The Effectiveness of Osteopathic Treatment for TMD with Disc Displacement Without Reduction and Limited Mouth Opening – Case Study

Konstantinos VATHRAKOKOILIS, Torsten LIEM, Ioannis AETOPOULOS, Konstantinos ANTONIADIS, Ekaterini TRIANTAFYLLIDOUHellenic Archives of Oral and Maxillofacial Surgery 19 (1): 35–42, 2018.Case StudyABSTRACT:Temporomandibular Dysfunction (TMD), which has become increasingly prevalent in recent years, is a disorder of the motor system of the jaw. It is characterized by limitations in mobility, deviation of the mandible during mouth opening, periarticular pain with facial radiation, arthritic sounds, and headaches. However, there are no scientific data regarding the application of osteopathic approaches to the treatment of such cases that have been unsuccessfully treated by conservative therapies. This case study concerns a 50-year-old woman with intense chronic pain in the temporomandibular joint (TMJ) and severely limited mouth opening with anterior disc displacement. A 4-week treatment plan using direct and indirect techniques was applied. Evaluation was performed using the DC/TMD (Schiffmann et al. 2016), the SQ, the JFLS-20 functional assessment scale, the DC/TMD Examination Form, and the Wilkes Test (1989). The results demonstrated significant changes in the evaluated measurement parameters. The study suggests that osteopathic treatment may represent an alternative for the treatment of temporomandibular dysfunction.KEYWORDS:osteopathic treatment, temporomandibular joint, myofascial dysfunctionINTRODUCTIONTemporomandibular Dysfunction (TMD) is a complex and multifactorial disorder that affects the temporomandibular joint and the masticatory muscles, resulting in pain and biomechanical changes (Mujakperuo et al. 2010). The exact causes of this dysfunction have not yet been fully elucidated. However, genetic (Pihut et al. 2016), anatomical (Murray et al. 2004; Peck et al. 2008), and hormonal (Hiraba 2000) factors have already been highlighted. While numerous studies suggest that trauma, masticatory behavior, and occlusal problems trigger TMD, there is a belief that psychosocial aspects may also play a role (Jayaseelan & Tow, 2016; Mapelli et al. 2016). Nevertheless, the etiopathological mechanisms of this dysfunction must be investigated more thoroughly. The latest treatment guidelines recommend the use of medications in combination with an intraoral splint, hyaluronic acid injection, blood injection, arthrocentesis, and in advanced stages, arthroscopic surgical interventions or open joint surgery (Al-Moraissi, 2015). This case study illustrates the results of using an osteopathic treatment plan as an alternative for treating TMD. Due to its positive effects and ability to alter fibroblast growth, the treatment is based on direct and indirect techniques (Paanalathi et al. 2014). Given the secretion of anti-inflammatory cytokines and proteins from the extracellular matrix, fibroblast growth is essential for the healing process. This also supports angiogenesis, hyperplasia, and the alignment of collagen fibers (Darby et al. 2007).CASE STUDYA 50-year-old female patient presented to our practice. She reported bilateral pain in the TMJ and progressive limitations in mouth opening that had intensified over the past 6-8 weeks. The patient reported that she had been experiencing pain in the left side of the TMJ for over a year. The pain and movement restrictions on the right side had developed and intensified over the past 8-10 weeks. The patient also reported a typical crepitation sound in the right TMJ during mandibular movement. With regard to her medical history, the patient reported that she had been diagnosed with ulcerative colitis but had not received any medication for approximately the past 10 years. One year before the onset of TMD symptoms, the patient received anti-inflammatory medications and muscle relaxants at irregular intervals, which did not produce any visible changes in symptoms.EXAMINATIONFor the examination of the patient, several diagnostic criteria according to Schiffmann for the DC/TMD were applied (Schiffmann 2016). These included the SQ (Symptoms Questionnaire), the JFLS-20 (Jaw Functional Limitation Scale), the GROC (Global Rating of Change score), the NPRS (Numeric Pain Rating Score), and the DC/TMD Examination Form. To classify the present case (Stage IV), Wilkes classification criteria were also used (Wilkes, 1989) (Table 1). According to the SQ, the patient had suffered from persistent pain over the past 30 days, which was exacerbated by chewing any type of food, by opening the mouth and lateral movements of the mandible, by other activities of daily living, and by the slightest movements of the temporomandibular joint such as kissing, frowning, and speaking. The patient also reported pain in the head, particularly in the temporal region, which had developed over the past month and would intensify with the aforementioned daily activities. The patient also mentioned that she had perceived a characteristic sound (crepitus) on her right side. Her mouth opening was so small that she was unable to introduce food into her mouth with the help of her tongue. However, the patient reported no blockage in the temporomandibular joint when closing the mouth. On examination, the patient indicated bilateral pain during palpation of all palpated masticatory muscles: masseter (pars superficialis and profunda), temporalis (anterior and medial portions), medial and lateral pterygoid, and the posterior belly of the digastric muscle. The patient also reported pain during palpation of the posterior portions of the joint capsule, the lateral aspects, and the surrounding region. Pain-free mouth opening was minimal (20 mm). Painful active mouth opening (23 mm) and assisted mouth opening were also minimal (29 mm). No deviation was observed during mouth opening (Table 1). The patient had a current panoramic radiograph showing degenerative changes and incipient arthritis in both TMJs with narrowing of the joint space. Table 1: Clinical signs and symptoms during the initial examination of the patient.

