Temporomandibular joint surgery: the past, present, and future.

Temporomandibular joint surgery for various pathological conditions and diseases affecting the integrity, mobility, and function of the joint has a long history. However, the greatest explosion of knowledge regarding the diagnosis and management of temporomandibular joint pain, pathology, and rehabilitation has occurred in the last 50 years. This review focuses on the incremental expansion of knowledge over time that led to the development of concepts that support our current surgical decisions and techniques, with the aim of identifying gaps in knowledge that require well-designed studies to move the field forward. Using this approach will allow an enhancement of our understanding of temporomandibular joint form and function, and enable focus to be placed on the evaluation, diagnosis, and non-surgical and surgical management strategies that are the most efficacious for our patients.

Total alloplastic temporomandibular joint reconstruction using Biomet stock prostheses: the University of Florida experience.

The purpose of this study was to report the subjective and objective outcomes of temporomandibular joint (TMJ) replacement with Biomet stock prostheses at a single institution in Florida. In this retrospective study, patients who underwent TMJ replacement using a Biomet stock prosthesis from 2005 to 2012 were analyzed. Subjective (pain, diet) and objective (maximal incisal opening) information was obtained. In addition, a quality of life measure was obtained pre- and postoperatively. Significance was set at <0.01. Thirty-six patients (26 bilateral, 6 left, and 4 right) who underwent TMJ replacement using a Biomet stock prosthesis were eligible for the study. Maximal incisal opening improved from 26.1mm preoperatively to a mean of 34.4mm postoperatively. The pain score decreased from 7.9 preoperatively to a mean of 3.8 postoperatively. Diet restriction decreased from 6.8 preoperatively to a mean of 3.5 postoperatively. Quality of life improved from a median of 4 preoperatively to a postoperative median of 2. Four implants were removed/replaced because of heterotopic bone formation, infection, and/or loose hardware. Follow-up ranged from 6 to 83 months. Overall, TMJ reconstruction using the Biomet stock joint is effective and safe in this patient population.

Adaptability of stock TMJ prosthesis to joints that were previously treated with custom joint prosthesis.

The purpose of this study was to determine if a temporomandibular joint (TMJ) replaced by a custom joint prosthesis could have been replaced by a stock joint prosthesis. Stereolithic models of patients treated with TMJ Concepts® patient fitted joint prosthesis (e.g., custom) were obtained. Biomet Microfixation® TMJ prostheses (e.g. stock) were adapted to these models. Intra-operative insertion of prosthesis, fit and size of stock joints were simulated and evaluated. Adaptability and stability of condyle and fossa as well as their articulation were recorded. 20 models consisting of 34 joints were examined by two oral and maxillofacial surgeons who were blinded to the patient's diagnosis. Overall, 77% of the stock TMJ system fit the stereolithic models. 3mm or less of bone modification was necessary to achieve an acceptable fit. In the majority of the cases examined, a stock TMJ prosthesis had good anatomical adaptation to stereolithic models of patients previously treated with custom TMJ prosthesis, so a stock TMJ prosthesis could have been an acceptable option for these patients. Further prospective clinical studies to compare both systems are necessary.

Temporomandibular joint reconstruction after failed teflon-proplast implant: case report and literature review.

Multiple reports document that a foreign-body giant cell reaction forms around Proplast-Teflon temporomandibular joint (TMJ) implants. This results in destruction of surrounding bone and instability of the implants. This case presents a patient whose Proplast-Teflon TMJ implants became displaced into her middle cranial fossa. The staged reconstruction of this patient is described, including removal of the TMJ implants, reconstruction of the defect, concomitant orthodontic treatment and final reconstruction with TMJ Concepts. This process involved a multidisciplinary approach between several medical and dental specialties. At her 3-year follow up, the patient had a stable postoperative result.

Arthrocentesis for the treatment of temporomandibular joint closed lock: a review article.

Although arthrocentesis is not a panacea, it has been widely used for a variety of temporomandibular joint (TMJ) disorders. Uncritical acceptance of the procedure has been cautioned against, as further analysis and clarification of published studies was required. The aim of this article was to review the efficacy of arthrocentesis in the treatment of patients with TMJ closed lock. The rationale behind this approach was based on the notion that TMJ surgical results should be reported by the specific category of TMJ disorder. After a Medline search of the international literature, 14 articles were found fulfilling the criteria set forth by this article. Another five articles were added after an additional hand search based on the available references of the papers found. The majority of the reviewed publications were prospective case series with flawed methodology and, despite the impression that arthrocentesis may be beneficial for patients with TMJ closed lock, there have been no good prospective randomized clinical trials that confirm the efficacy of this procedure.

