Miljenko Marotti

A quantitative analysis of splint therapy of displaced temporomandibular joint disc

OBJECTIVES The effects of the Michigan splint on the change in disc displacement (DD) as well as the position of the condyles were determined by metrical analysis using magnetic resonance imaging (MRI). METHODS Twenty-five patients with clinical DD symptoms were treated by means of the Michigan splint, and an assessment of the effects of the splint was conducted or verified by MRI before and during the period of therapy, 5 months follow-up. The positions of the condyles and the disc were calculated from the MRI in the parasagittal plane. RESULTS There were no changes in the positions of the disc and condyles in the physiological joints of the patients (n=23) prior to and during the time the splint was in place (p>0.05). The splint achieved a DD decrease (p<0.05), and pain was eliminated in 69.2% of the DD joints with reduction (n=13). As far as the DD joints without reduction (n=13) are concerned, pain was eliminated in 74.9% of the joints, that is, without any change in the positions of the disc and condyles (p>0.05). CONCLUSIONS The evaluation of the Michigan splint therapy showed that it has no influence in the repositioning of the DD joints without reduction, but the DD joints with reduction have a limited positive effect. In both forms of these displacements, conditions for the elimination of the clinical symptoms are created.

Superoxide dismutase and cytochrome P450 isoenzymes might be associated with higher risk of renal cell carcinoma in male patients

Literature data support the hypothesis that oxidative stress and the accompanying antioxidant defense might play an important role in renal cell carcinoma (RCC) growth and progression. It is also known that the incidence of renal tumors is two times higher in men than in women. Thus, the aim of this study was to determine whether the oxidant/antioxidant profile of renal cell carcinoma tissue, adjacent to tumor tissue and nontumor tissue was different in male and female patients. Significantly higher lipid peroxidation (LPO) in renal cell carcinoma tissue compared to nontumor tissue was demonstrated only in male patients. Besides, gender-related difference in copper zinc superoxide dismutase (CuZnSOD) and manganese superoxide dismutase (MnSOD) in nontumor and renal cell carcinoma tissue was obtained at the level of transcription, translation and activity of these antioxidant isoenzymes. Morever, we demonstrated that the gene expression of 3 CYPs out of 7 was altered; CYP2D6 mRNA was decreased in both sexes while gender-related suppression of mRNA for CYP2E1 (women) and CYP2C19 (men) was observed. Taken together, these parameters might be potentially responsible for higher risk of renal cell carcinoma in men than in women.

Computed Tomography Analysis of Head and Spinal Cord Injuries Inflicted by Missiles and Explosives

Cerebral and spinal column computed tomography (CT) was performed in 53 patients wounded during war in the Republic of Croatia from June through December 1992. Of these, 36 (67%) suffered craniocerebral injuries; 10 (18%) sustained facial, neck, and paranasal sinus wounds; and 7 (13%) had vertebral andjor paravertebral lesions. Twenty‐five (70%) of the patients with craniocerebral injuries had penetrating wounds with diffuse and multiple, predominantly hemorrhagic lesions of cortical and subcortical structures, with basal ganglia lesions in 15 (43%) and brainstem lesions in 6 (20%). Of the 7 vertebral studies. 4 showed paravertebral tissue damage to the spinal column and cord.

Temporomandibular Disorders and Orthodontic Treatment – A Review with a Reported Clinical Case

