Prospective Multicenter Comparison of 4 Temporomandibular Joint Operations

Concomitant Temporomandibular Joint Replacement and Orthognathic Surgery

The treatment of patients with severe temporomandibular joint (TMJ) disorders and associated skeletal discrepancies presents a complex challenge for oral and maxillofacial surgeons. It is widely recognized that TMDs can impact the stability and outcomes of surgical treatments for dentofacial deformities. Consequently, addressing TMDs prior to or in conjunction with orthodontic or surgical interventions may be necessary to achieve optimal and long-lasting results. Alloplastic temporomandibular joint replacement (TMJR) and orthognathic surgery have emerged as the standard approach due to their predictability, long-term stability and excellent outcomes when addressing end-stage TMJ disease in conjunction with DFDs as it provides a comprehensive solution to address both functional and aesthetic aspects of these patients' conditions. Understanding the appropriate utilization of TMJR in conjunction with orthognathic surgery can lead to improved treatment planning and successful outcomes for patients with complex TMJ disorders and associated dentofacial deformities. This review aims to discuss the indications, preoperative evaluation, staging, sequencing, and surgical considerations involved in utilizing alloplastic TMJ replacement in the presence of dentofacial deformities.

Suprafoveal condylar arthroplasty in unilateral disc displacement without reduction - A retrospective study

The aim of this study was to evaluate the efficacy of suprafoveal condylar arthroplasty (SFCA) in the management of patients with unilateral temporomandibular joint (TMJ) disc displacement without reduction (DDWoR). A retrospective study comprising patients who underwent unilateral SFCA for clinically and radiologically confirmed unilateral DDWoR from 2008 to 2020 was conducted. Patients older than 18 years at the time of diagnosis with a minimum of 6 months of unsuccessful non-surgical and minimally invasive management (including diet and life style modification, physiotherapy, appliance therapy, pharmacotherapy, arthrocentesis and arthroscopic lysis and lavage) before undergoing surgery with a minimum of 1 year follow-up post-surgery were included in the study. Patients with other articular and extra-articular causes of restricted mouth opening, prior history of mandibular surgery and/or trauma, growth abnormalities, systemic, metabolic, infective, neoplastic conditions affecting TMJ, including gross occlusal disharmony, untreated existing para-functional habits and bilateral DDWoR, were excluded from the study. Patients were assessed in terms pain on a visual analog scale (VAS), interincisal mouth opening (MO) and subjective assessment of mandibular range of movements including deviation of mouth opening, protrusion and ability for contralateral laterotrusion. 23 patients (10 males and 13 female) were included in the study, with a mean age of 35.09 years and mean follow up period of 37.7 months (range = 12-58; SD = 15.3). The mean pain scores on the VAS reduced from 6.35 preoperatively to 1.13 postoperatively and were found to be statistically significant (p < 0.0001). The improvement of the mean pre-operative mouth opening of 21.83 mm to a mean post-operative mouth opening of 42.09 mm was also found to be statistically significant (p < 0.0001). The subjective improvement in protrusive (p = 0.0003), laterotrusive (p = 0.0005) and opening movements (p = 0.0001) after 1 year were also found to be statistically significant. No patient developed any significant changes in occlusion post-operatively. Four of 23 (17.3%) patients developed transient neuromotor deficit of the temporal branch of the facial nerve. Within the limitations of the study, it seems that SFCA (without addressing the disc) might be an alternative to less invasive treatment approaches, if the latter turned out not to be successful.

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.

An International Survey on Temporomandibular Joint Surgeon's Implementation and Management of Discectomy in Treating Temporomandibular Joint Internal Derangement

PURPOSE

To survey temporomandibular joint (TMJ) surgeons to determine current practice trends and perceptions regarding the role of discectomy for the treatment of TMJ internal derangements.

