Indian Journal of Dental Research

: 2020  |  Volume : 31  |  Issue : 3  |  Page : 350--353

Role of structured rehabilitation protocol in post surgical cases of restricted mouth opening

Ankita Chugh1, Kriti Mishra2, Kushal K Sahu1, Yogesh Mittal3, Vinay K Chugh1,  
1 Department of Dentistry, AIIMS, Jodhpur, Rajasthan, India
2 Deparment of Neurology, KS Hegde Medical Academy, Deralakatte, Mangalore, Karnataka, India
3 Department of Oral and Maxillofacial Surgery, Jodhpur Dental College, Jodhpur, Rajasthan, India

Correspondence Address:
Dr. Ankita Chugh
Department of Dentistry, AIIMS, Jodhpur – 342005, Rajasthan


Background: Long term effectiveness of surgical management of chronically restricted mouth opening in OSMF or TMJ ankylosis depends largely on postoperative physiotherapy. This in turn is dependent on patient's compliance. Use of adjunctive aids besides pharmacotherapy that reduces patients pain and improves compliance with exercise is warranted. Aims: To evaluate the role of TENS and structured rehabilitation programme in postoperative physiotherapy in OSMF and TMJ ankylosis patients. Methods and Materials: A pilot study was conducted in which 6 patients of restricted mouth opening were put on a structured rehabilitation protocol in which TENS, heat and cold therapy with structured mouth opening exercise regimes. Interincisal opening, VAS score and a subjective assessment of post surgical discomfort was evaluated. Results and Conclusions: Results revealed an improved compliance and cooperation by patients. Pain on VAS scale also reduced from mean of 7.8 on day 1 to 3.6 on day 5 in this group. The mean discomfort on day 3 was reported as mild to moderate. An early attainment of passive mouth opening closest to intraoperative mouth opening was also reported on day 5 which is usually not achievable without any physiotherapy intervention.

How to cite this article:
Chugh A, Mishra K, Sahu KK, Mittal Y, Chugh VK. Role of structured rehabilitation protocol in post surgical cases of restricted mouth opening.Indian J Dent Res 2020;31:350-353

How to cite this URL:
Chugh A, Mishra K, Sahu KK, Mittal Y, Chugh VK. Role of structured rehabilitation protocol in post surgical cases of restricted mouth opening. Indian J Dent Res [serial online] 2020 [cited 2022 Aug 12 ];31:350-353
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Temporomandibular joint (TMJ) ankylosis and oral submucous fibrosis (OSMF) are the two common entities reported to maxillofacial surgeons with restricted or many times nil mouth opening. TMJ ankylosis is the bony or fibrous fusion of the joint. Various etiologic factors are related to it, such as congenital, developmental birth trauma, infections, middle ear infections, and autoimmune disorders. Over the years, surgical management of this pathology has progressed from gap arthroplasty to interpositional arthroplasty, reconstruction of joint with bone grafts, use of distraction to reconstruct ramus to latest total alloplastic joint replacements. Based on the onset and presentation of the disease with the evident deformity, the type of intervention is selected. Most of these modalities have proven to be efficient in getting the improved mouth opening, but most of them have been associated with a common complication of recurrence. Because of this, the effective management of TMJ ankylosis depends not only on an adequate surgical therapy with appropriate gap creation but also compliance with postoperative mouth opening exercises. Despite adequate bony gap creation and interposition of a suitable tissue or material, if postoperative rehabilitation protocol is not followed, partial or complete bony fusion may reoccur. The diligence and perseverance of the patients in exercise regime accounts for retention of good interincisal opening which plays an important role in defining the end treatment outcome.

Similar is the case with OSMF in which even after the release of fibrotic bands and coverage with a suitable graft or flap, a long-term rehabilitation consisting of mouth opening exercise schedule is mandatory for stable results irrespective of the type of defect coverage that is opted. Aggressive physical therapy has been advocated in all the protocols in initial healing phase for at least 12–24 weeks till soft tissue is remodeling.