Five-year retrospective evaluation of temporomandibular joint arthrocentesis.

This retrospective study is aimed to evaluate the long-term outcome of arthrocentesis for the treatment of temporomandibular joint (TMJ) internal derangements, and to document the impact of patient, time and symptom-related factors on the outcome of the procedure. Thirty-four patients (48 joints) who underwent TMJ arthrocentesis were included in this study. The scores for preoperative maximal mouth opening, and VAS scores for pain and dysfunction were compared with the follow-up scores obtained by the questionnaire and clinical examination. Several factors that may affect the long-term outcome of arthrocentesis are further evaluated. Statistical evaluation of the baseline and follow-up data was made by linear regression analysis and paired t-test. The mean follow-up period was 22 months. There was a significant (P< 0.001) increase in the maximal mouth opening (MMO) postoperatively that held during the longer term follow-up period. The pain and dysfunction levels at the follow-up were significantly (P< 0.001) lower than the preoperative values. Twenty-six per cent of patients were pain free and also showed a total relief in dysfunction at the follow-up. Although both preoperative and follow-up pain scores were higher in patients with bruxism, there was not a significant difference in the outcome when compared with non-bruxers. However, there was a greater reduction in dysfunction with improvement in MMO in non-bruxers. The duration of symptoms before arthrocentesis has not been found to affect the outcome. Also, there were no significant differences between the results of follow-up when comparing the shorter follow-up time results (<20 months) and longer term results. Arthrocentesis for the treatment of TMJ internal derangements offers favourable long-term stable results with regard to increasing maximal mouth opening, and reducing pain and dysfunction.

The role of temporomandibular joint surgery in the treatment of patients with internal derangement.

Surgery of the temporomandibular joint (TMJ) has made considerable progress, although significant failures have plagued this field in recent years. Despite the controversies, surgery of the TMJ continues to have a small but important role in the management of specific temporomandibular disorders. This article presents an overview of TMJ surgery. It is concluded that careful case selection is the most important aspect for a successful outcome.

Temporomandibular disorders. Part 3. Surgical treatment.

Surgery of the temporomandibular joint has a small but nonetheless important role in the overall management of temporomandibular disorders. Appropriate case selection is the mandatory requirement for successful surgical intervention in order to achieve the desired outcome of treatment, such as relief of symptoms and improved function. In this, the third article in the series, a general overview of the current surgical treatment modalities for temporomandibular disorders will be presented.

Temporomandibular joint arthrocentesis and lavage for the treatment of closed lock: a follow-up study.

OBJECTIVES: Temporomandibular joint (TMJ) arthrocentesis and lavage, first described in the North American literature in 1991, is a simplified method used for the treatment of severe, limited mouth opening. The purpose of this study is to evaluate the efficacy of this technique as a treatment for closed lock of the TMJ. DESIGN: Forty-six patients with persistent closed lock of the TMJ of acute onset were treated by TMJ arthrocentesis and lavage with manipulation in an out-patient setting. Clinical data was collected in the form of visual analogue scales for pain and chewing ability, and measurements of maximum mandibular opening before and after treatment. RESULTS: On follow-up ranging from 6 to 30 months, jaw opening and mandibular function had significantly improved (p < 0.001), and pain had substantially decreased in all but one patient as a result of this procedure. CONCLUSION: TMJ arthrocentesis and lavage is recommended as a simple alternative to more invasive TMJ procedures as an effective technique for the treatment of acute persistent closed lock of the TMJ.

Is there a role for temporomandibular joint surgery?

In North America, surgery of the temporomandibular joint (TMJ) has made considerable progress, although significant failures have plagued this field in recent years. In spite of the controversies, surgery of the TMJ continues to have a small, but nonetheless, important role in the management of specific temporomandibular disorders (TMD). A general overview of the current thinking in TMJ surgery is presented with the clear message that careful case selection is the most essential ingredient for a successful outcome.

Morbidity from anterior ilium bone harvest. A comparative study of lateral versus medial surgical approach.

The morbidity of bone harvest was compared between anterior lateral and medial surgical approaches in a randomized prospective study. Forty consecutive patients, each requiring a minimum 40 cc of loose corticocancellous bone for maxillofacial reconstruction, were randomly placed into two equal groups. Morbidity vectors assessed included bone volume, blood loss, length of surgery, length of hospital stay, incidence of seroma, incidence of anterior thigh paresthesia, postoperative pain, and gait disturbance. The results demonstrated no significant difference in morbidity between these two approaches; therefore selection of either approach is the surgeon's personal preference. A thorough understanding of the osseous anatomy of the anterior ilium and its muscular attachments, a good surgical technique, an efficient surgical team, and a continuous flow of required surgical instruments are essential to reduce the morbidity of bone harvest.

