Evaluation of Intermaxillary Fixation (IMF) Screw Therapy with Craniomandibular Index Analysis for Chronic Recurrent Dislocation in the Temporomandibular Joint.

BACKGROUND: Temporomandibular joint (TMJ) hypermobility is classified as a subluxation, complete (luxation), unilateral, or bilateral, acute, chronic protracted, or chronic recurrent dislocation. AIMS: This controlled randomized clinical study aims to evaluate the effectiveness of intermaxillary fixation (IMF) screw application and autologous blood injections in the treatment of chronic recurrent dislocation of TMJ in comparison with the placebo group. PATIENTS AND METHODS: The patients who were admitted to the Faculty of Dentistry of the Atatürk University between October 2018 and January 2020 were evaluated. Three hundred patients diagnosed with bilateral chronic recurrent dislocation of TMJ based on clinical findings and radiographs were included in the study. The patients were randomly divided into three groups according to the evaluation criteria. Group 1 received IMF, group 2 received autologous blood injection, and group 3 (placebo group) received an intraarticular saline injection. RESULTS: The results of the patients who received IMF, autologous blood injection, and saline injection were evaluated by the craniomandibular index. The IMF group showed significant improvement after 1 month and 6 months (P < 0.001), while the patients who received autologous blood injection and saline injection showed no significant improvement (P > 0.05). The data were analyzed with IBM SPSS V23. The significance level was P < 0.05. CONCLUSION: In our study, the IMF gave the best results among all the study groups. The IMF technique can be used in patients with protracted chronic recurrent dislocation in whom autologous blood injection has failed.

OROFACIAL PAIN - DIAGNOSTIC AND THERAPEUTIC CHALLENGES.

The concept of diagnostics and therapy of musculoskeletal and neuropathic diseases of the stomatognathic system, which are the subject of this paper, has been developing for decades. It can be said that in order to avoid misunderstanding, the orofacial pain as a clinical problem, in the narrower sense, involves non-odontogenic and non-malignant causes of orofacial region. In this study, the results of clinical diagnosis of the population of 557 consecutive patients with orofacial pain based on multidisciplinary diagnostics were evaluated. 15.6% of patients have given up on the participation in the study. It has been shown that the patients who dropped out of the study were significantly older (p=0.0411) than those who agreed to participate, but there was no difference in gender ratio (p=0.185) since the proportion of female patients prevailed. In an analysis of 84.4% of patients participating in the study, the elevated anxiety values were established (mean value on STAI 1 was 39.2 and STAI 2 was 41.1) and statistical significance was found in correlation between elevated anxiety and intensity of pain as shown on visual analogue scale on open mouth (p<0.0001). Compared to the age, the statistical significance was for STAI 1 (p=0.0097) but not for STAI 2 (p=0.5599). The most common form of therapy is Michigan stabilization splint: for disc displacement of temporomandibular joint (TMJ) in 38.9% of patients and in combination with physiotherapy in 18.7% of patients; for osteoarthritis of TMJ in 28.4% and in combination with physiotherapy in 26.4% of patients. The treatment with anticonvulsant drugs for trigeminal neuralgia predominates in 54.3% of patients, which is combined with acupuncture in 25.7% of patients and only acupuncture in 17.1% of patients. In this study, a multidisciplinary co-operation in initial diagnostics and differential was designed to develop subspecialist knowledge on orofacial pain.

The role of electrophysiological investigations of masticatory muscles in patients with persistent idiopathic facial pain.

INTRODUCTION: The authors tried to establish whether there is any electrophysiological difference of masticatory muscle activity between patients with persistent idiopathic facial pain (PIFP) and healthy subjects. METHODS: Twenty-eight PIFP patients (6 men and 22 women, mean age 40 years) and 28 normal subjects (12 men and 16 women, mean age 40 years) underwent EMG of temporal and masseter muscles before and after transcutaneous electric nerve stimulation (TENS). RESULTS: After TENS stimulation, the mean amplitude difference was found to be smaller than the baseline before TENS in the PIFP patients compared with healthy subjects. CONCLUSIONS: The peculiar behavior of masticatory muscles after TENS could be relevant in order to explain the well-known improvement of pain reported by some PIFP patients after orthosis positioning.

