Temporomandibular disorders (TMDs) are considered the major cause of orofacial pain. Internal derangement (ID) of the temporomandibular joint (TMJ), which is classified as disc displacement with or without reduction, is one of the disorders of the TMJ that is frequently seen. Displacement of the articular disc can result in decreased joint space, joint noise (clicking, popping, or crepitation), arthritis, condylar resorption, inflammation, and compression of the bilaminar tissue, all of which can cause various degrees of pain and dysfunction.

1. GOOD MORNING

2. Comparison of the effectiveness of three different
treatment methods for temporomandibular joint
disc displacement without reduction
Presented by:
Dr Kamini Dadsena
Post Graduate
Int. J. Oral Maxillofac. Surg. 2017; 46: 603–609
U. Tatli, M. E. Benlidayi, O. Ekren, F. Salimov

3. Outline
• Aim
• Introduction
• Materials and methods
• Inclusion and exclusion criteria
• Treatment groups
• Data collection
• Statistical Analysis
• Results
• Discussion
• References

4. Aim
• The aim of this prospective clinical study was to evaluate and
compare the effectiveness of three different treatment
modalities (arthrocentesis, splint therapy following
arthrocentesis, and splint therapy only) on pain, function,
disability and psychological status of patients with unilateral
DDwoR.
• Explore whether simultaneous splint therapy has an
additional effect on the effectiveness of arthrocentesis.

5. Introduction
• Temporomandibular disorders (TMDs) are considered the major cause of
orofacial pain. Internal derangement (ID) of the temporomandibular joint
(TMJ), which is classified as disc displacement with or without reduction, is
one of the disorders of the TMJ that is frequently seen.
• Displacement of the articular disc can result in decreased joint space, joint
noise (clicking, popping, or crepitation), arthritis, condylar resorption,
inflammation, and compression of the bilaminar tissue, all of which can
cause various degrees of pain and dysfunction.

6. • Untreated or inadequately treated ID can cause chronic disc displacement,
which may lead to deformation of the disc and breakdown of the
fibrocartilage covering the condyle and fossa, resulting in osteoarthritis of
the TMJ.
• Disc displacement without reduction (DDwoR) is the worst subgroup of ID of
the TMJ. It is a clinical condition in which the joint disc is dislocated from the
condyle and does not return to its normal position during joint movement.
• Macro- and micro-trauma are the most common causes of DDwoR. Pain and
restricted range of mandibular motion are the most frequent symptoms of
DDwoR.
Introduction

7. • Treatment methods for DDwoR fall into two categories: conservative
methods and surgical methods.
• Conservative treatments include manipulation, medication,
modification of habits, physical therapy, and splint therapy.
• Surgical treatments include arthrocentesis, arthroscopy, and open
joint surgeries.
Introduction

8. • The contemporary treatment strategy for ID of the TMJ consists of
conservative methods initially. If there is no response to conservative
methods, arthrocentesis is generally performed as a second-step therapy.
• Splint therapy is used to reduce the excessive loading on the joint, relax the
masticatory muscles, and support the adaptation of the articular structures
and regenerative processes in the joint. Splint therapy is often successful,
but the length of time required to reach a pain-free normal range of joint
function is sub-optimal.
Introduction

9. • Thus splint treatment may delay the achievement of efficient therapy
and the arthropathy may become worse and more persistent.
Alternatively, arthrocentesis removes degradation products and
inflammatory mediators directly and quickly, and healing is rapid.
Promising results have been reported with the use of arthrocentesis
as an initial treatment method in DDwoR.
Introduction

10. Materials and Methods

11. Inclusion criteria
• The inclusion criteria for the study were clinical and magnetic
resonance imaging (MRI) diagnosis of unilateral TMJ DDwoR, and
persistent pain after 2 weeks of daily non-steroidal anti-inflammatory
(exclusion of acute inflammatory pain) and muscle relaxant drug
consumption, a soft diet, and physical exercises (exclusion of patients
with mainly myogenous symptoms).

