Trismus – An Aetiology and Management

Dr.J.Arun Kumar*

WHAT IS TRISMUS???
2. Traumatic
 Trismus is derived from a Greek term  Fractures of mandible, zygomatic arch or
meaning “Grinding together”. temporal bone.
 It is defined in Taber’s cyclopedic medical  Haematoma in the joint or muscles of
dictionary as tonic contraction of muscles of mastication.
mastication.  Local anaesthetic injection or injury.
 True trismus is a muscular involuntary  Paradoxical muscle sparm following head
protective reflex. injury.
 As a result of localised muscle irritation or  Post-surgical. Eg: TMJ surgery, 3rd molar
inflammation afferent signals of pain and input extraction.
from reset muscle spindles to the central nervous
system cause foreshortening of the muscles of
mastication.
 This is different from voluntary muscular
guarding that can occur in patients with a TMJ
internal derangement.
 Such patients resist normal opening due to
joint pain and dysfunction.
3. Neoplastic (Benign)
ETIOLOGY  Tumors involving TMJ & surrounding
structures. Eg: Osteochondroma.
 Odontogenic infection.  Hyperplasia of condyle or coronoid process.
 Multiple inferior alveolar nerve anaesthetic
injection.
 Masticatory muscle disorder (Acute
exacerbation).
 Surgery. Eg: Third molar extraction.
 Trauma with mandibular fracture or muscle
contusion.
 Neoplasia irritating or invading muscles of
mastication.
 Radiation treatment.
 Psychologic hysterical trismus.
 Pharmacologic phenothiatines.
 Neuromuscular tetanus.

CLASSIFICATION
4. Neoplastic (Malignant)
Trismus can be classified in the etiologic basis.  Chondrosarcoma.
 Osteosarcoma.
1. Congenital  Cerebellopontine angle tumor.
 Birth injury  Tumors of oropharynx.
 Trismus pseudo camptudacrtyly syndrome  Metastatic tumors involving mandible and
 Arthrogryposis multiplex congenita infratemporal fossa.

* Senior Lecturer

Department of Oral and Maxillofacial Surgery,

Vinayaka Mission’s Sankarachariyar Dental
College & Hospital, Salem.
  Radiation therapy
 Myofacial pain dysfunction syndrome
 Ankylosing spondylitis
 Myositis ossificans
 Rheumatoid arthritis

5. Neuromandibular disorders 8. Psychogenic

 Parkinson’s disease.  Hystorical trismus.

6. Reactive (Acute) 9. Drug induced

 Septic arthritis.  Extra pyramidal reaction.
 Tetanus.  Strychnine poisoning.

CLINICAL FEATURES
Trismus is usually acute in onset, unilateral,
painful, and associated with an identifiable cause.
 When a patient presents with trismus, history
and clinical examination are of paramount
importance in arriving at a diagnosis.
 While taking history, the following questions
should be asked
 Osteomyelitis of mandible and temporal bone.  How long the trismus was present?
 Abcesses of the submasseteric, lateral  Is there history of trauma or
pharyngeal, pterygomandibular, sub-mandibular infection?
and temporal spaces.  Is it of slow or sudden onset?
 Tonsillitis and peritonsilar abscess.  Is it progressive?
 Parotid abscess.  Is there any systemic disease?
 Mumps.  Is the patient currently receiving any
 Cancrum oris. medication?
 Encephalitis.  Is there any associated pain?
 Meningitis.  Are there any swellings?
SIGNS: Most obvious effect of trismus is difficulty in
7. Reactive (Chronic) opening the mouth. Regardless of the cause.
 TMJ ankylosis (Fibrous and bony)

