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The Journal of Craniomandibular & Sleep Practice

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Manual therapy and exercise in

temporomandibular joint disc displacement
without reduction. A systematic review

Roy La Touche , Tania Boo-Mallo , Joseba Zarzosa-Rodríguez , Alba Paris-

Alemany , Ferran Cuenca-Martínez & Luis Suso-Martí

To cite this article: Roy La Touche , Tania Boo-Mallo , Joseba Zarzosa-Rodríguez , Alba Paris-
Alemany , Ferran Cuenca-Martínez & Luis Suso-Martí (2020): Manual therapy and exercise in
temporomandibular joint disc displacement without reduction. A systematic review, CRANIO®, DOI:
10.1080/08869634.2020.1776529

To link to this article: https://doi.org/10.1080/08869634.2020.1776529

Published online: 26 Jun 2020.

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 ®
CRANIO : THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE
https://doi.org/10.1080/08869634.2020.1776529

PHYSICAL THERAPY

Manual therapy and exercise in temporomandibular joint disc displacement

without reduction. A systematic review
Roy La Touche PT, PhD a,b,c, Tania Boo-Mallo PT, MSca, Joseba Zarzosa-Rodríguez PT, MSca, Alba Paris-Alemany MD,
PT, PhDa,b,c, Ferran Cuenca-Martínez PT, MSc a,b and Luis Suso-Martí PT, MSc b,d
a
Department of Physiotherapy, Centro Superior de Estudios Universitarios La Salle, Autonomous University of Madrid, Madrid, Spain; bMotion
in Brains Research Group, Institute of Neuroscience and Sciences of the Movement (INCIMOV), Centro Superior de Estudios Universitarios La
Salle, Autonomous University of Madrid, Madrid, Spain; cNeuroscience and Craniofacial Pain Institute, (INDCRAN), Madrid, Spain; dDepartment
of Physiotherapy, Universidad Cardenal Herrera-CEU, CEU Universities, Valencia, Spain

ABSTRACT KEYWORDS
Objective: The aim of this systematic review was to analyze the effectiveness of exercise and Disc displacement; exercise
manual therapy interventions in patients with disc displacement without reduction. therapy; temporomandibular
Method: The authors performed a systematic review of Medline, EMBASE, PEDro, CINAHL, and disorders; manual therapy
Google Scholar databases. Two independent reviewers conducted the eligibility and quality
assessment of studies. Interventions based on exercise and manual therapy regarding pain
intensity and maximum mouth opening as primary outcomes were examined.
Results: Ten articles were included, according to the inclusion criteria. Most of the interventions
showed statistically significant improvements in the primary outcomes.
Conclusion: Results show that interventions based on therapeutic exercise or manual therapy may
be beneficial and play a role in the treatment of disc displacement without reduction. Limited
evidence suggests that exercise significantly improves mouth opening in comparison to splints.
Due to the heterogeneity of the included studies, these results should be interpreted with caution.

Introduction the temporomandibular joints [11,12]. The cause of disc

Temporomandibular disorders (TMDs) are
a heterogeneous group of musculoskeletal disorders
that affect temporomandibular joints, masticatory mus­
cles, and facial structures that can cause pain and
impairment of the mandibular function [1,2]. TMDs
are the main cause of nonodontogenic orofacial pain,
with considerable prevalence and chronicity rates [3]. In
addition, they involve high costs, in terms of both the
high disability they cause and the socioeconomic level,
and are frequently associated with psychological disor­
ders such as pain catastrophism [4–6]. It is considered
that TMDs’ etiology is multifactorial and is related to
structural, psychological, and functional factors [7,8].
Disc dysfunction is one of the most common causes of
TMDs, presenting a prevalence of approximately 41% in
patients with TMDs [9]. Disc dysfunction includes disc
displacement with reduction, disc displacement with
reduction with intermittent blocks, displacement without
reduction with limited opening, and displacement without
reduction without limitation to the opening [10].
Specifically, the most common type of disc dysfunction is
displacement with reduction, characterized by a click on
displacement is not clear, but possible reasons that could
explain changes in temporomandibular joint function
include functional habits or anatomical and biomechanical
factors [9].
Regarding treatment, invasive surgery has been pro­
posed, consisting of an adaptive remodeling of the joint,
or a radial resection of the disc to avoid its anterior
displacement [13]. On the other hand, conservative inter­
vention techniques focused on education, intra-oral
devices (splints), pharmacological therapy or physical
therapy interventions, especially mandibular manipula­
tive or manual therapy techniques and therapeutic exer­
cise, have been suggested [9,14]. Conservative treatments
are considered the first therapeutic option for disc dis­
placement without reduction patients, and exercise and
manual therapy treatments are widely used in this field
[9]. However, the effectiveness of these treatments
remains unclear, as well as the comparison with other
types of conservative or surgical treatments. The aim of
this systematic review was to analyze the effectiveness of
exercise and manual therapy interventions in patients
with disc displacement without reduction.

