[Pain in the temporomandibular joint and the masticatory muscles].
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Biomedical subjects
Publications and source records attributed to O C Rasmussen.
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Four cases of psoriatic arthritis of the temporomandibular joint are presented. Three patients suffered from polyarthritis, but in one the disease was monoarticular. Clinically, the affection of the TMJ was associated with symptoms and signs characteristic of chronic arthritis. Radiologic examination, including arthrography, demonstrated signs of erosive arthritis in three patients. The TMJ affections were treated by physiatrics and by correction of oral function.
The favorable spontaneous course of TMA indicates a conservation approach to treatment. One-half of the percent 119 patients were either not treated or treated by physiatric measures only. One-third of the patients were treated by pivotation, whereby TMJ pain was relieved within an average of 2 months. Pivotation seemed to prolong the spontaneous course of TMA. Steroids were injected intraarticularly in one-fifth of the patients, whereby TMJ pain was relieved within an average of 5 d. There were, however, symptoms other than pain that tended to persist after steroid injection. The various treatments did not result in any lasting differences in mandibular mobility. Pivotation and steroid injection seemed to result in a higher frequency of irregularity of the mandibular condyle as seem in transpharyngeal radiographs.
The progress of symptoms in temporomandibular arthropathy can be divided into six phases. Phases 1 and 2 make up an initial stage of clicking and locking, Phases 3 and 4 an intermediate stage of temporomandibular joint pain and constriction, and Phases 5 and 6 make up a terminal stage of crepitation and constriction followed by freedom from symptoms. The abrupt replacement of clicking and locking by pain and constriction is highly characteristic and may be considered the true debut of arthropathy. During the course of arthropathy all temporomandibular joint symptoms but crepitation improve, resulting practically always in freedom from symptoms. Complete recovery is most favorable in the case of full dentures of intact natural dentition. Subject to some variation, the three stages endure 4, 1, and 1/2 year, respectively; unaffected by age, dentition or eliciting factors. Relapses of arthropathy seem unlikely whereas muscular symptoms or contralateral clicking may develop.
During the painful phases of temporomandibular arthropathy, the mobility is restricted, pain is present in the affected joint on maximal horizontal movement, and the joint capsule and masticatory muscles are tender. As the joint pain ceases, mobility improves and crepitation may appear. Crepitation is the most frequent finding in patients with lasting symptoms. Contralaterally, the muscular reaction is less impressive and of shorter duration. TMJ clicking may appear contralaterally as the symptoms of arthropathy disappear. The man change in signs takes place as pain disappears. However, signs still change years after debut of arthropathy.
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Traumatic neuromas in facial pain are characterized by a history of surgery at time of onset and by pain of an atypical neuralgic or nonneuralgic type with a stinging, burning, or paresthetic character. Pressure on the suspected area provokes pain, and localized analgesia relieves the pain. In six cases out of seven diagnosed clinically according to these criteria, excision biopsy revealed traumatic neuroma. One week postoperatively all patients were improved. One to 3 years later four patients out of six were still satisfactorily improved. In cases of painful oral traumatic neuromas where conservative measures have failed, a single excision then seems justified.
According to appearance of the condyle on transpharyngeal radiographs temporomandibular arthropathy has a destructive phase and a reparative phase terminating in the stable state of the joint. The destructive phase is characterized by erosion. No common trait of the healing process exists as the healed condyle varies from the normal to the most irregular appearance. Once it occurs, the healing is stable. Ongoing radiologic changes take place within 1-3 years. Some technical considerations including radiation doses of the transpharyngeal projection are presented.
Arthrography was performed in 166 temporomandibular joints with known disorders. The results reflected the pathology expected in each disorder. Clicking and locking were characterized by an increased inferior synovial cavity. The superior cavity was either normal or with irregularity of the articular space. In degenerative diseases, the most frequent finding was perforation of the disc. Rheumatoid arthritis was characterized by reduced extent and irregular outline of the synovial cavities. A late effect from contusion of the temporomandibular joint was a slight reduction in the extent of the synovial cavity. Late effects from intracapsular fracture of the mandibular condyle were considerable irregularity of the articular space and perforation of the disc. As a rule, the arthrographs were highly characteristic, and it seems possible to distinguish between the current disorders by means of arthrography. The arthrographs of 15 intact joints are described. The features of unsuccessful arthrography based on 32 instances of extrasynovial injection are described.
Autopsy was performed on the right temporomandibular joint in eleven individuals with a mean age of 71 years. Standard positions indicative for protrusion, laterotrusive border movement and posterior opening movement were photographed in the sagittal plane. Size of movements of the disc and condylar head were recorded, as well as movements of a reference point in the mental region. The slope of the anterior discal movement was estimated and mandibular rotation during posterior opening was registered. Centre of rotation during the hinge movement was in all cases located to the craniodorsal part of the condylar head. Attempt to construct centres of rotation in the eminence and condylar head for the horizontal movements was in vain. The discussion deals with the influence of the specific kind of material on the results and the possible systematic differences to clinical material.
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