopy and arthrocentesis by Fridrich 27. Investigator found no statistically significant difference in outcome between the two groups in terms of reducing pain and increasing pain movement. The overall success rate was 82% for arthroscopy and 75% for arthrocentesis.
Sanroman et al 28 also did a prospective study to compare the outcome of arthrocentesis and arthroscopy in 26 patients. Both arthroscopy and arthrocentesis give good results in patients with closed lock. There is significant reduction in pain and increase in maximal mouth opening and lateral movement.
Holmlund et al 29 conducted a study to compare the efficacy of discectomy and arthroscopic with chronic closed lock of the TMJ in a prospective, randomized clinical trial. Both surgical techniques significantly reduced pain and improved mandibular function. Discectomy showed more reduced pain than arthroscopy.
Both high condylectomy and eminectomy were compared in a study by Epply 30 with eminectomy patients exhibiting greater opening distances at end-stage evaluation. Less residual pain was observed in the eminectomy group.
The general consensus among the studies published is that surgery plays a significant role in the treatment of TMJ closed lock. TMJ surgery had undergone a change with the adoption of minimally invasive surgery as the main surgical treatment modalities. According to the literature, authors conclude that arthrocentesis was more likely to be more effective in cases with recent onset limited mouth opening, while arthroscopy was preferable in patients who had chronic closed lock. 4, 17, 20, 21, 22, 23
Eminectomy and also both TMJ arthroscopy and arthrocentesis provided the opportunity for researchers to investigate the TMJ joint and compare the synovial fluid of healthy and diseased joints.
The arthrocentesis is a clinically effective and minimally invasive treatment for TMJ closed lock. This treatment efficacy is comparable to arthroscopic lysis and lavage although it is a relatively new surgical treatment. Nitzan et al 20 described the high success rate of 91% in his literature.
Arthroscpoy has also been reported to have favourable results with minimal complications.14 Multiple studies reported 80% to 90% success rate with arthroscopic lavage and lysis for the management of TMJ closed lock. 14, 15, 17, 18, 25, 31
Eminectomy also appears to be a safe, simple method of relieving a closed lock of the TMJ 25.
Although the sample size of most of the studies is small, however the use of consecutive patients strengthens the study. Also, the standard evaluation form and the timing and length of follow-up enhance the validity of the results. Most of the studies evaluate pain using the Visual Analogue Scale as one of their criteria for success. Pain is often a very subjective, emotional experience. Often, patients perceive pain very differently among individuals; some patients may have a higher pain threshold compared to the others. This may affect the outcome of the success. Placebo effects in the treatment of TMJ disorders are well known and this could also affect the results of the studies. A clinical examination was used along with a questionnaire in some studies to collect data and this could have led to underreporting and dishonest of patient when filling the questionnaire.
Treatment of TMJ closed lock starts with non-surgical technique; surgery is often the treatment option when non-surgical treatments have failed.
Surgical technique is effective in eliminating symptoms of TMJ pain and restoring mandibular function in patient with closed.
Eminectomy, arthroscopy and arthrocentesis proved to be efficient procedure in managing patients with TMJ closed lock syndrome.
Arthrocentesis, a least invasive technique with predictable outcomes, could be the best indicated treatment for patients with closed lock.
Arthroscopy permits direct visualization of pathological tissues and allows removal of adhesions with injection of anti-inflammatory drugs and coagulation into the inflamed synovial tissues shows good success rates.
More studies needed to show long term success of arthrocentesis.
More research is required to better define the benefits of TMJ surgery in the management of closed lock syndrome.
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