Basic concepts

‘Temporo mandibular joint dysfunctions’
Basic information
Modified from ‘Corriere della Sera’; October 18th, 1998 (Corriere Salute) – Interview to Prof Riccardo Ciancaglini. Professor of Clinical Gnathology – University of Milan

The first and most frequent problem.
A ‘click’ sound while chewing or at the end of a yawn, and soon after the impression of not being able to close your mouth; or even worse, the unpleasant feeling of being unable to open your mouth and, maybe, being obliged to maintain such a position for days. Although they might seem exceptional, these disorders are actually more widespread than one thinks.
Indeed 60-70 % of the population presents at least one sign of sufferance of the chewing muscles or of the temporo mandibular joint, namely of the joint that connects the mandible to the skull and that works any time you open your mouth, either for talking or chewing.
 

The list of causes, however, does not finish here. We have to add traumas, dental prostheses and badly done dental work (orthodontic treatment, fillings, etc.): all of these situations may result in aching of the joint and chewing muscles.
Temporomandibular dysfunction can be more or less serious and cause a variety of disorders. Pain is due to bad positioning of the fibrous disc (similar to the knee meniscus), which lies interposed between the two ends of the bones that enter in contact in the joint capsule.

Different types of disorders (signs and symptoms)
Jaw joint clicking sound, a click that accompanies the movement of the jaw, is the milder symptom. It is simply an ‘instability’ of an ‘hyper-mobile’ joint (because of a congenital or acquired ligamentous laxity). It does not always have a pathologic meaning. Therefore, unless it is accompanied by pain, there is no need for treatment, except for some exceptional cases.
Chewing difficulties, represented by the inability to crush hard foods and fatigue accompanied by pain while chewing, are instead more frequent.
Jaw joint locking, occurs when the disc “gets stuck” and remains fixed in a wrong position (Fig. 4). 

In other words, when a dislocation occurs (see figure), the patient finds himself suddenly unable to open his/ her mouth, or, more seldom, to close it. 
“In these cases, it’s necessary to intervene promptly in order to ‘unlock the lock’, otherwise the incorrect movement of the joint, in the long run, risks tearing the ligaments, triggering those processes that can lead to arthrosis. And to all the disorders that follow”. 

Pain can be focused around the ear (but differs from the usual earache because it sharpens when chewing), “or it can reveal itself with severe headaches” explains again Ciancaglini.
- Ringing in the ear
- balance disorders (unsteadiness)
- mandibular tremors
- generalized loss of muscle tone
- hand and arm numbness and impaired ability to ‘grasp’,
are less frequent but not rare symptoms and often represent a chronic evolution of the problem.

Pain, or even only the difficulty mouth opening, are conditions that may interfere heavily in everyday life. This is why some of these patients also suffer from anxiety and stress, to the point of true depression.

Possible treatments.

Manipulation
Formerly, dentists used to intervene by seizing the lower jaw in order to reposition it correctly. “As it requires a certain pressure, this procedure involves some risk” stresses Ciancaglini. “In fact, if the joint can’t be easily led back to its site, the ligaments may be damaged. Furthermore, muscle opposition to the maneuver is remarkable. Unskilled or very aggressive maneuvers usually produce ligamentous sprains, which are not immediately recognized. Personally, I carry out these maneuvers only with the induction of a very short general anesthesia, that allows total muscle relaxation”.

Exercise
“Ten years ago I conceived a sort of mandibular exercise to reduce locking without causing trauma” says Ciancaglini. “It’s a very simple technique that patients can carry out on their own, at home. And it is successful (maybe even after days or months) in any case where the lock is reversible” (see figure above). But there is more to it: this exercise strengthens the muscles located around the joint. “This is a very important aspect, because in every case of joint instability, the defect must be looked for in the ligaments . When the ligaments are injured or even only weakened, they can’t carry out their holding function well” explains Ciancaglini. “If muscles get stronger with exercise, they will be able to make up for the ‘laziness’ of the ligaments. Thus, relapses are also avoided”.
Occlusal plates (bites) are oral appliances that exercise a true orthopedic action on the lower jaw. Formerly they were used alone. Today, in contrast, they are mostly used in combination with self-physiotherapy. They must be planned with accuracy, because, if inadequate or incorrectly worn, they can cause more damage than advantage. Plates of several different types and materials have been used. The one which is most effective and of best quality, is represented by CBC plates (acronym for Ciancaglini, Brandazzi, Ceresola).
These bites are, in many cases, a very useful therapeutic medium, and in some phases of therapy they are irreplaceable. 
Intra-articular irrigation. Used in the very few cases where active physiotherapy is not enough. “It’s a sort of irrigation carried out with a needle inserted into the joint (arthrocentesis). “This type of operation is necessary in less than one case out of a hundred”.
Surgery. It is indicated only when there is a severe bony or fibrous ankylosis (total lock) of the joint with intra-articular adherences and calcifications.
Current techniques allow us to also intervene with microinvasive methods (endoscopic intra-capsular microsurgery in local anesthesia).
Counseling. “In many cases a psychologist may help” Ciancaglini reports again. “A classic example is when the pain is so strong to the point of being debilitating”. In some of these situations, indeed, pain is the manifestation of a psychologic disorder.
“Experience teaches me, though, that a disorder must never be regarded as of psychologic origin without first excluding its organic origin”.
Physiotherapeutic/ physiatric treatment. It has been proved that patients with temporomandibular disorders suffer from neck and spinal problems twice as much as average people. It is therefore very useful to seek the collaboration of a physiotherapist and, in some cases, physiatric orthopedic consultation during both diagnosis and therapy.
Drugs. Several drugs have been used, but only temporarily, until physiotherapy produces its benefits. They range from anti-inflammatory drugs to antidepressants, but the most preferable are usually those that have both a sedative and analgesic effect. 

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