METHODS

An anonymous 5-part web-based survey was sent to TMJ surgeons. The survey was created and distributed, and the data were collected with the University of Michigan Qualtrics platform. Responses were compared based on operative volume, tendency to replace the disc, and likelihood of requiring temporomandibular joint replacement (TJR) after discectomy. Spearman correlations were used to test statistically significant differences. Domain-level analyses were also performed by summarizing items into 3 domain scores. Analyses were performed in SAS V9.4 (SAS Institute Inc., Cary, NC, USA).

RESULTS

Fifty-nine surgeons (33.9%) completed the survey. Discectomy was not considered to be a useful procedure by 85% of respondents, and 74% would not consider discectomy as a first surgical option. Most would consider discectomy (64%) before alloplastic total joint replacement. Discectomy was preferred over discopexy for the management of anterior disc displacement with reduction by high volume surgeons (89%), but most (72%) did not feel that discectomy was beneficial over arthroscopy in the treatment of anterior disc displacement without reduction and concomitant degenerative bony changes. In managing symptomatic disc perforation, 66% agreed that discectomy is the procedure of choice and 49% felt that interpositional tissue is indicated in most cases after discectomy. Respondents who reported fewer re-operations requiring alloplastic TJR after discectomy had, on average, more positive perceptions of discectomy on the benefits domain (P = .03), better than alternatives domain (P = .03), and fewer concerns on the perceived adverse effects domain (P = .03).

CONCLUSIONS

TMJ surgeons do not employ TMJ discectomy in most cases of TMJ internal derangement. However, discectomy is considered useful in cases of disc perforation or for persistent symptomatic disc displacement without reduction, in an attempt to avoid alloplastic TJR. Common adverse effects included joint noises and osteoarthrosis, and the use of interpositional disc replacement tissue did not alter the incidence of adverse effects or complications reported.

Arthroscopic versus open disc repositioning and suturing techniques for the treatment of temporomandibular joint anterior disc displacement: 3-year follow-up study

The aim of this study was to evaluate the outcomes of temporomandibular joint (TMJ) arthroscopic and open disc repositioning procedures in the management of anterior disc displacement (ADD). All consecutive patients treated with arthroscopic (group I) or open (group II) disc repositioning between April 2014 and August 2018 were included prospectively. The patients were assessed clinically (1, 3, 6, 12, 24, and 36 months postoperative) and with magnetic resonance imaging (MRI). The statistical analysis was performed using IBM SPSS Statistics v.22.0; P < 0.05 was considered significant. A total of 177 patients (227 joints) were included: 104 patients (130 joints) in group I and 73 patients (97 joints) in group II. There were statistically significant improvements in pain score, clicking, quality of life, diet, and maximum inter-incisal opening when comparing pre- and postoperative clinical parameters within the two groups (P < 0.05 at all time-points for all clinical parameters); however, improvements occurred earlier in group I (at 1 month) than in group II (6 months). Postoperative MRI revealed an overall success rate of 98.1% in group I and 97.3% in group II. New bone formation was found in 70.2% in group I and 30.1% in group II. Arthroscopy may be a better choice for ADD patients, with the advantages of faster clinical improvement and recovery, minimal invasiveness, and better condylar remodelling.

Effectiveness of disk repositioning and suturing comparing open-joint versus arthroscopic techniques: a systematic review and meta-analysis

OBJECTIVE

The aim of this study was to present a systematic review of the effectiveness of discopexy in managing internal derangement of the temporomandibular joint (TMJ).

STUDY DESIGN

We searched MEDLINE through PubMed, SCOPUS, Web of Science, and Cochrane Central Register of Controlled Trials and grey literature accessed through Google Scholar, Openthesis, and hand-searching from inception to July 2020. The search strategy yielded 363 potentially relevant studies. After screening titles and abstracts, 41 full-text articles were assessed for eligibility and 7 studies were included in the meta-analysis.

RESULTS

There was an overall decrease in visual analog scale (VAS) pain score of 4.59 cm (95% confidence interval [CI], 2.03-7.16; P < .001) during the follow-up time and an overall increase of 10 mm (95% CI, 6.93-13.01; P < .001) in mouth opening after TMJ surgeries with discopexy.