In the postoperative phase of both these surgeries, thus, rehabilitation protocol is the mainstay. However, considering the fact that in TMJ ankylosis usually we are dealing with an early childhood group of 5–15 years age, expecting a very high compliance from them for vigorous mouth opening exercises in the immediate postoperative phase is a task too high. Forcible exercise schedule while in pain further increases anguish in the child and reduces the compliance. In long-standing cases, especially if mandible is severely retruded, severe bradycardia on jaw stretching both under anesthesia and in the postoperative period has been reported.[1] Hence, this must be kept in mind and stretching should be performed very slowly in these cases. What is known is that this phenomenon gradually reduces over 10–14 days. Similarly, in OSMF, despite adequate excision of bands, there are areas in mouth where complete excision of bands is not possible like in soft palate and pharyngeal area. Active stretching schedule of the area where irreversible collagen has formed and tissues are not conducive to good elasticity can be painful.

Despite these hurdles of pain and subsequent possibility of poor compliance, active rehabilitation protocol has to be started within 24–48 h postoperatively in both the cases. Surgical edema, postoperative pain, and muscular spasms can be minimized to a large extent with pharmacotherapy. However, other nonpharmacological therapeutic physical modalities, if used, can improve the compliance of mouth opening exercises. This article emphasizes the need for including these therapeutic physical modalities in the postoperative rehabilitation protocol to enhance its compliance by these patients and hence prevent reoccurrence.

 Materials and Methods

A pilot study was conducted in which six patients in age range of 7–44 years operated for TMJ ankylosis and OSMF were referred on first postoperative to the Department of Physical Medicine and Rehabilitation. All the patients were initiated on a structured postoperative rehabilitation protocol; starting with cold compresses for the initial 2–3 days three times daily for 10 min (intermittently), an active exercise regime and usage of physical modality transcutaneous electrical nerve stimulation (TENS) from day 2 postoperatively for 10 days. The exercise regime included manual stretching of the involved muscles, TMJ mobilization exercises, myofascial band release, orofacial massage, mouth opening exercises (manually and using jaw openers), and contract-relax, antagonist contract (CRAC) technique. After 2 days, heat wave therapy was also given. A questionnaire was filled by patients and/or their guardians regarding the amount of discomfort and pain perceived on each day. This study was done as per International Conference on Harmonisation- Good Clinical practice(ICH-GCP) and following guideline principles of declaration of Helsinki & other regulatory guidelines.


The results revealed an improved compliance and cooperation by patients. Pain on visual analog scale also reduced from a mean of 7.8 on day 1 to 3.6 on day 5 in this group. The mean discomfort on day 3 was reported as mild to moderate. An early attainment of passive mouth opening closest to intraoperative mouth opening was also reported on day 5 which is usually not achievable without any physiotherapy intervention. However, the sample size was small for any statistical tests to be applied [Table 1] and [Table 2].{Table 1}{Table 2}


Rehabilitation administered as structured physical therapy program can increase mouth opening. Especially the phase of tissue remodeling can be exploited with aggressive physical therapy to attain gigantic and long-lasting results. An early initiation of exercise regime has been found to be beneficial as it prevents reoccurrence of adhesions, progressive tissue fibrosis, and soft tissue contractions and also helps restoring normal muscular and joint function. These exercise regime includes both active range of movement driven by musculature around the joint and passive range of motion applied by external force, in the absence of muscle activity; either manually by therapist or using tools such as rubber plugs, wooden blades, dynamite bite openers, and TheraBite exerciser.[2],[3] The passive exercises help improve the mobility of the joint and stretching helps in making connective tissue more flexible.[4] Orofacial massage by squeezing the cheek between fingers and thumb inside the mouth helps warm up the tissue before stretching. For severe trismus, sometimes aggressive exercise in form of CRAC is used. It involves partially opening the mouth with the external device, biting it for 20 s, opening the mouth wide actively for 20 s and then relaxing, and again stretching device for 20 s and relaxing for 60 s.

It has been shown that a combination of stretching and range of motion exercises is more efficacious than stretching alone.[4] Compliance with exercises is most important, and evidence from literature mentions a huge heterogeneity in the regime followed at various setups mainly in terms of techniques, duration, and repetition of exercises.[5],[6]

However, pain is one of the major limiting factors for execution of mouth opening exercises. Reduction of pain is foremost for mouth opening exercises. Undertreatment of postoperative pain is common in surgical patients. It has been reported that approximately 40% of surgical patients suffer from moderate to severe pain during the first 24 h postoperatively in the general surgical setting.[7] Pharmacologic methods with use of anti-inflammatory drugs such as steroids and nonsteroidal anti-inflammatory drugs along with muscle relaxants have been used as a routine, but does not suffice always.

