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ORIGINAL ARTICLE
Year : 2018  |  Volume : 5  |  Issue : 2  |  Page : 66-70

Does the frequency of temporomandibular myofascial dysfunction differ in patients treated for different mandibular and zygomatic fractures?


Department of Dental and Maxillofacial Surgery, Oral and Maxillofacial surgery Unit, University of Calabar Teaching Hospital, Calabar, Nigeria

Date of Submission19-Nov-2017
Date of Acceptance15-Dec-2017
Date of Web Publication13-Aug-2018

Correspondence Address:
Dr. Charles E Anyanechi
Department of Dental and Maxillofacial Surgery, University of Calabar Teaching Hospital, P. O. Box 3446, Calabar, 540001
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhrr.jhrr_98_17

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  Abstract 

Aim: To determine whether the frequency of Temporomandibular myofascial dysfunction (TMD) differs in patients treated for different mandibular and zygomatic fractures. Materials and Methods: This was a 9-year prospective study. The diagnosis of TMD was based on standard diagnostic criteria and was made during follow-up reviews of patients after the treatment of the fractures. Additional information obtained from the patients and their case files were age, gender, site of fracture (s), and treatment methods. One-way analysis of variance was used to compare the presence of TMD among the study groups. Results: Overall, 42/587 (7.2%) patients were diagnosed with TMD between 2.3 and 4.7 years after treatment commenced. Patients who presented with TMD were those treated for isolated zygomatic (n = 5/42, 11.9%), isolated condylar (n = 7/63, 10.0%), and multiple mandibular (n = 30/475, 6.3%) fractures, which was significant (P = 0.01) in favor of those treated for isolated zygomatic and isolated condylar fractures. Patients who were treated for unilateral zygomatic complex/arch(P == 0.001), unilateral intracapsular condyle (P = 0.001), and parasymphyseal/body/angle/condyle (P = 0.01) fractures also had higher frequencies of TMD. Conclusions: Patients who were treated for isolated zygomatic or condylar fractures had higher frequencies of TMD than those with multiple mandibular fractures. Future research work needs to be directed toward the description of the pathogenesis of the different types of TMD symptoms so that more information can be gathered on the natural course of the disorders and identify the risk factors for pain persistence and chronicity.

Keywords: Dysfunction, fractures, mandible, myofascia, temporomandibular, zygoma


How to cite this article:
Anyanechi CE. Does the frequency of temporomandibular myofascial dysfunction differ in patients treated for different mandibular and zygomatic fractures?. J Health Res Rev 2018;5:66-70

How to cite this URL:
Anyanechi CE. Does the frequency of temporomandibular myofascial dysfunction differ in patients treated for different mandibular and zygomatic fractures?. J Health Res Rev [serial online] 2018 [cited 2018 Nov 17];5:66-70. Available from: http://www.jhrr.org/text.asp?2018/5/2/66/238866


  Introduction Top


Temporomandibular myofascial dysfunction (TMD) is a symptom complex, clinical condition characterized by the presence of pain, dysfunction of the muscles of mastication, and temporomandibular joints (TMJs).[1],[2],[3] The etiological and predisposing factors are multifactorial, poorly understood, and there is still controversy over their relative clinical importance.[4],[5],[6],[7] The condition is not life threatening but may impact adversely on the patients' quality of life as the symptoms can progress to chronicity and become difficult to manage.[8],[9],[10] In the adult population, about 15%–35% are affected, involving mostly young adults who are healthy between the ages of 20 and 40 years.[11],[12] The clinical features of TMD vary in their presentation as all the symptoms and signs may not always be found in one particular patient.[1],[12] However, the patients' complaints will usually involve more than one component of the masticatory system such as muscles, nerves, tendons, ligaments, bones, connective tissues, or teeth.[2],[6],[12]

There is an evidence to suggest that TMD can develop following trauma to the orofacial region particularly those affecting the zygoma and mandible which may impair mouth opening or limit mandibular movement when they present.[13],[14],[15] This study determines if the frequency of TMD differs in patients treated for different mandibular and zygomatic fractures.