CONCLUSIONS

The available evidence showed an overall decrease in VAS pain score and an improvement in mouth opening after TMJ surgeries with discopexy. Changes in maximal interincisal opening were greater after arthroscopic disk repositioning compared to open-joint procedure.

Is Arthroscopic Disk Repositioning Equally Efficacious to Open Disk Repositioning? A Systematic Review

PURPOSE

Temporomandibular joint disc repositioning surgery is 1 of the treatment modalities used for treating anterior disc displacement of the temporomandibular joint. The procedure can be arthroscopic disc repositioning or open disc repositioning. This systematic review measured and compared the efficacy of arthroscopic and open disc repositioning procedures.

MATERIALS AND METHODS

The authors conducted a systematic review without meta-analysis by performing a literature search electronically and manually covering arthroscopic and open disc repositioning studies published up to July 2020 in Pubmed, Embase, and Cochrane databases. Surgical outcomes such as changes in maximal incisal opening (MIO) and pain scores, temporomandibular joint noises, diet consistency, malocclusion, and postoperative complications were extracted and analyzed.

RESULTS

A total of 28 studies were included in the review and split into those assessing open disc repositioning (n = 13) and those assessing arthroscopic disc repositioning (n = 15). The average age of the study patients in the included studies was 31.5 ± 6.8 years, and women represented 83.3% of the study population. Both arthroscopic and open disc repositioning showed to be efficacious in reducing pain and increasing MIO. Due to heterogeneity in study designs and data reporting between the studies, no quantitative analysis was performed, and the groups were not directly compared.

CONCLUSIONS

Both arthroscopic and open disc repositioning led to significant improvements in clinical outcomes based on pain scores and MIO. This study highlights the need for comparative studies of the 2 techniques with well-documented case selection including standardized diagnosis based on Wilkes stages and rigorous outcomes assessment including patient reported outcomes.

The three-dimensional evaluation of positional change in mandibular condyle after intraoral vertical ramus osteotomy

OBJECTIVES

The purpose of this study was to compare the changes of the condylar axis, the anteroposterior condylar position relative to the glenoid fossa, after intraoral vertical ramus osteotomy (IVRO).

STUDY DESIGN

21 patients diagnosed as skeletal class III malocclusion underwent IVRO and were followed according to the authors' postoperative management regimen. The three-dimensional positions of the condyles were evaluated by cone-beam computerized tomography (CBCT) at pre-op, post-op, and at follow-up. CBCT images were referenced to assess the condylar axis change and the anteroposterior condylar position in the glenoid fossa. A repeated-measures analysis of variance (P<0.05) also was performed.

RESULTS

After surgery, both the axial condylar angles and the anteroposterior condylar position were significantly different (P<0.05). The coronal condylar axis rotated outwardly. The anteroposterior condylar position in the glenoid fossa had moved from the concentric to the anterior position. But the condyle changes between post-op and follow-up (P>0.05) were insignificant.

CONCLUSIONS

With postoperative intermaxillary elastic traction, the condyles changed their positions physiologically for newly established jaw movement after IVRO.

Extracellular matrix bioscaffolds in tissue remodeling and morphogenesis

During normal morphogenesis the extracellular matrix (ECM) influences cell motility, proliferation, apoptosis, and differentiation. Tissue engineers have attempted to harness the cell signaling potential of ECM to promote the functional reconstruction, if not regeneration, of injured or missing adult tissues that otherwise heal by the formation of scar tissue. ECM bioscaffolds, derived from decellularized tissues, have been used to promote the formation of site appropriate, functional tissues in many clinical applications including skeletal muscle, fibrocartilage, lower urinary tract, and esophageal reconstruction, among others. These scaffolds function by the release or exposure of growth factors and cryptic peptides, modulation of the immune response, and recruitment of progenitor cells. Herein, we describe this process of ECM induced constructive remodeling and examine similarities to normal tissue morphogenesis.