12. Exclusion criteria
• Patients with a diagnosis of systemic rheumatic disease, myalgia,
degenerative joint disease, or collagen vascular disease, those who
were pregnant, and patients who had medical contraindications,
were unwilling to receive one of the study treatments, had
undergone prior open TMJ surgery, had a malocclusion, or were aged
<16 years were excluded from the study.

13. Patients and Methods
• TMJ DDwoR was diagnosed by a history of reduction in mouth
opening (unassisted maximum inter-incisal mouth opening <35
mm)
• Mandibular opening with assistance increased by 3 mm over
unassisted opening, and
• TMJ pain during palpation and/or function.
• A previous history of click, click disappearance, and decreased
mouth opening must have coincided.

14. Materials and Methods
Group 1
40 Patients
with
arthrocentesis
alone
Group 2
40 patients with
arthrocentesis
and splint
therapy
Group 3
40 patients with
splint therapy
alone
120
patients
With TMD

15. Treatment Group 1

16. Treatment Group 1

17. Treatment Group 1

19. Treatment Group 2
• Patients assigned to group 2 were treated with a stabilization splint following
arthrocentesis plus sodium hyaluronate injection. An intraoral hard acrylic
splint was prefabricated before the arthrocentesis. Following the
arthrocentesis, the patients were instructed to use the oral appliance during
the night and also for 1 or 2 h in the daytime for 6 months, to get used to the
desired jaw position. The splint treatment was performed by the same
experienced prosthodontist, as described by Okeson. The contact points of
all teeth were provided at centric occlusion. A canine protective occlusion
was prepared for laterotrusive and protrusive jaw movements.

20. Types of Occlusal Splints Used in TMJ
Disorders
• Stabilization splints
• Repositioning splints
• Pivot splints
• Soft splints
• Bite plane splints

21. Stabilization splints:

22. Pivot splints

23. Repositioning splints

24. Soft splints:

25. Treatment Group 3
• Patients assigned to group 3 were treated with a stabilization splint
only.
• All participants were instructed to use pain medication when needed
(ibuprofen 600 mg).

26. Parameters
• Maximum mouth opening (MMO; measured between the edges of the
upper and lower central incisors in millimetres)
• Maximum laterotrusive movements (horizontal distance between the
midpoints of the upper and lower incisors during ipsilateral and contralateral
jaw movements in millimetres)
• Joint pain on palpation, and mandibular function. Pain was evaluated by
patient self-assessment using a visual analogue scale (VAS, 0–10 cm).
• The success criteria for surgery for ID of the TMJ were those proposed by the
American Association of Oral and Maxillofacial Surgeons (AAOMS)

27. Parameters
AAOMS indicating successful treatment of TMDs when there is an
absence of pain or mild pain and a MMO of 35 mm. Thus treatment
was considered successful in the presence of a MMO 35 mm and pain
VAS score <3 at the follow-up visits. The percentage of patients who
met these criteria was considered as the success rate.

28. Results
EVALUATION OF PAIN SCORES

29. Results
EVALUATION OF FUNCTIONAL VALUES

30. Results
EVALUATION OF FUNCTIONAL VALUES

31. Results
EVALUATION OF FUNCTIONAL VALUES

32. Results
EVALUATION OF FUNCTIONAL VALUES

33. Results
EVALUATION OF THE BIOBEHAVIOURAL QUESTIONNAIRE

34. Results
EVALUATION OF THE SUCCESS RATES OF THE TREATMENT METHODS

35. Discussion
• Internal derangement of the TMJ is a complicated phenomenon
involving inflammation of the articular structures, changes in the
intra-articular pressure, alterations in the volume and biochemical
composition of the synovial fluid, and disc derangements.
• Splints are considered to cause alterations in the mechanical sensory
input arising from the periodontal tissues and masticatory muscles
and therefore to decrease intra-articular pressure in the TMJ. Thus,
splints are used for the non-surgical treatment of ID of the TMJ to
reduce bruxism, stress, and excessive loading on the joint structures.

