CLINICAL STUDY
Mandibular Manipulation for the Treatment
of Temporomandibular Disorder
Betania Mara Franco Alves, MD,* Cristiane Rufino Macedo, MD,* Eduardo Januzzi, MD,*
Eduardo Grossmann, MD,Þ Álvaro Nagib Atallah, MD,* and Stella Peccin, MD*
Abstract: The aim of this study was to conduct a systematic review to identify the randomized clinical studies that had investigated the following research question: Is the mandibular manipulation
technique an effective and safe technique for the treatment of the
temporomandibular joint disk displacement without reduction? The
systematic search was conducted in the electronic databases: PubMed
(Medical Publications), LILACS (Latin American and Caribbean
Literature in Health Sciences), EMBASE (Excerpta Medica Database), PEDro (Physiotherapy Evidence Database), BBO (Brazilian
Library of Odontology), CENTRAL (Library Cochrane), and SciELO
(Scientific Electronic Library Online). The abstracts of presentations in physical therapy meetings were manually selected, and the
articles of the ones that meet the requirements were investigated.
No language restrictions were considered. Only randomized and
controlled clinical studies were included. Two studies of medium
quality fulfilled all the inclusion criteria. There is no sufficient evidence to support the effectiveness of the mandibular manipulation
therapy, and therefore its use remains questionable. Being minimally
invasive, this therapy is attractive as an initial approach, especially
considering the cost of the alternative approaches. The analysis of
the results suggests that additional high-quality randomized clinical trials are necessary on the topic, and they should focus on
methods for data randomization and allocation, on clearly defined
outcomes, on a priori calculated sample size, and on an adequate
follow-up strategy.
Key Words: Mandibular manipulation, temporomandibular
disorders, disk displacement, meta-analysis, Cochrane
(J Craniofac Surg 2013;24: 488Y493)
M
ore than 120 million individuals worldwide suffer from severe
facial pain with limitation of mouth opening as a consequence
of disk displacement without reduction (DDWR) of the temporomandibular joint (TMJ).1
The TMJ may be affected by several conditions, including
not only disk displacements (DDs) but also degenerative disease
(osteoarthritis), inflammatory arthritis, and synovitis.2 The studies
From the *Department of Internal Medicine, Federal University of São Paulo,
São Paulo; and †Department of Morphological Sciences, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.
Received August 29, 2012.
Accepted for publication November 4, 2012.
Address correspondence and reprint requests to Betania Mara Franco Alves,
Federal University of São Paulo, The Brazilian Cochrane Centre, Rua
Pedro de Toledo, 598-Vl. Clementino, São Paulo, SP CEP 04039-001,
Brazil; E-mail: [email protected]
The authors report no conflicts of interest.
Copyright * 2013 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0b013e31827c81b3
488
on TMJ also show that the prevalence of temporomandibular disorder (TMD) symptoms ranges from 10% to 76%, depending on
the methods used for data collection.3,4 Despite the discrepancy of
the symptoms, it may be safely stated that TMD commonly affects the general population, being more prevalent within the population of individuals ranging from 20 to 40 years of age.3,4
Clinically, the DDWR of the TMJ may be associated with
significant pain, important limitation of the articular function, and
consequent impairment of masticatory functions. This condition may
be caused by altered structural relations or by misalignment between the disk and the mandibular head during mandibular translations; as a consequence of the described above, the disk is not
reduced to its anatomical position. Approximately 2% of the individuals with TMD present with the closed lock of the TMJ,1 with
significant limitation of the mandibular function.
Clinical diagnostic criteria for DDWR were established by
the American Academy of Orofacial Pain.5 Subsidiary diagnosis of
DDWR was used to obtain arthrography.6 However, currently, magnetic resonance imaging (MRI) is the criterion standard for confirming the diagnosis because of its accuracy in the identification
of the correct position of the articular disk7,8 (Fig. 1).9
Because both diagnostic criteria and criterion standard subsidiary investigation are available, it is important to assess the efficacy of different treatments available at the moment. One of them,
the mandibular manipulation (MM) is often used for reducing displaced disk.