  Materials and Methods Top


This was a prospective study of patients who sustained fractures of the zygoma and mandible, treated by malar elevation for zygomatic fractures, and closed reduction technique for mandibular fractures and was reviewed during follow-up. The participants presented to the Oral and Maxillofacial Surgery Clinic of the study institution between August 2007 and July 2016. The study was approved from ethical clearance by the Regional Research Ethics Committee of the institution (UCTH/HREC/33/393), informed consent was obtained from the patients studied before treatment commenced. The diagnoses of TMD were made during the follow-up reviews of the patients after the treatment of the fractures and were based on the patients' complaints when they persist >6 months from the commencement of treatment. Also before being included, the patients admitted at presentation before treatment commenced, not having the symptoms and signs of TMD before the trauma. Those patients who had systemic disease, concomitant injuries, and fractures of the orofacial region and other body parts were excluded from the study. The participants who met the diagnostic criteria were included in the study, while those who did not were excluded from the study.

The diagnoses of TMD were made with the instrument used to collect the patients' data, Research Diagnostic Criteria (RDC)/TMD Axis I and II of Dworkin and LeResche.[16] The RDC/TMD Axis I criteria are based on the measurement of symptoms and signs of TMD (jaw pain, limited mouth opening, and TMJ noise). On the other hand, the Axis II protocol is divided into the screening and comprehensive self-report instrument sets. The screening instruments consisting of 41 questions assess pain intensity, pain-related disability, psychological distress, jaw functional limitations and parafunctional behaviors, and a pain drawing used to assess locations of pain. The comprehensive instruments, composed of 81 questions, assessed in further detail jaw functional limitations and psychological distress as well as additional constructs of anxiety and presence of comorbid pain conditions. These instruments are validated, reliable, specific, sensitive and have been shown to adhere to internal consistency.[12],[17],[18] The data were collected from the patients by two examiners: an oral and maxillofacial surgeon who regularly deals with trauma patients but different from the one that treated the patients initially and a dental surgeon who has interest in orofacial traumatology. Before the study commenced, these clinicians were trained and acquainted themselves with the use of the instruments.

Additional information obtained from the patients and their case files were recorded in some pro forma and included age, gender, site of fracture(s), treatment methods used to manage the fractures, dates treatment commenced, and when a patient presented with TMD. Statistical analysis was performed with Epi Info 7, version 0.2.0, 2012 software package (CDC, Atlanta, GA, USA). Simple frequency charts, descriptive statistics, and test of significance were utilized for analysis. Comparative statistics were done using Fisher's exact test while one-way analysis of variance was used to compare the presence of TMD among the study groups using the types of fracture and treatment methods as variable. P < 0.05 was considered statistically significant.


  Results Top


Overall, 42/587 (7.2%) patients were diagnosed with TMD between 2.3 and 4.7 years after treatment commenced. All the patients presented to the hospital within 48 h after sustaining the fractures. [Table 1] shows the distribution of patients according to the type of fractures and TMD after treatment. The patients who presented with TMD were those treated for isolated zygomatic (n = 5/42, 11.9%), isolated condylar (n = 7/63, 10.0%), and multiple mandibular (n = 30/475, 6.3%) fractures. This was significant (P = 0.01) in favor of those treated for isolated zygomatic and isolated condylar fractures. For the multiple mandibular fractures, the more the sites involved the greater the frequency of TMD that presented.
Table 1: Distribution of patients, fractures, and temporomandibular myofascial dysfunction after treatment of fractures

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The distribution of age and gender of patients that presented with TMD is shown in [Table 2]. The age of patients ranged from 17 to 36 years with a mean age of 30 ± 2.2 years. Majority (n = 18, 60.0%, P = 0.01) of the patients were in the age group of 21–30 years. The females outnumbered the males in all age categories with a male-to-female ratio of 1:2.8 and this was significant (P = 0.01).
Table 2: Distribution of age and gender of patients with temporomandibular myofascial dysfunction

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  Discussion Top


TMD is a complex disease entity, and this has compelled researchers to come up with diagnostic criteria that have overcome certain controversies. The Axis I clinical assessment protocol is designed to render TMD diagnoses, and the Axis II screening instruments assess psychological status and pain-related disability. The reliability and validity of the instruments used for diagnosis in this study have been found to be effective and consistent by other researchers.[17],[18],[19]