36. Discussion
• The present study compared the effectiveness of arthrocentesis, splint
treatment, and a combination of both therapies in the treatment of
unilateral TMJ DDwoR. Based on the results, all three treatment methods
yielded significantly improved outcomes regarding pain, joint function, and
disability and psychological status of the patients compared to baseline.
• The results indicate that arthrocentesis as the initial treatment provides
comparable results whether used alone or in combination therapy. It was
observed that simultaneous splint treatment did not have a significant
additional effect on the outcome compared with arthrocentesis alone.

37. Discussion
• Machon et al. evaluated the effectiveness of various therapeutic
options in the treatment of unilateral TMJ osteoarthritis, and showed
that arthrocentesis combined with splint therapy achieved higher
success rates than splint treatment alone.
• Alpaslan et al. showed that the use of splints in addition to
arthrocentesis did not affect the prognosis in the treatment of
DDwoR.

38. Discussion
• A study by Vos et al. showed that arthrocentesis reduced the pain and
functional impairment more rapidly than conservative treatment in TMJ
arthropathy patients.
• Dıraçoğlu et al. compared the outcomes of arthrocentesis and conventional
treatment in patients with DDwoR and noted that arthrocentesis was
superior only regarding pain management.
• Ohnuki et al. compared the MRI findings of patients with DDwoR after
manipulation, splint therapy, arthrocentesis, and arthroscopy. The authors
noted that clinical symptoms were alleviated but that MRI findings of
DDwoR remained.

39. Discussion
• Ghanem compared the outcome of arthrocentesis and splint therapy
following arthrocentesis for the treatment of acute closed lock and
noted that the success rate of combination therapy was better.
• Lee et al. reported that the simultaneous application of
arthrocentesis and occlusal splints could reduce patient discomfort
more rapidly and that these patients met the success criteria earlier
than those who only used a splint.

40. Discussion
• Murakami et al. compared the efficacy of non-surgical treatment,
arthrocentesis, and arthroscopy for the management of TMJ closed lock and
noted success rates of 55.6%, 70%, and 91%, respectively, at 6 months after
treatment.
• The results of the present study showed rapid improvements in the
parameters assessed with the application of arthrocentesis compared to
splint treatment. This rapid improvement after arthrocentesis may be
explained by the release of intra-capsular adhesions and the immediate
elimination of inflammatory cytokines, matrix-degrading enzymes, and
degeneration products.

41. Discussion
• Lavage and lysis of the upper joint space will eliminate the vacuum
effect and alter the viscosity of the synovial fluid, thereby aiding
mobilization of the disc.
• These progressions require more time to occur in splint therapy,
which may lead to possible complications: patients may become
bored or drop out of treatment, or the TMD may worsen or become
persistent.

42. Discussion
• Bruxism is thought to be one of the major contributing factors to the aetiology of
TMD. Thus, patients with bruxism were not excluded from the present study.
• The percentages of patients with bruxism were similar in the three groups. A
better outcome may be expected in patients treated with a splint that reduces
the intra-articular pressure.
• Nevertheless, no adverse results were observed in patients treated with
arthrocentesis.
• A 5-year retrospective study demonstrated that the long-term outcomes of
arthrocentesis for the treatment of ID of the TMJ were comparable in bruxer and
non-bruxer patients.

43. Discussion
• While evaluating the effectiveness of treatment methods for TMD,
the psychological status of the patients should also be considered.
The results of this study showed that arthrocentesis and combination
therapy rehabilitated the psychological status of the patients more
rapidly and effectively than splint therapy alone, at 1 month after
treatment. However, after 3 and 6 months, all treatment methods
showed similar effects on the psychological status of the participants

44. Discussion
• In the literature, the success rates of splint therapy and
arthrocentesis have been reported to be 30–90% and 70–95%,
respectively.
• Since DDwoR is the worst subgroup of ID of the TMJ, methods that
are time-consuming and less effective may lead to disease worsening
or persistence. Thus, the principle that conservative treatment
methods, particularly splint treatment, should be used as the initial
option because this will be less harmful should be reconsidered for
TMJ DDwoR.