WITHDRAWN: Arthroscopy for temporomandibular disorders

The Cochrane Oral Health Group withdrew this review as of Issue 12, 2015. The review is out of date and does not meet current Cochrane methodological standards. It will be superseded by a new Cochrane review on Surgical interventions for managing temporomandibular disorders.

The editorial group responsible for this previously published document have withdrawn it from publication.

Retrospective study of facial nerve function following temporomandibular joint arthroplasty using the endaural approach

The aim of this retrospective case-control study is to evaluate the incidence of facial nerve injury associated with temporomandibular joint (TMJ) arthroplasty using the endaural approach for the treatment of TMJ pathology. The sample consisted of 36 consecutive patients who underwent TMJ arthroplasty. A total of 39 approaches were performed through an endaural incision. Patients undergoing total joint replacement and/or with preexisting facial nerve dysfunction were excluded from the study. Five patients were lost to follow-up and were excluded from the study. Facial nerve function of all patients was clinically evaluated by resident physicians preoperatively, postoperatively, and at follow-up appointments. Facial nerve injury was determined to have occurred if the patient was unable to raise the eyebrow or wrinkle the forehead (temporalis branch), completely close the eyelids (zygomatic branch), or frown (marginal mandibular branch). Twenty-one of the 36 patients or 22 of the 39 approaches showed signs of facial nerve dysfunction following TMJ arthroplasty. This included 12 of the 21 patients who had undergone previous TMJ surgery. The most common facial nerve branch injured was the temporal branch, which was dysfunctional in all patients either as the only branch injured or in combination with other branches. By the 18th postoperative month, normal function had returned in 19 of the 22 TMJ approaches. Three of the 22 TMJ approaches resulted in persistent signs of facial nerve weakness 6 months after the surgery. This epidemiological study revealed a low incidence of permanent facial nerve dysfunction. A high incidence of temporary facial nerve dysfunction was seen with TMJ arthroplasty using the endaural approach. Current literature reveals that the incidence of facial nerve injury associated with open TMJ surgery ranges from 12.5 to 32%. The temporal branch of the facial nerve was most commonly affected, followed by 4 of the 22 approaches with temporary zygomatic branch weakness. Having undergone previous TMJ surgery did not increase the incidence of facial nerve injury using the endaural approach. This information is important for patients and surgeons in the postoperative period, as a majority of patients will experience recovery of nerve function.

Extracellular matrix as an inductive scaffold for functional tissue reconstruction

The extracellular matrix (ECM) is a meshwork of both structural and functional proteins assembled in unique tissue-specific architectures. The ECM both provides the mechanical framework for each tissue and organ and is a substrate for cell signaling. The ECM is highly dynamic, and cells both receive signals from the ECM and contribute to its content and organization. This process of "dynamic reciprocity" is key to tissue development and for homeostasis. Based upon these important functions, ECM-based materials have been used in a wide variety of tissue engineering and regenerative medicine approaches to tissue reconstruction. It has been demonstrated that ECM-based materials, when appropriately prepared, can act as inductive templates for constructive remodeling. Specifically, such materials act as templates for the induction of de novo functional, site-appropriate, tissue formation. Herein, the diverse structural and functional roles of the ECM are reviewed to provide a rationale for the use of ECM scaffolds in regenerative medicine. Translational examples of ECM scaffolds in regenerative are provided, and the potential mechanisms by which ECM scaffolds elicit constructive remodeling are discussed. A better understanding of the ability of ECM scaffold materials to define the microenvironment of the injury site will lead to improved clinical outcomes associated with their use.

