Abstract
The aim of the study was to investigate patients with temporomandibular joint (TMJ) disc derangement with its two clinical variants reciprocal clicking (RC) and chronic closed lock (CCL) with regard to the etiologic factors, previous jaw trauma and general (GJH) and local joint hypermobility (LJH). 42 patients (21 with RC and 21 with CCL) and 20 control individuals were studied. The patients and controls were asked whether they had sustained any jaw trauma in the past and were then examined for the presence of GJH and LJH, using defined criteria. Patient and control groups were compared. Statistical evaluation included χ 2 test and paired Student’s t test. Odds ratio was calculated in order to assess the relative risk of developing RC and CCL when the etiological factor was present. The results showed a significant association between RC and GJH (OR = 9.6, p = 0.0010) as well as LJH (OR = 38, p = 0.0001). CCL was clearly associated with GJH (OR = 7.5, p = 0.0030) while its association with LJH was not significant (OR = 9.5, p = 0.0582). No significant association with previous trauma was found. The results indicate that GJH is an important etiologic factor for the development of RC and CCL of the TMJ.
Temporomandibular joint (TMJ) disc derangement (DD) is the most common TMJ disorder leading to surgery. About 19% of the adult population in Sweden show symptoms of TMJ DD. There are two distinct clinical variants of TMJ DD, which differ from a tissue point of view, clinical characteristics and by the way they are treated, namely reciprocal clicking (RC) and chronic closed lock (CCL).
RC has a prevalence of 7% in the population. In patients, the condition usually runs with a varying degree of pain. TMJs with RC, typically show no degenerative changes and inflammation is minor or absent. The disc has a callous formation in the posterior part, formed by tightly packed, thick collagen bundles. Clinically the condition is recognized as a reproducible RC caused by the disc with its callous displacing back and forth over the condyle. If the clicking becomes more pronounced a catch develops, which may be painful. This more severe subgroup may be treated surgically by discectomy. RC also progresses to CCL in many patients.
CCL has a prevalence of about 12% in the population. In patients, the condition usually has an acute onset and rapidly develops into a degenerative joint disease where inflammation and adhesions are frequently found. The translation of the disc-condyle is typically reduced.
Clinical signs and symptoms are painful reduced vertical and horizontal mandibular movements. About 40% of CCL patients seem to recover spontaneously within a 2.5 year period while in the remaining 60% symptoms persist. The first choice of treatment is arthroscopic lysis and lavage. If this treatment is unsuccessful discectomy may be performed. Both treatments have about the same effectiveness, but arthroscopy is less invasive.
It has been indicated that disc derangements and previous trauma to the jaw may be associated. Other suggested etiologic factors for DD are general (GJH) and localized joint hypermobility (LJH). Westling and Mattiasson studied adolescents and found that signs and symptoms of TMJ DD were more common in adolescents with a GJH. In a systematic review, Dijkstra et al. found that very few studies investigating GJH and temporomandibular joint dysfunction (TMD) were of good quality considering methodology and selection criteria. Since then a few other studies have appeared, indicating an association between TMJ DD and GJH. To the authors’ knowledge, patients with more severe TMJ DD requiring surgical treatment have not been investigated.
The authors’ hypothesis is that trauma and joint hypermobility (general and local) are etiological factors for the development of advanced RC and CCL and that differences exist between the two patient groups. The aim of this study is to investigate the two clinical variants of TMJ DD, RC and CCL requiring TMJ surgery, with regard to previous trauma to the jaws and existing GJH and LJH.
Material and methods
Consecutive patients with TMJ DD, referred to the division of Oral and Maxillofacial Surgery, Department of Dental Medicine, Karolinska Institutet Huddinge, as well as a control group (C) comprising consecutive patients receiving dental care at the dental school of the Karolinska Institutet from March 2010 to March 2011, were asked to participate in the study. Inclusion criteria for RC were reproducible reciprocal clicks with catching, with or without pain. Inclusion criteria for CCL were painful impaired vertical and horizontal mandibular movements with or without previous clicking. Exclusion criteria were all other TMJ diseases. The control group were age and gender matched with the patients. Informed consent was received from all patients and control individuals prior to inclusion in the study. The study was approved by the regional research ethics committee (3 February 2010).
