Keywords prosthodontic treatment - maxillofacial muscles - orofacial pain - temporomandibular
joint - clinical efficiency
Introduction
In recent decades, there have been increasing reports of about the necessity to assess
such pathologic features as orofacial pain, temporomandibular joint (TMJ) dysfunction
and occlusion changes when examining patients with edentulism in need of dental treatment
and prosthodontic rehabilitation. The role of TMJ dysfunction in the development of
occlusion disorders has been shown. It is very important to take into account these
pathological manifestations when planning treatment and rehabilitation measures in
this category of patients. According to the data of different authors, 27 to 76% of
dental patients complain about dysfunction and pains in the TMJ area.[1 ]
[2 ]
Orofacial pain is defined as “pain localized to the region above the neck in front
of the ears and below the orbitomeatal line, as well as pain within the oral cavity,
including pain of dental origin and TMJP.”[3 ]
[4 ] In turn, TMJP is defined as “conditions that contribute to the incomplete or impaired
function of the temporomandibular disorders and/or muscles of mastication.” The occlusion
is defined as “statistical relationship between the incisal and/or masticatory surfaces
of teeth of the upper and lower jaw.”[1 ]
The types of edentulism, anatomical, and functional features of the dental system
that occur after the loss of teeth, determine the choice and use of methods of treatment
and rehabilitation practices with the use of dentures of various shapes, sizes, and
design. According to the analysis of literature data, the efficiency of treatment
is determined not so much by the type and brand of products used, but by a differentiated
approach involving a rational selection of the dentures’ design, their proper manufacture,
and fixation.[2 ] At the same time, regardless of the purpose of treatment, specialists should minimize
the impact of the installed dentures on the condition of the central nervous system
(CNS) of the patients. Such influences can be caused, in particular, by violations
of occlusal relations contributing to the manifestations of orofacial pain and temporomandibular
disorders.[3 ]
[5 ] However, there are very few works in the available literature investigating different
aspects of these pathological manifestations, peculiarities of their diagnostics,
and treatment.
Acute and chronic manifestations of orofacial pain syndrome are divided into the three
main categories: somatic, neurogenic, and psychogenic.[6 ]
[7 ]
[8 ] Acute pain in the maxillofacial area is often manifested, for example, in conditions
such as aphthous ulcers and pulpitis and is relatively easy to relieve. At the same
time, chronic pain tends to be refractory, which makes it difficult to treat the manifestations
of this syndrome. Somatic pain (in the soft or hard tissue area) is usually characterized
as dull, painful, pulsating, and thermally sensitive.
Neuropathic pain (often resulting from nerve damage) is described as burning or stabbing
pain. Psychogenic pain (especially somatoform pain) is not caused by any somatic pathology
but is usually associated with emotional disorders, mood changes, and cognitive impairment.
Patients with maxillofacial disorder often show two or three of the above major types
of orofacial pain.[9 ]
Neuroplasticity of human CNS contributes to its sensitization, strengthening, or weakening
of regulatory effects, which in particular may take place through the activation of
glial cells.[10 ]
[11 ] Nociceptive signals can be transmitted to the CNS from tooth pulp (cracked tooth
syndrome, odontoblast excitation, and pulp pathology), which is an example of central
neuroplastic disorders with associated physiological and clinical presentation.[8 ]
[11 ]
To date, a large number of different pathological reciprocal influences and pathogenetic
mechanisms in the CNS caused by nociceptive impact from the head and neck area has
been described, which causes rather often observed incorrect interpretations of clinical
presentations of the pathology by medical practitioners and erroneous diagnoses when
treating patients with edentulism.[12 ] Therefore, it is necessary for dentists to have a clear understanding of the pathogenesis
of orofacial pain, disorders in the TMJ, and the need to look at the whole maxillofacial
area during dental and prosthodontic treatment. It seems optimal to use a multidisciplinary
approach for treatment of these manifestations.
The multifactorial approach determines the planning of prosthodontic rehabilitation.
As part of comprehensive interdisciplinary approach to diagnostics, it is necessary
to use diagnostic techniques with the corresponding evidence base to verify the prevalence
of neuromuscular or occlusive and articular pain syndromes as well as to evaluate
their systemic influence on the biomechanics of the musculoskeletal system.