CONTACT Roy La Touche roylatouche@yahoo.es Facultad de Ciencias de La Salud, Centro Superior de Estudios Universitarios La Salle, Madrid 28023,
Spain
© 2020 Taylor & Francis Group, LLC
2 R. LA TOUCHE ET AL.
Materials and methods
This systematic review was performed in accordance
with a predefined protocol based on the PRISMA state­
ment [15], which is composed of a 27-item checklist and
a four-phase flow diagram, which assists in reporting
systematic reviews [15].
Inclusion criteria of the studies
The selection criteria used in this review are based on
methodological and clinical aspects, such as the popula­
tion, intervention, control, outcomes, and study design
criteria defined for this systematic review [16]. This is
based on the answer to the PICO question, an acronym
for the following: population (P); intervention (I); con­
trol (C); and dependent variables or result (s) of interest
(O) [16].
Population
Randomized controlled clinical trials (RCTs) were
selected, in which comparisons were made with
a control group or other protocolized therapeutic inter­
ventions. Studies without language or time restriction
were included. Patients had to have been diagnosed with
disc displacement without reduction in the TMJ.
Intervention
The studies that were selected had to be RCTs, in which
the main interventions were based on exercise or man­
ual therapy interventions.
Control
No restriction was placed on the comparative element.
Outcomes
The measures to check the results and effects of the
treatment had to assess variables related to pain inten­
sity and mouth opening. The pain intensity had to be
assessed with a visual analog scale (VAS) (minimal
clinically important change, MCIC = 15 mm) or
Numerical Rating Scale (NRS) (MCIC = 2-points).
Search strategy
Two independent reviewers conducted a search of
scientific articles, generating an agreement for the initial
selection of the studies, after which the concordances
were searched.
The search of scientific articles was performed using
the Pubmed (1950 to February 2019), EMBASE (1988 to
February 2019), PEDro (1999 to February 2019),
CINAHL (1982 to February 2019), and Google Scholar
(February 2019) databases. This search phase was con­
cluded on February 24, 2019.
The search process was based on the equation for
clinical trials proposed by Haynes et al. [17], which
presents a sensitivity of 99% and a specificity of 97%
and was adapted to each specific database: ((clinical
[Title/Abstract] AND trial [Title/Abstract]) OR clini­
cal trials as topic [MeSH Terms] OR clinical trial
[Publication Type] OR random* [Title/Abstract] OR
random allocation [MeSH Terms] OR therapeutic use
[MeSH Subheading]) AND (randomized controlled
trial [Publication Type] OR (randomized [Title/
Abstract] AND controlled [Title/Abstract] AND trial
[Title/Abstract])). The terms used for the search strat­
egy were “Physical Therapy,” “Rehabilitation,”
“Exercise,” “Exercise Therapy,” “Temporomandibular
Disorders,” “Temporomandibular Joint,” “Disk
Anterior Displacement without Reduction,” and
“Temporomandibular Joint Closed Lock.”
Selection criteria and data extraction
First, an analysis of information was carried out by two
independent reviewers, who evaluated the relevance of
the RCTs in relation to the question and the objective of
the investigation. This first analysis was made based on
the information of the title, summary, and keywords of
each study. In case there was no consensus or the
abstracts did not contain the necessary information,
the full text was accessed.
In the second phase of analysis, the full text was
checked to determine whether the studies met the inclu­
sion criteria. The differences between reviewers were
resolved by moderate consensus by a third reviewer.
The data described in the results were extracted by
means of the structured protocol that guarantees to
obtain the most relevant information of each study
[18]. The flow chart related to the selection criteria can
be seen in Figure 1.
Risk of bias assessment
The assessment of the risk of bias of the studies was
performed using the PEDro scale (Table 1). The meth­
odological criteria collected in the table were graded as
follows: if the criterion was met (1 point), and if it was
not met (0 points). The maximum possible score was 10
points. Acceptable quality studies were considered if
they met six or more criteria. The PEDro scale was
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 3

Identification
Records identified through Additional records identified
database searching through other sources
(n = 96) (n = 15)

Records after duplicates removed

(n = 53)
Screening

Titles, Abstracts screened Records excluded

(n =16) (n = 37)
Eligibility

Full-text articles excluded, with reasons

Full-text articles assessed (n =6)
for eligibility - Population: n=4
(n = 10) - Intervention: n=2
Included

Studies included in
qualitative synthesis
(n = 10)

Figure 1. Study search strategy flow chart (PRISMA).

