Conservative Treatment of TMJ Disorder A Case Report

Dr. Santosh Kumar, B.D.S, M.D.S (Principal Author)

Dr. Kumar is Professor & Head in the Department of Orthodontics & Dentofacial
Orthopedics of the Kothiwal Dental College & Research Center, Moradabad
(U.P), India. He is the member of Indian Orthodontics Society & Indian Dental
Association.
Postal Address:
Dr. Santosh Kumar, B.D.S, M.D.S
Professor & Head Department of Orthodontics & Dentofacial Orthopedics
Kothiwal Dental College & Research
Center, Moradabad (U.P), India- 244001
Vikas Goyal, B.D.S (Corresponding Author)
Dr. Goyal is third year post graduate student in the Department of Orthodontics
& Dentofacial Orthopedics of the Kothiwal Dental College & Research Center,
Moradabad (U.P), India. He is the member of Indian Orthodontics Society
Postal Address:

email: dr_goyal1982@yahoo.com

Dr. Vikas Goyal, B.D.S

Department of Orthodontics & Dentofacial Orthopedics
Kothiwal Dental College &
Research Center, Moradabad (U.P),
India- 244001

Abstract:
Aim: To treat the temporomandibular joint disorder conservatively to relieve pain and to
increased restricted mouth opening
Background: To a great extent treatment for TMJ disorder has been described by
several authors. Few of them suggested the conservative method using oral splint2,3,4.
Case Description: Two cases reported with restricted mouth opening and TMJ pain
while opening & chewing were successfully treated using soft oral splint made by 2mm
bioplast material on a vacuum forming machine.
Summary:

With the use of soft oral splint cases with disk displacement without

reduction can be treated successfully as a conservative and an effective mode of

treatment
Clinical Significance: In the contemporary dental practice dentists frequently come
across the TMJ disorders. A thorough understanding of TMJ disorder will lead to proper
diagnosis of TMJ joint pain & dysfunction. Soft oral splints can be used as effective
means of treatment for such patients. This can be easily made & gives good comfort to
the patient.
Keyword: A case report, TMJ disorder, occlusal splints, disc displacement without
reduction, conservative treatment of TMJ disorder.

Conservative Treatment of TMJ Disorder A

Case Report
No single treatment is appropriate for all

manipulation, g) diagnostic anesthetic

temporomandibular disorders (TMDs),

blockade

therefore making a proper diagnosis

becomes an extremely important part of
managing the disorder,

a) History :

The clinician should

encourage the patient to recall the

events that seemed to initiate the

The two most common masticatory

problems (other then odontalgia) that
present in dental office are

disorder
b) Mandibular restriction: Restriction of
mouth opening and eccentric movements are common findings with

1. Masticatory muscle disorder

both joint disorders and muscle

2. Intra-capsular joint disorders

disorders. The character of the

Its extremely important that they should
be

differentiated

because

their

treatments are quite different

restrictions, however, can be quite

different.

Restriction

in

mouth

opening because of intracapsular

According to Okeson1 seven keys to

problems (e.g., a dislocated disc

diagnose case are, a) History, b)

without reduction) usually occurs at

Mandibular restriction, c) Mandibular

25 to 30 mm. At that point the mouth

interference, d) acute malocclusion, e)

cannot be opened wider, even with

loading

mild passive force. Restricted mouth

of

joint,

f)

functional

opening as a result of muscle dis3

orders can occur anywhere during

interincisal distance of the deviation,

the

For

and if the location of deviation is the

example, a restricted opening of 8 to

same for opening and closing , then

10 mm is most certainly of muscle

a structural incompatibility is a likely

origin. When muscles restrict mouth

diagnosis

opening

movement.

opening, mild passive force will

d) Acute

malocclusion.

As

stated

usually lengthen the muscles slightly

earlier, it is a sudden alteration of

and result in a small increase in

the occlusal condition secondary to

opening.

a disorder. An acute malocclusion

c) Mandibular interference when the

caused by a muscle disorder will

mouth is opened: the pathway of the

vary

mandible

involved.

is

to

the

muscles

for

any

If

the

e) Loading the joint: Positioning the

deviation occurs during opening and

condyles in the musculoskeletally

the jaw then returns to midline

stable (MS) position and loading the

before 30 to 35 mm of total opening,

structures with manipulative force

it is likely to be associated with the

does not produce pain in a healthy

disc derangement disorder. If the

joint. When pain is produced, the

speed of opening alter the location

clinician should be suspicious of an

of the deviation, it is likely to be

intracapsular source of pain

deviations

discal

or

observed

according

deflection.

movement

(e.g.,

disc

f) Functional manipulation: functional

displacement with reduction). If the

manipulation

can

be

helpful

in

speed of opening does not alter the

identifying the location of pain.