ROM: Range of Motion Fig. 1: Panoramic radiograph, a. At occlusion, b. During mouth openingDIAGNOSISBased on the patient’s medical history, the panoramic radiograph, and the examination, a diagnosis of disc displacement without reduction, reduced mouth opening, and myalgia of the masticatory muscles was made. The patient was subsequently informed about the various treatment options. The options included resuming medication in combination with a splint, arthrocentesis with hyaluronic acid injection into the joint, and osteopathic treatment. Due to her experiences with medication and the potential difficulties of inserting the splint and her aversion to minimally invasive surgical interventions, the patient opted for the osteopathic treatment plan.EXPERIMENTAL DESIGNThe treatment plan included 2 treatments per week for a duration of 4 weeks, i.e., 8 treatments in total. Before each treatment, an examination and redefinition of the parameters using the above-mentioned scales took place. Diagram 1: Data collection and treatment plan.

INTERVENTIONEach treatment session included the following components: a. Re-examination of the patient (10 minutes), b. Implementation of the osteopathic treatment plan (30 minutes) with the aim of reducing symptoms and accelerating the healing process. The protocol included indirect and direct techniques. The selection of techniques was dependent on clinical findings, such as the patient’s response to palpation and changes in joint mobility. The following direct techniques were applied:

1. Desensitization of painful trigger points, whereby minimal pressure was applied with the fingertips to the corresponding point. The pressure served to release the tension of the sarcomeres without causing pain and to restore normal muscle function.
2. Periosteal techniques near the symptom region (FDM), whereby high pressure was applied primarily through the thumb to the point of fascial distortion in the transition area between capsule-ligament and bone.
3. Mobilization and manipulation techniques (HVLA manipulation) for the posterior part of the capsule and the bilaminar zone, whereby the therapist applies multiple manipulations at high velocity and low amplitude. The therapist fixes the patient’s head with the cranial hand, while the caudal hand mobilizes the mandible to reduce tensions in the articular structures and soft tissue.
4. Muscle Energy Technique (MET), whereby the therapist applies gentle pressure to inhibit the normal mobility of the joint. The patient performs an isometric contraction in the opposite direction, so that the muscles relax, leading to sensitization of local proprioceptors and improvement of joint mobility.

The following indirect techniques were applied:

1. Myofascial release techniques, whereby the therapist induces slight movements of the body to reduce the influence of gravity and overcome the reactive static tone. This occurs through the engagement and unfolding of restricted tissue throughout the multivectorial fascial movement pattern.
2. Reciprocal inhibition to balance soft tissue tensions, whereby the patient’s active muscle contraction is combined with passive mobilization by the therapist, thus positioning the soft tissue in the direction of least tension.