As of today, several conservative methods of pain syndrome treatment in combination
with correction of anatomical disorders and dysfunction of the TMJ are proposed. Treatments
actively used in clinical practice include selective grinding, acupuncture, therapeutic
gymnastics, autogenic training, and physiotherapeutic procedures.[2 ]
[13 ]
[14 ] Together with other specialists, patients are prescribed medication therapy such
as analgesics, sedatives, antidepressants, and myorelaxants. In addition to reduction
of pain, the use of these drugs helps to reduce emotional discomfort and the severity
of spasm of the masticatory muscles.[15 ]
[16 ]
[17 ] Application of such approach determines the necessity to apply methods of functional
and imaging diagnostics, making it possible to perform quantitative and qualitative
analysis of systems involved in the pathological process and develop a system of treatment
and rehabilitation with subsequent quantitative and qualitative analysis of its effectiveness.[4 ]
[18 ]
Thus, the problem of improving the results of rehabilitation of patients with various
types of occlusion problems becomes highly relevant. At the same time, function of
the masticatory system is an essential component of proper quality of human life.
This problem poses a challenge that requires an interdisciplinary approach and a collaboration
of doctors of different fields for the purpose of comprehensive assessment of the
clinical situation, development of the best possible algorithm of diagnosis, and treatment.
Nevertheless, existing publications on comprehensive study of this problem are poorly
systematized.
The study objective is to improve the efficiency of prosthodontic rehabilitation in
patients with complete dental reconstruction on the basis of an assessment of the
severity of orofacial pain.
Working hypothesis: Application of the interdisciplinary approach to diagnostics and
planning of prosthodontic rehabilitation makes it possible to improve the treatment
results significantly due to reduction of pain in the area of muscles of the maxillofacial
joint and the TMJ.
Materials and Methods
Study Design
In 2017 to 2019, a single-center open prospective nonrandomized study was conducted
at the premises of the Department of prosthodontics of the Sechenov University, сlinics
of JSC “Medicine,” clinics “ART ORAL Sergey Chikunov,” involving examination, and
treatment of 452 patients. The follow-up of the patients included in the study was
maintained for 3 years, the studied indicators were assessed before the prosthodontic
treatment, as well as 1 and 3 years after it.
Study Subjects
The study enrolled 452 patients with the mean age of 44.3 ± 15.2 years, including
282 males and 170 females. The criteria for inclusion in the study were as follows:
Patient age from 20 to 75 years
Partial or total edentulism
Presence of signs of increased teeth abrasion
Occlusion problems after prior incorrect prosthodontic treatment
Presence of the necessity of dental restoration due to functional and aesthetic indications
Exclusion criteria:
Presence of severe somatic pathology or severe chronic diseases
Lack of an informed consent for inclusion in the study signed by the patient
Patients were randomized into two groups:
∘ Group 1 (control): 218 patients treated with standard prosthodontic practices
∘ Group 2 (study): 234 patients treated with the involvement of the proposed interdisciplinary
approach to prosthodontic rehabilitation
Methods of Patient Treatment and Rehabilitation
Both groups of patients were given prosthodontic treatment: the control group received
conventional prosthodontic treatment based on the average anatomical parameters of
the patient with the use of metal ceramic fixed dentures and without taking into account
the individual characteristics of the patient, such as centric relation, therapeutic
position, individual hinge and orbital axis, occlusal plane, inclination of the central
incisors, and bite height.
It should be noted that there are no standard protocols of diagnostic, therapeutic,
and rehabilitation measures in patients with edentulism and the need for full-mouth
reconstruction.
We have developed a rehabilitation system based on an interdisciplinary approach,
used in the course of treatment, and rehabilitation of patients of the study group
(2). In the course of implementing this system, we take into account results of physical
examination of patients to plan bite correction. These data were obtained using a
set of diagnostic methods to assess the condition of various systems of the body (respiratory,
central nervous, cardiovascular, and musculoskeletal).
The patients were treated using the following methods:
Sprint therapy
Mounting casts in an articulator
Wax-up of teeth
Installation of long-term temporary crowns
Installation of implants
Fabrication of the final restorations
The follow-up checking of the treatment results was performed with the use of methods
of palpation of muscles of the maxillofacial area, condylography and cephalometry,
analysis of models, brux checker tool, and occlusiography.
