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MPD, TMJ dysfunction, trigger point injection Patient 3, a 15-year-old female, was referred to the department of pediatric dentistry, Tufts University School of Dental Medicine, for evaluation of considerable pain in the face while eating, and limited jaw opening. Since 10 years of age, the patient had experienced frontal and bilateral temporal headaches. These had gotten progressively worse, and on eating she now had considerable pain in her cheeks, TM joints, and around the eyes. She felt the worst on awakening, with headaches, pain, stuffiness, and ringing in both ears. She felt pressure behind her eyes and occasionally had right eye. Throughout the day, she experienced tightness in her neck with upper back pain, clicking of both TM joints and limited jaw opening. Her medical history revealed no serious illness or known drug allergies. She took 3 to 4 aspirins a day for her headaches, and Dramamine at night to sleep. The only history of trauma elicited was a fall at the age of 3 to 4 years, in which she sustained a severe blow to her chin. Positive history of clenching during the day and bruxism at night was obtained. The psychological evaluation showed a very depressed and anxious young individual. Clinical examination revealed pain on lateral palpation over both TM joints, and posteriorly displaced condyles with early reciprocal clicking of both joints. She had pain on opening and closing, with maximal opening being limited to only 26 mm. She had good lateral excursions and protrusive excursions of her mandible and was not closed locked. Orthodontic evaluation revealed a Class I cuspid and molar relationship, with a 50% deep bite (Figs. 9-1∼9-7)  (Figs. 9-1∼9-7). Facial view of patient 3. Profile view of patient 3. Intraoral view of incisor region. Mirror view of maxillary Arch. Mirror view of mandibular arch. Mirror view of right side. Mirror view of left side. (continues) A panoramic radiograph revealed no bony pathology. The transcranial radiograph (Fig 9-8), revealed a steep articular eminence, and a reduction of the posterior joint space as the mandible moved from the rest position to the centric occlusion position. On anteriorly repositioning the mandible to the position in Fig. 9-9, the early reciprocal clicking was reduced.  ▲(Fig 9-8). Transcranial radiograph showing reduction of posterior joint space from rest position to centric occlusion. Left to right:  left
condyle position in centric occlusion, rest, and maximal opening; right
condyle on maximum opening, rest, and centric occlusion. (continued)(Fig. 9-9). Anterior repositioning of the mandible reduces reciprocal clicking if opening is initiated from this position. On palpation of the musculature, tenderness was elicited in the following muscles: RL masseters, R-L temporalis, R-L medial and lateral pterygoids, R-L sternomastoids, and L-trapezius. The diagnosis of TMJ and MPD syndrome was made. A maxillary soft mouthguard (nighttime wear) and a mandibular acrylic flat occlusal splint (daytime wear) to reposition the mandible anteriorly and increase the vertical dimension were inserted on 1-16-86 (Figs. 9-10∼9-11).
(Figs. 9-10∼9-11). Mandibular flat occlusal splint, facial view. Mandibular flat occlusal splint, occlusal view.  (Fig. 9-12). Right this position.Right sternomastoid TP located between interrupted horizontal and vertical lines. Notice that the position of the mandible resembles the non-click position determined during the initial evaluation (Fig. 9-12). The following description shows the progress of the patient's treatment. 2-6-86 Less pain in the face. Headaches are 50% better, less pressure behind the eyes, ringing in the ears less frequent. Appliance equilibrated. 3-7-86 Pain in the joints and cheeks are 50% better. Headaches almost gone. Infrequent attacks of sharp retro-orbital pain (right). Pressure in the eyes almost gone. "When the splint is in, the joint doesn't crack any more." She is sleeping very well at night and has stopped Dramamine and aspirin tablets. Appliance checked and equilibrated. 4-29-86 No headaches at all, very infrequent joint pain. No ringing, stuffiness, or pain in the ears. Experiences a tired feeling in the masseters and attacks off and on of retro-orbital pain (right). Neck and upper back stiffness are still present, no improvement noted. Reciprocal clicking eliminated and tenderness to palpation only elicited in masseters, sternomastoids, and trapezius muscles. Appliance equilibrated. 6-23-86 Patient is asymptomatic, except that stiffness in the neck and upper back remains unchanged, and she experiences some attacks of retro-orbital pain (right). Palpation of the sternomastoid and the trapezius reveal presence of TPs. Digital palpation of the TP in Fig 9-11. of right sternomastoid referred pain to behind the right eye. Palpation of the left trapezius TP referred pain up along the side of the neck to the most tender TP in the right sternomastoid were scheduled to be treated at the next appointment. 7-25-86 TP injections done into TPs of right sternomastoid and left trapezius, using xylocaine without epinephrine (epinephrine is a muscle irritant), with a 24 needle. Within a few minutes, she was feeling better, describing a feeling of a great weight being lifted from her shoulders. |
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