A modified approach for eminectomy for temporomandibular joint dislocation under local anaesthesia: report on a series of 50 patients.

Conventional eminectomy for habitual dislocation of the temporomandibular joint is usually performed under general anaesthesia. This technique was modified for use under local anaesthesia to treat medically compromised patients. Fifty elderly patients (90 joints) were treated, for whom general anaesthesia was considered a serious risk due to systemic diseases; the dislocation was habitual in 39 and long-standing in 11. Following intravenous sedation and local anaesthesia, a 2-cm superficial vertical skin incision was made directly above the articular eminence. Careful and gentle dissection of the subcutaneous tissue was performed until the lateral joint capsule was exposed. The superior compartment was entered, followed by shaving of the articular eminence in a conventional manner. The surgery was successful in all patients, with a mean operative time of 47±12minutes. Intraoperative events occurred in 10 patients (20%). Postoperative complications affected 25 patients (50%), varying from severe (two deaths, due to cardiopulmonary arrest and accidental fall) to mild (local infection, etc.). Eleven patients (22%) had facial nerve palsy limited to the temporal branch; all recovered after 6 months. This approach is useful when general anaesthesia is contraindicated due to existing medical conditions. However, prudent consideration may be required to avoid serious complications when local anaesthesia is used.

Injectable Agents Versus Surgery for Recurrent Temporomandibular Joint Dislocation.

Recurrent temporomandibular joint dislocation (TMJD) is a distressing entity to the patient and a therapeutic challenge to the treating provider. Absence of high-level evidence in literature among currently available treatment options creates a lack of consistency in management. This article reviews the current literature on common injectable agents used and the open surgical techniques. Based on the findings, an injectable agent is the initial treatment of choice for recurrent TMJD, with capsulorraphy and eminectomy being used in nonresponding patients.

Intraoperative mandibular nerve block with peripheral nerve stimulator for temporomandibular joint ankylosis.

We describe the use of peripheral nerve stimulator for mandibular nerve block intraoperatively in a 4.5year old child with complete temporomandibular joint ankyloses. The block was not possible preoperatively, therefore, it was administered after release of ankyloses. The use of peripheral nerve stimulator increased the chances of a successful block. No intraoperative analgesics and muscle relaxants were required. Postoperative pain relief was excellent. Peripheral nerve stimulator is an easy way of for accurate needle tip placement for mandibular nerve block in patients with distorted anatomy.

Comparison of local and general anaesthesia for arthrocentesis of the temporomandibular joint.

Arthrocentesis of the temporomandibular joint is an effective treatment for some disorders, and is usually done under local anaesthesia. We know of few studies that have compared the ease of arthrocentesis and its outcomes under local or general anaesthesia, so we studied 32 patients (n=16 in each group). Postoperative oedema and pain, maximum mouth opening, duration of arthrocentesis, and ease of operation were assessed to compare the relative effectiveness of the two types of anaesthetic. Scores for duration of arthrocentesis (p=0.003) and ease of procedure (0.004) differed significantly, while the other results were similar in the two groups. We noticed some superior outcomes when the procedure was done under general anaesthesia, but because of its limitations, selection of patients becomes more important.

Ear pain following temporomandibular surgery originating from the temporomandibular joint or the cranial nervous tissue? A case report.

A patient presenting with local pain and limitation of movement in the temporomandibular region following surgery of the left temporomandibular joint (TMJ) is described. Manual techniques like distraction of the TMJ combined with motor control exercises to restore TMJ function were not sufficient to relieve the patient's symptoms and her orofacial functions. However, during manual assessment and treatment of cranial nervous tissue, in this case the auriculotemporal nerve and its interface, pain was relieved and orofacial functions improved.

