Results of reoperation after failed modified condylotomy

Clinical-surgical treatment of temporomandibular joint disorder in a psoriatic arthritis patient

Introduction

Condylotomy is a surgical procedure that has been used as an option to treat temporomandibular disorder (TMD) patients. This technique has the advantage of avoiding intra-capsular alterations that might be found involving other surgical procedures. Its use, even when unilateral, has positive effect on treatment of both joints.

Methods

In order to better evaluate the benefits of a clinical-surgical treatment for TMD, the present report describes the case of a psoriatic arthritis patient. The case was clinically characterized by dental malloclusion, and imaging exams showed joint degeneration of the right mandibular condyle. The patient was treated by condylotomy technique after a prosthetic oral rehabilitation.

Results

No clinical-radiological signs or symptoms of progression of articular disease were observed within a period of 16 months after surgery. Furthermore, there was functional stability of the temporomandibular joint, total absence of local pain and improvement of mouth opening.

Conclusion

The present study suggests that condylotomy can be considered as a valid option for the management of TMD, since it has low surgical morbidity and favorable clinical outcomes. In this case, the patient had a medical diagnosis of systemic disease presenting general pain and pain at the temporomandibular joint (TMJ), in addition of causal agent of TMD (dental malloclusion). The difficulty of finding a single etiology (malocclusion vs. systemic disease) did not exclude the indication of a clinical-surgical treatment to re-establish the balance of TMJ.

Evaluation of the mechanism and principles of management of temporomandibular joint dislocation. Systematic review of literature and a proposed new classification of temporomandibular joint dislocation

BACKGROUND

Virtually all the articles in literature addressed only a specific type of dislocation. The aim of this review was to project a comprehensive understanding of the pathologic processes and management of all types of dislodgement of the head of the mandibular condyle from its normal position in the glenoid fossa. In addition, a new classification of temporomandibular joint dislocation was also proposed.

METHOD AND MATERIALS

A thorough computer literature search was done using the Medline, Cochrane library and Embase database. Key words like temporo-mandibular joint dislocation were used for the search. Additional manual search was done by going through published home-based and foreign articles. Case reports/series, and original articles that documented the type of dislocation, number of cases treated in the series and original articles. Treatment done and outcome of treatment were included in the study.

RESULT

A total of 128 articles were reviewed out which 79 were found relevant. Of these, 26 were case reports, 17 were case series and 36 were original articles. 79 cases were acute dislocations, 35 cases were chronic protracted TMJ dislocations and 311 cases were chronic recurrent TMJ dislocations. Etiology was predominantly trauma in 60% of cases and other causes contributed about 40%. Of all the cases reviewed, only 4 were unilateral dislocation. Various treatment modalities are outlined in this report as indicated for each type of dislocation.

CONCLUSION

The more complex and invasive method of treatment may not necessarily offer the best option and outcome of treatment, therefore conservative approaches should be exhausted and utilized appropriately before adopting the more invasive surgical techniques.

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.

Tissue-engineered composites of bone and cartilage for mandible condylar reconstruction

PURPOSE

This study evaluated the feasibility of creating a tissue-engineered adult human mandible condyle composite of bone and cartilage.

MATERIALS AND METHODS

A polymer template composed of polyglycolic acid (PGA) and polylactic acid (PIA), and formed in the shape of the human mandible condyle, was seeded with osteoblasts isolated from a bovine periosteum suspended in calcium alginate. Chondrocytes isolated from the same calf suspended in 30% pluronic were then "painted" onto the articular surface of the scaffold, and it was then implanted into subcutaneous pockets on the dorsum of athymic mice. Animals were divided into 3 groups: group I (n = 6) received a PGA/PLA scaffold saturated with hydrogels not containing cells; group II (n = 6) received scaffolds seeded with both cell types suspended in saline rather than hydrogels; and group III (n = 6) received scaffolds seeded with both cell types suspended in hydrogel composites. Constructs were harvested after 12 weeks and evaluated grossly and microscopically by using histologic stains.

RESULTS

In group I, the constructs formed a small mass without evidence of new bone or cartilage. In group II, the constructs were small and irregular. Microscopically they contained scattered islands of bone and cartilage. All specimens in group III retained their original condylar shape and were quite firm. Microscopic evaluation indicated trabecular bone interfacing with hyaline cartilage on the articulating surface.

CONCLUSION

These findings show that the composites of bone and cartilage can be engineered to serve as condylar substitutes. The interdigitation of bone and cartilage at their interface is similar to the normal interface of these composite tissues seen in articulating joints.

Prospective study of modified condylotomy for treatment of nonreducing disk displacement

OBJECTIVE

This study was performed to provide an objective assessment of the outcome of modified condylotomy for treatment of the painful temporomandibular joint with nonreducing disk displacement (Wilkes late stage III, IV, V).