Mandibular manipulation is a noninvasive technique, if compared with open and arthroscopic surgical interventions.10 It is indeed a conservative and relatively simple procedure of intraoral
manipulation, therefore frequently used and well accepted. It consists of forcing the mandible with consecutive movements, inferior,
anterior, superior, and posterior.11Y19 Nonetheless, the effectiveness and safety of this technique have been poorly studied. Many of
these studies have not used MRI as the criterion standard, and most
of the long-term studies, with a good sample size, were case series, not interventional trials.20Y22
Lately, systematic reviews of clinical studies have been used
to assess how safe and efficient certain techniques are. One of the
most efficient methodologies has been the Cochrane methodology,23Y26 used mainly to minimize possible biases.
Accordingly, the aim of this study was to assess the efficacy
and safety of MM alone or in combination with other techniques
in the treatment of acute and chronic DDWR.
MATERIALS AND METHODS
The current systematic review tried to answer the following
question: Is the MM therapy an effective and safe technique for
the treatment of DDWR?
Randomized or quasi-randomized controlled studies (RCT
and quasi-RCT) were identified in PubMed (Medical Publications),
LILACS (Latin American and Caribbean literature in health sciences), EMBASE (Excerpta Medica Database), PEDro (Physiotherapy Evidence Database), BBO (Brazilian Library of Odontology),
The Journal of Craniofacial Surgery
& Volume 24, Number 2, March 2013
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The Journal of Craniofacial Surgery
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Mandibular Manipulation and TMJ Disorder
TABLE 1. Risk of Bias in the Study of Minakuchi et al. 2001
Item
Proper allocation of treatment
Blinding to allocation
Handling of missing data
FIGURE 1. Resonance imaging of the TMJVanterior DD (Department of Health,
Government of West Australia), sagittal proton-density image of the right
TMJ with mouth closed.
CENTRAL (The Cochrane Library), and SciELO (Scientific Electronic Library Online). Descriptors and synonymous were used to
identify MM, as well as DD with and without reduction. Filters for
narrowing the search to identify randomized and controlled studies
were used. The strategy was customized according to each database.
The studies included in the research were all the RCT and
quasi-RCT studies that mentioned MM and that presented enough
information to be assessed (Fig. 2).27,28 Studies were all assessed
according to the Cochrane methodology. The additional inclusion
criteria stated that the participants of the studies should be 18 years
or older and should have had a clinical or imaging diagnosis of
DDWR and interventions consisting of MM alone or in association with other conservative treatments (anti-inflammatory medication, exercises, cognitive interventions, and others), surgical treatment
(arthroplasty and arthroscopy), and placebo.
Assessed outcomes were reduction of pain, as measured by
at least one of the following: visual analog scale (VAS), McGill
Assessment
Description
Low
Moderate
Low
Computer-generated allocation list
Not described
Dropouts of 15%, without apparent
differences between groups;
intent-to-treat assessment
Not identified
Pain was primary outcome, and
measurements were accepted
and validated
Blinding was effective
Other biases
Outcomes
Low
Low
Blinding for measurements
Low
Pain Questionnaire, or by the symptom severity index (SSI); and
daily limitation of normal activities, as assessed by the Mandibular
Function Impairment Questionnaire and by the Craniomandibular
Index (CMI). The secondary outcome was the maximal mouth opening measured in millimeters.
Two independent reviewers (B.M.F.A. and C.R.M.) identified
the studies that were suitable and extracted the data. Discrepancies
were resolved by consensus or, when necessary, by a third investigator (E.J.). The standard data extraction form was used. Reviewers
were not blinded by author, affiliation, or journal. Studies were
assessed for the potential risk for biases (Tables 1 and 2). Reviewers
also assessed the quality of the methods used by the studies.
The subjects of the studies who received MM (physical medicine and rehabilitation) were grouped as receiving ‘‘physical therapy.’’
The other subjects who underwent other interventions, (palliative
care, control, arthroscopic surgery, and medical managing) were
labeled as ‘‘others.’’