 Degenerative joint disease

 Systemic sclerosis
 Oral submucous fibrosis

Trismus caused by radiation treatment present with

 Xerostomia, mucositis, and pain due to
radiation burns.
 Headache, jaw pain, earache, deafness or pain
on moving the jaw.
 Soft tissue fibrosis
 Polymyocitis
 PROBLEMS CAUSED BY TRISMUS
TREATMENT
To know how to treat this condition we should
first concentrate.
WHEN DOES TRISMUS START?
WHAT ARE THE RISK FACTORS??
Severity of the condition varies from no
limitation in opening to 4 or 5 mm.
The severity of the condition varies
- With the placement of radiation.
- The amount of radiation received.
- Patient’s own ability to tolerate the treatment.
- Radiation in excess of 60 Gr. is more likely to
cause trismus.
 X-patients who are previously irradiated and
who are being treated for recurrence, appear to
be at high risk than those who are receiving their
first treatment.
 Radiation induced trismus may begin towards
the end of radiation treatment or anytime during
subsequent 12 months.
 Trismus due to scarring and edema after
surgery.
 Inspite of the difference in the cause of
condition, diagnosis & treatment is similar for
both the type of patients.
WHAT’S HAPPENING TO CAUSE THIS ???
Primary factor
Rapid formation of collagen secondary to
radiation damage or surgery.
Muscles of Mastication; Masseter,
Temporalis, Lateral Pterygoid, Medial Pterygoid.
Each muscle plays an important role in
mastication when damaged each can cause limited
mouth opening.
A SIMPLE TEST FOR TRISMUS
“THREE FINGER TEST”
 Ask the patient to insert 3 fingers in to the
mouth.
 If all three fingers fit between the central
incisors, mouth opening considered functional.
 It less than 3 fingers can be inserted
restriction is likely.
TREATMENT OPTIONS
 Treatment should be as soon as possible.
 Therabite jaw motion rehabilitation system.
 Trismus appliances
(a) Cork screw
(b) Tongue blade
(c) E-Z flex jaw exerciser
PROTOCOL
 Recent research of the university of Pittsburgh
has shown that passive motion provides significant
reduction in inflammation and pain.
 Passive motion applied several times per day
is more effective than static stretching.
 Before starting the treatment its important to
measure initial opening and record the opening.
 Also, record the opening after each session,
and note any pain or discomfort as well as the
number of exercises performed.
THERABITE
It comes with
 Bite pads
 Patented range of molar scales
 Patient log-book.
  It has low cost but not cost effective
 They can’t show much improvement in mouth
opening < 5 mm.

STARTING REGIMEN - “7-7-7”

a) Open and close the mouth with assisted opening 7
times. E- Z FLEX JAW EXERCISER
b) Hold the open position to the maximum opening  The E-Z flex jaw exerciser works by a pump
that can sustained without pain for 7 secs. action which opens the jaw portion when the
c) They should perform these exercises 7 times/day. patient squeezes the pump.
 In all cases, be alert for signs of pain and  The jaw portion is placed in patient’s mouth.
muscle soreness.  This device has the advantage of working
 Advise against the “No pain no gain” well with edentulous patients.
philosophy.
 Pain should be avoided, because it will result
in muscle guarding that may reduce the
effectiveness of therapy.
 Total time needed to complete this protocol is
less than 10 min/day.
 Over time regimen is reduced.
 It is better to reduce the number of stretches Jaw Exerciser
per session, rather than reducing the number
of sessions.

MECHANISM
 Therabite system not only stretches the
connective tissue, but also allows for proper
mobilization of the temporomandibular joint. Pump portion of EZ Flex
1. Increase jaw opening  Stretching connective tissue
via
- Lengthening and realigning muscle and
collagen fibers.
- Mobilizing joints that have shown
degenerative changes.
- Strengthening muscles across their full range EZ Mouth – The jaw portion of the EZ Flex opening the
of motion. patient’s mouth
2. Reduce pain and inflammation by activating anti-
inflammatory properties by passive mobilization of the
joints.

TRISMUS APPLIANCES
CORKSCREW
 Can be used to exercise a patient’s mouth EZ Measure – Measuring the Jaw Opening
opening when under going radiation treatment
with TMJ in the radiation field.
 This device works by gradually opening the
jaw when the patient places it between the teeth
and turns the corkscrew.
 Patient does this several times a day.

EZ Flex Kit

CONCLUSION
TONGUE DEPRESSOR
 Least expensive
 Trismus is associated with various etiologies.
An early diagnosis with prompt treatment will usually
result in a complete cure.
REFERENCES
 www.ominimedicalsearch.com
 Disorders of Temporomandibular Joint and
Muscles of Mastication.
 Textbook of Oral Medicine - Promod John