Mohammed A. Sad Aldeen, MD

1. Anterior deprogramming devices versus muscle relaxant on TMJ in patient with lateral pole anterior disc displacement REPLACE THIS BOX WITH YOUR ORGANIZATION’S HIGH RESOLUTION LOGO Mohamed. A. Saad-Eldeen , Shawky Elmorsy , Mansoura university,Egypt ABSTRACT INTRODUCTION RESULTS RESULTS DISCUSSION Objectives:The conservative treatment of tempromandibular disorder is recommended as a basic principle in management by using splint especially anterior disk displacement. Aim of the work:This study aimed to compare the effect of wearing anterior deprogramming devices (two types) and muscle relaxant on TMJ in patient with lateral pole anterior disc displacement Material and methods:In a prospective study from 2005-2009, 30 patients with lateral pole anterior disc displacement were evaluated in this study before and after wearing devices for six months. Magnetic resonance imaging (MRI) was used for evaluation in this study. Patients were randomly divided into three equal groups. In Group I, anterior deprogramming devices were used. Group II used anterior midline stop device and group III used muscle relaxant appliance for six months. Outcome assessment was done by MRI and clinical findings. Results:The results of this study revealed that anterior deprogramming devices were more rapid and effective in treatment of TMJ displacement than muscle relaxant appliance. Conclusion:It can be concluded that anterior deprogramming devices can be used for treatment lateral pole anterior disc displacement of TMJ. Many problems associated with TMD which include pain in the preauricular area TMJ or muscles of mastication, limitation or deviation in mandibular joint, usually aggravated by function; muscle tenderness to palpation; restricted range of motion; and joint sounds, such as clicking, popping and crepitus All treatment methods being used for TMD can be categorized generally into one of two types: definitive treatment and supportive therapy. Definitive treatment is aimed directly toward the elimination or alteration of the etiologic factors that are responsible for the disorder while the supportive therapy consist of conservative treatment and surgical treatment The conservative treatment is recommended as a basic principle in management of TMD intends to modify the occlusion or the function of the masticatory apparatus or both. The anterior deprogramming devices and its modification as the anterior midline point stop device very effective in permitting complete seating of both condyles and suppression of clenching and rapid relief of muscles hyperactivity, and getting patients comfortable The aim of this study was to evaluate the effect of anterior deprogramming devices (two types) and muscle relaxant on TMD diagnostic categories and specific signs and symptoms regarding alleviation of patients' symptoms and disc position Clinical finding: Improvement of clinical finding include pain on movement of mandible(P), TMJ pain(D), maximum mouth opening(T), TMJ noise(S), muscle pain(M) and talking(TA) for group I,II and group III 3 and 6 months after insertion the appliance. Table (1) show clinical dysfunction index based on evaluation of clinical signs during insertion appliance and after 3 and 6 months forgroup I,II and group III. MRI findings: All 60 joints showed slight to moderate displacement with lateral pole ADD with reduction on pre-treatment MRI. A change to normal disc position was not found in both groups under study on post-treatment MRI. Degree of displacement All 60 joints showed slight to moderate displacement with reduction on treatment MRI. In group I, 18 out of 20 joints involved (90%) showed slight displacement and remaining 2 joints (10%) showed moderate displacement. Post treatment MRI after 3 months follow up showed 11 joint that change to normal. On other hand, after 6 months post treatment MRI all joint change to normal. In group II, 17 out of 20 joints involved (85%) showed slight displacement and remaining 3 joints (15%) showed moderate displacement. Post treatment MRI after 3 months follow up showed 12 joint that change to normal. On other hand, after 6 months post treatment MRI all joint change to normal Disc morphology (deformity) In group I, pretreatment MRI showed that 4 joints (20 %) had slight disc deformity, 16 joints ( 80 %), had disc deformity. On post treatment MRI, after 3months only 2 joints(10%) still had slight disc deformity. After 6months all joints become normal(biconcave) In group II, pretreatment MRI showed that 14 joints (70 %) had slight disc deformity, 6 joints ( 30 %), had disc deformity. On post treatment MRI after 3months, 18 of joints(90%) with disc deformity became slight disc deformity. After 6months all joints become normal(biconcave) In group III, pretreatment MRI showed that 15 joints (75 %) had slight disc deformity, 5 joints ( 25 %), had disc deformity. On post treatment MRI after 3months, 10 of joints(50%) with disc deformity became slight