23-year-old woman 30 days after accidental extraction of a mandibular second molar during extraction of a third molar on the left side. Difficult extraction. Severe joint pain on the right side after surgery, difficulty in mouth opening and a deviation to the opposite side of the extractions. 23-mm mouth opening. DDX: permanent trismus, mandibular fracture or ADDWoR on the right side of the TMJ. Magnetic resonance imaging (MRI) confirmed ADDWoR on the right side of the TMJ).
ICE, NSAID, Steroid dose pack?? The patient was advised to performing lateral movements, to the contralateral side of displacement, and, from this position, try to reach maximum mouth opening. This was unsuccessful. First attempt of manual manipulation of TMJ (with only extraoral local anesthesia) was unsuccessful due to patient's discomfort. One week later, we used extraoral anesthesia with IV sedation, wait 10 mins, had successful reduction of disc displacement. 40-mm mouth opening and immediate improvement of mandibular functions were achieved.
Panoramic radiograph showing orthodontic indication for extraction of tooth #38.
Panoramic radiograph after extraction of tooth #38, also showing accidental avulsion of teeth #37.
Mouth opening measuring 23 mm.
Mandibular deviation to the right.
A) Detail of MRI sagittal slice of the right TMJ with mouth closed, evincing displacement of the TMJ articular disc. B) MRI sagittal slice of the right TMJ at maximal mouth opening, in which ADDWR is evident.
Place the thumb and forefinger on the maxillary canine on the nonaffected side and the mandibular canine on the affected side. Hold the gonion with the forefinger and middle finger of the other hand. 2) Instruct the patient to make maximal lateral gliding excursive jaw movements to the nonaffected side with teeth slightly occluded. Support movement with fingers and ensure that lateral excursive position is maximal. Lateral excursion with the jaw protruding is not adequate for this procedure. 3) Subsequently, instruct the patient to make jaw opening movements through the lateral border path on the nonaffected side. Support this opening movement with assisting fingers. 4) Continue to support voluntary mouth opening up to the maximal opening position.
The patient received a prescription of anti-inflammatory drugs (100 mg of nimesulide, 12/12 hours, orally) during five days, and also was advised not to force mandibular movements after reduction.
The patient was instructed to use a stabilizer plate immediately after correct manipulation, so as to avoid a new disc displacement and reduce muscle hyperactivity. There were no complications after the manipulation maneuver, and an immediate 40-mm mouth opening was achieved after manual manipulation. The patient was followed-up on a weekly basis in the first month and every two weeks until the third month, showing no episodes of TMD.
Manual manipulation for reduction of ADDWoR of TMJ.
A) Immediate 40-mm mouth opening after manual manipulation. B) Improvement in mandibular function.
A) MRI sagittal slice of the right TMJ with the mouth closed, evincing the persistence of TMJ articular disc displacement. B) MRI sagittal slice of the right TMJ at maximal mouth opening, evincing reduction of TMJ articular disc.
DISCUSSION
Importance of an improved technique for surgical removal of impacted third molars, so as to avoid keeping the mouth opened for long periods of time. Additionally, intraoral devices are recommended to maintain jaw stability during surgery.
Nonsurgical treatment is effective in most cases. TMJ surgery for patients with internal derangements refractory to conservative treatment for at least 6 months.
Occlusal splints play a major role in TMD treatment- The stabilization splint, in cases of anterior disc displacement without reduction.
In the present case, after manual reduction of articular disc displacement. Subsequently, the patient was advised not to force mandibular movements. However, it is noteworthy that the normalization of joint function does not necessarily imply in recapture of articular disc. Therefore, it is important to perform new MRI after manual reduction maneuver.
When normal morphology is present, TMJ articular disc is more likely to return to its normal position. However, when morphology is permanently compromised, it is difficult to keep the disc in position. This is the reason why manual manipulation is only effective in mild conditions. Should the attempts of manual reduction of the articular disc fail, we do not recommend multiple attempts in sequence, as they may worsen patient's signs and symptoms. It is suggested that these maneuvers be made respecting a seven-day interval.
If treatment modalities classified as conservative (medication, physical therapy, stabilizing and repositioning occlusal splints, guidelines) do not achieve successful outcomes, the literature recommends minimally invasive techniques (assisted mandibular manipulation with increased hydrostatic pressure, arthrocentesis) or even invasive techniques (arthroscopy, arthroplasty, arthrotomy).
Arthrocentesis, same indication of assisted mandibular manipulation, but has a great advantage of being used in acute and chronic cases. Conventionally, two needles are introduced into the compartment above the disc, inserting a solution - that can be a local anesthetic, Ringer's lactate solution, opioids and sodium hyaluronate - so as to perform joint lavage, dilute local algogenic substances, restore intra-articular normal pressure and assess which substances are present in the synovial fluid.
Arthroscopy is a more invasive technique, performed under anesthesia, and generally involving cannulae, trocars and a small-sized arthroscope containing a camera system connected to a monitor. It can promote lysis of adhesion, washing and manipulation of the head/ articular disc complex, myotomy of muscles, biopsy, removal of bone spicules, injection of sclerosing agents, repositioning and stabilizing the disc, among others.
Arthrotomy can be divided into disc anchoring, disc repositioning discectomy with or without interposition of material, tuberculotomy, condylectomy graft, or complete joint replacement. Disc anchoring has been the most used technique and consists in making a perforation in the posterior-lateral portion of the condyle, so as to have an anchor that will support the disc. It is indicated in cases of disc displacement without reduction, in which conservative clinical therapy or minimally invasive surgical procedures have failed.