Table 1. Assessment of the studies’ quality, based on PEDro for the total calculation of the PEDro scale score. The
Scale. reliability of this scale has been demonstrated by Tooth
Items 1 2 3 4 5 6 7 8 9 10 11 Total et al. [20], and Maher et al. [21].
Alajbeg et al. 0 0 1 0 0 0 1 1 1 1 5
Bas et al. 1 1 1 0 0 0 0 1 1 1 6
Two independent reviewers examined the quality of all
Capan et al. 1 1 1 0 0 0 1 1 1 1 7 the articles selected for the qualitative analysis following
Craane et al. 1 1 1 0 0 1 1 1 1 1 8 the same methodology. Disagreements between reviewers
Dıraçoğlu et al. 0 0 1 0 0 1 1 1 1 1 6
Haketa et al. 1 1 1 0 0 1 1 1 1 1 8 after the first analysis were resolved by the intervention of
Minakuchi et al. 1 1 1 0 0 1 1 1 1 1 8 a third independent evaluator to the first process. Inter-
Nagata et al. 1 1 1 0 0 0 1 1 1 1 7
Tajima et al. 0 0 0 0 0 0 1 1 1 1 4 rater reliability was determined using the Kappa coefficient
Yuasa et al. 1 0 1 0 0 0 1 1 1 1 6 (>0.7 = high level of agreement among evaluators, between
1: Subject choice criteria are specified; 2: Random assignment of subjects to 0.5 and 0.7, a moderate level of agreement, and <0.5, a low
groups; 3: Hidden assignment; 4: Groups were similar at baseline; 5: All
subjects were blinded; 6: All therapists were blinded; 7: All evaluators were level of agreement) [22]. Consistency between the two
blinded; 8: Measures of at least one of the key outcomes were obtained reviewers who performed the methodological assessment
from more than 85% of baseline subjects; 9: Intention-to-treat analysis was
performed; 10: Results from statistical comparisons between groups were was evaluated with the Cronbach’s coefficient α.
reported for at least one key outcome; 11: The study provides point and
variability measures for at least one key outcome.