Oral and maxillofacial surgical therapy for the older adult.

Older adults can present with a wide range of oral and maxillofacial diseases and conditions, and many of these are best treated surgically. One of the distinguishing features of geriatric surgery is the large percentage of older adults who have medical conditions that must be planned for perioperatively. Good communication between the surgeon and the primary care physician is important for this perioperative management. Orofacial infections, the most common of which are odontogenic in origin, require some form of surgical treatment and may or may not require treatment with antibiotics. Preprosthetic and reconstructive surgery may be necessary to treat the sequelae of oral and maxillofacial fractures, the sequelae of tooth loss, or surgical defects incurred during the treatment of cancer, osteomyelitis, osteoradionecrosis, or disorders of the TMJ.

Prevalence and variance of temporomandibular dysfunction in orthognathic surgery patients.

Seventy-five patients were studied retrospectively to assess the prevalence and variance of temporomandibular dysfunction in an orthognathic surgery population. Preoperatively, 49.3% of the sample presented with temporomandibular dysfunction. After orthognathic surgery, of the symptomatic patients, 89.1% had improved temporomandibular function after surgery, 2.7% were unchanged, and 8.1% had increased symptoms. Of the patients asymptomatic prior to surgery, 7.9% developed temporomandibular dysfunction postoperatively. Temporomandibular dysfunction was significantly more prevalent in patients with a Class II skeletal deformity than in those with a Class III deformity, and temporomandibular function generally improved in both groups postsurgically.

Temporomandibular joint arthrocentesis: a simplified treatment for severe, limited mouth opening.

Seventeen patients complaining of suddenly occurring, severe, and persistent limited mouth opening were treated by irrigation of the upper compartment of the affected temporomandibular joint with lactated Ringer's solution. This simple treatment was found to be highly effective in reestablishing normal opening and relieving pain for a follow-up period of 4 to 14 months.

Facial erysipelas: report of a case and review of the literature.

The diagnosis of erysipelas is usually made clinically. Features that help distinguish erysipelas are acute onset, erythema, warmth, edema, pain, fever, and isolated regional involvement with clearly demarcated margins. High ASO titers and response to penicillin therapy are reassuring. Simple uncomplicated erysipelas or cellulitis in adults can usually be treated on an outpatient basis. Extensive facial involvement with fever and a toxic appearance warrants hospitalization. Facial cellulitis or erysipelas in children, unless quite limited, requires hospitalization because of the high risk of Hemophilus influenzae infection and sepsis. Hospitalized patients should show visible signs of resolution and be afebrile for at least 24 hours prior to discharge. They should be maintained on oral antibiotic therapy at home for an additional 7 to 10 days.

An alternative explanation for the genesis of closed-lock symptoms in the internal derangement process.

Clinical and surgical data on 194 operated joints (135 patients) were used to substantiate a new concept challenging the presumed natural history of temporomandibular internal derangement (ID). A number of findings were incompatible with the traditional depiction of a progressive process based on gradual changes in disc position and shape. These findings were a lack or correlation between increasing age and the stages of the process; the percentage of patients in the third stage (closed lock) with limited opening (less than 25 mm) too severe to be caused solely by a nonreducible, displaced disc; the unexpectedly high incidence (greater than 50%) of normally shaped discs in the third stage of the process. A specific condition of severe and stubborn limited maximal mouth opening caused by total cessation of gliding, liable to occur at any age and unrelated to disc shape or position, which responds successfully to simple treatment by lavage and lysis, pressured injection, or arthrocentesis, was discerned. Lack of gliding was attributed to adherence of the disc to the fossa by a reversible effect such as a vacuum and/or decreased volume of synovial fluid of high viscosity. This condition was deemed worthy of an independent identity, dissociated from disc displacement, as a causative factor in the second and third stages of ID, and particularly as an aid to accurate diagnosis and treatment.

Arthroscopic lavage and lysis of the temporomandibular joint: a change in perspective.

Arthroscopic surgery was applied to correct various disorders of the temporomandibular joint (TMJ). Lysis and lavage of the upper TMJ compartment proved of value in patients with anterior disc displacement without reduction ("closed lock"), because it increased the range of mouth motion and alleviated pain in the TMJ. Because this beneficial arthroscopic intervention did not encompass repositioning the disc, its surgical relocation when attempting to overcome dysfunction and pain in the TMJ is questioned.