Temporomandibular Joint Disorder and Occlusal Changes: Case Reports

CASE REPORT J Korean Dent Sci. 2018;11(1):21-31 https://doi.org/10.5856/JKDS.2018.11.1.21 ISSN 2005-4742

Young-Kyun Kim1,2

1Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam, 2Department of Dentistry and Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Korea

Occlusion may change spontaneously but dental treatment or trauma in the patients with temporomandibular disorders (TMDs) may also alter occlusion. This report presents three cases displaying occlusal changes. Review of literature emphasizes the significance of TMD treatment. Conservative treatment modalities such as counseling, medication, physical therapy and splint therapy may be selected as initial treatment options. Irreversible or invasive treatment, such as orthodontic, prosthodontic, and occlusal adjustment should not be attempted early. In case there is no response to conservative treatment, joint injection, muscle injection, arthrocentesis or arthroscopic surgery might be performed.

Key Words: Occlusal change; Temporomandibular disorder; Temporomandibular joint disorders

Introduction initial occlusal pattern. Occlusal changes caused by TMD are usually associated with disc dislocation, Patients with normal occlusion may undergo natu- osteoarthritis of the temporomandibular joint (TMJ), ral occlusal changes, and dental procedures or inju- and condylar resorption. While normal recovery ries may result in various occlusal changes as well. can be expected following non-invasive treatment In such cases, temporomandibular disorder (TMD) of TMD, subsequent irreversible or invasive treat- is presumed to be the primary underlying factor. ments such as occlusal adjustment, orthodontic Psychological factors also are known to contribute treatment or prosthetic treatment may cause per- to the TMD. Diffierential diagnosis must be made manent change in the occlusion1-3). to detect possible occlusal changes in contrast to the Clinicians should confidently recognize with TMDs

Corresponding Author: Young-Kyun Kim, https://orcid.org/0000-0002-7268-3870 Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea TEL : +82-31-787-7541, FAX : +82-31-787-4068, E-mail : [email protected] Received for publication March 26, 2018; Returned after revision June 26, 2018; Accepted for publication June 26, 2018 Copyright © 2018 by Korean Academy of Dental Science cc This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Journal of Korean Dental Science 21 Young-Kyun Kim: Temporomandibular Joint Disorder and Occlusal Changes Young-Kyun Kim: Temporomandibular Joint Disorder and Occlusal Changes

and other causative diseases that can induce occlu- disengagement. The patient then underwent laser sal changes. It is advised to attempt selective and physical therapy and pharmacotherapy. Although careful procedures only to correct occlusion and to the symptoms significantly improved one year after try not in recruit unnecessary procedures. the prosthesis placement, the patient subjectively perceived a lack of occlusion on the right side (Fig. Case Report 1B). After removing the prosthesis from the maxilla, a temporary prosthesis was placed in order to ad- 1. Case 1 just the occlusion. Subsequently, a splint treatment A 56-year-old female patient who developed oc- and a Dysport® (Ipsen Pharma Ltd., Paris, France) clusal changes following long-term implant treat- injection were performed on both temporal regions ment of the posterior maxilla. as well as the masseter muscles. Twenty-five Units A 56-year-old female patient completed implant were injected at individual muscles. Three months placement (#16, #18) and prosthetic treatment after later, the final prosthesis was placed again, and the undergoing surgery for right maxillary sinusitis splint was readjusted. All TMJ symptoms except and maxillary sinus bone grafting for three years. for intermittent clicking were resolved during the Two months after the prosthesis was placed, the follow-up period (Fig. 1C). patient began to experience pain and pressure in the left temporal region, pressure in the mastica- 2. Case 2 tory muscles on both sides of the face, and cracking A 58-year-old female patient who suddenly devel- sound in the left TMJ (Fig. 1A). Although the symp- oped occlusal changes in the posterior region. toms were remarkably alleviated after the patient A 58-year-old patient was admitted with chief underwent pharmacotherapy, physical therapy and complaints of pain in the right TMJ and noises splint therapy, pain continued in both temporal from the TMJ. The patient tended to chew on the regions. Five months after the prosthetic treatment, left side, had severe bruxism, and experienced pain the right implant prosthesis exhibited occlusal around both temporal regions as well as the right

Fig. 1. A 56-year-old patient who developed temporomandibular disorder (TMD) and occlusal changes after undergoing long- term implant treatment. (A) Panoramic radiograph obtained 2 months after the final prosthesis placement. (B) Panoramic radiograph obtained 1 year after the final prosthesis placement. (C) C Panoramic radiograph obtained 4 years after the final prosthesis placement.