The software RevMan 5.0, offered by Cochrane Collaboration, was used to conduct the meta-analysis. Continuous variables
were summarized using mean and SD.
The mean difference was used for the outcomes related to
similar parameters and assessed with the same instruments. The standard mean difference (SMD) was used for estimated effects and
measurements of variability for continuous variables between groups,
The SMD is used as summary statistics in meta-analysis, transforming the results of different studies with a similar outcome in
a uniform scale before combining them.29 The following equation
was used to calculate SMD:
SMD ¼
Mean difference of results between groups
SD of results among participants
TABLE 2. Risk of Bias in the Study of Schiffman et al18
Item
Proper allocation of treatment
FIGURE 2. Flow of the systematic review. Adapted from Ross et al27 and
the Agency for Health Care Policy and Research.28
Assessment
Description
Moderate
Not described in the article
(random blocks)
Sealed envelops opened after inclusion
in study
Dropouts of 9.4%, without apparent
differences between groups;
intent-to-treat assessment
Nonidentified
Pain was the primary outcome, and
measurements were accepted
and validated
Blinding was effective
Blinding to allocation
High
Handling of missing data
Low
Other biases
Outcomes
Low
Low
Blinding for measurements
Low
* 2013 Mutaz B. Habal, MD
Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
489
The Journal of Craniofacial Surgery
Alves et al
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RESULTS
From the 238 identified studies, 28 were included in the first
attempt. However, only 2 of them satisfied the inclusion criteria:
Minakuchi et al15 and Schiffman et al18 (Fig. 3).
Some studies were excluded for being case reports,30Y37
whereas others for being case series38,39; others conducted a nonrandomized clinical study40; others reported retrospective data,12,41
whereas others were review articles42Y44; others45Y53 discussed other
types of intervention, and Minakuchi et al54 did not report any
outcome that would suit our revision interests (Fig. 3).
General Description of the Studies
The 2 studies included herein enrolled 175 patients (15 men
and 160 women), with their age ranging from 18 to 65 years. All
patients had DDWR as per the MRI. Control groups were similar
regarding their baseline characteristics. The inclusion criteria used
for the original studies were as follows: pain when opening the
mouth and/or functional impairment. The criteria for diagnosing
DDWR followed those proposed by Orsini et al55 and Wilkes.56
Patients were excluded when they did not consent in participating in
the study, when they had been previously submitted to TMD treatment, or when they presented a severe systemic rheumatic disease.
In the study of Minakuchi et al,15 the comparisons were made
between controls, general care plus nonsteroidal anti-inflammatory
medications, and physical medicine, which included MM, occlusal
techniques, and nonsteroidal anti-inflammatory medications. Schiffman
et al18 compared groups submitted to medical management of arthroscopic surgery with postsurgical rehabilitation and arthroplasty
with postsurgical rehabilitation. The rehabilitation used the MM
as physical therapy. Minakuchi et al15 followed up the patients for
2 months, and these patients were assessed at baseline and at 1, 4,
and 8 weeks after the treatment. Schiffman et al18 followed up patients for 60 months, and the assessments were made at baseline and
at the 3rd, 6th, 12th, 18th, 24th, and 60th months after the treatment.
The VAS scores were used to assess pain in the TMJ area15;
the SSI was used to assess the severity of the pain, and CMI18 and
daily activity limitation (DAL) score were used to assess mandibular function. A millimetric scale was used to measure mouth opening.15 The sample of Minakuchi et al15 presented 155 dropouts, and
FIGURE 4. Assessment of risk of biases per item, as a function of percentage
of included studies.
Schiffman et al18 had 9.4% without a significant difference between
the groups in each study. The intent-to-treat analysis was used. Sample
size calculations were not presented. Minakuchi et al15 reported 10 exclusions during the study, and patients were lost to follow-up. Schiffman
et al18 reported 10 exclusions after randomization, but 8 were reexamined after 5 years, and data were used for post hoc analyses.