Comparative clinical study of light analgesic effect on temporomandibular disorder (TMD) using red and infrared led therapy.

Low-level laser therapy (LLLT) has been widely applied in pain relief in several clinical situations, including temporomandibular disorders (TMD). However, the effects of LED therapy on TMD has not been investigated. This study aims to evaluate the effects of red and infrared LEDs on: (1) tissue temperature in ex vivo and (2) pain relief and mandibular range of motion in patients with TMD. Thirty patients between 18 and 40 years old were included and randomly assigned to three groups. The two experimental groups were: the red LED (630 ± 10 nm) group and the infrared LED (850 ± 10 nm) group. The irradiation parameters were 150 mW, 300 mW/cm(2), 18 J/cm(2), and 9 J/point. The positive control group received an infrared laser (780 nm) with 70 mW, 1.7 W/cm(2), 105 J/cm(2), and 4.2 J/point. LED and laser therapies were applied bilaterally to the face for 60 s/point. Five points were irradiated: three points around the temporomandibular joint (TMJ), one point for the temporalis, and one near the masseter. Eight sessions of phototherapy were performed, twice a week for 4 weeks. Pain induced by palpating the masseter muscle and mandibular range of motion (maximum oral aperture) were measured at baseline, immediately after treatment, 7 days after treatment, and 30 days after treatment. There was an increase in tissue temperature during both the red and the infrared LED irradiation in ex vivo. There was a significant reduction of pain and increase of the maximum oral aperture for all groups (p ≥ 0.05). There was no significant difference in pain scores and maximum oral aperture between groups at baseline or any periods after treatment (p ≥ 0.05). The current study showed that red and infrared LED therapy can be useful in improving outcomes related to pain relief and orofacial function for TMD patients. We conclude that LED devices constitute an attractive alternative for LLLT.

Prospective analysis of temporomandibular joint reconstruction in ankylosis with sternoclavicular graft and buccal fat pad lining.

PURPOSE: To evaluate the feasibility of sternoclavicular graft (SCG) as an adaptive center along with buccal fat pad (BFP) lining for temporomandibular joint (TMJ) reconstruction in TMJ ankylosis. PATIENTS AND METHODS: A prospective, preliminary, short-term study with only 6 months' follow-up was performed in 10 patients with TMJ ankylosis. All patients had complete osseous ankylosis, and the mean duration of ankylosis was 6.4 years (range, 3 to 13 years). Interpositional arthroplasty with SCG along with BFP lining was done in all cases. Postoperative clinical and radiographic follow-up was performed for 6 to 9 months. RESULTS: Maximum interincisal opening at 6 months' follow-up was 35.6 ± 4.97 mm (range, 31 to 45 mm). Similarly, protrusive movement at follow-up of 6 months was 2.7 ± 1.25 mm (range, 1.5 to 5.5 mm), whereas laterotrusive movement was 4.1 ± 1.98 mm (range, 1.5 to 7.0 mm) toward the affected side and 2.4 ± 0.99 mm (range, 1 to 4.0 mm) toward the normal side. After 3 months, 9 of 10 patients had no pain on function, and all the patients were relieved of pain at the end of 6 months. On radiographic follow-up at 9 months, there was noticeably significant adaptation and remodeling of SCG as observed on panoramic radiography and computed tomography scan. In all the patients there was some degree of mandibular deviation toward the operated side, although the occlusion was satisfactory and they were pleased with the outcome. CONCLUSION: On the basis of the findings of this study, we conclude that after release of TMJ ankylosis, reconstruction with SCG combined with interposition of BFP lining followed by vigorous physiotherapy is a successful strategy for the management of TMJ ankylosis with short-term follow-up of 6 months.

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.

Functional surgery of the temporomandibular joint with conscious sedation for "closed lock" using eminectomy as a treatment: a case series.