disc deformity. After 6months all joints become normal(biconcave) Signal intensity In group I, 16 out of 20 joints involved (80%) showed normal signal intensity and remaining 4 joints (20%) showed slight signal intensity. Post treatment MRI after 3 months follow up showed 4 joint that change from slight signal intensity to normal signal intensity. After 6months all joints become normal. In group II 13 out of 20 joints involved (65%) showed normal signal intensity and remaining 7 joints (35%) showed slight signal intensity. Post treatment MRI after 3 months follow up showed 6 joint that change from slight signal intensity to normal signal intensity. After 6months all joints become normal. In group III 12 out of 20 joints involved (60%) showed normal signal intensity and remaining 8 joints (40%) showed slight signal intensity. (Management of chronic pain Conditions is among the most difficult problems especially TMDS. The management goals are reduction of pain reduction of adverse loading improvement of function and restoration of normal daily activities. In study of treatment for TMDS careful description of the patient population is necessary to understand of the treatment response of specific TMD diagnosis to specific treatments. MRI is able to discern change in the marrow space of TMJ. Also, useful for determining the position of the disc in relation to the condyle because sagittal cuts can be made at different depths through condylar head. The medial pole can be clearly differentiated from lateral pole The result of this study showed that wearing anterior deprogramming device (ADD) and anterior mid line point stop device (AMPS) were rapid successful in alleviating most of the signs and symptoms associated with TMDS more than muscle relaxant splint (MRS). This may be due to very effective in permitting complete seating of condyles by complete separation of posterior teeth which may be causes most of the elevator muscles to completely release contraction, This agree with dowsan et al. who mentioned that any device that permits complete seating of condyles during clench closure of mandible will effectively eliminate the need for lateral pterygoid contraction is the point at which relief of discomfort is effected. On the other hand (MRS) do not completely separate posterior teeth without complete relaxation of muscles thus take long period of time for achieving the improvement. METHODS AND MATERIALS CONCLUSIONS A total of 30 patients of TMJ disorder with lateral pole disc displacement stage III according to piper's classification; (12) All patients had full or nearly full complement of natural teeth their age of the patients ranged between 18 -45 years. They were diagnosed clinical and radio-graphically by MRI, selected from E.N.T. department, faculty of medicine, Mansoura University, The patients must be free from systemic diseases affecting masticatory system (as rheumatoid arthritis) and osteoarthritic change of TMJ. History of click, Auscultation (by Doppler) is quit on rotation and crepitus on translation. Clinical observation, range and path of motion vary from normal to abnormal paths and restriction of opening. Palpation to masticatory muscles is painful. Loading test, for verification of comfort in centric relation, has no pain, thus no intracapsular disorder . Radiographic (MRI) evaluate lateral pole anterior disk displacement. For all patients the following was done: Upper secondary cast was mounted using face bow and lower secondary cast was mounted using centric relation (CR) record. The patients were classified into 3 equal groups, where for group I the patients wear anterior deprogramming devices, group II patients wear anterior midline stop device and group III patients wear muscle relaxant appliance. Anterior deprogramming device and anterior midline point stop device are more effective for alleviating most of the signs and symptoms associated with the disc derangement with treatment lateral pole anterior disk displacement of TMJ, alternatively with stabilizing splint, than muscle relaxant splint. Fig 3: musele relaxant stent inserted in patient mouth REFERENCES Fig 2: anterior midline point stop device (amps) inserted in patient mouth Fig 1: Anterior Deprogramming device (ADD) inserted in patient mouth. Mohammed A. Sad Aldeen, MD Ass. Professor of prosthodontic,Faculty of dentistery, Mansoura University Egypt Phone: +20105246254 Fax: +20502267016 Mohamed.elkhodary@hotmail.com Elkhodary.net • Jens C, Turp MD, Jorg R: Prosthetic rehabilitation in patients with temporomandibular disorder. J Prosthet dent 1996;76: 418-23. • -Katzberg RW : Temporomandibular joint imaging. Radiology 1989; 170:297-299. • Kurita K, Ohtsuka A, Kurashina A.: Efficacy of a mandibular technique in reducing the permanently displaced temporomandibular joint disc. J Oral Maxillofacial Surg 1999; 57: 784-87. CONTACT Fig.(4) : MRI of a right TMJ with anterior disc displacement with: (A) opened-mouth view,(B) closed-mouth view.