STUDY DESIGN

A prospective study of 31 consecutive patients (43 joints) was conducted. All patients had nonreducing disk displacement verified by means of disk imaging. Independent evaluations were performed to assess pain, dysfunction, and progression of disease. The examinations were performed before modified condylotomy and at intervals up to 1 year after the operation. Eighteen patients (26 joints) completed the required examinations. Patient-based assessments were completed for pain and diet on 15 of these 18 patients (23 joints) 3 years after the operation.

RESULTS

Visual analog scale (VAS) scores (mean +/- SE) for pain improved from 7.4 +/- 0.4 before modified condylotomy to 2.4 +/- 0.5 1 year later (P <. 001). Joints with degenerative joint disease (Wilkes stage IV, V) had less satisfactory pain relief compared with stage III joints (3. 6 +/- 0.9 vs 1.1 +/- 0.4, P =.05) and an 11-fold higher risk (P <. 04) for serious residual pain (VAS score >4). Dietary restrictions improved from a mean VAS score of 5.3 +/- 0.7 before the operation to 7.7 +/- 0.5 1 year later (P =.02). Minor differences between mean VAS scores at 1 (2.1 +/- 0.5) and 3 (2.1 +/- 0.5) years for pain, and 1 (7.4 +/- 0.6) and 3 (8.1 +/- 0.6) years for diet, were not significant. Mean maximal interincisal opening was 36.7 +/- 2.0 mm before the operation, and this improved to 40.1 +/- 2.0 mm 1 year later (P <.02). Mean contralateral movement was 8.3 +/- 0.5 mm before the operation and 8.4 +/- 0.6 mm 1 year after the operation (P >.05). None of the 12 Wilkes late III joints progressed to Wilkes IV or V, and none of the 14 Wilkes IV, V joints showed evidence of further bone resorption. The rate for reoperation was 4%. Minor complications occurred in 5 patients and were resolved in all but 1 a year later. When these outcomes were judged by 7 American Association of Oral and Maxillofacial Surgeons assessment indices for internal derangement, the mean rate of favorable outcome was 87%.

CONCLUSION

Modified condylotomy is a safe and effective operation for treating pain and diminished function of temporomandibular joints with nonreducing disk displacement. It also seems to be an effective treatment for slowing further progression of the internal derangement and associated pathologic conditions.

One- and three-year prospective outcome study of modified condylotomy for treatment of reducing disc displacement

PURPOSE

This outcomes study was designed to provide a comprehensive evaluation of modified condylotomy for the treatment of the painful temporomandibular joint with reducing disc displacement (Wilkes stage II, early III).

PATIENTS AND METHODS

A prospective study of 48 consecutive patients (79 joints) was conducted. All reducing disc displacements were verified by disc imaging. Independent evaluations were performed to assess pain, dysfunction, and progression of disease before modified condylotomy and at intervals up to 1 year after operation. Thirty-one patients (50 joints) completed the examination before the operation and 1 year later. Patient-based assessments were made for pain and diet in 22 patients (35 joints) 3 years after operation.

RESULTS

The mean (+/- SE) visual analog scale (VAS) score for pain improved from 6.9+/-0.4 before modified condylotomy to 2.0+/-0.4 1 year later (P < .001). Serious pain (VAS score greater than 4) after operation was 7 times more likely (P < .04) when there was persistent disc displacement. The mean frequency of pain each day decreased from 14.6+/-1.4 hours to 4.8+/-1.3 hours (P < .001). Dietary restrictions improved from a mean VAS score of 6.1+/-0.5 before operation to 8.8+/-0.3 at 1 year (P < .001). Small differences between mean VAS scores for pain at 1 (2.0+/-0.5) and 3 (2.7+/-0.5) years and diet at 1 (8.6+/-0.4) and 3 (8.4+/-0.5) years after operation were not significant. Mean maximal incisal opening was 41.7+/-1.2 mm before operation and 43.5+/-1.1 mm 1 year later, but the difference was not statistically significant. Mean contralateral movement improved from 8.1+/-0.3 mm to 8.9+/-0.3 mm 1 year after operation (P < .05). Clicking was reduced from 64% of joints to 16% 1 year after operation (P < .001). The disc was reduced in 72% of joints, healing of an incipient degenerative lesion occurred in 1 joint, and there was no evidence of progression to nonreducing disc displacement (Wilkes late III, IV, V) or DJD (Wilkes IV, V) in any joint 1 year after modified condylotomy. The rate for reoperation was 4%. Complications occurred in 4 patients after operation and were resolved 1 year later. When these outcomes were judged by 7 AAOMS assessment indices for internal derangement, the mean rate of favorable outcome was 94%.

CONCLUSION

Modified condylotomy is an effective operation for treating pain and diminished function of temporomandibular joints with reducing disc displacement. It is also an effective treatment for slowing and, in some cases, reversing the progression of internal derangement.