To ensure the stability of the dental range, the methods of selective grinding of
dental hard tissues, temporary and permanent splinting, and ceramic restorations in
a new therapeutic position were used. Acrylic crown dentures or bridgework were used
for temporary restorations.
To implement the treatment plan with interdisciplinary approach, the anatomical and
functional characteristics of the dental system were studied, with special attention
paid to the assessment of manifestations of muscle pain syndrome, in particular, the
severity of pain with palpation associated with the TMJ dysfunction.
Examination of the patients’ anamnesis involved revealing and analysis of major errors
in prior prosthetic dentistry in full-mouth reconstruction patients and specifying
the causes of complications of prosthodontic treatment. Specialists in related fields
(otorhinolaryngologist, neurologist, psychologist, speech therapist, and osteopathic
physician, cosmetologist) are consulted.
Results of aesthetic, clinical functional, and instrumental analysis performed in
the course of diagnostics using the methods of condylography and cephalometry make
it possible to determine the centric relation when the models are mounted into the
articulator. To achieve this, Gamma Dental software functionality is used to analyze
the occlusion model. The interdisciplinary approach provides for taking into account
and timely correcting functional and aesthetic disorders associated with an incorrect
bite in patients undergoing full-mouth reconstruction.
In the study group of patients, treatment was performed with permanent ceramic restorations.
Fabrication of the dentures was performed with the use of adjustable Gamma articulators,
the advantages of which include casts mounting along a customized hinge axis, occlusal
plane measurement, and γ rotation evaluation. At the same time, wax modeling with
subsequent disconnection makes it possible to obtain high functional and aesthetic
results of prosthodontic rehabilitation of patients in need of full-mouth reconstruction
([Fig. 1 ]).
Fig. 1 Occlusion simulation using Gamma Dental software.
Study Methods
[Table 1 ] lists the stages of prosthodontic rehabilitation of patients including diagnostics
and full-mouth reconstruction on the basis of individual anatomical, functional, and
clinical characteristics of the TMJ.
Table 1
Stages of prosthodontic rehabilitation of patients in need of full-mouth reconstruction
Item no.
Rehabilitation stage
Methods of treatment and diagnostics
Abbreviations: CPM, continuous passive motion; CT, computed tomography; MRI, magnetic
resonance imaging; TMJ, temporomandibular joint.
1.
Clinical functional analysis
Medical history
Muscles palpation
Brux checker
Occlusiography
Dental history
Cast analysis
2.
Clinical instrumental analysis
Сondylography
Cephalometric Analysis
Cast analysis for the centric relation
CPM
Variator ≥ mandibular position indicator
3.
Clinical investigations using imaging methods
Cone-beam computed tomography
MRI of the TMJ
Panoramic radiograph + CT of the maxilla and the mandible
Clinical examination involved palpation of all groups of muscles of the maxillofacial
area, head, and neck. Individual thresholds of pain sensitivity of each patient were
taken into account during the palpation, with the force of pressure being varied as
appropriate.
The patient was questioned about the presence of pain during chewing and opening the
mouth. We also performed subjective assessment of joint pain in patients using a 10-point
visual analog scale (VAS).
Orthopantomography and condylography methods were used to diagnose the state of the
dental and mandibular system. The study of the TMJ condition was performed with the
purpose of detection of painful joint dysfunction or other TMJ disorders caused by
long-term presence of occlusal disorders and teeth alignment defects in the patient.
In addition, the presence of pain when chewing was also assessed.
Assessment of the treatment results was performed during the examination of patients
immediately after the comprehensive treatment in 1 and 3 years.
The results obtained with this method were analyzed by summing up qualitative and
quantitative indicators, and the final assessment of “improvement,” “deterioration,”
or “no change” was made by summing up the characteristics for the corresponding study
period.