This study showed that patients who were treated for isolated zygomatic and isolated condylar fractures seem to be more likely to develop TMD than those who were treated for multiple mandibular fractures. This study corroborates earlier reports which stated that patients treated for fractures of the zygoma and mandible can develop symptoms and signs suggestive of TMD postoperatively.[20],[21],[22] The complications of mandibular fractures after treatment such as TMD have been partly attributed to the increase in the interarch width of the anterior mandible that occurs following the fractures.[13],[15] Fractures of the zygoma, on the other hand, may impede or reduce the movement of the coronoid process and by so doing limit mouth opening, and this may persist to some degree if not properly treated or even after treatment if the patients do not properly follow the posttreatment instructions.[14],[22] Worsaae and Thorn [23] also emphasized that the emergence of complications after the treatment of these fractures may be due to the inability of the participants to overcome the different neuromuscular and functional problems associated with the repositioning of the fractured segments. Consequently, some authors showed that the natural history of TMD is benign and self-limiting with symptoms and signs slowly improving and resolving over time without causing permanent damage to the orofacial region.[24],[25],[26] However, certain researchers thought otherwise and had suggested that the condition can progress to chronicity causing degenerative conditions such as rheumatoid arthritis and osteoarthritis of TMJ with their deleterious effect to life.[9],[10],[27] This is sequel to their observation that the persistent pain, psychological discomfort, physical disability, and functional limitations may impact negatively on the patients' quality of life. Furthermore, it has been noted that 33% of the general population have at least one symptom suggestive of TMD, but that only in 3.6%–7.0% will this be of significant severity to make the person seek medical treatment.[11],[12],[28],[29] Consequently, 7.2% of patients in this study who presented with this condition are closely similar to those of the previous reports.

Although the average age of occurrence of TMD in patients differs from study to study, the present study confirmed an earlier assertion that TMD affects predominantly participants in their 20–40 years of age.[1],[11],[12] As shown in this study like in most other reports, females are mostly affected.[11],[24],[25],[26] The reason for female gender being more affected than their male counterparts is unknown. Certain authors suggested that females are more likely to seek treatment for their TMD than male patients who ordinarily may not have much time to spare for consultation in the hospital unless the medical condition has weighed down on them.[21],[24],[25] Some other authors reported that it might be associated with menopause or the onset of menopause in some females.[1],[4],[11] However, this factor may be inconsequential in the present circumstance as the female patients who presented in this study have not reached the age of menopause.

The methods of treatment used to manage the fractures have been reported in contemporary practice to be effective but may have been partly the reason for the reported TMDs in this study.[6],[23],[30] The treatment methods lead to unstable fractures after reduction with or without immobilization, and immobilization of the mandible causes limitation of movements and increased risk of organization of intra-articular hematoma. In addition, the risk of mal-union of the proximal segment can cause a disturbance in joint mechanics which would take some months to remodel.[28],[30],[31] Likewise, mal-union of a zygomatic fracture will cause alteration of muscle function and potentially impede normal joint mechanics.[30]

This study was limited by the severity of TMD in the patients not being graded as the instruments used for the diagnosis allow for identification of patients with a range of simple to complex TMD presentation. Furthermore, part of the selection criteria used in recruiting the patients into the study is subjective but prospective, like the self-report to not having symptoms and signs of TMD before the trauma which may not be wholly accurate in some cases as it may have been present or subclinical at presentation, and this would have introduced some discrepancies to the data used in the analysis. The stress of traumatic injury either psychological or direct may exacerbate these symptoms. Furthermore, because of the study duration, it was not possible to determine the cases that would enter into chronicity as suggested by Garofalo et al.[27] Magnetic resonance imaging was not used to determine the status of TMJs of the patients. This would have revealed whether the disc was displaced or not as it is generally known that intracapsular fractures of the condyle are more predisposed to TMD than extracapsular. Furthermore, rigid internal fixation is preferred to closed reduction technique in the management of certain types of mandibular fractures as this could have contributed to alteration in joint function and limitation of movements even when the joint has not been directly traumatized. This was not used in the present study because of unavailability and unaffordability of the hardware during the study.