Temporomandibular disorders (TMDs) are musculoskeletal disorders which affect the structures of the stomatognathic system. They include two separate entities of functional disorders: masticatory muscles disorder (tendomyopathy) and temporomandibular joint (TMJ) disorder (anterior disc displacement, osteoarthritis). Their shared symptomatology is pain related to masticatory muscles and/or TMJs, limited mouth opening and pathological noise in the TMJs (clicking, crepitations). In general, TMDs are considered to be multifactorial disorders with pain as the most pronounced symptom and the main reason for patients (from 75 – 90% female) to seek medical help. As the musculoskeletal form of the disorder and due to clinically pronounced pain, TMDs include a biopsychosocial component which is an important factor in creating a clinical picture, wherein the chronic aspect of musculoskeletal pain makes the relatively moderate clinical picture much worse. Therefore, like in many other musculoskeletal disorders in the body, their etiopathology is considered nonspecific, which is to say, they have an idiopathic cause on the level of the patient – individual. Clinical examinations, particularly manual examination techniques, are an integral part of TMD diagnostics and they serve to determine the indication for imaging techniques. Magnetic resonance imaging (MRI) has become the gold standard in diagnopstics and differential diagnostics of TMDs because it shows both hard and soft tissues of the TMJ (primarily of the disc) as well as joint effusion. Since the etiology of TMDs is mostly unknown, the indicated treatment methods are mostly symptomatic, noninvasive and reversible. These methods include the well known occlusal splint, physical therapy, cognitive-behavioral methods, acupuncture in cases of chronic pain and psychological treatment. Masticatory muscles and, especially, TMJs are directly connected to occlusal relations and due to that, TMDs are in correlation with occlusal disorders, ranging from obvious occlusal anomalies, variations of static and dynamic occlusal relations to loss of teeth. The Michigan type of the occlusal splint as the most widely used non-permissive splint serves as reversible initial treatment. Definitive occlusal treatment is not recommended for TMD patients as well as prosthodontic appliances and orthodontic treatments. Namely, orthodontic treatment by itself is not confirmed as a potential etiopathogenic factor of TMDs but it should not be performed in patients with a painful form of TMD. All irreversible and relatively long and expensive occlusal treatments, including orthodontic treatment, are never indicated without prior initial treatments. Manual examination techniques can be used as screening methods for detecting clinical symptoms of TMDs. Although a possibility of TMDs prevention is considered, the orthodontic, prosthodontic or any other form have not been scientifically proven because there is no consensus on the factors which cause TMD. Long-term follow-ups of patients undergoing orthodontic treatments did not show subsequent appearance of TMD and certain occlusal variables (cross bite, Angle class II/1, etc.) do not dominate the overall sample of TMD patients. In the review of literature, there is a clinical case described regarding a 5 year follow-up of a 26-year-old female patient who sought specialist prosthodontic help due to pain in the right TMJ and clicking in the left one with limited mouth opening. From patient history: 7 months ago a general dental practitioner referred her to an orthodontist due to clicking in the same joint and the specialist started treatment with a bimaxillary removable appliance (bionator). Namely, the patient previously had Angle class II/1 (prognate jaw) with a horizontal overlap of 11 mm and non-matching medial line of 1 mm. However, the patient did not realize at first that the pain in the TMJ was not being treated and the orthodontist did not realize that her intention was not to treat the orthodontic anomaly. In the course of orthodontic treatment her right TMJ became painful. The orthodontic appliance fixated the occlusion in an anterior (protrusive) position wherein the posterior teeth were in non-occlusion. A clinical examination confirmed the patient’s symptoms (left with reduction, right without reduction) and the anteriorly displaced disc was identified by MRI in habitual closed mouth position, a protrusive position conditioned by the orthodontic appliance and open mouth position. Besides stopping the orthodontic treatment, the patient initially wore the Michigan splint around 5 months and, after a year, still had pain in the right TMJ, with evident chronic character of pain. TMD treatment continued at home by physical therapy and oral exercises. At a recall 5 years later, the patient did not have pain in the TMJs and only felt discomfort in the right TMJ during wide mouth opening with clinically evidenced minor crepitations. MRI showed no change in the anterior disc displacement bilaterally with osteoarthritic changes in the right joint. Now, she does not have esthetic or functional needs for orthodontic treatment. In conclusion, TMD hinders orthodontic treatment and a prior initial treatment is necessary. Orthodontic treatment does not cause TMD symptoms in previously asymptomatic persons. Occlusal variables as well as anomalies and tooth loss have a limited proven direct connection with TMD appearance.

S247 PHYSICAL TREATMENT OF TEMPOROMANDIBULAR JOINT PAIN IN PATIENTS WITH VARIOUS BONE MINERAL STATUSES

Background and aims. The bone mineral density (BMD) of patients with temporomandibular joint (TMJ) disorder was analyzed. Methods. Clinical examination and magnetic resonance imaging as a gold standard was used in the TMJ diagnostics. 35 female patients (mean age 59 years, range 28 – 78) with TMJ disorder (disc displacement, osteoarthritis) underwent physical therapy. Clinical symptomatology included pathological sounds (clicking, crepitation) and/or pain in the TMJs (measured by visual-analogue scale (VAS) 0-10) with one-year follow-up after the beginning of treatment. Apart from the body mass index (BMI in kg/m2), due to medical indications, BMD (in g/cm2) was measured in the lumbar and femoral area by means of dual-energy x-ray absorptiometry. Results. From the total number of patients, 9 of them (25.7%) had normal BMD, 18 (51.4%) had osteopenia and 8 (22.9%) had osteoporosis. Physical therapy significantly reduced pain intensity (p 0.05). Conclusions. Densitometry is not a standard examination procedure within TMJ diagnostics and therefore the sample is rather small. Physical therapy can significantly reduce pain but it does not depend on patients’ BMI.

P01-131 Impact of anxiety on the pain intensity in patients with temporomandibular joint disorder during splint treatment

Objectives Level of anxiety and pain intensity before and after splint treatment of patients with temporomandibular joint disorder (TMJD) was compared. Methods TMJD in 60 patients (mean age 37.9 years, 80% women) was diagnosed using patients history and clinical examination, and was confirmed by magnetic resonance imaging of the TMJs. Pain intensity was rated on a visual-analogue scale. The anxiety was confirmed by Spielbergers State-Trait Anxiety Inventory (STAI). Results A higher level of anxiety was determined due to the fact that the mean score in STAI 1 was 39.80 and STAI 2 was 41.10. Before visiting a dentist, the patients suffered pain for 8.7 months on average. There is a statistically significant difference between patients depending on how long they previously suffered pain and anxiety values for all patients in STAI 1 and 2 (p 0.05). There is a correlation between anxiety values on STAI 1 scale and post-treatment pain intensity (p Conclusions There is a possibility of negative interaction of psychological and psychosocial factors within all forms of musculoskeletal disorders’ treatment, including TMDs. This study confirmed the connection between anxiety and various categories of pain intensity in patients during splint treatment.