Clinical management of a patient following temporomandibular joint arthroscopy.

Arthroscopic surgery of the temporomandibular joint (TMJ) (Fig. 1) is becoming recognized as a viable and favorable alternative to open TMJ surgery.[1] The procedure used on the patient described in this case report is called "lysis and lavage," meaning to break or cut adhesions and irrigate the joint. The procedure is used to eliminate mechanical limitations (adhesions) between the TMJ disc and the articular eminence that inhibit normal movement.[2] The lavage flushes any foreign material out of the joint. After treatment, with no adhesions present, the surgeon is able to mobilize the joint to its full range of motion (ROM).

Indications for TMJ arthroscopy include a painful joint that does not respond to nonsurgical (conservative) therapy and limitation in mandibular movement that is perceived as a disability to the patient and does not respond to conservative therapy. We believe psychological factors should also be taken into consideration. We also believe that some individuals may have psychological problems that contribute to their perception of pain. If these problems are severe, these individuals may continue to report experiencing pain, regardless of whether surgery is performed. This type of patient is not considered a good candidate for this type of surgery (Steven Kalisch, PhD; personal communication; October 27, 1990).

In rehabilitation, the pathophysiology of the joint following surgery and the goals of postsurgical management should be considered. Normal jaw opening consists of two primary movements (Fig. 2). The first movement is rotation of the condyle in the glenoid fossa. The second movement is translation of the condylar head to the tip of the articular eminence. Limited jaw opening, in some cases, is a result of adhesions holding dislocated TMJ discs to the articular eminence in such a way that condylar translation is limited (Fig. 3). These adhesions are broken in surgery, and the joint is mobilized.[2] Normal ROM should thus be available postsurgery. We believe, however, that ROM may continue to be limited secondary to pain.

The goals of rehabilitation include (1) elimination of pain, (2) elimination of edema, (3) elimination of inflammation, (4) normalization of mandibular ROM, and (5) return to normal function without restriction. Mandibular ROM is easily measured. Edema and inflammation may be assessed using clinical signs (eg, redness, heat, and puffiness to palpation). Assessment of pain and normal function, however, can be quite subjective. The therapist must rely on the patient's descriptions of pain and function. The following case report provides a brief introduction to TMJ arthroscopy and describes postsurgical management of a patient who has undergone this procedure.

History

The patient was a 17-year-old white female who was seen for treatment before surgery at the Regional Head, Neck, and Temporomandibular joint Treatment Center at Our Lady of Mercy Hospital (Dyer, Ind). She complained that her jaw had been "popping" for a "long time" and suddenly stopped. She claimed her jaw would not open as wide after it stopped popping. She had a 40-mm interincisal opening at the time she was seen for evaluation. Her other original complaint was of headaches that occurred upon awakening in the morning and went away gradually during the day. The patient also complained of jaw pain. She noticed the pain first in the right jaw, then in both jaws. She had no notable medical history.

Preliminary psychological testing showed no signs of abnormal illness behavior. These tests consisted of the McGill Pain Questionnaire and a visual analog scale. The patient would have had to have scored an 8 or above on the visual analog scale and circled eight or more categories on the McGill Pain Questionnaire before her scores would have been considered an indication of abnormal illness behavior. We recognize that there may be other standards used to score these examinations and better diagnostic tools; however, these were the tests used in this case. Had we felt the patient was exhibiting abnormal illness behavior, she would have been referred to a psychologist for diagnostic testing to include the Minnesota Multiphasic Personality inventorv and appropriate follow-up, as determined by the psychologist.

The patient was an active high-school student who participated in three sports. She had a 7-year history of participation in field events, particularly the shot put. She reported that she "constantly" traumatized her right jaw with the shot. We were unable to establish a cause-effect relationship, but it is interesting to consider that this traumatization with the shot may have been a significant etiological factor. After 8 weeks of conservative management including moist heat, high voltage electrical stimulation, transcutaneous electrical nerve stimulation, ultrasound, mobilization, therapeutic exercise, and splint therapy administered by a physical therapist and a dentist, the patient was essentially no better. Magnetic resonance images were taken of her bilateral TMJs. These images showed that the patient's TMJ discs were displaced bilaterally (Fig. 4). She was referred to an oral and maxillofacial surgeon with a diagnosis of bilateral internal derangement of the TMJs without reduction, synovitis, cervical dysfunction, and myalgia. The surgeon decided to perform arthroscopic surgery to both TMJs.