TMJ Disc Removal

The debate continues surrounding the use of disc removal (discectomy) as the primary surgical treatment for patients suffering from severe temporomandibular joint disorders. Furthermore, the effectiveness of pre-clinical animal models for predicting the response of the joint to discectomy in humans remains uncertain. This review compares the results of animal models with the most recent clinical findings while also focusing on investigations that use imaging as an assessment tool. After a review of the literature from well-established animal studies to clinical findings, it was found that the results of animal models for discectomy corresponded to the clinical findings seen in patients. Overall, there is adaptive remodeling or degeneration of the TMJ following discectomy. Additionally, there is some reduction in pain but with various amounts of dysfunction remaining following disc removal. Noteworthy, in the most recent clinical studies, imaging was not used as an outcome to assess the success of discectomy at preventing further joint degeneration.

Extracellular matrix as an inductive template for temporomandibular joint meniscus reconstruction: a pilot study

PURPOSE

A device consisting of powdered porcine urinary bladder extracellular matrix (UBM-ECM) encapsulated within sheets of the same material was investigated as a scaffold for temporomandibular joint (TMJ) meniscus reconstruction.

MATERIALS AND METHODS

Five dogs underwent unilateral resection of the native meniscus and replacement with a UBM-ECM device. Necropsies were performed at 3, 4, 8, 12, and 24 weeks. Two additional dogs underwent bilateral resection of the meniscus with replacement with a UBM-ECM device on 1 side, leaving the contralateral side empty as a control. Necropsies were performed at 24 weeks for bilaterally treated animals.

RESULTS

Macroscopically, the UBM-ECM implants were remodeled rapidly and were indistinguishable from newly deposited host tissue at all time points. Microscopically, remodeling was characterized by a dense infiltration of predominantly CD68(+) mononuclear cells and smooth muscle actin-positive fibroblast-like cells at early time points changing with time to a sparse population of smooth muscle actin-negative spindle-shaped cells resembling those of the native fibrocartilaginous TMJ meniscus. Furthermore, the remodeling process showed deposition of predominantly type I collagen, the density and organization of which resembled those of the native meniscus by the 24-week time point. Ingrowth of calsequestrin-positive skeletal muscle tissue was also observed at the periphery of the remodeled UBM-ECM device and was similar to that found at the attachment site of the native meniscus to the surrounding soft tissues. Histologic results were identical for samples excised from both unilaterally and bilaterally treated animals. No adverse changes in the articulating surfaces of the condyle or fossa were observed in UBM-ECM-implanted joints. In the bilaterally treated animals, the unimplanted control side was characterized by degeneration and pitting of the articulating surfaces of both the condyle and the fossa, with disorganized bands of fibrous connective tissue observed within the joint space.

CONCLUSION

Results of this study suggest that the UBM-ECM device provides an effective interpositional material while serving as an inductive template for reconstruction of the TMJ meniscus.

Arthroscopy for temporomandibular disorders

BACKGROUND

Temporomandibular disorders (TMDs) are considered a collection of disorders involving many organic, psychological and psychosocial factors. They can involve the masticatory muscles or the temporomandibular joint (TMJ) and associated structures, or both. It is estimated that 40% to 75% of the population displays at least one sign of the disease and 33% of the population reports at least one symptom. Arthroscopy has been used to reduce signs and symptoms of patients with TMD but the effectiveness has still not been totally explained.

OBJECTIVES

To assess the effectiveness of arthroscopy for the management of signs and symptoms in patients with TMDs.

SEARCH STRATEGY

The Cochrane Oral Health Group Trials Register (to 23 December 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 4, 2010), MEDLINE via OVID (1950 to 23 December 2010), EMBASE via OVID (1980 to 23 December 2010), LILACS via BIREME Virtual Health Library (1982 to 23 December 2010), Allied and Complementary Medicine Database (AMED) via OVID (1985 to 23 December 2010), CINAHL via EBSCO (1980 to 23 December 2010). There were no restrictions regarding the language or date of publication.

SELECTION CRITERIA

Randomized controlled clinical trials of arthroscopy for treating TMDs were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, and three review authors independently assessed the risk of bias of included trials. The authors of the selected articles were contacted for additional information.