based on the Delphi scale [19]: criteria 2–9 scored the
internal validity of the RCTs, and the 10–11 criteria
punctuated the statistical information so that the results
were interpretable. Criterion 1 was related to external
validity, was an additional criterion, and was not used
Qualitative analysis
The qualitative analysis used in this review was based on
the classification of the results according to the levels of
scientific evidence. The evidence was categorized into
five levels, depending on the methodological quality of
the studies [23], as follows:
4 R. LA TOUCHE ET AL.
(1) Strong evidence: Provided by statistically signifi­
cant findings in outcome measures in at least two
high-quality RCTs.
(2) Moderate evidence: Provided by statistically sig­
nificant findings in outcome measures in at least
one high-quality RCT and at least one low-
quality RCT and/or one high-quality clinical
controlled trial (CCT).
(3) Limited evidence: Provided by statistically signif­
icant findings in outcome measures in at least
one high-quality RCT and/or at least two high-
quality CCTs (in the absence of high-quality
RCTs).
(4) Indicative findings: Provided by statistically signif­
icant findings in outcome measures in at least one
high-quality CCT and/or low-quality RCTs (in the
absence of high-quality RCTs) and/or two studies
of a non-experimental nature with enough quality
(in the absence of RCTs and CCTs).
(5) No or insufficient evidence. Cases where the
results of eligible studies did not meet the criteria
for one of the above-stated levels of evidence
and/or in the case of conflicting (statistically sig­
nificant positive and statistically significant nega­
tive) results among RCTs and CCTs, or in the
case of a lack of eligible studies.
A requirement to describe the results and conclusions
based on scientific evidence levels is the clinical and
methodological homogeneity in the studies. The results
described in the format that includes levels of evidence
can be observed in the results and conclusion sections.
Results
The study search strategy is shown in the form of a flow
chart (Figure 1). Ten articles that met the inclusion
criteria were selected. The characteristics for which
data were extracted (sample size, demographic charac­
teristics, intervention, outcomes, main results, and con­
clusions) are presented in Table 2.
The mean total score for methodological quality was
6.5, with a standard deviation of 1.35 and a range of 4–8
points.
Characteristics of the study population
All patients in the studies had anterior disc displace­
ment without reduction. The required research designs
were randomized controlled studies, and the samples
were varied; the total number of patients included was
509. The percentage of women participating in the stu­
dies was 84%. The average age of participants in the
included studies ranged from 12 to 74 years, in which
the average age of the women was 48 years (standard
deviation (SD) of 27.19 years).
Characteristics of the interventions
All studies included interventions based upon exercise or
manual therapy, in combination or in isolation. Exercise
protocols were generally variable between studies. Most
of the included studies included self-mobilization exer­
cises related to jaw opening and closing or side-to-side
movement. In addition, some interventions combined
mobilization exercises with isometric strength exercises
or specific jaw muscle stretching exercises. In relation to
manual therapy, the most often-used techniques were the
mobilization of the TMJs using traction and translation
movements, as well as massage techniques on the mass­
eter and temporal muscle. Finally, some studies included
heat or cold treatments or the use of stabilization splints.
Most studies did not specify what type of professional
performed the interventions, with the physiotherapist and
dentist being the most common practitioners. A detailed
description of interventions is shown in Table 3.
Risk of bias analysis
The RCTs were evaluated with the PEDro scale, and
only five showed a high methodological quality with
scores of 7–8 points [24–28]. According to analyses of
the two reviewers, eight of the studies had methodolo­
gies that were good, in terms of quality [24–31]. Table 1
