The role of surgery in the management of disorders of the Temporomandibular Joint: a critical review of the literature. Part 1

Invasive surgical procedures for the management of internal derangement of the temporomandibular joint: a systematic review and meta-analysis regarding the effects on pain and jaw mobility

OBJECTIVES

This systematic review compared minimally and invasive surgical procedures to manage arthrogenous temporomandibular joint (TMJ).

MATERIALS AND METHODS

The review included clinical trials assessing surgical procedures of arthrogenous temporomandibular disorder (TMD) management by carrying out comparisons within the same surgical procedure (pre- and post-treatment) as well as between different surgical procedures. Meta-analyses were conducted only for similar comparison reporting the same outcome measures, visual analog scale (VAS) values to evaluate pain and maximum incisal opening (MIO) values.

RESULTS

Of the 1,015 studies identified by the search strategy, 26 were selected for full-text reading, and 19 were included in the review. Of these, 16 studies were included in the meta-analysis and 3 in the qualitative analysis. The VAS scores showed significantly lower values after discectomies (p < 0.001) and discoplasties (p < 0.001) in the within-group comparison. Moreover, significantly lower VAS scores and higher MIO values were observed after discectomy compared to arthroscopy, eminectomy, and discoplasty (p < 0.05).

CONCLUSION

The findings of this systematic review suggest that although significantly lower VAS scores and higher MIO values were observed after discectomy, the currently available scientific evidence is unclear, and the use of invasive surgical procedures should be implemented as an efficient first-line treatment option for arthrogenous TMD management.

CLINICAL SIGNIFICANCE

VAS and MIO outcomes could be insufficient to describe the success or failure of open surgical procedures like discectomy and discoplasty.

Arthrocentesis of Temporomandibular Joint- Bridging the Gap Between Non-Surgical and Surgical Treatment

The temporomandibular joint forms one of the most fascinating and complex synovial joints in the body. Movements of the temporomandibular joint are regulated by an intricate neurological controlling mechanism, which is essential for the system to function normally and efficiently. Lack of such harmony may cause disruptive muscle behavior or structural damage to any of the components. The management of refractory pain and dysfunctions in the temporomandibular joint poses challenge both to the oral physician and maxillofacial surgeon. Arthrocentesis is a simple, minimally invasive technique that can be used instead of more invasive procedures in patients with pain that fails to respond to conventional conservative measures. This review provides a full comprehensive overview of the literature about the various technical and prognostic aspects in relation to arthrocentesis of the temporomandibular joint, and every clinician must take into account this consideration when performing this procedure in treating patients with temporomandibular disorders.

TMJ inferior compartment arthroplasty procedure through a 25-year follow-up (functional arthroplasty)

OBJECTIVE

The purpose of this study was to assess the outcomes of temporomandibular joint (TMJ) "functional arthroplasty" on the inferior compartment and disc reposition as a surgical treatment for internal derangement (ID).

PATIENTS AND METHODS

By retrospective chart review, all patients who had TMJ surgery on the inferior compartment for TMJ ID from 1985 to 2010 were identified. Their charts were reviewed and subjective data as well as objective data was collected.

RESULTS

The chart review yielded 352 patients treated through this approach for a total of 696 joints involved. Analysis of the data showed that there was a good health improvement. The mid VAS about pre surgical TMJ pain was 58.3, after surgery 7.7. About headache and cervical pain the pre surgery mid VAS was 47.7, after surgery 16.7.

CONCLUSIONS

Outcome data presented show that TMJ surgery on the inferior compartment and disc reposition could be an effective and successful surgical treatment of TMJ ID. This success has been seen and maintained also in long term follow up in this specific patient population. For this reason, we propose to call this procedure "functional arthroplasty".

Temporomandibular Joint Surgery: What Does it Mean to India in the 21st Century?

While India boasts the largest collective experience in the surgical management of TMJ ankylosis, times are changing and Indian Surgeons will need to begin thinking about other TMJ disorders that have previously gone under the radar. A growing Indian middle class with greater access to health facilities will demand treatment for TMJ disorders like myofacial pain and dysfunction, internal derangement and osteoarthrosis which Oral & Maxillofacial Surgeons must be prepared to manage. The aim of this paper is to review the role of TMJ surgery and its place in the treatment armamentarium of temporomandibular disorders. Indications, rationale for surgery, risks vs benefits are discussed and complemented with examples of clinical cases treated by the author. As India moves up the economic ladder of success, TMJ disorders that have largely been confined to Western nations will begin to appear in the rising middle classes of India. Indian Oral & Maxillofacial Surgeons must be prepared to recognize and manage disorders which present with more complex symptomatology where the role of TMJ surgery is less clear cut.