MAIN RESULTS

Seven randomized controlled trials (n = 349) met the inclusion criteria. All studies were either at high or unclear risk of bias. The outcome pain was evaluated after 6 months in two studies. No statistically significant differences were found between the arthroscopy versus nonsurgical groups (standardized mean difference (SMD) = 0.004; 95% confidence interval (CI) -0.46 to 0.55, P = 0.81). Two studies, analyzed pain 12 months after surgery (arthroscopy and arthrocentesis) in 81 patients. No statistically significant differences were found (mean difference (MD) = 0.10; 95% CI -1.46 to 1.66, P = 0.90). Three studies analyzed the same outcome in patients who had been submitted to arthroscopic surgery or to open surgery and a statistically significant difference was found after 12 months (SMD = 0.45; 95% CI 0.01 to 0.89, P = 0.05) in favor of open surgery. The two studies compared the maximum interincisal opening in six different clinical outcomes (interincisal opening over 35 mm; maximum protrusion over 5 mm; click; crepitation; tenderness on palpation in the TMJ and the jaw muscles 12 months after arthroscopy and open surgery). The outcome measures did not present statistically significant differences (odds ratio (OR) = 1.00; 95% CI 0.45 to 2.21, P = 1.00). Two studies compared the maximum interincisal opening after 12 months of postsurgical follow-up. A statistically significant difference in favor of the arthroscopy group was observed (MD = 5.28; 95% CI 3.46 to 7.10, P < 0.0001). The two studies compared the mandibular function after 12 months of follow-up with 40 patients evaluated. The outcome measure was mandibular functionality (MFIQ). This difference was not statistically significant (MD = 1.58; 95% CI -0.78 to 3.94, P = 0.19).  

AUTHORS' CONCLUSIONS

Both arthroscopy and nonsurgical treatments reduced pain after 6 months. When compared with arthroscopy, open surgery was more effective at reducing pain after 12 months. Nevertheless, there were no differences in mandibular functionality or in other outcomes in clinical evaluations. Arthroscopy led to greater improvement in maximum interincisal opening after 12 months than arthrocentesis; however, there was no difference in pain.

Reoperative temporomandibular joint surgery

TMJ surgeries are not always successful. Many potential pitfalls can occur during any phase of the treatment and can lead to complications, less than desirable results, and short- or long-term failures. Unsatisfactory results can occur for multiple reasons, including misdiagnosis of the original pathologic condition, incorrect selection of surgical technique, technical failures, complications, systemic disease, and unrealistic expectations. This article focuses on the reoperation of the TMJ primarily in cases of internal derangement and discusses TMJ arthrocentesis, arthroscopy, modified condylotomy, and open joint procedures.

A biomechanical basis for primary arthroplasty of the temporomandibular joint

Biomechanical principles of temporomandibular joint (TMJ) loading are unique, particularly in an orthopedic system that exhibits curvilinear general plane motion. Certain type-specific derangements can be surgically challenging and may primarily require open arthrotomy techniques rather than arthroscopy. This article discusses the basic biomechanical principles in normal and pathologic function. Three-dimensional preoperative imaging of TMJs is necessary for appropriate assessment of all patients and when open techniques are necessary as the initial surgical procedure.

The effects of changing position and angle of the proximal segment after intraoral vertical ramus osteotomy

The authors evaluated changes in position and angle of the proximal segment, including the condyle, after intraoral vertical ramus osteotomy (IVRO) with and without a Le Fort I osteotomy to verify whether displacement of the proximal segment could induce postoperative complications. Changes in condylar angle, ramus angle, and displacement of proximal segment were measured pre- and postoperatively. The position of the temporomandibular joint (TMJ) disc was examined pre- and postoperatively. Trigeminal nerve hypoesthesia in the lower lip was assessed bilaterally. The postoperative horizontal condylar angle was significantly smaller than the preoperative one on the deviated and non-deviated sides (P<0.0001). The postoperative coronal condylar angle was significantly larger than the preoperative one on the deviated side (P=0.0483). The postoperative sagittal ramus angle was larger than the preoperative one on the deviated (P<0.0001) and non-deviated (P=0.00005) side. Most joints with an anteriorly-displaced disc with and without reduction improved on the non-deviated side; 5 of 16 joints improved on the deviated side. Results suggest the position and angle of the proximal segment, including the condyle, could change after IVRO. This could be associated with symptomatic improvement in TMJ, and extreme medial displacement of the proximal segment could delay recovery from lower lip hypoesthesia.