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TMJ upon finger pressure. The patient had received splint treatment (Fig. 2). However, one year and 10 pharmacotherapy at another dental clinic, but the months later, the patient visited our clinic again, symptoms did not improve. The patient then vis- complaining of the right molar being lifted upward, ited our clinic. Teeth grinding was assessed using leading to a lack of occlusion. Occlusal contact in the BiteStrip (portable electromyography [EMG]; the posterior region was reduced at a weak bite, Alldent, Port Melbourine Victoria, Australia). BiteS- but complete occlusal contact was gained with a trip displays the following values. L: when there is forceful bite. The patient experienced pain and dis- no or little grinding, i.e., 30 times or less in 5 hours, 1: comfort when the lateral side of the left TMJ was mild, 31~60 times for 5 hours, 2: moderate, 61~100 pressed (Fig. 3). A diagnostic model showed lack times, 3: severe, 100 times or more, E: operation of occlusion at the right premolars and molars. The error. The patient had Grade 3 bruxism, and her patient was tentatively diagnosed as acute maloc- pain was alleviated after Valium and Naxen were clusion due to anterior displacement of the right injected for diagnostic purposes. The patient was articular disc and resumed pharmacotherapy and then diagnosed as TMD 1 (muscle disorder) and splint treatment. After one year, malocclusion was type 3 TMJ internal derangement, based on clini- mostly relieved, and the patient had no difficulty cal and radiographic findings. The symptoms were chewing. Treatment was thus terminated. relieved after five months of physical therapy and

Fig. 2. Initial panoramic and temporomandibular panoramic radiography (TM panoramic radiography) of 58-year-old female patient. The patient was diagnosed as temporomandibular disorder 1 (muscle disorder), and type 3 temporomandibular joint internal derangement, based on clinical and radiographic findings. The symptoms were relieved after five months of physical therapy and splint treatment.

Fig. 3. Panoramic and temporomandibular panoramic radiography (TM panoramic radiography) 1 year and 10 months after initial examination. Left posterior open bite was observed. The patient experienced pain and discomfort when the lateral side of the left temporomandibular joint was pressed.

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3. Case 3 indicate osteoarthritis (Fig. 6). The patient was di- A 54-year-old patient with mouth opening limita- agnosed as acute mouth opening limitation due to tion and malocclusion. type 3 TMD (anterior displacement of the articular A 54-year-old female patient visited our clinic disc without reduction). Accordingly, the patient with a chief complaint of mouth opening limitation. underwent splint treatment, pharmacotherapy, and Upon the clinical examination, the patient’s maxi- two sessions of intra-articular injection (stenoid, mum mouth opening ranged from 27 to 31 mm. hyaluronic acid), but did not see much symptom re- The patient experienced a lack of occlusion in both lief. As a result, the patient underwent bilateral TMJ posterior regions, pain in the lateral side of the right arthroscopy and thereafter, consistently underwent TMJ under finger pressure, lower jaw displacement physical therapy, pharmacotherapy, and traction upon mouth opening, stiff jaw in the morning, and therapy using SAS screws. TMJ arthroscopic lavage tinnitus. Despite splint treatment at another dental and lysis were performed at both TMJ superior joint clinic, the symptoms were not relieved. The patient spaces. Arthroscope showed fibrous adhesion and also underwent a radiographic examination and ecchymosis (Fig. 7). Posterior open bite was elimi- received medication at a nearby hospital. When she nated after arthroscopic treatment and elastic trac- visited our clinic (Fig. 4, 5), she had systemic disor- tion (Fig. 8). In 4 years and 10 months after the ini- ders including hypertension, rheumatoid arthritis, tial visit, the occlusion is stable and well maintained and chronic lung disease. Anterior displacement (Fig. 9). Radiograph 4 years and 10 months after the of the articular disc without reduction was found initial visit shows right condyle remodeling change on the magnetic resonance imaging (MRI). Slight and all therapies were terminated on February 15th, increase in hot uptake was observed at both TMJ on 2013 (Fig. 10). radioisotope bone scan, which did not necessarily

Fig. 4. Initial panoramic and temporomandibular panoramic radiography (TM panoramic radiography) of 54-year-old female patient.

