Abstract
The goal of rehabilitation after temporomandibular joint (TMJ) surgery is to achieve a normal range of motion. The aim of this study was to compare the impact of a comprehensive and early supervised rehabilitation programme with home-based exercise after TMJ condylar discopexy. Patients diagnosed with disc displacement without reduction were randomized to the study and control groups. After baseline assessments, the same surgical condylar discopexy procedure was applied to both groups. Following surgery, the study group patients underwent a supervised exercise programme conducted by a physiotherapist in the outpatient clinic. This comprised 30-min sessions 3 days per week for 8 weeks in the hospital. The control group patients performed the same exercise programme at home. Maximum mouth opening (MMO), protrusion, and right and left lateral movements were measured. Based on the results, the supervised rehabilitation programme yielded significantly better outcomes for pain at rest and with activity, MMO, and protrusion compared with the home-based exercise programme. Also certain parameters of quality of life improved significantly in the study group. In conclusion, exercise therapy is the cornerstone of rehabilitation of the TMJ, and a supervised rehabilitation programme after TMJ surgery is effective in improving functional parameters.
The main symptoms and dysfunctions related to temporomandibular disorders (TMDs) are associated with altered condyle–disc function. Temporomandibular joint (TMJ) disc displacement without reduction (DDw/oR) is commonly seen in TMDs. Disc displacement can only occur in the intercuspal occlusal position (disc displacement with reduction (DDw/R)) or during condylar movements when opening the mouth (DDw/oR).
The newly recommended Research Diagnostic Criteria (RDC) for TMDs have been demonstrated to be valid for the most common pain-related TMDs and for TMJ intra-articular disorders. TMDs are considered the most frequent causes of chronic orofacial pain. Disc displacement is a clinical condition in which the disc is dislocated from the condyle, most frequently anteromedially, and does not return to its normal position with condylar movement. Macrotrauma and microtrauma are the most common causes of DDw/oR.
The majority of patients with TMDs can be treated successfully with conservative non-surgical therapies, and surgical interventions are required for only a small proportion of the TMD population. All non-surgical treatment options must be exhausted before invasive methods are undertaken for the management of TMDs. Conservative treatment consists of medication, physical therapy, occlusal splints, manipulation, and intra-articular injections (hyaluronic acid, corticosteroids, prolotherapy, or irrigation with saline). The success of conservative treatment is reported to be above 80%. Symptoms typically resolve within 2–4 weeks in 50% of patients, and a surgical intervention is required in only 5%. When symptoms begin, arthroscopy, lysis and lavage, and injections may be effective for establishing normal maximum mouth opening (MMO) and pain relief. Procedures that are sometimes used to correct minor disorders include condylar discopexy, eminectomy, and arthroplasty. In severe cases where there is irreversible resorption and joint degeneration, prosthetic TMJ devices can be the best choice.
Mitek (DePuy Mitek, Raynham, MA, USA) has developed an anchor system for attaching soft tissues to bone in ligament repair, which is used in orthopaedic surgery. This system has a cylindrical titanium body with two wings. Dr L. M. Wolford in Dallas, Texas, has adapted this system for repositioning the TMJ disc.
After condylar discopexy, physiotherapy is an essential part of the treatment for an effective MMO. Physiotherapy prevents hypomobility and ankylosis and must include TMJ opening and closing exercises. There are many benefits to the use of a physiotherapy rehabilitation programme starting within the first 24 h after surgery, not least its important role in preventing the formation of abnormal fibrous tissue. Successful outcomes of appropriate postoperative rehabilitation programmes conducted after TMJ surgery have been reported in terms of pain relief, the restoration of joint function, and protection against harmful injury. Exercises can improve muscle vascularity, increase muscle mass and protein metabolism, decrease muscle fatigability, and increase strength. If the exercise programme is performed regularly, the reversal of atrophic and degenerative changes within the joints and restoration of the normal anatomy of the internal fibrous structure can be achieved.
The aim of this study was to investigate the impact of a comprehensive and multicomponent early supervised rehabilitation programme in comparison with home-based exercise after TMJ condylar discopexy, and to determine the effect on mandibular movements and patient quality of life (QOL).
Materials and methods
Study design and patient evaluation
The current study was a prospective, randomized, controlled interventional trial, which was conducted in the Department of Physical Medicine and Rehabilitation of Istanbul University Istanbul Faculty of Medicine, Turkey. All patients were informed of the type and purpose of the diagnostic procedures and had given their written consent for participation and the execution of the study. The study was approved by the Ethics Committee in conformity with the Declaration of Helsinki. The study inclusion and exclusion criteria are listed in Table 1 .