Statistical analysis: The analysis of the study results was performed using Statsoft
software packages STATISTICA 10 and Microsoft Excel 2016. The selection of the main
attributes and statistical criteria for their comparison was made after studying the
distribution of each attribute and its comparison with a Gaussian distribution by
using Kolmogorov–Smirnov’s test. Due to the fact that the total sample amount exceeded
200 subjects and the number of patients in each group exceeded 100, intergroup comparisons
for quantitative indicators were made using the Student’s t test for unrelated samples. Qualitative parameters were presented in the form of
attribute occurrence rates as percentages of the total number of patients in the respective
groups. Chi-squared test was used to analyze differences in qualitative parameters.
The differences were considered statistically significant when the p -value was under the threshold value of statistical significance level of the null
hypothesis (α) of 0.05.
Results
Pain assessment during palpating m. masseter superficialis in patients included in
the study demonstrated that all patients of both groups had pain prior to the commencement
of treatment. After the end of treatment, the absolute majority of patients of the
study group (98.3%) demonstrated an improvement in the form of a decrease of pain
sensations. At the same time, the fraction of such patients was statistically significantly
(p < 0.05) lower in the control group, only 42.3% ([Table 2 ]).
Table 2
Changes in pain on palpation of m. masseter superficialis
Condition
Group 1
(control)
(n = 218)
Group 2
(study)
(n = 234)
abs.
%
abs.
%
Abbreviation: abs, absolute.
a The difference is statistically significant (p < 0.05) relative to the corresponding indicator in group 1 using the Chi-square test.
After the treatment
Improvement
92
42.3
230
98.3a
No change
86
29.5
4
1.7a
Worsening
40
18.3
After 1 year
Improvement
90
41.3
228
97.4a
No change
73
33.5
4
1.7a
Worsening
55
25,2
2
0.9
After 3 years
Improvement
40
18.3
228
97.4a
No change
151
69.3
1
0.5a
Worsening
27
12.4
5
2.1
Follow-up examinations showed that after 1 and 3 years the above ratio remained: the
decrease or absence of pain sensations in this muscle area was also observed in 97.4%
of patients, while the absence of changes or deterioration was noted only in single
cases.
The severity of pain with palpation of other muscles such as m. masseter deep part,
m. pterygoideus medialis, and lateralis was at the similar level.
Pain in m. temporalis medialis experienced with palpation was also high in all patients
in need of prosthodontic rehabilitation, while 97.9% of patients of the study group
showed a decrease in the severity or absence of pain after the treatment ([Table 3 ]). At the same time, pain on palpation were much more frequent in the control group,
their reduction, that is, improvement was statistically significantly (p < 0.05) less frequent and found only in 54.1% of patients. At the same time, in one
third of patients of this group, no changes were registered, and in 13.8% of cases
pain with palpation increased while in group 2 (study), these manifestations were
not observed.
Table 3
Changes in pain on palpation of m. temporalis medialis
Condition
Group 1
(control)
(n = 218)
Group 2
(study)
(n = 234)
abs.
%
abs.
%
Abbreviation: abs, absolute.
a The difference is statistically significant (p < 0.05) relative to the corresponding indicator in group 1 using the Chi-square test.
After the treatment
Improvement
118
54.1
229
97.9a
No change
70
32.1
5
2.1a
Worsening
30
13.8
After 1 year
Improvement
121
55.5
320
98.7a
No change
69
31.7
4
1.3a
Worsening
28
12.8
After 3 years
Improvement
114
52.3
227
97.0a
No change
72
33.0
7
3.0a
Worsening
32
14.7
–
–
It should be noted that the changes of pain with palpation was similar for other muscles
in this area: m. masseter deep part, m. pterygoideus medialis, m. pterygoideus lateralis,
m. temporalis anterior, m. temporalis posterior, m. mylohyoideus, and m. digastricus.
Pretreatment pain when chewing was observed with a similar frequency in both groups,
in 83.5 to 88.9% of patients ([Table 4 ]). However, after 1 year, this sign was found in the control group in 77.1% of cases,
while in the study group it was 8.6% (p < 0.0001). After 3 years, 69.7% of the patients in Group 1 reported pains when chewing,
while in Group 2 it was reported by only 7.7% of the patients (p < 0.001).
Table 4
Pain during chewing
Condition
Group 1
(control)
(n = 218)
Group 2
(study)
(n = 234)
abs.
%
abs.