  Conclusion Top


This study shows that 7.2% of patients were diagnosed with TMD and that patients who were treated for isolated zygomatic or isolated condylar fractures had more frequency of TMD than those treated for multiple mandibular fractures. The RDC/TMD diagnostic criteria seem to be the most suitable instrument that helps researchers compare results from different studies and to acquire more knowledge about the distribution of TMD symptoms and signs in the general population and in different patient samples as in this study.[12],[16],[17],[26] The baseline reports of pain and impairment, oral parafunctional activities, pain elsewhere in the body, and somatization are associated with the severity and time course of myofascial TMD complaints after treatment.[32] According to earlier researchers,[2],[10],[12],[26] the suggested predictors of pain chronicity have been intensity and frequency of baseline pain coupled with the presence of widespread pain in other parts of the body, but the greater knowledge of the pathogenesis of the different causes of TMD pain is needed. If this is established, the natural course of the clinical symptoms can be better understood. Furthermore, future research work needs to be directed toward the description of the pathogenesis of the different types of TMD symptoms, so that more information can be gathered on the natural course of the disorders and identify the risk factors for pain persistence and chronicity. This will involve multidisciplinary research collaboration among different specialists that treat orofacial pain disorders.

Acknowledgment

The author is grateful to the oral and maxillofacial surgeon, dental surgeons, nurses, dental therapists and dental surgery assistants at the study center who were of immense assistance during the management of the patients and collection of the data.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gözler S. Myofascial pain dysfunction syndrome: Etiology, diagnosis, and treatment. In Temporomandibular joint pathology-current approaches and understanding, Y. Emes, B. Aybar, G. Dergin (eds.). Intech Open, Istanbul, Turkey 2018, pp.17-45.  Back to cited text no. 1
    
2.
Cairns BE. Pathophysiology of TMD pain – Basic mechanisms and their implications for pharmacotherapy. J Oral Rehabil 2010;37:391-410.  Back to cited text no. 2
    
3.
Anderson GC, Gonzalez YM, Ohrbach R, Truelove EL, Sommers E, Look JO, et al. The research diagnostic criteria for temporomandibular disorders. VI: Future directions. J Orofac Pain 2010;24:79-88.  Back to cited text no. 3
    
4.
Fernández-de-las-Penas C, Svensson P. Myofascial temporo-mandibular disorder. Curr Rheumatol Rev 2016;12:40-54.  Back to cited text no. 4
    
5.
Eweka OM, Ogundana OM, Agbelusi GA. Temporomandibular pain dysfunction syndrome in patients attending Lagos University Teaching Hospital, Lagos, Nigeria. J West Afr Coll Surg 2016;6: 70-87.  Back to cited text no. 5
    
6.
Anyanechi CE. Mandibular fractures associated with domestic violence in Calabar, Nigeria. Ghana Med J 2010;44:155-8.  Back to cited text no. 6
    
7.
Kindler LL, Bennett RM, Jones KD. Central sensitivity syndromes: Mounting pathophysiologic evidence to link fibromyalgia with other common chronic pain disorders. Pain Manag Nurs 2011;12:15-24.  Back to cited text no. 7
    
8.
Fricton J. Myofascial pain: mechanisms to management. Oral Maxillofac Surg Clin North Am 2016;28:289-311.  Back to cited text no. 8
    
9.
Cho SH, Whang WW. Acupuncture for temporomandibular disorders: A systematic review. J Orofac Pain 2010;24:152-62.  Back to cited text no. 9
    
10.
Bouloux GF. Use of opioids in long-term management of temporomandibular joint dysfunction. J Oral Maxillofac Surg 2011;69:1885-91.  Back to cited text no. 10
    
11.
Fuentes AD, Sforza C, Miralles R, Ferreira CL, Mapelli A, Lodetti G, et al. Assessment of electromyographic activity in patients with temporomandibular disorders and natural mediotrusive occlusal contact during chewing and tooth grinding. Cranio 2017;35:152-61.  Back to cited text no. 11
    
12.
Manfredini D, Guarda-Nardini L, Winocur E, Piccotti F, Ahlberg J, Lobbezoo F, et al. Research diagnostic criteria for temporomandibular disorders: A systematic review of axis I epidemiologic findings. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:453-62.  Back to cited text no. 12
    
13.
Banks P, Brown A. Fractures of the Facial Skeleton. 1st ed. Oxford, Woburn: Butterworth Heinemann; 2001. p. 171-85.  Back to cited text no. 13
    
