Journal of Oral Rehabilitation. 1991, Volume 18, pages 497-500

Mandibular manipulation of anterior discdisplacement without reduction*

R . G . J A G G E R Department of Prosthetic Dentistry. University of Wales College of Medicine,

Cardiff, U.K.

SummaryThe history and clinical symptoms of anterior temporomandibular joint disc displace-ment without reduction are characteristic, and include limitation of mandibular move-ment and mandibular deviation on opening of the mouth. Twelve consecutive patientsattending a clinic with such symptoms were treated by mandibular manipulation. Animmediate increase in the range of mandibular movement was obtained for all patients,with a mean increase in interincisal opening of 8 mm. The method of manipulationis described, and the implications of the results for the treatment of TMJ patientsare discussed.

IntroductionInternal derangement of the temporomandibular joint (TMJ) is defined as an abnormalrelationship of the articular disc to the condyle.

Inaccessibihty of the joint and articular tissue has made it difficult to determinethe nature of the tissue response. The application of arthrography, arthrotomographyand magnetic resonance imaging, and correlation of the findings of these techniqueswith clinical and surgical observations has led to an improved understanding of internalderangements of the TMJ (Katzberg et al, 1980; Bronstein, Tomasetti & Ryan, 1981;Donlon & Moon, 1987).

Although posterior disc displacement and partial lateral displacement have beendescribed, the disc is usually antero-medially or anteriorly displaced (Westesson &Rohlin, 1984).

Anterior disc displacement (ADD) has been classified functionally as displace-ment with or without reduction. ADD with reduction implies normalization of thedisc position on opening of the mouth, and subsequent anterior displacement whenthe mouth is closed again. This is associated with reciprocal clicking, i.e. clicking bothon opening and on closing the mouth.

ADD without reduction implies that the relationship between the disc and thecondyle is not normalized, the disc remaining displaced at all times. The condition ischaracterized by a distinctive combination of signs and symptoms, which are listed inTable 1 (Schwartz & Kendrick, 1984).

Although surgical procedures to correct ADD without reduction have been shownto yield good results (McCarty Jr & Farrar, 1979), few data are available on conservative

* Presented at a British Society for the Study of Prosthetic Dentistry Meeting, Manchester, April 1990,

Correspondence; Mr R.G, Jagger, Department of Prosthetic Dentistry, University of Wales Collegeof Medicine, Dental School, Heath Park, Cardiff CF4 4XY, U.K.

497

498 R.G. Jagger

treatment. Middleton (1972) reported a 75% success rate using manipulation of themandible under general anaesthesia, but did not describe details of patient selection,the manipulative technique or criteria for evaluation of success. Murakami et al. (1987)described mandibular manipulation for disc displacement after inereasing the intra-articular pressure of the TMJ by 'pumping" fluid into the upper joint compartment.Farrar (1978) has described a teehnique of manipulation to recapture the disc, butconsidered that the method that he used was useful only if the disc had been displacedfor less than 3—4 weeks.

The aim of the present study was to investigate the use of a method of mandibularmanipulation to treat a group of patients who presented at a clinic with signs andsymptoms of ADD without reduction.

Materials and methodsSubjects were seleeted from patients who were referred to the TMJ Clinic at theDepartment of Prosthetic Dentistry, Cardiff Dental School. Twelve consecutive pa-tients (8 women and 4 men, of mean age 21-8 years) with a history of TMJ dise dis-placement without reduction, as described in Table 1, were included in the study. Theduration of these symptoms was recorded, and the mean duration was found to be 3months (range 1—9 mouths).

All patients were examined for signs of TMJ dysfunction. All patients with signsand symptoms listed in Table 1 were included in the investigation. Maximal inter-incisal opening (without taking into account overbite) was noted.

A simple explanation of the probable cause of the limitation was given to the patients,and the proposed manipulation proeedure was described.

The mandible was depressed by pressing with the index fingers on the patient'slower molar teeth. Leverage was obtained by placing the thumbs on the upper teeth(Fig. 1). The patient was asked to attempt to reproduce the clicking noise which hehad experienced in the affeeted joint before the limitation had occurred, whilst pressurewas applied to the lower molars.

Mandibular movement eapacity was reassessed after manipulation.

ResultsAn immediate improvement in inter-incisal opening was observed for all 12 patients(mean improvement 8mm, range 5-12mm). The results are shown in Table 2.

Deviation on opening was no longer present, and alJ patients were able to performunrestricted lateral excursions.