PURPOSE: The purpose of this case series study was to evaluate the advantages and disadvantages of using local anesthesia and conscious sedation (CS) rather than general anesthesia (GA) for performing functional surgery on patients suffering from temporomandibular joint (TMJ) closed lock, using the eminectomy procedure. Performing this procedure using CS allows functional assessment of the TMJ meniscus at the time of surgery. The objectives of this study were to determine if this surgery is possible under CS, to determine the benefits of being able to see the meniscus in action, and to investigate the patients' acceptability for this form of anesthesia. PATIENTS AND METHODS: Twenty-two patients who underwent this eminectomy procedure under either CS or GA on a day-case basis participated in this retrospective case series study. All the recruited patients had this procedure carried out after a course of nonsurgical conservative treatment that had failed to relieve the symptoms associated with their TMJ disorder--"closed lock." RESULTS: Objective results obtained were as follows: preoperative and postoperative mouth opening; preoperative investigations; preoperative treatments. Subjective results obtained were as follows: preoperative and postoperative pain; noises; clicks; hearing and deviation on opening; patient rating of operation success. Paired t testing showed a significant change in mouth opening for both groups. The mean mouth opening change in the CS group (n = 9) was 10.6 mm (P = .014) and in the GA group (n = 13) was 13.7 mm (P < .001). An unpaired t test showed there is no statistical difference between these groups (P = .467). The subjective data recorded showed comparable outcomes and acceptance for the 2 techniques in terms of pain and operation success. CONCLUSIONS: The use of local anesthesia and CS is an alternative to GA for performing TMJ procedures in appropriately selected patients. The advantage of direct visualization of the meniscus and its movements in the nonasleep patient requires further evaluation.

Efficacy of eminectomy in the treatment of prolonged mandibular dislocation

Surgery of the temporomandibular joint is indicated for different clinical situations, including internal derangements,hipomobility, hipermobility, pathology and trauma. Mandibular dislocation is an acute painful condition that causes severe functional limitation. Manual reduction, with or without pharmacological assistance, is the treatment of choice and should be performed as early as possible. On rare situations mandibular dislocation maynot be perceived by the patient and remain undiagnosed or misdiagnosed for a long period. This may include severe illness, neurological diseases and prolonged intensive care hospitalization with oral intubation and sedation.Treatment of prolonged mandibular dislocation is different. Morphological changes of the joint and associated structures will prevent successful manual reduction even with the patient under general anesthesia. Basically, two types of surgery may be indicated: elimination of the articular eminence (eminectomy) or reestablishment of a new condyle - ramus relationship, that can be achieved by condilotomy. This article reports a case of prolonged mandibular dislocation that was treated surgically with success. A review of the literature is performed by authors and advantages and disadvantages of each type of treatment are discussed (AU)

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Long-term results of radiation prophylaxis for heterotopic ossification in the temporomandibular joint.

PURPOSE: To assess the long-term efficacy and toxicity of radiation therapy (RT) for postoperative prophylaxis of recurrent heterotopic ossification (HO) in the temporomandibular joint (TMJ). PATIENTS AND METHODS: Twelve patients (18 joints) with bony ankylosis of the TMJ from HO were referred to undergo RT after arthrotomy with osseous recontouring, gap arthroplasty, or costochondral grafting. Treatment consisted of 10 Gy in 5 daily fractions to a field encompassing the TMJ with an adequate margin. RT was initiated 1 to 3 days postoperatively. Response to therapy was assessed by routine x-ray films obtained preoperatively, immediately postoperatively, and at follow-up by use of the Turlington-Durr grading system. Treatment efficacy was defined as freedom from HO re-formation requiring further surgical intervention. Efficacy and toxicity data were obtained from review of the medical records and were augmented by telephone interview of patients when possible (6 patients, all with follow-up >16 years). Efficacy rates by patient were estimated by the Kaplan-Meier method. RESULTS: The median follow-up after RT was 16.4 years (range, 2.5-19.2 years). Symptomatic re-formation of HO requiring further surgery occurred in 5 patients (7 joints). Treatment efficacy rates were 71% (95% confidence interval [CI], 44-99) at 5 years and 48% (95% CI, 15-80) at 10 years. Of the 6 patients contacted regarding late toxicity, 2 had clinical xerostomia (grade 1, CTCAE v3.0) attributable to RT; no other late RT-related toxicities were noted. None of the 12 patients had malignancy attributable to RT. CONCLUSIONS: Postoperative RT prevented re-formation of TMJ HO in 50% of treated patients long term. Late toxicities from RT were mild and infrequent.