shows the results of the evaluation according to the
PEDro scale. The two reviewers reported a discrepancy
in the evaluation of four RCTs; the discrepancy for those
studies concerned their scores for Items 3, 4, 6, and 9 (3:
concealed allocation; 4: similarity between groups at
baseline; 6: therapist blinding; 9: intention to treat ana­
lysis). A consensus was reached after a third reviewer
intervened. The inter-rater reliability of the methodolo­
gical quality assessment was high (κ = 0.74).
Comparisons of interventions
Conservative intervention versus surgery
Only one study compared conservative versus surgical
treatment. Dıraçoğlu et al. [29] compared the use of
splint plus massage and exercise in comparison to
arthrocentesis in patients with disc displacement with­
out reduction. Positive results were noted in terms of
pain and maximal mouth opening (MMO) in both
groups, but the surgery group showed statistical differ­
ences in pain intensity versus the exercise group.
Table 2. Demographic data and results of studies.
Diagnostic Primary Measuring
Demographic data criteria Intervention group Control group outcomes tools Results Notes
Alajbeg et al. n = 12; IG:6; CG:6 Age: 31.5 DC/TMD Splint + Joint mobilization, Splint Pain VAS Statistically significant reduction in pain in both Small sample size.
2015 (12.85); 29.5 (16.19) and MRI massage, self-care and MCO Millimeter groups, although the size of the effect in the
Pain: 74.0 (8.39); 65.3 mobilization exercises MAO ruler group receiving physiotherapy is greater.
(18.23) Regarding the opening, it was modified in
MCO: 32.43(6.12); 31.33 intervention group.
(13.18)
Bas et al. 2018 n = 27 DC/TMD Self-administered No treatment MMO VAS No differences between groups in either variable After arthrocentesis
IG:13 CG:14 and MRI mobilization and Lateral and Millimeter at 1 week. Statistical differences in pain at 1
7.4% (n = 2) male and resistance exercise protrusion ruler and 3 months in IG, but no differences were
92.5% (n = 25) female. program ROM found in MMO.
Age range: 18–66 Pain
(average = 33) intensity
Capan et al. 2017 n = 31 MRI Mobilization, posture, Same protocol MMO VAS Statistically significant improvements in MMO Post-surgical
G1:16; CG:15 men/ strengthening, without Pain Micrometer and pain intensity for both groups. Between- intervention
women: 1/15;0/15 coordination and supervision intensity caliper groups comparison, there was a significant
Age: 31(5.9); 32.2 (6.0) resistance exercises. (home-based PPT Algometer difference for IG in both variables.
TMJD right/left/bilateral: Self-massage. program)
4/6/6; 5/3/7 Supervised program.
Craane et al. 2012 n = 49 DC/TMD Joint mobilization, Information MMO Plastic ruler Statistically significant improvements in MMO
G1:23; CG:26 exercise, massage, and Pain VAS and pain in both groups. IG did not have an
Age: 34.7 (14.0); 38.5 information to avoid Intensity additional effect.
(15.1) Men/women: 0/ parafunctions
23;2/26 Diagnostic: 12
RCD IIb, 11 IIc;13 IIb, 13
IIc
Dıraçoğlu et al. n = 110 MRI Arthrocentesis Splint + massage + Pain, VAS Millimeter Statistically significant reduction in pain, MMO, Quasi-experimental
2009 IG: 54 (51 women, 3 mobilization, intensity ruler and lateral and protrusion ROM for both design
men). isometric, MMO, groups.
CG: 56 (49 women, 7 coordination, Lateral and Significantly better pain in IG compared to
men). Age: and flexibility protrusion CG.
IG = 33.4 years (range exercises. ROM
15–64 years).
CG = 34.8 years (range
17–61 years)
Haketa et al. 2010 n = 44 MRI Mobilization and Splint +NSAIDs MMO VAS MMO and pain intensity significantly improved
IG:19; CG:25 Age: 38.8 stretching exercise + Pain Millimeter in both groups. MMO only significantly
(15.2); 38.6 (13.8) Men/ NSAIDs intensity ruler increased in the IG.
women: 0/19;4/21 and LDF
function
Minakuchi et al. n = 69 RNM IG1: Splint + jaw Information Pain VAS All the groups showed
2001 CG:21; IG1:25; IG2: 23 mobilization+ self- care regarding MCO Millimeter a significant improvement, but there were no
Age: 36.9 (17.1); 32.0 (mobilization exercises prognosis. MAO ruler significant differences between them.
(15.8); 33.3(13.3) + NSAIDs MPO
IG2: Self-care
(mobilization exercises)
CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE

+ NSAIDs
(Continued)
5
6 R. LA TOUCHE ET AL.

Exercise interventions after surgical treatment

CG: Control group; IG: Intervention Group; MMO: Maximum mouth opening; VAS: Visual Analog Scale; MCO: Maximum comfortable opening; MAO: Maximum assisted opening; MRI: Magnetic Resonance Imaging; TMD:
Both groups showed significant improvement in Quasi-experimental
Two studies compared exercise after surgical treatment

Notes
[24,30]. Bas et al. [30] compared an intervention program

Temporomandibular disorder; PPT: Pain Pressure Threshold; NSAIDs: Nonsteroidal anti-inflammatory drugs; RDC: Research diagnostic criteria. DC/TMD: Diagnostic criteria for temporomandibular disorders.
design
based on non-supervised exercise versus no treatment after
surgical treatment. Statistically significant differences were
found between groups in VAS scores at 1 and 3 months, as

MMO was significantly lower in IG compared

No statistical difference was observed between

evaluation, IG showed better improvements the score decreased only in the exercise group. No differ­
ences were found in MMO. On the other hand, Capan et al.

There was a 60% improvement in the IG

the two treatment groups. At the first

[24] compared an exercise program supervised by

a therapist versus home-based exercise program with no

compared to 33% in the CG.

supervision. Based on the results, the supervised rehabilita­
Results

MMO and pain intensity.

tion program showed significantly better outcomes for pain

at rest and with activity, MMO, and protrusion, compared
with the home-based exercise program. There were no
statistically significant improvements in quality of life
in MMO.

with CG.

(QOL) scores after surgery; but, comparing supervised

with non-supervised exercise programs, the patients in
the supervised program had significantly decreased diffi­
culty in chewing, improved effectiveness at work, and
Millimeter

Millimeter
Measuring
tools

Caliper

reduced nervous tension (p < 0.05).

ruler

ruler
Pain intensity NRS

VAS

Pain intensity VAS

Manual therapy and exercise interventions vs

outcomes

intensity
Primary

splints
MMO

MMO
Pain
MMO

Two studies compared the use of splints versus man­

ual therapy or exercise interventions [25,32]. Alajbej
CG: No treatment
Control group
Mobilization and

et al. [32] compared the use of splints versus splints

functional

Mobilization
exercises

plus exercise and manual therapy joint mobilization.

exercise

Results showed improvements in pain and mouth

opening in both groups, but only relevant statistical
differences were obtained between groups in the
therapy combined with