Functional manipulation procedures

the mandible during opening and closing

that do not produce pain tend to rule

movement. Patient is having Angles

out muscle disorders as the source

class I molar relationship with complete

of the problem

deep bite. Pretreatment OPG & TMJ

g) Diagnostic anesthetic blockade. For

tomogram shows normal joint (Fig 3, 4)

patients in whom the preceding six

procedures have not convincingly
assisted in making a differential
diagnosis between joint and muscle
disorders, anesthetic blockade is
indicated. Anesthetic blocking of the

Fig 1 Pretreatment reduced mouth opening (23mm)

auriculotemporal nerve can quickly

diagnose an internal disorder.
Case 1
A 20 year old Female patient reported to
the

Department

of

Orthodontics

&

Fig. 2 Pretreatment model showing deep bite

Dentofacial orthopedics with restricted

mouth opening (23 mm) (Fig.1). She
complained about pain in left TMJ area
with the pain radiating to head and
numbness on the left side of the face

Fig. 3 Pretreatment O.P.G showing no pathology

since 10 days. On examination there

was no clicking, crepitus & deviation of
5

Diagnosis: On clinical examination &

patient reported there was increased in

examination of OPG & TMJ tomogram,

the mouth opening (28 mm).

case has been diagnosed as Disc

displacement without reduction. It was
decided that case should be treated
conservatively using soft occlusal splint.

Fig. 5 Soft splint 2mm Bioplast

But patient was still complaining of the

pain in left TMJ area during chewing
only. After check up, patient advised to
Fig. 4 Pretreatment TMJ tomogram

Treatment:
Alginate Impression of the lower arch
made. Working cast poured with dental
stone. A 2mm Bioplast mandibular splint
fabricated on a vacuum machine (Fig.
5). The patient was instructed to wear
the appliance constantly for at least two
weeks, removing it only for oral hygiene
& having food. After two weeks when

continue the splint for another 1 month.

After 1 month when patient reported
back, there was good mouth opening
(32mm) (Fig.7). Patient was relieved
from the pain completely during rest
except slight amount of the pain during
chewing. Patient advised to continue the
appliance for another 1 month. On next
visit patient was relieved from pain
completely during rest as well as
chewing. After 2.5 month, anterior bite
6

plane was inserted in the patient for

opening the bite. Bite was opened in
posterior area by 2.5 mm. patient
recalled at monthly interval. After two
month there was opening of the bite
1mm; height of bite plane was increased
Fig. 7 Mouth opening after 1.5 month (32mm)

by 1 mm to maintain opening in
posterior region by 2.5 mm. appliance
discontinued 4 month after insertion.
2mm of total bite opening was achieved.
Total duration of treatment was 6.5
month. Patient advised to continue the
appliance for retention.
Fig. 8 Bite opening of 1 mm after 2 month

Case 2:
A 21 year old Female patient reported in
the Department with the chief complaint
of pain in TMJ area. On examination
there was single opening click with
restricted mouth opening of 16mm
Fig. 6 Anterior bite plane

(Fig.9). She was suffering from pain

since last 15 days. She consulted to
general dentist for the same and was

taking muscle relaxants. There was no

relief in pain or improvement in mouth
opening. Patient exhibited an Angle
Class I molar relationship with normal
overjet and overbite. Pretreatment OPG
& TMJ tomogram shows normal joint.
Fig. 10 Soft splint 2mm Bioplast

Treatment:
A 2mm Bioplast mandibular splint made
(Fig 10). The patient was instructed to
wear the appliance constantly for at
least two weeks, removing it only for
Fig. 9 Pretreatment reduced mouth opening (16mm)

Diagnosis: On clinical examination &

examination

of

OPG

and

TMJ

tomogram, case has been diagnosed as

Disc displacement without reduction. It
was decided that case should be treated
conservatively using soft occlusal splint.

oral hygiene and eating. After two

weeks the patient reported increased
mouth opening (31mm) (Fig.11). Patient
was relieved from the pain completely
during rest except slight amount of the
pain during chewing. Click was less
audible

than

previous.

Appliance

discontinued After 3 month as the

patient

was

relieved

from

pain

completely during rest as well as

chewing.
8

Angle Orthodont 1989; 59:16580.

3. Paulo Csar Rodrigues Conti
et.al. The treatment of painful
temporomandibular joint clicking
with oral splints. A randomized
clinical trial. J Am Dent Assoc

Fig. 11 Mouth opening after 2 weak (30mm)

Conclusion:

2006;137;1108-1114

The conventional soft occlusal splint

4. Venkatesh Naikmasur et al. Soft

therapy is a much safer and effective

occlusal splint therapy in the

mode of a conservative line of therapy in

management of myofascial pain

comparison to the surgical therapy for

dysfunction syndrome: A follow-

temporomandibular joint disorders. It

up study. Indian J Dent Res,

has better patient compliance, fewer

19(3), 2008; 196-203

side effects, and is more cost-effective

5. John C. Voudouris, Christopher

than surgical treatment.

G. Cameron, Serge Sanovic. The

References:

Anterior Bite-plane Nightguard for

Neuromuscular Deprogramming:

1. Okeson

JP.

Management

of
JCO,2008: Feb(2); 84-97

temporomandibular disorders and

occlusion. 5th ed. St. Louis:
Mosby; 2003. p. 260.
2. Boero RP. The physiology of
splint therapy: A literature review.
9