Table 1. Signs and symptoms of disc displacement without reduction

1, Joint previously clicked2, Clicking stops followed immediately by limitation of mouth opening3, On examination:

Limitation of mouth openingPain in joint on opening mouthTenderness of joint to palpationDeviation of mandible to affected side on openingLimited lateral excursion possible away from affected side

Mandibular manipulation of anterior disc displacement 499

Fig. 1. Method of obtaining leverage on mandible; index fingers pressing on mandibular mt)lar teeth,thumb on opposing maxillary teeth.

Table 2. Results of manipulatton

Patient

1 RT2 SD3 CF4 WW5 JD6 LM7 C.P8 RD9 MH

10 SJ11 RR12 KF

Sex

FMFMFFFMFFFM

Age(years)

432516362520152016161634

Inter-ineisal distanee(tnni)

Pro-manipulation

2cS3035283620243633192819

Post-manipulation

4035434046303!423«253524

Duration of limitation(tnonths)

49*32132**12

"Not recorded.

DiscussionThe manipulation procedures in this study were applied only to patients who presentedwith the symptom complex characteristic of ADD without reduction. The author hadpreviously attempted manipulation for patients with reciprocal clicking, without success.

All patients included in the study experienced an immediate improvement in man-dibular movement capacity. The most striking finding after manipulation was the in-creased inter-incisal opening (Table 2). Also notable was the absence of mandibular

500 R.G. Jagger

deviation on opening of the mouth, and the ability of the patient to make unrestrictedlateral excursions.

The manipulation technique described here differs from that reported by Farrar(1978). It would be interesting to test his statement that his method might only be ofvalue for locking of short duration (3—4 weeks). The present study suggests that evenlonger-term ADD without reduction may be treated by the manipulation techniquedescribed here.

The intra-articular effect of the manipulation procedure is uncertain, and arthro-graphy or magnetic resonance imaging would be necessary to establish whether thedisc is completely repositioned.

On only one occasion (patient 6) was a loud snap heard on manipulation, as describedby Farrar (1978).

Although all the patients who participated in the study benefited from manipulation,when ADD without reduction is chronic, the condyle has been shown to push the discforward and stretch the posterior ligaments, sometimes resulting in perforation. Itwould be most unlikely that a perforated disc could be manipulated successfully.

This study provides support for the view that mandibular manipulation may reduceADD without reduction, and demonstrates that such a procedure may be successfuleven for long-standing displacement. Farrar (1978) has recommended that an inter-occlusal bite-raising appliance be placed immediately following successful manipu-lation, in order to retain the recaptured disc.

Further studies should include an assessment of the long-term results of manipu-lation, and also investigate the need for post-manipulation conservative treatment inorder to maintain the benefits of the manipulation procedure.

ReferencesBRONSTEtN, S.L., ToMASETtt, B.J. & RYAN, D.E. (1981) Internal derangements of the temporoman-

dibular joint: correlation of arthrography with surgical findings. Journal of Oral Surgery, 39, 572.DoNLON, W.C. & MOON, K.L. (1987) Comparison of tnagnetic resonance imaging, arthrotomography

and clinical and surgical findings in temporomandibular joint internal derangements. Journal ofOral Surgery, 64, 2.

FARRAR, W . B . (1978) Characteristics of the condylar path in intcmal derangements of the TMJ. Journalof Prosthetic Dentistry, 39, 319.

KATZBERG, R.W.. DoLwtcK, M.F., HELMS, C.A., HOPENS, T. , BALES, D.J. & COGGS, G . C . (1980)Arthrotomography of the tetnporomandibular joint. American Journal of Roentgenologv, 134, 995.

MCCARTY, Jr., W.L. & FARRAR, W.B. (1979) Surgery for internal derangements of the temporoman-dibular joint. Journal of Prosthetic Dentistry, 42, 191.

MtDDLETON, D.S. (1972) Chnical approach to derangement of the mandibular joint. Journal of theRoyal College of Surgeons of Edinburgh, 17, 287.

MuRy\KAMi, K-I., itzuKA, T., MATSUKt, M. & TAKATOKJ, O . (1987) Recapturing the persistent anteriorlydisplaced disc by mandibular manipulation after pumping and hydrauhc pressure to the uppercavity of the temporomandibular joint. Journal of Craniomandibular Practice and Facial Pain, 5, 17.

SCHWARTZ, H.C. & KENDRtCK, R.W. (1984) Internal derangements of the temporomandibular joint:description of clinical syndromes. Journal of Oral Surgery, 58, 24.

WESTESSON, P-L. & ROHLIN, M. (1984) Internal derangement related to osteoarthrosis in temporo-mandibular joint autopsy specimens. Journal of Oral Surgery, 57, 17.