14.
Tadj A, Kimble FW. Fractured zygomas. ANZ J Surg 2003;73:49-54.  Back to cited text no. 14
    
15.
Anyanechi CE, Saheeb BD. Mandibular sites prone to fracture: Analysis of 174 cases in a Nigerian tertiary hospital. Ghana Med J 2011;45:111-4.  Back to cited text no. 15
    
16.
Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: Review, criteria, examinations and specifications, critique. J Craniomandib Disord 1992;6:301-55.  Back to cited text no. 16
    
17.
Dworkin SF, Sherman J, Mancl L, Ohrbach R, LeResche L, Truelove E, et al. Reliability, validity, and clinical utility of the research diagnostic criteria for temporomandibular disorders axis II scales: Depression, non-specific physical symptoms, and graded chronic pain. J Orofac Pain 2002;16:207-20.  Back to cited text no. 17
    
18.
Schiffman EL, Truelove EL, Ohrbach R, Anderson GC, John MT, List T, et al. The research diagnostic criteria for temporomandibular disorders. I: Overview and methodology for assessment of validity. J Orofac Pain 2010;24:7-24.  Back to cited text no. 18
    
19.
Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet JP, et al. Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: Recommendations of the international RDC/TMD consortium network* and orofacial pain special interest group†. J Oral Facial Pain Headache 2014;28:6-27.  Back to cited text no. 19
    
20.
Gupta SK, Rana AS, Gupta D, Jain G, Kalra P. Unusual causes of reduced mouth opening and it's suitable surgical management: Our experience. Natl J Maxillofac Surg 2010;1:86-90.  Back to cited text no. 20
[PUBMED]  [Full text]  
21.
Manfredini D, Guarda-Nardini L, Winocur E, Piccotti F, Ahlberg J, Lobbezoo F, et al. Research diagnostic criteria for temporomandibular disorders: A systematic review of axis I epidemiologic findings. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:453-62.  Back to cited text no. 21
    
22.
Anyanechi CE, Saheeb BD. The clinical presentation and management of zygomatic complex fractures in a Nigeria teaching hospital. Niger J Med 2012;21:308-12.  Back to cited text no. 22
    
23.
Worsaae N, Thorn JJ. Surgical versus nonsurgical treatment of unilateral dislocated low subcondylar fractures: A clinical study of 52 cases. J Oral Maxillofac Surg 1994;52:353-60.  Back to cited text no. 23
    
24.
Orlando B, Manfredini D, Salvetti G, Bosco M. Evaluation of the effectiveness of biobehavioral therapy in the treatment of temporomandibular disorders: A literature review. Behav Med 2007;33:101-18.  Back to cited text no. 24
    
25.
Manfredini D, Lobbezoo F. Relationship between bruxism and temporomandibular disorders: A systematic review of literature from 1998 to 2008. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:e26-50.  Back to cited text no. 25
    
26.
Manfredini D, Chiappe G, Bosco M. Research diagnostic criteria for temporomandibular disorders (RDC/TMD) axis I diagnoses in an Italian patient population. J Oral Rehabil 2006;33:551-8.  Back to cited text no. 26
    
27.
Garofalo JP, Gatchel RJ, Wesley AL, Ellis E 3rd. Predicting chronicity in acute temporomandibular joint disorders using the research diagnostic criteria. J Am Dent Assoc 1998;129:438-47.  Back to cited text no. 27
    
28.
Miller JR, Burgess JA, Critchlow CW. Association between mandibular retrognathia and TMJ disorders in adult females. J Public Health Dent 2004;64:157-63.  Back to cited text no. 28
    
29.
Quail G. Atypical facial pain – A diagnostic challenge. Aust Fam Physician 2005;34:641-5.  Back to cited text no. 29
    
30.
Motamedi MH. An assessment of maxillofacial fractures: A 5-year study of 237 patients. J Oral Maxillofac Surg 2003;61:61-4.  Back to cited text no. 30
    
31.
Tabrizi R, Bahramnejad E, Mohaghegh M, Alipour S. Is the frequency of temporomandibular dysfunction different in various mandibular fractures? J Oral Maxillofac Surg 2014;72:755-61.  Back to cited text no. 31
    
32.
van Selms MK, Lobbezoo F, Naeije M. Time courses of myofascial temporomandibular disorder complaints during a 12-month follow-up period. J Orofac Pain 2009;23:345-52.  Back to cited text no. 32
    



 
 
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