Assessment of the Quality of the Studies
The measurements of the studies were conducted by blind
examiners to the treatment group,15,18 and the examiner had no contact with the participants, with the exception of those who were in
the follow-up visits.18 Regarding randomization, the risk of bias
was low in the study of Minakuchi et al,15 as the allocation was generated by a computer software,15 whereas in the study of Schiffman
et al,18 the risk was questionable, because randomization was determined by random blocks (author personal clarification). There
is a possible chance for bias when the concept of blinding is taken
into consideration. The study of Minakuchi et al15 has possible
chance of bias, because its methods are not clear, and Schiffman
et al,18 using sealed envelopes only until registration was concluded,
posed a high risk of bias. Regarding end points, the risk of bias was
low for both studies; pain was the primary outcome, and the methods of assessment are standard and validated ones. Dropout rates
were 15% for Minakuchi et al15 and 9.4% for Schiffman et al.18
FIGURE 3. Flow of included studies.
490
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The Journal of Craniofacial Surgery
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Mandibular Manipulation and TMJ Disorder
FIGURE 5. Meta-analysisVpain reduction. Physical medicine versus other treatments.
FIGURE 6. Meta-analysisVmandibular function. Physical medicine versus
other treatments.
Incomplete data pose low risk of bias in both studies, because retention was high, and no differences in dropout as a function of
treatment arm were seen. Furthermore, intent-to-treat analyses were
used. Other significant biases were not identified (Tables 1 and 2).
Our assessment is presented in Figure 4.
Efficacy of Interventions
Rehabilitation Versus Medical Management at 60 Months.
No significant differences in pain outcomes were seen using SSI
(mean difference [MD], 0.04; 95% confidence interval [CI], j0.08
to 0.16; P = 0.52). No significant differences were seen regarding mandibular function (CMI) (MD, 0.01; 95% CI, j0.08 to 0.10;
P = 0.82).
Rehabilitation Versus Arthroscopic Surgery at 60 Months.
No difference in pain were seen using the SSI scale (MD, j0.10;
95% CI, j0.22 to 0.02; P = 0.11). No differences were seen for
mandibular function (CMI) (MD, j0.03; 95% CI, j0.12 to 0.06;
P = 0.50).
Rehabilitation Versus Arthroplasty at 60 Months. No difference
in pain was seen using the SSI scale (MD, j0.06; 95% CI, j0.19
to 0.07; P = 0.36). No differences were seen for mandibular function (CMI) (MD, j0.03; 95% CI, j0.12 to 0.06; P = 0.51).
Physical Medicine Versus Palliative Care at 8 Weeks. Mouth
opening (in millimeters) was not statistically different across groups
(MD, 2.80; 95% CI, j2.95 to 8.55; P = 0.34). Pain (VAS) was not
statistically different across groups (MD, j2.60; 95% CI, j10.09 to
4.89; P = 0.50). Mandibular function (DAL) was not statistically
different across groups (MD, 1.80; 95% CI, j0.13 to 3.73; P = 0.07).
Physical Medicine Versus Controls at 8 Weeks. Mouth opening (in millimeters) was not statistically different across groups (MD,
1.40; 95% CI, j3.94 to 6.74; P = 0.61). Pain (VAS) was not statistically different across groups (MD, j3.50; 95% CI, j8.05 to
1.05; P = 0.13). Mandibular function (DAL) was not statistically
different across groups (MD, 1.30; 95% CI, j0.90 to 3.50; P = 0.25).
Meta-Analysis
A total of 46 individuals were formally tested for MM, and
112 were tested for other interventions. Both studies,15,18 nonsignificantly, suggested that the conservative therapy was more effective for pain control and functional improvement. For pain control,
differences nonsignificantly favored conservative therapy (SMD,
j0.27; 95% CI, j0.61 to 0.08; P = 0.13) using VAS and SSI (Fig. 5).
Similarly, nonsignificant differences favored conservative therapy
regarding the improvement of the mandibular function (SMD, 0.29;
95% CI, j0.06 to 0.64; P = 0.10), using CMI and DAL (Fig. 6).