45. Management of non-reducing temporomandibular
joint disk displacement Evaluation of three treatments
Objective. The purpose of this study is to evaluate the responses of patients with anterior disk
displacement without reduction to natural course, stabilization splint, and surgery.
Study design. Thirty-one patients refused any treatment (natural course group), 20 patients were
treated with a stabilization splint (stabilization splint group), and 24 patients who had not responded to
nonsurgical treatment for a mean period of 19.0 months underwent surgery (surgical group). The
success rate was evaluated in each of the three groups.
Results. The success rate was 41.9% in the natural course group, 55.0% in the stabilization splint group,
and 76.9% in the surgical group.
Conclusions. No statistically significant benefit from treatment with a stabilization splint over no
treatment was identified although both groups of patients experienced alleviation of discomfort. The
patients who had not responded to nonsurgical treatment for a mean period of 19 months benefited
from surgery.
Shuichi Sato, Hiroshi Kawamura and Katsutoshi Motegi
(ORAL SURG ORAL MED ORAL PATHOL ORAL RADIOL ENDOD 1995;80:384-8)

46. Arthrocentesis versus nonsurgical methods in the treatment
of temporomandibular disc displacement without reduction
Objective. The aim was to compare the short- and medium-term results of arthrocentesis and conventional treatment (splint, heat, and exercise) in patients
with early temporomandibular joint (TMJ) disc displacement without reduction (DDw/oR).
Study design. One hundred twenty consecutive patients (104 female, 16 male), who had been followed by a multidisciplinary TMJ unit with the diagnosis of
DDw/oR were enrolled in this single-blind prospective study. Patients either underwent arthrocentesis or they were given a combination of splint, hot pack,
and home exercise program. Visual analog scale (VAS) was used for pain assessment. Maximal mouth opening (MMO), lateral movement, and protrusion
were measured. Repeat measurements were performed on the first, third, and sixth months following treatments.
Results. Arthrocentesis group consisted of 54 individuals (51 female, 3 male), and the conventional treatment group consisted of 56 individuals (49 female,
7 male). The mean age values of the groups were 33.4 years (range 15-63 years) and 34.8 years (range 17-61 years), respectively. Baseline VAS and MMO
values of the arthrocentesis and conventional treatment groups were similar (P .05). Regarding VAS and MMO, lateral movement, and protrusion, the
intragroup analyses showed a statistically significant reduction in both groups compared with baseline values (all P .01). Regarding VAS values, the
difference values between each evaluation and the baseline measurement were significantly higher in the arthrocentesis group, except for the first-month
difference. Regarding MMO, lateral movements, and protrusion, the differences between the baseline values and each evaluation thereafter were
statistically similar between the 2 groups (P .05).
Conclusion. We conclude that early treatment either with conservative methods or with arthrocentesis is beneficial in DDw/oR. However, arthrocentesis
seems to be superior regarding pain management. Therefore, arthrocentesis may be indicated in patients where painful complaints overwhelm despite
other conservative treatments
Demirhan Dıraçog˘lu, Bayraktar Saral, Barıs Keklik, Hanefi Kurt, Ufuk Emekli, Levent Özçakar, Ayse Karan, Cihan Aksoy
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:3-8)

47. Strengths & Weekness of Study
• Strengths of the present study include the randomized allocation of
participants with only unilateral involvement to the treatment
groups, the blinded follow-up recordings, a sufficient sample size,
and the evaluation of the participants’ disability and psychological
status by means of a validated questionnaire.
• A possible weakness of the study was that the duration after
symptom onset was not recorded. The possible differences in the
duration of TMD could have affected the results, since it has been
shown that the initiation of treatment within a short period after
symptom onset increases the treatment efficacy.

48. Conclusion
• Arthrocentesis reduces pain and functional impairment more rapidly
and effectively than splint therapy.
• Simultaneous splint application has no additional effect on the
effectiveness of arthrocentesis for the treatment of unilateral
DDwoR.

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51. THANK YOU