Surgery

The patient was admitted for surgery as a hospital outpatient. After administering general naso-endotracheal anesthesia to the patient and placing her in a supine position on the operating table, the surgeon palpated the bony landmarks of the left TMJ while the surgical assistant manipulated the mandible intraorally. Two 3-mm stab incisions were made, one at the top of the glenoid fossa and the other at a point 5-mm anterior and 5-mm inferior to the tip of the temporal eminence. A 1.9-mm-diameter Stryker TMJ arthroscopic cannula and trocar(*) were used to enter the superior joint space through these incisions. A continuous infusion of lactated Ringer's solution with exit flow was established. A 30-degree Stryker TMJ arthroscope(*) with a video camera was placed into the posterior cannula, and a systematic examination of the upper joint space was performed. This examination revealed that the disc was displaced anteriorly and was nonreducing. This means that the disc was stuck to the roof of the glenoid fossa and was blocking normal translation of the mandibular condyle. Evidence of chondromalacia, chronic synovitis, and joint adhesions between the disc and the roof of the glenoid fossa was noted. The adhesions were dense and extended anterior to the eminence into the anterior recess. Through the anterior cannula, under direct vision via triangulation, a powered rotary instrument full-radius microdebrider(*) was used to lyse and remove these adhesions. Removal of the adhesions facilitated movement of the disc, which was observed directly.

Following removal of the arthroscopic cannulas, the surgical assistant mobilized the left TMJ and found that normal translation was present. A similar procedure was then performed for the right TNIJ, with similar findings and results. The patient was discharged the same day as surgery with a 24-hour pressure dressing.

Rehabilitation

The patient was seen at the Regional Head, Neck, and Temporomandibular Joint Treatment Center at Our Lady of Mercy Hospital 4 days after surgery. Her chief complaint was jaw pain anct decreased mandibular opening. She stated that her headaches had stopped since surgery. Assessment of passive ROM of the patient's cervical spine revealed there was a slight decrease in the side-bending/rotation motion at the C2-3-3-4 levels. Her active mandibular opening was 36 mm. We believe her mandibular opening was restricted by pain in the TMJs. This was, technically, a normal three-fingered opening[3] (Fig. 5); however, it was less than what the patient believed to be her normal ROM. She believed her normal ROM to be greater than the 40-mm opening she initially exhibited in our clinic. We therefore believe she had a restricted mandibular opening. We also assessed the patient for tenderness to palpation on the head, neck, and shoulders. Tenderness was noted with palpation to both TMJs, the masseters, and the suboccipital muscles. Minor swelling was noted in the area overlying both TMJs. Two small incisions were noted bilaterally in this area. The patient reported no abnormal sensation on the head, neck, or shoulders. Subsequent to this assessment, we formed our impression list.

Our primary finding was capsulitis of the TMJs. We believed that inflammation was present because of the tenderness to palpation of the TMJs and pain in the TMJs with mouth opening and because she was 4 days postsurgery. Palpation revealed myalgia in the masseters and suboccipital muscles. Because a deficit was found in cervical ROM, cervical dysfunction was noted. Abnormal posture was noted because the patient demonstrated rounded shoulder,s and forward head posture. Swelling was noted over both TMJs. We also took into account the presence of bilateral TMJ internal derangement before surgery, which indicated to us that the patient's TMJ discs were displaced. This displacement was confirmed by the surgeon, and no attempt to reposition the discs was made.

Our impression list included (1) capsulitis of both TMJs, (2) myalgia, (3) cervical dysfunction, (4) abnormal posture, (5) edema, and (6) bilateral TMJ internal derangement. Our short-term goal was to decrease pain in the patient's muscles and TMJs by 50% within 2 to 4 weeks. Our long-term goals, to be accomplished within 8 to 12 weeks, were the elimination of pain, normal cervical ROM (assessed manually), normal mandibular opening, elimination of edema, and mandibular function without restriction (as determined by the patient).

