Introduction
Temporomandibular joint dysfunction (TMJD) is clinically associated with restriction of mouth opening, limitation of the range of motions (ROM) in jaw, pain in joint by palpation, and deviation of the jaw in mouth opening and locking sensation. The purpose of this case report is to evaluate the effect of stomatognathic alignment exercise and jaw strengthening exercise on a chronic stroke patient with TMJD.
Case report
On December 2018, an 18-year-old female sustained head trauma after traffic accident. The initial brain CT image showed Lt. EDH, SDH, so the patient underwent several craniectomy and hematoma removal, duroplasty. After VP shunt operation on March 2019, the patient underwent cranioplasty with 3D printing implant due to extensive skull defect of Lt. frontotemporal area.
The chief complaint included not only cognitive impairment (coma recovery scale = 10, at first admission) and quadriplegia but also dysphagia. For the 3rd admitted time on March 2020, dietary build-up had already been leveled up to semisolid food. Hence, therapeutic goal was set to build up to soft-solid diet that needed more chewing. However, there was a major obstacle to this: restricted mouth opening and mandibular movement. The patient’s maximal mouth opening was 10mm, while passive stretch opening was 13mm. Also, intermittent opening click was heard on Rt. and the patient complained Lt. TMJ pain. The facial bone CT showed that no TMJ adhesion or ankylosis was shown. The patient’s restricted mouth opening could be more likely due to TMJ muscle problem as a postoperative complication.
A stomatognathic alignment exercise and strengthening exercise program that focused on oral phase were applied to the patient. For postural correction exercise, cervical ROM exercise was applied to the patient in sitting position with a back support. For TMJ strengthening exercise, the therapist placed a thumb under the patient’s chin and pushed the chin downward with moderate force. Then, the patient was instructed to resist the force and hold it for 5-10 seconds. This exercise program was performed twice a day for a 30-minute session over the 2 weeks interval. At the bedside, the patient’s guardian conducted passive jaw opening exercise by using two tongue depressors as leverage between upper and lower molar teeth. The results showed that stomatognathic alignment exercise and jaw strengthening exercise program significantly improved the TMJ function and overall swallowing ability (Table 1 and 2). The patient was able to perform gum chewing for 10 minutes, and some soft solid food was clinically feasible.
Conclusion
This study shows that the stomatognathic alignment exercise to achieve postural correction and jaw muscle strengthening could be an effective treatment option for dysphagia associated with TMJD. It is also important to invent strategic treatment method rather than continuing with conventional dysphagia therapy in a chronic stroke inpatient.
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