| Inclusion criteria |
| 1. Clinical diagnosis of temporomandibular DDw/oR |
| a. History of reduction in mandibular opening >6 months |
| b. Unassisted mandibular opening ≤35 mm |
| c. TMJ pain (VAS >5 cm) |
| d. Deflection of the mandibular opening pathway to the ipsilateral side |
| e. Restrictions in lateral movements of the ipsilateral side |
| f. No longer present joint sounds |
| 2. MRI diagnosis of DDw/oR |
| 3. Despite all conventional conservative treatment methods, have not received an adequate response |
| 4. No previous TMJ surgery |
| Exclusion criteria |
| 1. Presence of other disorders involving the TMJ (e.g., degenerative joint disease or collagen vascular disease) |
| 2. History of major jaw trauma |
| 3. Dentofacial deformity |
| 4. Psychiatric illness |
| 5. Chronic headache |
| 6. Inflammatory disorders |
| 7. Bleeding disorders |
| 8. Neurological disorders |
The diagnosis of DDw/oR was based on magnetic resonance imaging (MRI) to confirm the clinical diagnosis and a comprehensive examination of TMJ movements.
Forty consecutive patients, who were referred to the TMJ unit, were studied. Eligible participants were allocated randomly to one of two groups in the order of their presentation to the outpatient clinics, using computer-generated random numbers. The participant flow chart and study profile are shown in Fig. 1 .
It is necessary to provide some motivation for patients with TMDs to perform exercises consistently. Both the study and the control group were informed prior to undergoing surgery about exercises and diet, and their clinical importance during rehabilitation.
Demographic data (age, sex, body mass index, current occupation) were obtained at the baseline assessment. After the baseline assessment, all patients underwent the same surgical procedure.
For the study group, a supervised exercise programme was applied after surgery in the outpatient clinic by a physiotherapist. This comprised a 30-min session 3 days per week for 8 weeks in the hospital. On the other days of the week, the patients completed the programme at home in a 30-min session each day. In the control group, a home-based exercise programme was applied and the exercises were reviewed every 2 weeks. The control group performed the exercises at home in a 30-min session each day for 8 weeks.
Clinical evaluations were undertaken before surgery and at 2 months after surgery.
Outcome measurement
All patients underwent the same surgical procedure (condylar discopexy). Functional parameters were the primary outcomes. MMO, protrusion, and right and left lateral movements were measured. The patient was asked to open their mouth to the maximum degree and MMO was measured using a micrometer caliper. In addition, patients were asked to rate their pain on a 10-cm visual analogue scale (VAS), with 0 indicating no pain and 10 indicating severe pain. Pain was evaluated at rest and in active movement. The pressure–pain thresholds at trigger points were also determined using algometric measurements for the masseter and temporal muscles.
Patient QOL was assessed in terms of feelings of depression, appetite, quality of sleep, difficulty in chewing, effectiveness at work, and nervous tension. These items were scored according to the level of impact from 0 to 4, where 0 = none, 1 = mild, 2 = moderate, 3 = bad, and 4 = severe.
Surgical treatment
All surgeries were performed under general anaesthesia with nasotracheal intubation. The surgeon used a modified pre-auricular incision to gain access to the TMJ. The disc was freed and mobilized by blunt and sharp dissection from the lateral, and mainly anterior, ligamentous attachments, and was observed to fit into its anatomical position. This step of the surgical operation was carried out with great care to minimize postsurgical adhesions. With the help of a standard Mitek device, a 2 × 10-mm hole was drilled in the posterior region of the head of the condyle, approximately 7–9 mm below the top and slightly lateral to the midsagittal plane of the condylar head. The Mitek anchor with 2–0 Ethibond sutures was placed in the hole with the inserter part of the device and secured in the bone by locking. Sutures were then placed through the posterior bands of the disc and the tissues fixed by tying the Ethibond sutures so that the disc was positioned anatomically. After meticulous haemostasis, the capsule, subcutaneous tissues, and skin were closed properly in layers.
Postoperative follow-up
Both the study and control group patients were discharged from hospital on average 24 h after surgery and were advised to take a soft diet and to apply cold packs for 2–4 min three times per day on the operated site for a period of 1 week.
Starting immediately after the operation, a non-steroidal anti-inflammatory drug, meloxicam 15 mg, was given orally once a day and the patients were instructed to take their medication for 2 weeks.
Physical therapy
Preoperative posture exercises, cold pack application, and dietary practices, and postoperative exercise training were given to both the study and control group patients. For the study group patients, a supervised rehabilitation programme was applied in the outpatient clinic. After surgery, the exercise programme was conducted by a physiotherapist, 3 days a week for 8 weeks, in the hospital. The patients were asked to do all of the exercises at home three times per day. In the first postoperative week, physical therapy consisted of cold pack application, massage, rotation exercises ( Fig. 2 ), and posture exercises. After the first postoperative week, exercises other than translational (rotation, active assisted self-stretching, self-mobilization) were introduced. After that, mandibular opening and closing exercises and stimulation of MMO (by keeping the mouth open at the widest range limit for a few seconds) were initiated.
From the fourth postoperative week onwards, forced mouth opening exercises were introduced with the use of wooden spatulas inserted between the posterior teeth. The proposed therapy was performed three times a week for a period of 2 months. Patients were encouraged to maintain the exercise routine at home. Details of the programme used in the study group are shown in Table 2 .