The patient's treatment was administered about twice a week. It began with the use of a variety of modalities. High voltage electrical stimulation was applied to both TMJs for 10 to 20 minutes using a large dispersive pad on the patient's back and 5.08-cm (2-in) square silicone electrodes over the TMJs. An Intelect 500 stimulator[dagger] with a frequency of 100 pps was used. The purpose was to decrease pain and facilitate a reduction in edema. Moist heat was used (concomitant with electrical stimulation) (Fig. 6) to facilitate muscle relaxation, increase blood flow, and decrease pain. Ultrasound was applied to both TMJs (Fig. 7). The ultrasound device (Intelect 240[dagger] with a 2-cm sound head) was set at 100% delivery, and ultrasound was administered as tolerated for 3 minutes. We commonly used a frequency of 1.0 to 1.25 W/[CM.sup.2] with this patient. The ultrasound was used to increase soft-tissue extensibility, increase blood flow, and speed up the rate of protein synthesis.[5-7]

After the use of modalities, we mobilized the patient's TMJs. Our two most frequently used techniques are explained as follows. The first is a passive technique called "long-axis distraction." In this technique, the therapist places his or her thumb on the patient's lower posterior molars and the index or middle finger under the distal chin. The head is stabilized by the chest and opposite hand. By gently pressing inferiorly with the thumb and stabilizing the distal chin, the therapist can distract the mandible along the long axis of the condyle. We believe this technique should be administered gently and held for approximately 5 seconds, then repeated three to five times or as needed (Fig. 8).

The second mobilization technique we used is called "overpressure with opening." This technique involves the same hand placement and stabilization as used for long-axis distraction, The patient is asked to open his or her mouth as wide as possible. The therapist then gently, presses down on the molars. This produces an "overpressure" with opening. It is held for about 5 to 10 seconds and may be repeated one to three times (Fig. 9). This active-assistive technique is performed in order to increase opening by theoretically taking advantage of reciprocal inhibition. The motoneurons to the antagonists to jaw opening (masseter, temporalis, and medial pterygoid muscles) should be inhibited as the patient uses the agonists (lateral pterygoid, suprahyoid, and infrahyoid muscles) to volitionally open the mouth wide. This technique should facilitate a decrease in muscle guarding. After mobilization, ice was applied to both TMJs for 8 minutes (Fig, 10). It was explained to the patient that the ice would be very uncomfortable for approximately 6 minutes and that she would perceive numbness and possibly decreased discomfort during the final 2 minutes. The ice as used to decrease inflammation secondary to joint mobilization. According to Belitsky et al,[8] direct ice is preferable to ice packs.

The patient was also taught a program of therapeutic exercises including (1) controlled opening, (2) resting tongue position, (3) easy stand posture correction, (4) mandibular stretch, (5) mandibular side stretch, (6) rhythmic stabilization, and (7) axial extension. Instructions and descriptions for these exercises are presented in the Appendix. The exercises are performed at clinical sessions and at home and are retaught as needed. Each exercise has a specific purpose. According to Rocabado (Mariano Rocabado, personal communication, February 1990), controlled opening provides input to the mechanoreceptors of the TMJs. Controlled opening also helps to retrain jaw movement so as to inhibit excessive translation of the jaw. We believe the resting tongue position described in the Appendix should become a habit for the patient. Once this position is attained, the patient concentrates on relaxing the jaw muscles. This position should be practiced constantly. The easy stand posture exercise is a technique for correcting overall standing posture. The more this technique is performed, the more good posture will become habitual. Kraus maintains that a decrease in muscle tension may be seen in the muscles of mastication as the therapist works with the mobility and position of the cervical spine (Steve Kraus, personal communication, May 1991). According to Rocabado, axial extension is specifically designed to promote stretching and adaptive lengthening of the posterior upper cervical musculature. This exercise should be performed frequently with a low degree of amplitude. Rocabado maintains that rhythmic stabilization is performed gently in order to enhance the sensed joint position. Mandibular stretch and side stretch are performed gently and are designed to increase ROM. Instructions for moist heat and ice treatments at home are also given.

This patient received an exercise book to reinforce our verbal instructions. These exercises, described in the Appendix, were taught at a rate of two or three per session. The patient performed her exercises during each clinical session. The sessions occurred approximately twice a week for the first 4 weeks.

A flat-plane orthopedic mouth appliance (splint) was worn 24 hours per day except at mealtime. This splint was designed to increase the patient's awareness of her jaw and was not designed to reposition the jaw. The patient's dentist was responsible for fabrication and management of the splint.