%
Abbreviation: abs, absolute.
a The difference is statistically significant (p < 0.05) relative to the corresponding indicator in group 1 using the Chi-square test.
Prior to the treatment
182
83.5
208
88.9
After 1 year
168
77.1
20
8.6a
After 3 years
165
69.7
18
7.7a
Pretreatment pains when opening the mouth were found in more than half of patients
in both groups, in 54.1 to 55.1% of patients ([Table 5 ]). After 1 year, this sign was found in 45.0% of cases in the control group, while
in the study group the level of this indicator was statistically significantly lower,
being 7.3% (p < 0.01).
Table 5
Pain during opening the mouth
Condition
Group 1
(control)
(n = 218)
Group 2
(study)
(n = 234)
abs.
%
abs.
%
Abbreviation: abs, absolute.
a The difference is statistically significant (p < 0.05) relative to the corresponding indicator in group 1 using the Chi-square test.
Prior to the treatment
118
54.1
129
55.1
After 1 year
98
45.0
17
7.3a
After 3 years
82
37.6
15
6.4a
After 5 years
79
36.2
14
6.0a
After 7 years
70
32.1
12
5.1a
After 3 years, 37.6% of the patients in Group 1 reported having pain sensations when
opening the mouth, while in Group 2 only 6.4% of the examined patients reported having
pains (p < 0.05).
Periodic neck pains and spasms were reported by patients with similar frequency in
both groups, in 82.6 to 82.9% of cases ([Table 6 ]). However, after 1 year, this sign was found in the control group in 77.5% of cases,
while in the study group the level of this indicator decreased to 15.0% (p < 0.0001). After 3 years, 71.6% of patients in Group 1 reported pain sensations in
this area, while in Group 2 the level of this indicator was statistically significantly
lower, being 8.6% (p < 0.001).
Table 6
Pains and spasms in the neck
Condition
Group 1
(control)
(n = 218)
Group 2
(study)
(n = 234)
abs.
%
abs.
%
Abbreviation: abs, absolute.
a The difference is statistically significant (p < 0.05) relative to the corresponding indicator in group 1 using the Chi-square test.
Prior to the treatment
180
82.6
194
82.9
After 1 year
169
77.5
35
15.0a
After 3 years
156
71.6
20
8.6a
It should be noted that a pronounced pain with palpation was found in postural muscles
such as m. suprahyoidale, m. infrahyoidale, m. omohyoideus, and m. sternocleidomastoideus
during the initial examination.
[Table 7 ] shows the figures of pain assessment by patients. As it can be seen, VAS score levels
prior to the treatment did not differ in the two study groups. After 1 year, there
was a statistically significant decrease of this indicator in the study group and
the value of VAS score was lower than in group 1 (p = 0.007).
Table 7
Changes in the 10-point visual analog scale assessment
Condition
Group 1
(control)
(n = 218)
Group 2
(study)
(n = 234)
a The difference is statistically significant (p < 0.05) relative to the corresponding indicator in group 1 using the Student’s t test.
Prior to the treatment
8.72 ± 0.45
8.54 ± 0.51
After 1 year
8.06 ± 0.32
5.84 ± 0.42a
After 3 years
7.87 ± 0.28
4.25 ± 0.36a
After 3 years, the severity of pain decreased in both groups of patients, and in patients
who were exposed to our proposed multidisciplinary approach to prosthodontic rehabilitation,
the level of this indicator was statistically significantly lower than in the group
where standard rehabilitation methods were used (p = 0.012).
Discussion
The necessity of an interdisciplinary approach in prosthodontic rehabilitation requires,
first and foremost, thorough and comprehensive examination of patients with orofacial
pain.[15 ]
[16 ]
The disadvantages of the traditional method of management of patients in need of full-mouth
reconstruction should include the use of average anatomical parameters of dentures
without taking into account the patient’s individual characteristics (centric relation,
therapeutic position, individual hinge axis, occlusal plane, inclination of the central
incisors, and occlusal dimension), lack of attention to the condition and evaluation
of the severity of the TMJ dysfunction, and absence of diagnostics of muscles of the
maxillofacial area and posture muscles.
