A stepped approach for the management of symptomatic internal derangement of the temporomandibular joint

Pressure Infusor Assisted Arthrocentesis

Temporomandibular joint internal disorders commonly present with limited mouth opening and pain. Treatment options range from invasive surgical procedures to minimally invasive interventions. This technical note aims to introduce a modification to the arthrocentesis technique in which a pressure infusion cuff (VBM Classic Infusor, Medizintechnik GmbH, Germany) is used for irrigation instead of syringes or peristaltic pumps. A pressure infusion cuff (bag) is an inflatable bag with a hand pump and a sphygmomanometer that allows monitorization of the pressure, and it is intended to apply pressure on intravenous fluid bags to assist with rapid infusion of fluids. This allows the operator to maintain an efficient and stable flow pressure throughout the procedure while avoiding occupational hand and wrist problems resulting from manual irrigation with syringes. Furthermore, pressure monitoring, as read on the sphygmomanometer of the cuff, facilitates the manipulation of the needles and adjustment of the pressure should the patient experience discomfort. This increases the patient's compliance, physician's comfort, and allows the collection of quantitative data in clinical studies.

Use of the Temporalis Myofascial Flap in Internal Derangement of the Temporomandibular Joint - An Evaluative Study

Introduction

Internal derangement is an abnormal relationship between the articular disc and the mandibular condyle. The most common cause is trauma. Various classifications have been given for internal derangement. Initial management is done conservatively and if the disease is progressed, surgery is the option. Various surgical methods and interpositional materials following discectomy have been given in the literature.

Materials and Methods

Over the past 15 years, we selected a group of 30 patients, Wilkes Class IV and V where conservative therapy had failed and were candidates for surgery. The patients had their disc repositioned, the damaged part of the disc was excised and disc was reinforced using the temporalis myofascial flap (TMF). In cases where the disc was non-salvageable, discectomy was done and TMF was placed between condyle and glenoid fossa, sutured with Prolene. The follow-up period was 3 years.

Results

Of the 30 patients, there were 9 male and 21 female. Range of mouth opening was 3.3-3.8 cm with improvements in 1 year. The jaw relations gradually improved and were restored after 3 weeks. Patients were totally pain free in 6 months.

Discussion

For the cases where surgery is the line of treatment, we strongly suggest disc repositioning and reinforcement with TMF as the flap is bulky, locally available and easy to harvest and causes no deformity at the donor site.

Temporomandibular disorder treatment algorithm for otolaryngologists

OBJECTIVE

To review current literature describing the management of temporomandibular disorder (TMD) and to propose an evidence-based algorithm for otolaryngologists.

DATA SOURCES

A literature review using PubMed and Scopus was conducted to identify manuscripts that describe TMJ disorder etiology, diagnostic methods, and management across the fields of otolaryngology, general practice medicine, physical therapy, dentistry, and maxillofacial surgery.

REVIEW METHODS

Two reviewers subjectively evaluated the studies based on the inclusion criteria, incorporating them into a comprehensive algorithm.

CONCLUSIONS

TMD is one of the most common conditions presenting to otolaryngology outpatient clinics. Etiologies of TMD vary widely, including myofascial, intraarticular, neurologic, traumatic, or psychiatric in origin. When conservative measures fail to produce symptom relief, alternative treatments and referral to outside specialists including psychiatry, physical therapy, dentistry, and maxillofacial surgery may be indicated. Premature or inappropriate referrals may lead to patients suffering TMD for extended periods of time, with alternating referrals between various specialists. Thus, we present a TMD treatment algorithm for otolaryngologists to aid in the decision-making process in managing TMD.

IMPLICATIONS FOR PRACTICE

Patients frequently present to otolaryngology outpatient clinics for symptoms of TMD. Multidisciplinary practice may be necessary to effectively treat TMD of varying etiology and severity. Following conservative treatment, appropriate referrals and treatment plans will reduce ineffective use of resources, deferral of treatment, and patient suffering. For this reason, a comprehensive algorithm for otolaryngologists will improve resource utilization and efficiency of treatment to ultimately provide improved treatment outcomes for patients.

Internal derangement of temporomandibular joint: Umbrella perforated screw technique

Introduction:

Umbrella shaped Perforated Screws (UPS) were developed for the use of orthopedic surgery to facilitate anchoring and fixation of the tissue to bone. We here present a retrospective study of Temporomandibular joint Internal derangement (ID) with fixation using this type of screws.

Materials & Methods:

We conducted a retrospective study including patients treated for ID using UPS to reposition the articular disc. The study included patients treated between 1998 and 2005. Patients were selected in concordance with clinical symptoms and signs of severity. All patients had an MRI (open/closed mouth) to confirm the diagnosis. Wilkes classification of temporomandibular disease (TMD) was adopted in the selection criteria.

Results:

Hundred and five patients were included, 92 female and 13 males with average age of 37.56. Dentists or general physicians mainly addressed these patients to our unit. The mean time from symptoms initiating to first consultation was 3.77 years, while the mean timing of surgery after initial consultation was 9.38 months. Patients have presented with various symptoms before the surgery including pain, limitation in eating habits and clicking. 77% of the patients had no or minimal pain post surgery. Hundred and one patients had good eating habits after surgery. Only 34 patients had persistent clicking despite surgery. We had neither infection nor hematoma as complication. Major complication to this technique is frontal paresis (14 patients), which was explained to all patients preoperatively. This paresis recovered in less than 2 months in all patients. We had 89.5% of the patients satisfied with their results.

Conclusion:

UPS are useful in the field of plastic surgery. This novel technique has the advantage of not compromising the vascular supply of the TMJ articular surface. This technique provides a simple, fast and efficient technique for posterior aponeurosis flap fixation. Our overall satisfactory rate was comparable to other studies.

Clinical outcomes of patients with bilateral anterior disc displacement without reduction and erosive change of the temporomandibular joint after performance of unilateral arthrocentesis and stabilisation splint therapy

The efficacy of a combination treatment of arthrocentesis and stabilisation splint for patients with bilateral anterior disc displacement without reduction (ADDWoR) and erosive change of the TMJ remains controversial. To evaluate clinical outcomes of patients with ADDWoR and erosive change of the TMJ after performance of unilateral arthrocentesis and stabilisation splint therapy. A retrospective study of 44 patients (37 females, 7 males, mean age of 34 years) with bilateral ADDWoR and erosive change of the TMJ were included in this study. Their clinical outcomes before and after arthrocentesis and stabilisation splint therapy were compared. Evaluation criteria were as follows: (a) Maximal mouth opening (MMO); (b) Right and left maximal lateral movement (RLM, LLM) and maximal protrusive movement (PM); (c) Visual analog scale (VAS) pain score during MMO, RLM, LLM and PM; and (d) VAS pain score during palpation of masticatory muscles. Wilcoxon signed-rank test, Mc Nemar test and paired t test were used for statistical analysis. Differences in VAS pain score between arthrocentesis and non-arthrocentesis sites were not statistically significant except MMO and LLM (P < .05) after 6 months. Differences in mean VAS pain scores for all variables between before arthrocentesis and 6 months follow-up in the arthrocentesis site were statistically significant. (P < .01). Unilateral arthrocentesis on more symptomatic TMJ and subsequent stabilisation splint therapy was highly successful for pain and achievement of normal range of mandibular movements in patients with both ADDWoR and bony change.