NSAIDs and mobilization

mobilization exercises

mouth opening variable. The splint plus exercise

Intervention group

functional exercises.
mobilization and

group showed better improvements in maximal com­

G1: NSAIDs and

fortable opening (MCO) and maximal active opening

exercise

(MAO). On the other hand, Haketa et al. [25]

Manual

assigned patients with disc displacement without

reduction to a splint or a joint mobilization self-
exercise treatment group. Results showed improve­
Diagnostic
criteria
DC/TMD

ment in pain and MMO in both groups, but the

MRI

MRI

exercise group showed better improvement in MMO.

women and 4 men). Age:
Female, 8/72; mean age,

IG: 30 (22 women and 8

men). Age: 25.5 (range
Age: 50.7 (18.3); 48.2
Demographic data

IG:19; CG:61. Male/

17–64). CG: 30 (26

Exercise vs exercise with manual therapy or NSAIDs

40.3 ± 16.6 years

28 (range 16–61)

Nagata et al. [26] compared exercise therapy versus exercise

CG:30; IG:31

therapy plus manual therapy. Results showed improve­

(21.1).
Nagata et al. 2018 n = 61

Tajima et al. 2013 n = 80

Yuasa et al. 2001 n = 60

ments in both groups in terms of MMO and orofacial

Table 2. (Continued).

pain, but no statistical differences were observed between

the two treatment groups at follow-up (18 weeks).
However, the exercise plus manual therapy group did
obtain significant differences in the first measurement
immediately after the intervention. In addition, Tajima
et al. [33] compared an exercise protocol with or without
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 7

Table 3. Description of interventions.

Follow-
Intervention up
Alajbej et al. Information about self-care, mobilizing the joint, passive traction and translation. 6 months
Movement + massage exercise of masseter and temporal muscles + stabilization splint + exercises to do at home.
Bas et al. Exercises (explanation and a practical demonstration and written program were given): 3 times daily 3 months
(1) Relax and lower your shoulders.
(2) Let your lower jaw relax and make the M sound. Make sure your teeth are not in contact. Relax your tongue.
(3) Make small, relaxed, up-and-down and side-to-side movements without tooth contact to warm up the muscles.
(4) Open and close your mouth as much as you can without pain or discomfort. Move your lower jaw as far forward as possible
and then back again. Make similar movements toward each side and then relax.
(5) Make the same movements as in exercise 4 but against resistance with your hand. Press with your fist below the chin during
mouth opening. Push your thumb against the point of your chin during forward movement and against the right and left sides
of your chin during lateral movements. Keep your lower jaw at the extreme point of each movement for a few seconds.
(6) Open your mouth as wide as possible and then try to close while you resist this movement by pushing downward against your
lower front teeth with your fingers. Hold the jaw in this position for a few seconds.
(7) Open your mouth as wide as you can. Then, stretch farther by pushing with your fingers against the upper and lower front
teeth.
(8) While looking in the mirror, try to move your lower jaw straight up and down. Avoid deviations and movements that produce
clicking or locking of the jaw.
(9) End the exercise program by resting on your back for 5 to 10 minutes.
Capan et al. Supervised exercises 3 days a week for 8 weeks. Cold pack + massage + mandibular opening and closing exercises + self- 8 weeks
stretching, self-mobilization.
Craane et al. 9 sessions of physical therapy, including joint mobilization, exercises, and massage, and the information on avoiding parafunctions 52 weeks
and oral habits.
Dıraçoğlu Stabilization splint + exercise (the program also included massage of painful muscles, TMJ active and gentle range of motion, 6 months
et al. isometric exercises, posture exercises, and relaxation techniques + hot pack.
Haketa et al. Verbal explanation + Exercise protocol: As a warm-up, the individual repeated small mouth-opening and -closing movements 8 weeks
several times. Then, the individual placed his/her fingertips on the edge of the mandibular anterior teeth and slowly pulled the
mandible down until pain occurred on the TMJ-affected side. This mouth-opening position was held for 30 seconds. Three
cycles of this stretching movement were defined as a single set. The participant performed 4 sets per day, one after each meal
and one while bathing.
Minakuchi Self-care management + NSAIDs + Physical therapy (opening and closing). 8 weeks
et al.
Nagata et al. All TE + MT and TE patients received standard therapy, including self-exercise, cognitive-behavioral therapy (e.g., guidance 18 weeks
regarding clenching control during waking hours, as well as coping with pain and stress) and education for TMD (a diet of soft
foods, avoiding gum chewing, and correcting bad posture). The self-exercise consisted of two types of exercise for the
mandibular jaw. One exercise pulled down on a patient’s bilateral lower last molars with their secondary fingers, while opening
the jaw to the greatest possible extent (molar pulldown type) with 10 repetitions, three or five times per day. The other exercise
comprised simplified myofunctional therapy, combined with maximum mouth opening, clenching, protrusion of the lip,
maximum mouth opening, and maximum tongue protrusion without use of the patient’s fingers.
TE + MT patients also underwent jog-type jaw manipulation, which was a combination of four different types of manipulations;
a pivot made of gauze was set on the last molar. The following four steps were executed continuously: (1) closing type with
fulcrums on both sides; (2) side-to-side type; (3) opening type; (4) closing type with fulcrums on the impaired side. If an
insufficient opening, < 40 mm, of the mouth could be obtained, the same process was repeated three times. The
implementation of this technique was conducted at the first visit and each subsequent visit of the patients until the restoration
of mouth-opening limitation.
Tajima et al. For the mouth-opening exercises, the thumb was placed on the maxillary anterior teeth and the forefinger on the mandibular 1 week
anterior teeth, which opened the mouth manually. The subject was asked to hold it at maximum opening for 10 seconds
repeatedly 10 times. Participants were advised to achieve the maximum mouth opening at 35 mm. The exercise was performed
4 times daily, 30 min after each meal and during a bath for 1 week.
Yuasa et al. NSAIDs + Physical therapy (4 times/day forced opening, maintained opening 10 s/10 reps). 4 weeks
TE: Therapeutic Exercise; MT: Manual Therapy