Fig. 5. Oral photograph at initial visit. Posterior open bite is observed.

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Fig. 6. Both disc displacement without reduction was observed in temporomandibular joint (TMJ) magnetic resonance imaging. Bone scan showed mild TMJ uptake ratio (right: 3.20, left: 3.34) (asym- metric index, right: 1.07, left: 0.93).

Discussion may have worsened as the implant support sank, causing the loss of both open bite and occlusal sup- Malocclusion may be indirectly related to TMD port. and numerous studies have revealed that there is TMJ osteoarthritis is a degenerative change ac- little evidence that occlusal treatment, prosthodon- companied by secondary joint inflammation that tic or orthodontic treatment effectively treats TMD4). can lead to bone disruption, which surpasses the There is no scientific evidence that orthodontic bone remodeling ability of the condyle. It can be or prosthodontic treatment to treat malocclusion caused by impaired growth, tumor, local tooth loss, induces TMD5). However, loss of occlusal support malocclusion, aging, metabolic abnormalities in the may be associated with the degenerative changes of cartilage, and systemic disorders such as rheuma- the TMJ. In other words, when the vertical occlusal toid arthritis. Symptoms may appear around the dimension decreases due to severe attrition, the risk TMJ after a delayed period in adult patients who for TMD significantly increases. In female patients, have been suffering from rheumatoid arthritis for loss of occlusal support with age increases the risk a long time. Juvenile idiopathic arthritis (JIA) is a for the degenerative condylar changes, and sub- systemic inflammatory disorder that induces the acute malocclusion may also occur6). In the case of destruction of hard tissue, soft tissue and various the first patient presented in this case report, TMD joints. When the TMJ are affected, swelling, pain,

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Fig. 7. Temporomandibular joint (TMJ) arthroscopic lavage and lysis were performed at both TMJ superior joint spaces. Arthroscope showed fibrous adhesion and ecchymosis.

Fig. 8. Posterior open bite was eliminated after arthroscopic treatment and elastic traction.

Fig. 9. Oral photograph 4 years and 10 months after the initial visit. The occlusion is stable and well maintained.

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TMJ osteoarthritis, JIA, and ICR can result in severe malocclusion and facial deformities. Patients without previous symptoms may begin to have symptoms after stress, or after a load application to the TMJ during dental treatment. For this reason, clinicians must be familiar with simple clinical ex- aminations or useful diagnostic methods that can be used to identify these patients. Common diagnostic methods include the following1,2,6-9). 1) ‌Physical examination for identifying systemic disorders: Measure the erythrocyte sedimenta- tion rate (ESR), C-reactive protein level (CRP), rheumatoid factor (positive for 80% of patients with rheumatoid arthritis and 33% of patients with scleroderma), and antinuclear antibodies (detected in 40%~60% of patients with rheumatoid arthritis) to identify patients with rheumatoid arthritis, scleroderma, and other autoim- mune diseases. 2) ‌Investigate the patient’s history of steroid use Right Left 3) ‌Investigate the patient’s history of orthodontic

Fig. 10. Radiograph 4 years and 10 months after the initial visit. or orthopedic treatment 4) ‌Investigate the patient’s history of orthodontic crepitation, mouth opening limitation, mandibular device use, such as chin cups, mandibular repo- retrognathism, anterior open bite, and facial asym- sitioning device, and orthopedic braces for the metry can result. Patients with JIA are more likely treatment of scoliosis or kyphosis. to experience craniofacial or neck pain, and to have 5) ‌Radiographic examination: Assess changes in impaired functions even after 20 years, when com- the condylar shape and morphology on radio- pared to people without JIA7-9). Idiopathic condylar graphic images, such as panoramic and com- resorption (ICR), also called condyle atrophy and puterized tomography images. Most patients progressive condyle resorption, is considered a se- show small and slender condyles with irregular vere type of osteoarthritis. It commonly occurs pre- cortical bone surfaces; however, if bone resorp- dominantly among women aged 15 to 35 years with tion has stabilized, the cortical bone may show high mandibular plane angle and Class II occlusion. a normal morphology. A shortened ramus of It frequently affects teenage girls who are physically the mandible may be observed on lateral cepha- active. The pathology can be caused or aggravated lograms, and various open bite patterns can be by microtrauma or microtrauma. For this reason, observed as the mandible rotates clockwise. it used to be called “cheerleader syndrome.” Ado- 6) ‌Nuclear medical imaging: The diagnostic value lescent internal condylar resorption is the most of single photon emission computerized to- common type of condylar resorption. It commonly mography (SPECT) is known to be significantly develops in teenage girls during puberty8). greater than that of common nuclear medical