After 4 weeks of postsurgical treatment, (ie, six visits), the patient had 45 mm of mandibular opening. Therefore, her mandibular stretch and side-stretch exercises were discontinued. She was independent with her home exercises and had normal cervical ROM. Her swelling had disappeared, and she reported that her pain had decreased approximately 80%. Mild discomfort, however, was reported at end-range mandibular opening. This was the only remaining TMJ discomfort. To remedy this discomfort, the patient was instructed to open her mouth fully while a mild overpressure was applied and held for approximately 5 to 10 seconds. Both sides were symptomatic, so both sides were treated. The technique was performed one to three times per session till discharge.

The patient reported immediate relief after mobilization. She was able to open her mouth fully with no discomfort at end range. We instructed her to gently repeat the overpressure technique, using the mandibular stretch exercise, five times per day. She was also told to continue the controlled opening, resting tongue position, postural correction, and axial extension exercises. The other exercises were discontinued. She reported that the absence of pain lasted for approximately 1 hour after leaving the clinic.

Over the next 4 weeks, the patient made five visits to the clinic. Her treatment included electrical stimulation, moist heat, ultrasound, and mobilization for overpressure with mandibular opening, as noted earlier.

The patient reported that clinical mobilization was more effective than selfmobilization for relieving end-range tenderness. At this point, the duration of posttreatment pain relief had increased to approximately 12 hours.

Over the next 8 weeks, the patient visited our clinic for treatment four times. At the last clinical visit, she reported no tenderness at end range, tightness, or restriction in function. In addition, she had slowly progressed to a 50-mm mandibular opening, which she considered to be a normal ROM. She reported no headaches or jaw pain. Therefore, the patient was discharged.

Follow-up

The patient was reevaluated 1 1/2 years postsurgery. The follow-up evaluation was similar to that performed immediately after her surgery. She reported having no headaches, jaw pain, limited mandibular opening, or pain with chewing and yawning. She reported occasional, nonpainful popping in the TMJs and had a 54-mm mandibular opening. The patient stated that she was very satisfied with her result.

Discussion

The purpose of this case report is to briefly introduce TMJ arthroscopy and illustrate the postsurgical management of such patients. The treatment outcomes of the patient described in this report were typical of those we see in our clinic postarthroscopy, with two exceptions.

First, we typically except these patients to recover within 4 to 12 weeks postsurgery. This patient took about 16 weeks to recover. She had scheduling difficulties that made it impossible for her to appear for her clinical visits as often as we would have liked. It is our desire that patients be seen three times per week. It has been our experience that this frequency of clinical visits facilitates a more rapid recovery and increased compliance.

Second, this patient experienced soreness with end-range mandibular opening as the last tenacious residual of her condition, Our usual postsurgical treatment alone was unsuccessful in resolving this problem. Overpressure applied to the end-range mandibular opening, used in conjunction with modality treatments, provided immediate temporary relief. The patient was instructed to include this technique in her home exercise program. When the soreness completely resolved, the technique and exercise were discontinued. A possible explanation for the success of this technique could be that immediate pain relief was achieved via nociceptive inhibition.[9] Long-lasting pain relief could be due to adaptive lengthening of the anterior portion of the capsule.

Capsular tightness may have been present all along. Progressive lengthening of the capsule, therefore, might explain her progressive decrease in tenderness with end-range mandibular opening. Her long-term pain relief may have been due to slow progressive healing of the injured and inflamed tissues. As the tissues healed, the patient may have become more responsive to therapeutic intervention, which may have led to her longer-lasting pain relief after each therapeutic session. These explanations, however, have not been proven through controlled research. Although this overpressure technique is not usually necessary, it is helpful in such cases. We believe that caution should be taken so as not to produce hyperomobility in the TMJs.

Our patient initially exhibited 40-mm mandibular oprning, which she complained was restricted. It is not surprising, therefore, that she considered 50 mm, the size of her mandibular opening at discharge, to be normal. She was obviously accustomed to functioning with this large mandibular opening. For this reason, we were not alarmed by her progressing to this degree of mandibular opening, even though it was far beyond her technically normal three-fingertip mandibular opening (36 mm).