In this connection, we proposed a new approach to the management of patients with
edentulism in need of full-mouth reconstruction, which is based on the consideration
of individual anatomical and physiological characteristics of the patient, providing
for a thorough clinical examination using a wide range of methods, including palpation
of the head and neck muscles, subjective assessment of pain, and the use of instrumental
methods to assess the state of the TMJ, in particular, condylography and computed
tomography.
It should be noted that in spite of the fact that currently used methods of X-ray
diagnostics applied to establish the TMJ condition have good sensitivity, their specificity
is relatively low with respect to long-term prognosis of development of the TMJ dysfunction.[17 ] TMD manifestations may be assessed via other techniques such as imaging test and
laboratory methods (e.g., C-reactive protein test, interleukin-6 test, rheumatoid
factor, and antinuclear antibody tests). It is also proposed to evaluate the quality
of sleep obstructive sleep apnea using appropriate questionnaires.[18 ]
The results of the study, as well as the data presented in the works of other authors,
confirm the necessity to assess local pain in the muscles by using myofascial trigger
points and also assess the severity of central indirect myositis. It is necessary
to provide a favorable environment for the dental treatment, taking into account the
diagnosis and special features of therapeutic and rehabilitation actions (treatment
of acute pain, elimination of aberrant nociceptive effects on the CNS that may be
caused by changes in dental occlusion, the presence of prosthodontic solid acrylic
resins, special stents, and topical drugs). Complex orthodontic, prosthodontic, and
restorative treatment should be considered as secondary to adequate treatment of the
patient's discomfort and dysfunction of the maxillofacial system and the body as a
whole.
Drug treatment, including the use of preventive analgesia methods, should be prescribed
on the basis of consultations with all specialists.[19 ] In several studies, high effectiveness of magneto-laser therapy in the elimination
of pain syndrome and normalization of the functional state of the masticatory muscles
was demonstrated. Analgesic effect of laser radiation relieves the patients of emotional
stress and anxiety, which also positively affects the treatment process.[3 ]
[5 ]
The TMJ dysfunction is positively influenced by prosthodontic and orthodontic treatment.[15 ] In several studies, the effectiveness of splint therapy combined with prosthodontic
and physiotherapeutic methods in treatment of pain syndrome with occlusive disorders
in the TMJ has been confirmed. It has been shown that occlusal splints change the
character of teeth occlusion, influence the periodontium, masticatory muscles, and
the TMJ.[11 ]
An important element of the comprehensive treatment of myofacial pain syndrome (MPS)
is the methods of orthodontic treatment aimed at the elimination of bite disorders.
Tecco et al[20 ] made an attempt to analyze the features of MPS in the process of orthodontic treatment
of patients. They analyzed the records of 91 Caucasian patients who were undergoing
orthodontic treatment of various bite disorders.[20 ] MPS was initially diagnosed in 37 patients. Of these, orthodontic treatment was
given to 30 patients (study group). After determining the class of correction and
alignment of teeth, the manifestations of MPS were assessed. In seven patients comprising
the control group, no MPS treatment was performed. At examination of patients of the
study group after the treatment given, there was statistically significant decrease
in the rate of the TMJ disorders (in particular, clicking). There was also a significant
decrease in the severity of pain sensations in the area of the jaws, TMJ, facial muscles.
At the same time, the authors noted a significant improvement in the quality of life
of these patients.[20 ]
Several patients showed signs of depression at the beginning of the follow-up observation,
followed by a decrease in the manifestation of these symptoms, with most patients
reporting an improvement in their subjective assessment. A statistically significant
decrease of pain during the palpation (when assessed using the VAS) found in the area
of the temporal muscles, masticatory, and posterior cervical muscles. After the treatment,
a significant decrease in the number of patients with pain in the area of temporal
and masticatory muscles was observed in the study group. Similar changes were also
found in patients with similar pain in the m. digastric and sternocleidomastoid muscles.[20 ]
Diseases and injuries of the TMJ are often combined with dental system and face deformities.
