The case for mandibular condylotomy in the treatment of the painful, deranged temporomandibular joint

Condylotomy to Reverse Temporomandibular Joint Osteoarthritis in Rabbits

PURPOSE

Osteoarthritis (OA) of the temporomandibular joint (TMJ) is characterized by local tissue degeneration and pain. Treatments have been aimed at reducing symptoms, and only some can interfere with the progression of pathophysiologic changes caused by OA. Condylotomy is an alternative treatment for patients with OA refractory to conventional treatment. The aim of the present animal study was to investigate the influence of condylotomy on TMJ OA in New Zealand rabbits.

MATERIALS AND METHODS

The 36 rabbits were divided into 3 groups: the osteoarthritis group (OG; induced OA), treatment group (TG; induced OA plus condylotomy), and control group (CG; neither OA nor surgery). OA was induced using intra-articular monosodium iodoacetate injection for 40 days. The rabbits in the TG underwent condylotomy and were killed 20, 40, and 60 days after treatment. The rabbits in the CG and OG were killed at the same points.

RESULTS

The articular joint condition was better in the TG 60 days after surgery (P = .032). A direct comparison revealed regression of TMJ OA over time among the treated rabbits (P = .008). Surgical treatment promoted mandibular condylar remodeling in the TG, reversing the tissue degeneration caused by OA.

CONCLUSIONS

Our findings suggest that condylotomy could be an option for the treatment of OA and prevent damage to TMJ structures. This could be of particular importance for patients without satisfactory responses to more conservative treatment.

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.

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.

Modified condylotomy versus conventional conservative treatment in painful reciprocal clicking--a preliminary prospective study in eight patients

Modified condylotomy may be relevant in severe painful reciprocal clicking of the temporomandibular joint (TMJ) where conservative treatment is insufficient. The effect of the modified condylotomy was analyzed and compared with conventional nonsurgical treatment in a randomized pilot study of eight patients, 19-44 years of age, with severe painful reciprocal clicking. Before and after treatment, assessments were performed by subjective reports, clinical recordings, and blinded evaluations of radiography and magnetic resonance imaging (MRI). Based on the clinical evaluations before treatment, all conditions were disc displacements with reduction and arthralgia (Research diagnostic criteria for temporomandibular disorders), but based on MRI, one patient had disc displacement without reduction and another had normal disc position. The treatment effect was significantly better and the disorders were significantly more reduced with condylotomy than with conventional nonsurgical treatment (P < 0.05, Mann-Whitney U test). In the surgical group, the clicking and locking had disappeared, the pain during function was significantly reduced (P < 0.05, Friedman ANOVA), and in two patients the disc position was normalized. The clicking still persisted in the nonsurgical patients and the disc position was unchanged. Our conclusion is that modified condylotomy is a promising option to reduce symptoms and signs in severe painful reciprocal clicking.

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.

Results of reoperation after failed modified condylotomy

PURPOSE

This retrospective study reports the reoperation rate for failure after modified condylotomy.

MATERIALS AND METHODS

A consecutive series from each of two surgeons constituted the study group of 361 joints in 235 patients. Reoperation rates were calculated for all joints and by type of disc displacement.

RESULTS

A second operation occurred in 4.2% of all joints. However, the cumulative rate of reoperation was 4.4%, because one of the joints required a third operation. Although the rate of reoperation varied (0% to 6.5%) according to the type of disc displacement, the differences were not statistically significant. All joints requiring reoperation had a displaced disc, and more than half had lost nearly all the joint space gained by the primary operation.

CONCLUSION

The rate of reoperation for modified condylotomy is low. Risk factors for reoperation appear to be recurrent or residual disc displacement and loss of joint space after the first operation. Bilateral operation was not a risk factor.