Walker repair of the temporomandibular joint: a retrospective evaluation of 117 patients

PURPOSE

This study evaluated the outcome of a high condylar shave with meniscal repositioning (Walker repair) in patients with internal derangement of the temporomandibular joint (TMJ). Changes in incisal opening, pain level, chewing ability, and preoperative TMJ symptoms (tinnitus, vertigo, and crepitus) were evaluated.

PATIENTS AND METHODS

A retrospective evaluation of 202 patients undergoing the Walker repair was completed using a questionnaire. A total of 117 patients responded to the questionnaire. Preoperative and postoperative examination findings, subjective questionnaire results, and panorex radiographs were analyzed.

RESULTS

The Walker repair resulted in a statistically significant (P < .001) decrease in pain by an average of 5.6 points on a scale of 0 to 10. The procedure also improved incisal opening by an average of 5.8 mm (P < .001). Improvements of 69% in tinnitus, 72% in vertigo, and 66% in crepitus were documented. Patients evaluated their motion, diet, comfort, and overall improvement; each area was rated as good or excellent by more than 90% of patients. The overall success rate for the Walker repair was 86%.

CONCLUSIONS

The Walker repair is an effective surgical treatment for internal derangement that significantly decreases pain level and increases incisal opening. No statistically significant difference in the success rate between unilateral and bilateral procedures was noted.

Disc derangements of the temporomandibular joint

Disc-related derangement of the temporomandibular joint is common and epidemiological research has found that about 20% of the population may be affected. Although very few of these people have the more prominent symptoms, recent data indicate that the numbers who need treatment is increasing. The two clinical variants of disc derangement, reciprocal clicking and closed lock, have long been recognized, but the association between them and their aetiology and pathogenesis is still unclear. As a consequence, there is still uncertainty on how to treat the conditions, and this is even more evident when surgery is involved. This paper describes new tissue research related to disc derangement. A simplified scheme is presented and implications for surgical treatment are discussed.

Prospective Study of Facial Nerve Function After Surgical Procedures for the Treatment of Temporomandibular Pathology

PURPOSE

The aim of this prospective study was to report facial nerve injury following surgical procedures for the treatment of temporomandibular pathology, using the House-Brackmann facial nerve grading system (HBFNGS) as a means of classifying and measuring the degree and type of injury.

PATIENTS AND METHODS

The sample consisted of 32 patients who underwent temporomandibular joint (TMJ) surgery. A total of 50 approaches were carried out. Surgical procedures consisted of TMJ reconstruction, gap arthroplasty, eminectomy, bone plates for the treatment of chronic mandibular luxation, and disc plication. Facial nerve function of all patients was evaluated preoperatively and 24 hours after surgery. Patients who presented postoperative facial nerve injury were likewise examined using the HBFNGS at 24 hours, 1 week, 1 month, and 3 months.

RESULTS

Of the 32 patients, 12.5% (ie, 8% of the 50 approaches) showed signs of facial nerve injury after TMJ surgery. The prevalence of postoperative facial nerve injury was significantly greater in the patients who had ankylosis (P = .014) and in those submitted to gap arthroplasty (P = .011). At 24 hours, none of the patients showed total nerve paralysis or severe dysfunction, only a moderately severe dysfunction (50%), or moderate dysfunction (50%). The forehead was the most affected area measured. At 3 months, all patients had recovered their normal facial nerve function. The overall improvement in facial nerve function was 40% for the patients classified initially with moderately severe dysfunction and 60% for those with moderate dysfunction.