At the same time, there is a link between this pathology and bite disorders and development
of mandibular disorders. Over the recent years, specialists have increasingly come
to the understanding that comprehensive dental, prosthodontic, and osteopathic treatment
is the most effective when treating temporomandibular disorders.[21 ]
[22 ] There is a category of patients in which other factors are also prove to be of great
importance, in particular, the psychological factor. In such cases, the stability
of positive effect after diagnostics and treatment is often rather low, and there
is an increase in the rate of recurrence of orofacial pain and manifestations of the
TMJ dysfunction.[4 ]
[23 ]
[24 ]
An increasing number of authors believe that introduction of diagnostics and treatment
methods based on modern methodologies is important in the treatment of this category
of patients.[13 ]
[21 ] This was confirmed by the results of our study, which have demonstrated that the
application of the complex interdisciplinary approach to prosthodontic rehabilitation
contributes to the fact that statistically significantly lower (relative to the control
group) levels of severity of pain during palpation of muscles of the masticatory organs,
pain during opening the mouth and chewing, as well as indicators of visual analogue
scale of assessment of painful sensations are observed in full-mouth reconstruction
patients 1 to 3 years after the treatment. These changes indicate that the rate of
improvement of the TMJ dysfunction condition was higher in the study group in comparison
with the corresponding rate for treatment using standard approaches to prosthodontic
rehabilitation.
Management of patients with severe chronic pain syndrome with the TMJ and muscle dysfunction
require participation of an orthodontist to correct bite disorder, as well as a neurologist
to relieve local myofascial pain syndrome.[25 ]
[26 ]
We agree with the opinion of several authors that the combination of dental, prosthodontic,
and osteopathic treatment is the most effective way to solve the problem of TMJ dysfunction.
In some cases, psychodiagnostic methods have the highest priority.
Therefore, the relief of painful sensations and treatment of the TMJ disorders should
be one of the key directions in rehabilitation of patients with full-mouth reconstruction.
The keypoint is a complete and consistent examination of full-mouth reconstruction
patients. When solving the challenges faced by specialists in the course of planning
the necessary therapeutic and rehabilitation measures, it is necessary—first and foremost—to
assess myofacial pain, which requires palpation of all muscle groups of the maxillofacial
area during the examination, as well as supplementing the traditional approach with
diagnostics of several other disorders: sleep (snoring, bruxism, and apnea), aesthetic,
and psychological problems. In the planning of prosthetic and prosthodontic treatment,
it is necessary to establish cause-and-effect relationship of the above disorders
with malocclusion and the TMJ pathology.
The introduction of the developed approach into clinical practice would result in
significant reduction in the severity of functional disorders of various body systems
after prosthodontic bite correction performed as part of an integrated approach to
human diagnostics and treatment.
Conclusion
In recent years, great achievements have been made in the development of dental prosthodontic
treatment technologies, including treatment of orofacial pain, temporomandibular disorders
and malocclusion in the course orthodontic, prosthodontic, and restorative treatment.
Interdisciplinary and multidisciplinary care has become a practical reality in the
context of modern integrative health care.
The results of the study demonstrate high clinical efficiency of the interdisciplinary
approach to prosthodontic rehabilitation of patients with full-mouth reconstruction.
The accumulated data confirm the necessity to take into account the etiopathogenesis
of pain in this category of patients, as well as their individual anatomical and physiological
characteristics. To achieve this, it is necessary to carry out comprehensive diagnostics
and further treatment with the involvement of specialists in various fields during
the planning of therapeutic actions.
We make the following conclusions:
Application of the proposed complex of prosthodontic rehabilitation measures contributes
to the fact that patients with full-mouth reconstruction treated with the interdisciplinary
approach demonstrated statistically significantly decrease in the rate of pain in
muscles of the maxillofacial area on palpation (1.8–2.3 times), as well as pain and
spasms in the neck area (5.2 times) as compared with the group where conventional
rehabilitation was used.
Patients treated with the interdisciplinary approach to diagnostics and prosthodontic
rehabilitation have a more pronounced decrease in pain in the area of the temporomandibular;
there is a statistically significant decrease in the rate of pains in the TMJ during
chewing (eight to nine times), pains during opening and closing of the mouth (6.2
times), and significantly lower level of subjective assessment of pain on the VAS
(1.4–1.9 times) than in the comparison group.
The identified signs of improvement in the condition of the dental system are persistent
and present 3 years after the set of treatment and rehabilitation actions.