Cold compresses produce rapid cooling of superficial layers with a late and lesser effect on deep tissues. Rapid cooling leads to vasoconstriction and reduces postoperative edema and bleeding besides reducing pain by anesthetic effect. Hence, the protocol involved usage of cold compresses in the initial 2–3 days for 10 min each session.[8]

Heat therapy involves placing moist hot towels over the affected area and is particularly effective before stretching exercises. It decreases joint stiffness, reduces pain and muscle spasm, increases extensibility of collagen tissue, increases blood flow, and helps resolve inflammatory infiltrate edema.[4]

Interferential therapy is an electrotherapy modality used as an adjunct in pain relief for different conditions. It involves application of two medium frequency currents to the tissues to generate low-frequency interference current. It can be used to relieve pain after initial postoperative edema dissolves. The evidence to recommend its use and efficacy in postoperative conditions is inconclusive.

TENS is a well-known nonpharmacological therapeutic physical modality, which is useful for the relief of pain in both acute and chronic conditions. With TENS, low-voltage electrical impulses are transmitted to pain generator sites through surface electrodes at specific stimulus parameters, namely, amplitude (1–100 mA), pulse width (40–250 μs), and pulse rate (1 or 2 Hz to 200–250 Hz).[3] It is a safe, noninvasive, effective, and swift method of analgesia, and the potential adverse reactions of other methods of pain control are eliminated. It is proposed that TENS works on the principle of gate theory and it stimulates large, fast, myelinated, non-nociceptive neurons in painful area thus closing the central gate for those stimuli generated by pain-specific fibers. According to the gate control theory by Melzack and Wall, on application of an electrical current to a painful area, transmission of pain sensation through small-diameter fibers to the brain is inhibited due to activation of large-diameter, fast-conducting highly myelinated, proprioceptive sensory nerve fibers. Another mechanism of pain relief is thought to be based on activation of descending inhibitory pathway, through release of endogenous opioids. The descending inhibition area in brain is primarily located at nucleus raphe magnus in rostral ventral medulla (RVM) and the periaqueductal gray (PAG). The pathway begins with projections from PAG to RVM and from RVM to dorsal horn at spinal cord level where ascending pain perception pathway spinothalamic tract cells are located. Hence, stimulation of PAG or RVM inhibits spinothalamic tract cells. The activation of PAG–RVM pathway is through specific and different opioid receptors' stimulation through release of endogenous opioids. Application of low-frequency TENS causes activation of δ-opioid receptors and high-frequency TENS activates μ-opioid receptors, which in turn activate the PAG–RVM pathway.[9]

Most of the previous available evidence in literature on efficacy of TENS for postoperative analgesia was inconclusive due to heterogeneous treatment protocols, different timings and duration of TENS application, and poor outcome assessors. However, a recent review concluded that TENS is effective in reducing postoperative pain following various surgeries as a part of multimodal analgesia. Hence, its inclusion in a comprehensive structured rehabilitation protocol is beneficial. Its role as a solo modality to provide postoperative analgesia is still to be largely explored.


Rehabilitation consisting of physical therapy regime and usage of splints is the mainstay of postoperative phase of treatment and this has been proved time and again. Simple mouth opening exercises with anti-inflammatory drugs and muscle relaxants with mouth stretching splints have been used for years. The initiation of rehabilitation protocol as early as on the first postoperative day has also been reinstated. But postoperative pain and edema reduce patient compliance. Stability or long-term maintenance of the acquired results depends extensively on the immediate postoperative rehabilitation, and thus patient compliance becomes a rate-limiting factor. Inclusion of therapeutic physical modality in the rehabilitation protocol addresses the issue of postoperative pain, thereby improving the compliance to the exercise regime. Hence, a structured rehabilitation protocol including appropriate usage of physical modality and specified exercise regime can enhance and expedite the recovery of these patients postoperatively with long-lasting results of improved mouth opening.

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Conflicts of interest

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