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tests. Teenage patients who are still undergoing mandibular condyle is pushed forward. When condylar growth tend to exhibit a symmetric TMD becomes chronic, permanent structural increase in uptake during a nuclear medical test. changes such as articular disc displacement, However, if uptake increases abnormally or condylar resorption, and condylar displacement asymmetrically, condylar resorption or progres- can occur. When the anterior displacement of sion to inflammatory lesions may be suspected. the articular disc without reduction continues, 7) ‌MRI: MRI is the most important diagnostic tool the mandibular condyle is pushed backward, for locating the articular disc, detecting changes and the mandible moves to the affected side, in bone and soft tissue, and tracking inflamma- leading to anterior open bite and centric rela- tory reactions. tion (CR)-centric occlusion (CO) discrepancy. Occlusal changes can occur because of impaired As bone resorption progresses, the height of growth of the muscles of the TMJ, and TMJ internal the mandibular ramus is reduced, leading to derangement such as articular disc displacement. excessive contact with the posterior part of the They can be classified as follows10): affected side and the posterior open bite of the 1) ‌Occlusal changes related to the progression of unaffected side. When osteoarthritis becomes TMD (Fig. 11, 12): Excessive effusion, swelling, bilateral, anterior open bite may occur11-13). and pain occur as articular capsules, retrodiscal 2) ‌Occlusal changes related to the treatment of tissue, and ligaments become inflamed, and the TMD (Fig. 13): If a patient wears a defective de- mandibular moves to the opposite side as the vice, wears an anterior repositioning device or

Fig. 11. Acute malocclusion developed 34 months after final implant prosthetic function (maxilla and mandible fixed hybrid prosthesis) in 48-year-old female patient. There were temporomandibular joint (TMJ) pain in the right side and mouth opening limitation (<20 mm). Irregular cortical surface on the right condyle was found in panoramic radiograph. This patient was treated with right TMJ steroid injection, medication, physical therapy and stabilization splint therapy.

Fig. 12. Malocclusion was re solved after conservative treatment (medication, joint cor- ticosteroid injection, physical therapy, stabilization splint).

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Fig. 13. Inaccurate appliance, anterior repositioning splint, ill-fitting appliances can cause irreversible occlusal change. Even if a normal device is made, if the patient does not want to go to the hospital well and is used for a long time arbitrarily, malocclusion may result. (A) Defective splints made by healthcare professionals other than dentists must not be used. It is best to choose a stabilization splint that does not cause irreversible occlusal changes and that has a good therapeutic effect. (B) A 37-year-old female patient presented with irreversible malocclusion with long-term intraoral appliance wear. On the panoramic radiographs, the shape of the bilateral condyles was normal. The device was worn for two years. Severe open bite remained long after removal of the device.

partial coverage splint for a long time, or has a For Case 1 in this study, occlusal changes were normal device but does not visit the hospital or presumably induced by anterior displacement of wear the device regularly, then occlusal changes the articular disc, or by the muscular disorder de- can occur. Therefore, it is desirable to choose a veloped due to long-term dental treatment. How- safe device (stabilization splint) that does not ever, the fact that malocclusion persisted for a long induce irreversible occlusal changes but instead period of time, even after TMJ treatment, suggests has excellent therapeutic effects14-16). that the occlusal changes may have been caused by If occlusal changes develop in association with other factors, such as sinking of the implant sup- TMD, then it must be determined whether occlusal port. Therefore, there is a possibility that occlusal treatment must be performed after initial treatment changes worsened the TMD. Prosthetic treatment of the TMD. Irreversible treatment such as occlusal in the maxilla to recover occlusion, occlusal stabili- adjustment, prosthetic treatment, and orthodontic zation following TMJ treatment, continuous BTX- treatment should be avoided in the beginning of A injections and the splint treatment, may resolve pathology11,17). Instead, remedies including nonste- TMD and malocclusion. For Case 2, it appears roidal anti-inflammatory drug injections for reduc- that acute malocclusion occurred as TMJ internal tion of inflammation, occlusal stabilization splint derangement recurred. It was successfully treated for reduction of the load applied to the TMJ, physi- by pharmacotherapy, physical therapy, and splint cal therapy, short-term oral administration or intra- treatment. Case 3 developed a mouth opening articular injections of steroids (in the case of severe limitation and malocclusion because the anterior symptoms), elastic traction using an intermaxillary displacement of the articular disc was maintained traction device or titanium screws, arthrocentesis, for a long period of time. The conditions were not and arthroscopic surgery may be considered. relieved even after pharmacotherapy, intra-articular