The following etiologic factors were investigated by interviewing and examining the patients. The participants were interviewed and specifically asked whether they had sustained any previous trauma to the mandible. General hypermobility was determined using the Carter and Wilkinson criteria (≥3 positive tests out of 5).
The 5 tests were: passive apposition of the thumb to the flexor aspect of the forearm; passive hyperextension of the fingers so that they lie parallel with the extensor aspect of the forearm; ability to hyperextend the elbow more than 10 degrees; ability to hyperextend the knee more than 10 degrees; an excess range of passive dorsiflexion of the ankle and eversion of the foot.
Local hypermobility of the TMJ was determined by interviewing and examining the participants for episodes for mandibular luxation or subluxations.
All patients and controls were also evaluated with regard to functional impairment and pain. Impaired mandibular function was assessed using a modified mandibular function impairment questionnaire (MFIQ) (minimum value 0, maximum value 21).
Pain in the TMJ when performing mandibular movements was registered on a visual analogue scale (VAS), where 0 denotes no pain and 10 worst pain imaginable.
The χ 2 test was performed in order to determine whether the differences between patient groups and control were significant or not. A p -level <0.05 was regarded as significant. If the p -level was between 0.01 and 0.05, Yate’s correction was performed. If the resulting new p -level was below 0.05 the difference was considered significant. The odds ratio (OR) was calculated in order to assess the relative risk of developing RC or CCL when the etiologic factor was present. An increased risk was considered if OR was above 1.
A paired Student’s t test was performed to analyse if the frequencies of MFIQ and VAS values between RC, CCL and controls were significant. A p -value <0.05 was regarded as significant.
Results
Tables 1–3 show the data for patients with RC or CCL and the controls. The mean values of MFIQ and VAS for the CCL patients were 11.38 (SD = 4.09) and 5.43 (SD = 2.38), respectively. For RC patients the corresponding values were 10.00 (SD = 3.26) and 4.24 (SD = 2.19). The corresponding values for the control patients were 0.45 (SD = 0.83) and 0.20 (SD = 0.52). The differences regarding MFIQ and VAS between the patient groups (RC and CCL) and the control group were significant ( p < 0.0001).
| Patient | Gender: men (1), woman (0) | Age (years) | Trauma | General hypermobility | Local hypermobility | MFIQ (max: 21) | VAS (max: 10) |
