Physical Exercises for Temporomandibular Disorders
Condition: Facial Pain; Temporomandibular Disorder; Temporomandibular Joint Disorders; Temporomandibular; Functional Disturbance
MeSH terms: Temporomandibular Joint Disorders; Temporomandibular Joint Dysfunction Syndrome; Facial Pain
Study type: Interventional

Summary: 
      Temporomandibular Disorders are a common clinical picture that appear in particular in people
      between the age of 20 and 40 years. About 33% of the total population shows symptoms and
      signs of TMD. Among the temporomandibular joint disorders anterior disc displacement appear
      to be the most common. In case of limitations of jaw movements and or pain conservative
      methods including combinations of behavior change, physiotherapy, stabilization appliance
      therapy and medication are most popular. The benefit of a self-treatment program to
      strengthen the lateral pterygoid muscle and to learn a properly executed lower jaw sideways
      movement to achieve pain reduction is up to now not well investigated. The aim of this study
      is to examine the effectiveness of muscle training for the treatment of patients with
      anterior disc displacement with reduction (DDWR). 60 patients with DDWR and pain (≥18 years)
      will be randomly allocated to two groups: 1. Physical exercises, 2. Stabilization appliance
      therapy. All patients receive a functional examination according to the Diagnostic Criteria
      for Temporomandibular Disorders (DC/TMD) at baseline.

      The training in group 1 includes eccentric and concentric counter-movements of the lower jaw
      muscle to strengthen and restore a physiological lateral movement of the mandible. The muscle
      exercises should be performed once a day with 5-6 repetitions per side. The treatment with an
      equilibration appliance in the lower jaw serves as a comparison group. Patients are
      instructed to wear the appliance while sleeping. The wearing rhythm is described as
      intermittent. (three nights - wearing the appliance, one night - not wearing the appliance).
      The primary target variable is the occurrence of pain in the head and joint area before and
      during therapy. The variable is measured using a numeric rating scale (NRS; 0-10) during the
      baseline examination and control check-ups after 2, 4 and 6 months.
    

Detailed description: 
      The literature describes the cause of a temporomandibular disorder (TMD) as a multifactorial
      event. It can be influenced by anatomical, neuromuscular, traumatic or psychosocial factors.
      Disturbances often occur in the condyle-disc complex of the temporomandibular joint. The
      relationship between the articular disc and the condyle head is pathologically altered. The
      Diagnostic Criteria for Temporomandibular disorders (DC / TMD) describe the displacement of
      the disc in 4 different forms: disc displacement with reduction; disc displacement with
      reduction and intermittent locking; disc displacement without reduction with limited opening
      and disc displacement without reduction without limited opening. TMDs are a common clinical
      picture that appears in particular in people between the age of 20 and 40 years. About 33% of
      the total population show signs and symptoms of TMD.

      Studies prove that the displacement of the disc with reduction is the most common disorder
      among temporomandibular joint disorders. According to the DC / TMD, this clinical picture
      shows intracapsular and biomechanical alterations. If the mouth is closed, the articular disc
      is often located in front of the mandibular condyle; if the mouth is opened, the disc moves
      back to its original position on the condyle. Anterior disc displacement appears to be the
      most common, although a medial or lateral displacement is also possible. During the disc
      repositioning clicking, popping or snapping noises are usually recorded. Temporomandibular
      joint disorders such as disc displacement, can also cause pain. Overstretching of the
      posterior ligament and a compression of the bilaminar zone mandibular movements can be
      pain-related. Therefore, clicking, popping or snapping noises in the area of the
      temporomandibular joint (TMJ) correlate with pain in the surrounding tissue. Those complaints
      intensify when opening the mouth or chewing food.

      The treatment of TMD should be oriented on evidence-based procedures that are easy to
      implement in practice and have a long-term positive effect on the patient's symptoms.
      Conservative methods including combinations of behavior change, physiotherapy, splint-therapy
      and medication are most popular. The physiotherapeutic treatment should pursue different
      strategies, including manual therapy methods (e.g. mobilization and stretching of the
      temporomandibular joint and / or the neck area) and the demonstration of exercises in
      everyday life (e.g. self-mobilization and stretching of the masticatory muscles and / or
      cervical spine) and in addition educating the patient (e.g. about the perception of
      parafunctions or relaxation techniques). Conservative attempts for patients with TMD should
      be the first choice. However, there is still no clear data situation and the data pool of
      randomized clinical studies on this topic needs to be improved. So far studies demonstrate a
      positive effect of the tested therapy forms. But the individual studies differ greatly in
      terms of the patient pool, diagnosis, treatment modalities and the result. Furthermore, a
      precisely described procedure is missing in some papers. Therefore, an exact reproducibility
      for practitioners is not executable. More research is needed into the benefits of various
      non-invasive treatments for TMD.

      The primary goal of this study is to decrease the ambiguity in this scientific field. In the
      past various manual and physiotherapeutic exercise methods have already been tested.

      This study is also intended to examine the effectiveness of muscle training for the treatment
      of patients with anterior disc displacement with reduction. The exercises are primarily
      supposed to train the lateral pterygoid muscle. The treatment with an equilibration appliance
      in the lower jaw serves as a comparison group.
    

Intervention name(s): Physical therapy; Appliance therapy
Intervention type(s): Other; Other
Intervention description(s): Coordination training for lateral movement of the mandible (spatula exercise):
A wooden spatula is loosely placed between the teeth of the upper and lower jaw; the head must be aligned with the body axis; the exercise should be performed in front of a mirror.
The lower jaw moves to the left and back to the center with little contact to the spatula
The lower jaw moves to the right and back to the center under contact with the spatula
Training of the left lateral pterygoid muscle:
The left palm is placed on the left temple region
Right hand forms a fist and is placed on the tip of the right chin
Both arms are aligned parallel to the surface of the floor
The lower jaw is moved to the right against a moderate resistance of the fist = concentric muscle work
With measured force of the fist, the lower jaw is brought back to the center = eccentric muscle work (Right lateral pterygoid muscle training with opposite hands.); Upper and lower jaw impressions are registered by using an intraoral scanner. The arbitrary hinge axis position is determined using a face bow.
The stabilization appliance with anterior canine guidance is manufactured in the Lexmann laboratory in Dresden.
The stabilization appliance is incorporated by the dentist and the static and dynamic occlusion is checked. A tension-free fit of the appliance on the lower jaw is necessary. Additionally, equal contacts in the side teeth area and incisors guidance in the case of mandibular protrusion are checked visually and by using occlusion foil. During mandibular lateral movement only the canine guidance takes place and is also registered optically and by using occlusion foil.Interference contacts should be adjusted.
The patient is instructed to wear the stabilization appliance while sleeping. The wearing rhythm is described as intermittent. (three nights - wearing the appliance, one night - not wearing the appliance).
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Prospective, randomized study with control group, stratified by gender.
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: physical therapy; stabilization appliance; clinical trial; dentistry