RESULTSBased on the examination of the above-mentioned measurement parameters, Table 2 summarizes the results of this treatment method. The patient showed significant improvement in her ability to open her mouth. She was again able to introduce food into her mouth with the help of her tongue and could gradually chew firmer foods. She reported that the perception of sound in her right TMJ had decreased and that she could perform painless laterotrusion, which contributed to the restoration of masticatory function. Pain intensity on the pain rating scale was also significantly reduced. The patient generally reported a strong reduction in pain perception compared to the initial examination. Table 2: Results of the various measurement parameters, based on the evaluation scales according to DC/TMD

NPRS: Numeric Pain Rating Score, JFLS: Jaw Functional Limitation Scale, GROC: Global Rating of Change Score, Mean (St. Deviation)DISCUSSIONThis case study demonstrates positive results from the application of osteopathic treatments in a patient with advanced temporomandibular joint dysfunction. Through the implementation of various techniques, pain was reduced and functionality improved. According to Scully et al. (2013), two models are described regarding pain in the masticatory system: the Pain Adaptation Model (PAM) and the Vicious Cycle Model (VCM). In the PAM, pain results from reduced muscle function of the agonist and overactivation of the antagonist to prevent pain. This leads to impairment of the normal function of the pterygoid muscles (Peck et al. 2008). In contrast, the VCM describes a release of acetylcholine (ACH) and calcium (Ca2+) from the sarcoplasmic network. The release is a reaction of the hyperactive muscle. This creates a vicious cycle of local muscle spasm leading to ischemia and oxygen deficiency (Gerwin et al. 2004). This causes chemical agents such as bradykinin, prostaglandins, serotonin, substance P, etc., to be released, which could cause pain and inflammatory processes. Additionally, the pH value is lowered, which inhibits acetylcholinesterase, and hypertonia develops in the local musculature (Butts et al. 2016). The osteopathic treatment protocol was implemented to inhibit the factors behind the aforementioned processes. The osteopathic techniques were divided into: a. Direct, b. Indirect, and c. A combination of both (Chase, 2011). The direct techniques achieved an increase in microcirculation in the region. Tissue mobilization led to mechanical distortion and activation of fibroblasts. It has already been demonstrated that fibroblasts respond to mechanical pressure by secreting anti-inflammatory chemical substances, cytokines, and growth factors. This accelerates the healing process and promotes angiogenesis (Zein-Hammoud, 2015). Indirect techniques (Hartmann, 1997) were applied due to the extent of symptoms and limited mobility. To release tensions in the area of restriction, these techniques were positioned in the direction of “ease” of joint mobility,  and also to stimulate the mechanoreceptors in the fascial tissue together with the CNS (Minasny, 2009). According to the Neurobiological Fascial Theory (Schleip, 2003), there is a strong relationship between the fascia and the autonomic nervous system (ANS). The mechanoreceptors are stimulated and decoded by the CNS and the ANS through myofascial manipulation techniques. This primarily influences the parasympathetic nervous system (PNS). The CNS responds with a reduction in muscle tone, whereas the PNS responds with general changes in muscle tone, local vasodilation, and a change in tissue viscosity. The PNS also ensures a reduction in tone in the intrafascial muscle fibers (Minasny, 2009). Indirect techniques are considered less stressful techniques because they reduce tension in the tissue. According to Tozzi (2012), no injuries have been documented as a result of applications with indirect techniques. Other studies have reached similar conclusions (Carnes et al. 2010). Nevertheless, mild reactions have been reported after the application of these techniques, such as muscle fiber pain, headaches, and generalized pain. The implementation of all these techniques achieves mechanical stimulation of the tissue or the area of dysfunction, so that a change in cell function occurs through the triggering of fibroblast activity (Johnson et al. 2003; Langenau et al. 2012). The fibroblasts respond immediately by proliferating. Initially, they develop granulated tissue in the problem area to ensure structural integration (Ritchlin et al. 2000; Dodd et al. 2006; Meltzer et al. 2007). After performing these techniques, there was a gradual improvement in mobility and mild symptoms. Above all, there was no intake of analgesics. Furthermore, relief occurred on the day after treatment. Despite the fact that there is little in the literature regarding the application of such techniques, other studies are discussed that explain how they work (Wong, 2012). This study discusses that osteopathic techniques can be safely used in patients with temporomandibular dysfunction. They aim to relieve pain and improve mobility without the use of anti-inflammatory analgesics (Roberts et al. 2012), given the risks posed to some patients by their medical conditions, as with our patient.