DISCUSSION
Our study assessed whether MM, alone or associated with
other conservative therapies, is effective and safe for the treatment
of acute and chronic DDWR. Only 2 studies fulfilled the inclusion criteria.15,18 We found no significant difference between the
groups treated with MM and the ones that underwent surgical intervention and/or other conservative therapies regarding the relief
of pain, mouth opening, and mandibular function. The systematic
revision was conducted according to the Cochrane methodology,
and the studies evaluated had no language barrier, and only randomized and controlled studies were included.
The use of meta-analyses usually enhances the degree of confidence on the results as the size of the sample increases, and consequently, it increases the possibilities of detecting differences when
compared with the results of individual studies. In both the studies
analyzed here and in the results of the meta-analysis, MM was
nonsignificantly associated with the alleviation of pain and betterment of functionality when compared with other functions. One
of the studies included here was conducted in Japan in 2001,15 and
the other in the United States in 2007.18 The studies had methodological differences, but their findings agreed noticeably.
Both studies15,18 conducted clinical assessment and MRI and
used criterion standard and validated tools for assessment.55,57Y59
They therefore likely reflect clinical reality.
Our findings are difficult to be put into context, because
studies on the topic are limited. Only 1 Cochrane review on the topic
was found, and it compared the intra-articular injection of sodium
hyaluronate versus other injections (steroids or others) or placebo
in the treatment of TMD,60 the results being inconclusive.60 Another systematic review was found in PubMed, assessing exercise,
manual therapy, electrotherapy, relaxation, and biofeedback in the
treatment of TMD, concluding that active exercises and manual
mobilization may be effective in improving, at least in the short
term, mouth vertical opening in patients with TMD.61
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491
The Journal of Craniofacial Surgery
Alves et al
The study of Sato et al22 assessed the natural evolution of
nontreated DDWR, showing that spontaneous resolution may be
expected within 12 months, mainly in young patients. They also
found that, during the studied period, the position of the articular
disk was not likely to change. Other authors also assessed the natural evolution of nontreated DDWR and found that 42.5% of participants became asymptomatic, and 32.5% improved (although
did not become asymptomatic) after 2.5 years.20 The authors, however, suggested that the time necessary to spontaneous remission
is too long, implying that the treatment may be necessary, because
a significant proportion of the patients (33%) presented no betterment, and 58% persisted with the symptoms.
The findings of Minakuchi et al15 suggest that patients with
anterior DDWR are likely to improve when submitted to a conservative treatment, and no significant difference was found among
the groups tested or the controls. Schiffman et al18 also found that
the patients felt better regarding the pain shortly after treatment,
regardless of the group. Randomized controlled trial data from
Minakuchi et al15 are in agreement with long-term data previously
published.62,63 Accordingly, the null hypothesis cannot be rejected,
because no difference was seen for the investigated procedures for
the treatment of TMD.
The lack of evidence from large, good-quality interventional
studies in physical therapy is a barrier for evidence-based clinical
decisions. Results from our study need to be cautiously interpreted,
as there are few studies included, and none of them properly defined the sample size a priori, raising question about their statistical power to detect changes. Data on outcomes are also limited
and come from studies where the intervention was evaluated as
a single procedure or had a very short follow-up. Therefore, our
conclusions have limitations, and this is not because of the quality
of the review, but because of an inherent limitation given by the
number of studies. Nonetheless, our findings are of relevance by
highlighting the need of additional good-quality studies, because
systematic data from only 175 patients certainly do not reflect a
disease that affects 2% of the global population.
Mandibular manipulation in association with other conservative therapies may be considered and is sometimes suggested as
the first choice for the treatment of anterior DDWR of the TMJ,
because it is minimally invasive and inexpensive, avoiding unnecessary surgical procedures. However, evidence for its use is missing,
and further studies are suggested. Because good-quality evidence
is also lacking for the alternatives, the intervention can be pragmatically used as an initial therapy. We therefore emphasize the
need for additional studies that will frame clinical rationale. Studies should stratify DDWR in acute and chronic and by disability
(mild, moderate, or severe impact). Studies should assess single interventions, rather than combination, and follow-up needs to be
adequate.
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* 2013 Mutaz B. Habal, MD
Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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