CASE REPORT J Korean Dent Sci. 2018;11(1):21-31 https://doi.org/10.5856/JKDS.2018.11.1.21 ISSN 2005-4742 Temporomandibular Joint Disorder and Occlusal Changes: Case Reports 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 AB Fig. 1. A 56-year-old patient who developed temporomandibu- lar disorder (TMD) and occlusal changes after undergoing long- term implant treatment. (A) Panoramic radiograph obtained 2 months after the final prosthesis placement. (B) Panoramic ra- diograph obtained 1 year after the final prosthesis placement. (C) C Panoramic radiograph obtained 4 years after the final prosthesis placement. 22 J Korean Dent Sci 2018;11(1):21-31 Young-Kyun Kim: Temporomandibular Joint Disorder and Occlusal Changes Young-Kyun Kim: Temporomandibular Joint Disorder and Occlusal Changes 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 de- rangement, 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. J Korean Dent Sci 2018;11(1):21-31 23 Young-Kyun Kim: Temporomandibular Joint Disorder and Occlusal Changes Young-Kyun Kim: Temporomandibular Joint Disorder and Occlusal Changes 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