Emerging intra-articular drug delivery systems for the temporomandibular joint

Temporomandibular joint (TMJ) disorders are a heterogeneous group of diseases that cause progressive joint degeneration leading to chronic pain and reduced quality of life. Both effective pain reduction and restoration of TMJ function remain unmet challenges. Intra-articular injections of corticosteroids and hyaluronic acid are currently used to treat chronic pain, but these methods require multiple injections that increase the risk of iatrogenic joint damage and other complications. The small and emerging field of TMJ tissue engineering aims to reduce pain and disability through novel strategies that induce joint tissue regeneration. Development of methods for sustained, intra-articular release of growth factors and other pro-regenerative signals will be critical for the success of TMJ tissue engineering strategies. This review discusses methods of intra-articular drug delivery to the TMJ, as well as emerging injectable controlled release systems with potential to improve TMJ drug delivery, to encourage further research in the development of sustained release systems for both long-term pain management and to enhance tissue engineering strategies for TMJ regeneration.

Evaluation of surgically retrieved temporomandibular joint alloplastic implants: pilot study

PURPOSE

The purpose of this study was to perform a retrieval analysis of temporomandibular joint (TMJ) alloplastic interpositional implants and test possible correlation between implant failure features and patient clinical outcomes. In addition, we investigated the implants' surface and examined the foreign body reaction associated with different types of alloplastic materials.

MATERIALS AND METHODS

Twelve implants (Proplast/Teflon [Vitek, Houston, TX] and Silastic [Dow Corning, Midland, MI]) were surgically removed from the patients' TMJs. Implant surface failure features (fracture length, perforation of the implants) were observed using stereomicroscopy and recorded for description of the failure mechanisms and to statistically compare with clinical outcomes. Patients' clinical data (pain symptoms and mandibular function) were collected and examined. Clinical outcomes were obtained relative to symptom severity (Symptom Severity Index [SSI]) and jaw function (modified Mandibular Function Impairment Questionnaire [mMFIQ]). Peri-implant soft tissues and implants were analyzed with light microscopy and stereo zoom microscopy. Electron microprobe analysis of implant fragments and peri-implant tissues was performed.

RESULTS

The statistical results showed that only the presence of implant perforation was statistically associated with the SSI, specifically with the pain tolerability dimension. No statistical association was seen between any of the other implant failure predictors and the SSI and between the predictors and the mMFIQ. Stereo zoom microscopy suggested that Proplast/Teflon implants (n = 7) were susceptible to perforation, layer tearing, fracture and fiber extrusion. The Silastic implants (n = 3) revealed a possible center perforation with fracture lines towards the periphery and fiber extrusion. Teflon implant wear debris particles appear to trigger a multinucleated giant cell foreign body reaction.

CONCLUSION

Facial pain was a significant correlate to perforation and breakdown of the alloplastic TMJ interpositional implants, and most likely was the reason for implant removal.

Principles of cartilage tissue engineering in TMJ reconstruction

Diseases and defects of the temporomandibular joint (TMJ), compromising the cartilaginous layer of the condyle, impose a significant treatment challenge. Different regeneration approaches, especially surgical interventions at the TMJ's cartilage surface, are established treatment methods in maxillofacial surgery but fail to induce a regeneration ad integrum. Cartilage tissue engineering, in contrast, is a newly introduced treatment option in cartilage reconstruction strategies aimed to heal cartilaginous defects. Because cartilage has a limited capacity for intrinsic repair, and even minor lesions or injuries may lead to progressive damage, biological oriented approaches have gained special interest in cartilage therapy. Cell based cartilage regeneration is suggested to improve cartilage repair or reconstruction therapies. Autologous cell implantation, for example, is the first step as a clinically used cell based regeneration option. More advanced or complex therapeutical options (extracorporeal cartilage engineering, genetic engineering, both under evaluation in pre-clinical investigations) have not reached the level of clinical trials but may be approached in the near future. In order to understand cartilage tissue engineering as a new treatment option, an overview of the biological, engineering, and clinical challenges as well as the inherent constraints of the different treatment modalities are given in this paper.