A flat-plane orthopedic out appliance (splint) was utilized concomitantly with physical therapy. Its purposes were to increase awareness of joint position and to protect the teeth in case of clinching. It was not designed to reposition the mandible. The patient wore the splint 24 hours a day, except when eating. These splints are commonly worn for a minimum of 60 days after symptoms resolve. We believe this helps to protect the TMJs while they are allowed to completely, heal. Patients are then weaned from the splints. This patient did not experience a loss of sensation over the TMJs after surgery. It has been our experience, however, that some patients do experience such loss of sensation. If such loss of sensation occurs, ultrasound administration may be inappropriate.

Postoperative treatment of this patient was administered by a physical therapist and a dentist. We believe that open communication and frequent staffings between professionals facilitate improved treatment results.

We hope that this case report of postoperative care will be of assistance to those clinicians treating patients who have intra-articular pathology and extracapsular pain. We find that the conservative therapy illustrated in this text often works for persons with similar symptoms and evaluation findings who do not require surgery.

(*) Stryker Corp, 420 Alcott St, Kalamazoo, MI 49001. (dagger) Chattanooga Corp, 4717 Adam Rd, Hixson, TN 37343.

References

[1] Sanders B, Buoncristiani R. Diagnostic and surgical arthroscopy of the temporomandibular joint: clinical experience with 137 procedures over a 2-year period. Journal of Craniomandibular Disorders and Facial and Oral Pain. 1987;1:202-213. [2] Arthroscopic lavage and lysis of the temporomandibular joint: a change in perspective. J Oral Maxillofac Surg. 1990;48:798-801. [3] Hoppenfeld S. Physical Examination of the Spine and Extremities. East Norwalk, Conn: Appleton-Century-Crofts; 1976:132. [4] Hayes KW. Manual for Physical Agents, Volume 3. Chicago, Ill: Northwestern University Press; 1984. [5] Harvey W, Dyson M, Pond JB, Grahame R. The in vitro stimulation of protein synthesis in human fibroblasts by therapeutic levels of ultrasound. In: Kazner E. Proceedings of the 2nd European Congress on Ultrasonics in Medicine. New York, NY: Elsevier Science Publishing Co Inc; 1975;10-21. [6] Abramson DI, Burnett D, Bell Y, et al. Changes in blood flow, oxygen uptake and tissue temperatures produced by therapeutic physical agents: effect of ultrasound. Am J Phys Med. 1960;39:51-62. [7] Lehmann JF. Therapeutic Heat and Cold. 3rd ed. Baltimore, Md: Williams & Wilkins; 1982. [8] Belitsky RB, Odam SJ, Hubley-Kozey C. Evaluation of the effectiveness of wet ice, dry ice, and cryogen packs in reducing skin temperature. Phys Ther. 1987;67:1080-1084. [9] Mannheimer JS. Physical therapy concepts in evaluation and treatment of the upper quarter. In: Kraus SL, ed. Temporomandibular Joint Disorders: Management of the Craniomandibular Complex. New York, NY: Churchill Livingstone Inc; 1988:314. [10] Melzack R. The McGill Pain Questionnaire: major properties and scoring method. Pain. 1975;1:277-299. [11] Husskisson EC. Measurement of pain. Lancet. November 1974:1127-1131.

FL Waide, PT, is Director, Associated Rehabilitation Services Inc, 110 Third St, Ste 250, Henderson, KY 42420 (USA). He is also a guest lecturer for the Physical Therapy Program, University of Evansville, PO Box 3295, Evansville, IN 47702, and a voluntary faculty member for the Physical Therapy Program, University of Kentucky, Lexington, KY 40536. Address all correspondence to Mr Waide at the first address. DM Bade, DDS, FAGD, is Medical Director, Regional Head, Neck, and Temporomandibular Joint Treatment Center, Our Lady of Mercy Hospital, US Hwy 30, Dyer, IN 46311. He is also Attending Staff Member, Michael Reese Medical Hospital and Medical Center, Lake Shore Drive at 31st St, Chicago, IL 60616, and is in private practice in Highland, IN. JH Lovasko, DDS, is in private practice at 8231 Calumet Ave, Munster, IN 46321. He is also Assistant Clinical Professor, Department of Oral and Maxillofacial Surgery, University of Illinois, Urbana, IL 61801. JM Montana, PT, is Physical Therapist and Vice President, Associated Rehabilitation Services Inc, 501 Wall St, Valparaiso, IN 46383.