CONCLUSION

The frequency of facial nerve injury was related to the diagnosis of the temporomandibular pathology and surgical procedures. Facial nerve impairment was shown to be of a temporary nature. Moreover, there is a need to standardize the reporting of facial nerve recovery.

Condylar and disc positions after intraoral vertical ramus osteotomy with and without a Le Fort I osteotomy

The purpose of this study was to examine the changes in temporomandibular joint (TMJ) morphology and clinical symptoms after intraoral vertical ramus osteotomy (IVRO) with and without a Le Fort I osteotomy. Of 50 Japanese patients with mandibular prognathism with mandibular and bimaxillary asymmetry, 25 underwent IVRO and 25 underwent IVRO in combination with a Le Fort I osteotomy. The TMJ symptoms and joint morphology, including disc tissue, were assessed preoperatively and postoperatively by magnetic resonance imaging and axial cephalogram. Improvement was seen in just 50% of joints with anterior disc displacement (ADD) that received IVRO and 52% of those that received IVRO with Le Fort I osteotomy. Fewer or no TMJ symptoms were reported postoperatively in 97% of the joints that received IVRO and 90% that received IVRO with Le Fort I osteotomy. Postoperatively, there were significant condylar position changes and horizontal changes in the condylar long axis on both sides in the two groups. There were no significant differences between improved ADD and unimproved ADD in condylar position change and the angle of the condylar long axis, although distinctive postoperative condylar sag was seen. These results suggest that IVRO with or without Le Fort I osteotomy can improve ADD and TMJ symptoms along with condylar position and angle, but it is difficult to predict the amount of improvement in ADD.

High condylectomy and disc repositioning compared to arthroscopic lysis, lavage, and capsular stretch for the treatment of chronic closed lock of the temporomandibular joint

OBJECTIVE

The article shows the 1-yr results comparing the efficacy of open-surgery high condylectomy and disc repositioning and the arthroscopic procedure of lysis, lavage and capsular stretch in patients with chronic closed lock of the temporomandibular joint (TMJ).

STUDY DESIGN

Twenty patients with a clinical and radiologic diagnosis of chronic closed lock were randomly chosen to be treated with either open surgery or arthroscopy. Each patient was evaluated with a visual analog scale (VAS) for pain and a mandibular functional impairment questionnaire (MFIQ). The evaluation also included a clinical examination. Each patient was recorded at baseline before surgery and at 1-yr follow-up. Statistical analysis was made to evaluate whether differences in MFIQ, VAS, maximum opening and protrusion, lateral joint tenderness, muscle tenderness, crepitation, and clicking at 1-yr follow-up from baseline were significant. Results were considered statistically significant when P < .05.

RESULTS

Both open surgery and arthroscopic surgery reduced pain and improved mandibular function. The severity of pain was significantly reduced in both groups (P = .005). In both the open and arthroscopy groups mandibular function improved significantly (P = .005). The clinical examination showed similar good results for the 2 surgical procedures. At 1-yr follow-up a majority of patients from both the open (80% of the patients) and the arthroscopy (70% of the patients) groups fulfilled the criterion of a cutoff point for maximum interincisal opening of equal or more than 35 mm (P = 0.005); all the patients in both groups fulfilled the criterion of the cutoff point for maximum protrusion of more than 5 mm (P = .007). At 1-yr follow-up, clicking was the same as before surgical procedures; no patient in the open group showed crepitation, but crepitation was found in patients in the arthroscopy group. Joint tenderness and pain on lateral palpation as well as muscle tenderness and pain were reduced in all the cases, disappearing in some of them, but the difference was significant only regarding joint tenderness (open surgery, P = .016; arthroscopy, P = .031).

CONCLUSIONS

Open-surgery high condylectomy and disc repositioning and the arthroscopic procedure of lysis, lavage and capsular stretch are both effective surgical methods to treat symptomatic patients with a diagnosis of chronic closed lock of the TMJ. Because of the minimally invasive character of the arthroscopic procedure, it should be considered as the first choice in the surgical treatment of the TMJ.