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injections, physical therapy, and splint therapy, and 6. Magnusson C, Nilsson M, Magnusson T. Degen- the patient was treated with TMJ arthroscopy. erative changes in human temporomandibular In conclusion, differential diagnosis of occlusal joints in relation to occlusal support. Acta Odontol changes associated with TMJ is very important. Scand. 2010; 68: 305-11. One should be careful about performing irrevers- 7. Engström AL, Wänman A, Johansson A, Kesh- ible treatment, and must try conservative treatment ishian P, Forsberg M. Juvenile arthritis and devel- instead. If they are not resolved after conservative opment of symptoms of temporomandibular dis- treatment, then TMJ arthrocentesis and TMJ ar- orders: a 15-year prospective cohort study. J Orofac throscopy may be considered. If malocclusion per- Pain. 2007; 21: 120-6. sists even after symptoms are relieved through TMJ 8. Scrivani SJ, Keith DA, Kaban LB. Temporomandib- treatment, then prosthetic or orthodontic treatment ular disorders. N Engl J Med. 2008; 359: 2693-705. may then carefully be considered. 9. Abramowicz S, Kim S, Prahalad S, Chouinard AF, Kaban LB. Juvenile arthritis: current concepts Conflict of Interest in terminology, etiopathogenesis, diagnosis, and management. Int J Oral Maxillofac Surg. 2016; 45: No potential conflict of interest relevant to this ar- 801-12. ticle was reported. 10. Kim YK, Lee YJ, Yoon PY, Choi YH, Kim SK. Com- plication Q & A in dentistry: dental surgery, sys- References temic problems and complications. Seoul: Daehan Narae Publisher; 2015. p. 266-79. 1. Pogrel MA, Kopf J, Dodson TB, Hattner R, Kaban 11. Choi JM, Ahn HJ, Choi JG. The effectiveness of LB. A comparison of single-photon emission com- TMJ distraction therapy for anterior open bite as puted tomography and planar imaging for quanti- consequence of degenerative joint disease. Korean tative skeletal scintigraphy of the mandibular con- J Oral Med. 2002; 27: 363-70. dyle. Oral Surg Oral Med Oral Pathol Oral Radiol 12. Huh YK, Jeong JG, Choi JG. Temporomandibu- Endod. 1995; 80: 226-31. lar joint disorder and occlusal changes: occlusal 2. Kaban LB, Cisneros GJ, Heyman S, Treves S. As- changes following prosthetic and orthodontic sessment of mandibular growth by skeletal scintig- treatments. Seoul: Well Publisher; 2013. p. 9-49. raphy. J Oral Maxillofac Surg. 1982; 40: 18-22. 13. van den Berg WB. Osteoarthritis year 2010 in re- 3. Lee BK. Evidence-based practice in the treatment view: pathomechanisms. Osteoarthritis Cartilage. of temporomandibular disorders. J Korean Assoc 2011; 19: 338-41. Oral Maxillofac Surg. 2012; 38: 263. 14. Al-Ani Z, Davies S, Sloan P, Gray R. Change in the 4. Hirsch C, John MT, Drangsholt MT, Mancl LA. number of occlusal contacts following splint thera- Relationship between overbite/overjet and click- py in patients with a temporomandibular disorder ing or crepitus of the temporomandibular joint. J (TMD). Eur J Prosthodont Restor Dent. 2008; 16: Orofac Pain. 2005; 19: 218-25. 98-103. 5. Antunes Ortega AC, Pozza DH, Rocha Rodrigues 15. Ekberg E, Nilner M. A 6- and 12-month follow-up LL, Guimarães AS. Relationship between ortho- of appliance therapy in TMD patients: a follow-up dontics and temporomandibular disorders: a pro- of a controlled trial. Int J Prosthodont. 2002; 15: 564- spective study. J Oral Facial Pain Headache. 2016; 70. 30: 134-8. 16. Magnusson T, Adiels AM, Nilsson HL, Helkimo M.

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