|---|---|---|---|---|---|---|---|
| 1 | 0 | 24 | 0 | 1 | 1 | 10 | 4 |
| 2 | 1 | 64 | 0 | 0 | 0 | 5 | 1 |
| 3 | 0 | 56 | 0 | 0 | 0 | 10 | 4 |
| 4 | 0 | 19 | 0 | 1 | 1 | 4 | 3 |
| 5 | 0 | 27 | 0 | 1 | 1 | 9 | 0 |
| 6 | 0 | 26 | 1 | 1 | 0 | 12 | 4 |
| 7 | 0 | 25 | 0 | 1 | 0 | 12 | 6 |
| 8 | 0 | 31 | 0 | 0 | 1 | 15 | 8 |
| 9 | 0 | 61 | 0 | 1 | 1 | 8 | 8 |
| 10 | 0 | 40 | 0 | 1 | 0 | 11 | 3 |
| 11 | 1 | 21 | 1 | 1 | 1 | 7 | 3 |
| 12 | 1 | 58 | 1 | 1 | 1 | 9 | 4 |
| 13 | 1 | 18 | 0 | 1 | 1 | 11 | 7 |
| 14 | 1 | 19 | 0 | 1 | 1 | 6 | 3 |
| 15 | 0 | 53 | 0 | 0 | 0 | 8 | 2 |
| 16 | 0 | 25 | 1 | 1 | 1 | 11 | 4 |
| 17 | 0 | 22 | 1 | 1 | 1 | 15 | 7 |
| 18 | 0 | 18 | 1 | 1 | 1 | 9 | 6 |
| 19 | 0 | 35 | 0 | 1 | 1 | 9 | 3 |
| 20 | 0 | 38 | 0 | 0 | 0 | 17 | 3 |
| 21 | 0 | 38 | 1 | 1 | 1 | 12 | 6 |
| ∑ | 5 | 718 | 7 | 16 | 14 | 210 | 89 |
| Mean value ( M ) | 0.24 | 34.19 | 0.33 | 0.76 | 0.67 | 10.00 | 4.24 |
| Total women | 16 | ||||||
| Total men | 5 | ||||||
| Percent (%) | 24 | 33 | 76 | 67 | |||
| SD | 0.4364 | 15.4552 | 0.4830 | 0.4364 | 0.4830 | 3.2558 | 2.1887 |
| Max | 1 | 64 | 1 | 1 | 1 | 17 | 8 |
| Min | 0 | 18 | 0 | 0 | 0 | 4 | 0 |
| Patient | Gender: men (1), woman (0) | Age (years) | Trauma | General hypermobility | Local hypermobility | MFIQ (max: 21) | VAS (max: 10) |
|---|---|---|---|---|---|---|---|
| 1 | 0 | 76 | 0 | 1 | 0 | 9 | 6 |
| 2 | 1 | 63 | 1 | 0 | 0 | 9 | 7 |
| 3 | 0 | 39 | 0 | 0 | 0 | 13 | 6 |
| 4 | 0 | 43 | 0 | 0 | 0 | 6 | 0 |
| 5 | 0 | 27 | 0 | 0 | 0 | 12 | 7 |
| 6 | 0 | 47 | 0 | 0 | 0 | 9 | 6 |
| 7 | 0 | 31 | 0 | 1 | 0 | 6 | 2 |
| 8 | 0 | 27 | 0 | 1 | 1 | 12 | 4 |
| 9 | 0 | 25 | 0 | 1 | 0 | 19 | 8 |
| 10 | 0 | 20 | 0 | 1 | 1 | 15 | 8 |
| 11 | 0 | 44 | 1 | 1 | 1 | 13 | 7 |
| 12 | 0 | 38 | 1 | 0 | 0 | 11 | 5 |
| 13 | 0 | 35 | 0 | 1 | 0 | 12 | 2 |
| 14 | 0 | 25 | 0 | 1 | 1 | 13 | 7 |
| 15 | 1 | 30 | 0 | 1 | 1 | 3 | 4 |
| 16 | 0 | 20 | 0 | 1 | 0 | 13 | 8 |
| 17 | 1 | 33 | 1 | 1 | 0 | 19 | 8 |
| 18 | 0 | 34 | 0 | 1 | 1 | 16 | 8 |
| 19 | 0 | 24 | 0 | 1 | 1 | 13 | 3 |
| 20 | 0 | 49 | 1 | 1 | 0 | 7 | 3 |
| 21 | 0 | 30 | 0 | 1 | 0 | 9 | 5 |
| ∑ | 3 | 760 | 5 | 15 | 7 | 239 | 114 |
| Mean value ( M ) | 0.14 | 36.19 | 0.24 | 0.71 | 0.33 | 11.38 | 5.43 |
| Total woman | 18 | ||||||
| Total men | 3 | ||||||
| Percent (%) | 14 | 24 | 71 | 33 | |||
| SD | 0.3586 | 13.9915 | 0.4364 | 0.4629 | 0.4830 | 4.0924 | 2.3785 |
| Max | 1 | 76 | 1 | 1 | 1 | 19 | 8 |
| Min | 0 | 20 | 0 | 0 | 0 | 3 | 0 |
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