non-steroidal anti-inflammatory drugs (NSAIDs) combi­
nation. Results showed significant improvement in MMO
and pain intensity in both groups, but patients in the
NSAID group started with a significantly smaller MMO.
Combined conservative interventions vs isolated
conservative interventions
Three studies compared the combination of exercise
with NSAIDs, splint, or manual therapy protocols vs
isolated treatments or no treatment [27,28,31].
Yuasa et al. [31] found statistical differences in
pain and MMO in the combination of NSAIDs and
exercise group versus the non-treatment group.
However, Minakuchi et al. [28] showed no significant
differences in pain intensity, MMO between control
group (no intervention) or intervention groups
(NSAIDs with splint and manual therapy or self-
care and NSAIDs). In addition, Craane et al. [27]
compared a manual therapy and exercise interven­
tion versus only information about disc displacement
without reduction as a control group. Results showed
that the manual therapy and exercise group did not
8 R. LA TOUCHE ET AL.
show better improvement in MMO and pain versus
the control group.
Qualitative analysis
Following is a description of the qualitative analysis of
the results according to the level of evidence. In this
section, the authors have only been able to group the
studies that presented clinical and methodological
homogeneity between them.
Limited evidence exists to suggest that exercise sig­
nificantly improves mouth opening in patients with disc
displacement without reduction compared to splints;
however, results regarding pain reduction were similar
for both treatments [25,32].
In addition, limited evidence also suggests that non-
supervised and supervised exercise significantly
improves pain intensity after surgical treatment in
patients with disc displacement without reduction
[24,30]. However, these results should be considered
with caution due to the heterogeneity of the data.
Finally, there is insufficient evidence supporting the
combination or isolated application of manual therapy,
exercise, NSAIDs, and splints in mouth opening and
pain intensity in patients with unreduced disc displace­
ment, due to conflicting results.
Discussion
The aim of this systematic review was to analyze the
effectiveness of exercise and manual therapy interven­
tions in patients with disc displacement without reduc­
tion. The results obtained in the present review show
a considerable heterogeneity between research studies
found in the current scientific literature. The large clin­
ical difference between the interventions performed and
the measurement instruments used for comparison does
not allow strong conclusions about the effectiveness of
exercise or manual therapy interventions in patients
with disc displacement without reduction. Similar
results have been found in previous reviews about the
effectiveness of treatments based on manual therapy and
exercise in patients with non-specific TMDs [34].
Therefore, in this review, a comparison was made of
the different interventions used based on exercise and
manual therapy, in addition to other types of conserva­
tive treatments. However, in most comparisons, only
one or two RCTs were homogeneous and could be
included in the comparison.
In relation to the comparison between the inter­
vention of conservative versus invasive treatments,
Dıraçoğlu et al. [29] showed better results in relation
to the intensity of pain in the group undergoing
arthrocentesis versus the group with conservative
treatment. However, a previous review study did not
show significant results between conservative and
non-conservative interventions [35]. The study
included in this review is a quasi-experimental
study, and the difference between different conserva­
tive treatment methods could explain the differing
results of this study. However, it seems that the asso­
ciation between a greater number of complications
shown in invasive versus non-invasive treatments
may justify the choice of non-invasive interventions,
such as exercise as the first treatment of choice in
these patients.
On the other hand, one of the most relevant com­
parisons of the present review is the use of splint
versus manual therapy or exercise treatments. The
results showed positive effects in relation to mouth
opening in the physiotherapy group versus splints,
with limited evidence. It has been suggested that
splints, as a solitary treatment approach, seemed to
have no additional effect over other active interven­
tions or no treatment, although as an adjunct to
others, they may help to alleviate symptoms [35,36].
However, results from a systematic review and meta-
analysis showed that the use of splints could have
a positive effect on both reducing pain and increasing
mouth opening in patients with non-specific TMDs
[37]. These authors suggest that the efficacy of splints
is related to the type of disorder and tissue damage
present in the TMJ, so the effectiveness of this type of
treatment may be less in patients with disc displace­
ment without reduction, according to the results of
this review. Physiotherapy interventions should be
considered clinically as an option to splints, although
these results should be interpreted with caution due
to diversity between the multiple exercises used; the
different manual therapy techniques and/or the dif­
ferent types of splints make it difficult to fully deter­
mine the effectiveness of this type of intervention.
It is important to note that most of the interventions
included in this review show statistically significant
improvements in the main variables analyzed: pain
intensity and mouth opening. However, between
group analyses rarely reveal significant differences
between the different interventions. Benefits obtained
in most interventions should be taken into account, as
the natural development of these patients is usually
toward remission of symptoms. This could be a source
of confusion about the effectiveness of treatments and
a possible hypothesis to results showing improvements
in groups with no or minimal intervention compared to
combined interventions, as well as heterogeneity of
these interventions [38,39].
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE
Only Nagata et al. [26] compared the effectiveness of
isolated exercise versus manual therapy combined with
exercise. Results showed that the group that received
manual therapy had better results in the short term,
although there were no differences between the groups
in the later assessments. These results are similar to
those found in patients with TMDs. Martins et al. [40]
performed a systematic review and meta-analysis show­
ing positive results in reducing pain intensity and
increasing mouth opening after manual therapy-based
interventions. In addition, the effects were superior in
the short term versus the long term. Therefore, manual
therapy may have a role in the treatment of patients with
disc displacement without reduction, although the
results may be better in combination with other
interventions.
Limitations
There are several limitations to be considered in the
interpretation of the results of this systematic review.
The considerable heterogeneity of studies in both
interventions and measurement instruments does
not allow comparison of results or determination of
clinically relevant changes. This reduces the possibi­
lity of obtaining conclusions about the effectiveness
of physiotherapy treatments in patients with disc
displacement without reduction. In addition, few stu­
dies have assessed multidimensional variables, such as
disability or quality of life, that could provide infor­
mation about the effectiveness of physiotherapy treat­
ments in this population. On the other hand, it has
not been possible to perform a meta-analysis that
could provide more accurate information about each
comparison of interventions for the main variables.
In addition, many of the studies have methodological
flaws or small sample sizes that may represent a bias
to be considered in the result interpretation.
Conclusion
Results show that interventions based on therapeutic
exercise or manual therapy may be beneficial and play
a role in the treatment of disc displacement without
reduction. Limited evidence suggests that exercise sig­
nificantly improves mouth opening in comparison to
splints. However, due to the heterogeneity of the
included studies, these results should be interpreted
with caution; it is not possible to determine which is
the best type of intervention or which parameters might
be most beneficial in these patients. Further research is
needed to investigate the effectiveness of physiotherapy
interventions in patients with disc displacement without
9
reduction.
Conflicts of interest
The authors declare that they have no conflicts of interest.
Funding
This research did not receive any specific funding.
ORCID
Roy La Touche PT, PhD http://orcid.org/0000-0001-6379-
6155
Ferran Cuenca-Martínez PT, MSc http://orcid.org/0000-
0003-4644-3758
Luis Suso-Martí PT, MSc http://orcid.org/0000-0001-
9191-4243
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