Effect of injection of botulinum toxin on lateral pterygoid muscle used together with the arthroscopy in patients with anterior disk displacement of the temporomandibular joint.

OBJECTIVES: In this study, we aimed to study the effects of an additional lateral pterygoid muscle (LPM), botulinum toxin-A (BTX-A) injection on arthroscopic lysis, lavage and posterior band coagulations. Subjective and objective measures have been documented. PATIENTS AND METHODS: Fourty-three subjects (6 females, 37 males; mean age 35 years; range 15 to 48 years) with 52 joints were enrolled in the study. Patients were divided into two groups. The first group was treated with arthroscopic lysis, lavage and posterior band coagulation. The second group received an injection of 20 U of BTX-A to the LPM in addition to the former treatment. Patients were assessed statistically in the 1st week, and in the 1st, 3rd and 6th months postoperatively with the measures of lateral deviations, protrusions and visual analogue scale (VAS) values using Student-t test. RESULTS: Group 1 and group 2 showed significant results within themselves with the exception of the 3rd month values of right deviations in group 1. When groups were compared with each other; significant results were observed in left deviation values only in the 3rd month, protrusion in the 1st month, and most importantly VAS values starting from the 1st month. CONCLUSION: Botulinum toxin-A injection to the LPM mostly improved subjective measures starting from the 1st month. Other objective measures like protrusions, and deviations were not found to be affected generally. These findings suggest the improvement of symptoms with BTX-A injections in additon to the standard arthroscopy. However, diminishing effect of BTX-A and lack of information on the exact mechanism of action of toxin on temporomandibular joint necessitate further studies on this topic.

Prospective multicenter comparison of 4 temporomandibular joint operations.

PURPOSE: This study was designed to compare the outcomes of 4 operations used for the treatment of painful temporomandibular joints with an internal derangement. PATIENTS AND METHODS: A prospective, controlled study of arthroscopy, condylotomy, discectomy, and disc repositioning was conducted at 3 sites. All sites used the same inclusion and exclusion criteria. Trained, independent examiners assessed pain, diet, and range of motion before operation and 1 month and 1 year after operation. RESULTS: There were statistically significant reductions in the amount of pain ( P < .001) and daily time in pain ( P < .001) that were similar for all 4 operations 1 month and 1 year after the procedures. The degrees of change after each of the 4 procedures were not statistically different from each other (amount: P = .453 and time: P = .416). Ability to chew, as measured by diet visual analog scale, was substantially improved 1 year after operation ( P < .001). The degrees of change for diet at 1 year also were not different from each other ( P = .314). There were, however, statistically significant differences ( P < .05) in range of motion that varied with procedure. CONCLUSIONS: All 4 operations were followed by marked improvements in pain and diet. The amounts of improvement varied slightly by operation, but these differences were not statistically significant. There were small but statistically significant differences between procedures for range of motion. If these findings are confirmed, they have an important implication for procedure selection.

The effect of physiotherapy on post-temporomandibular joint surgery patients.

The purpose of this study was to investigate the effect of physiotherapy on rehabilitation of patients who had temporomandibular joint (TMJ) surgery. The treatment group consisted of 22 post-surgical patients who were treated with physiotherapy, and the non-treatment group consisted of 22 post-surgical patients who received no physiotherapy. The assessment tools were made using visual analogue scale (VAS) and craniomandibular index (CMI) which consisted of dysfunction index (DI) and palpation index (PI). All patients received follow-up for 7 months. The subjects were measured three times; before surgery, 6 weeks after surgery and 7 months after surgery. On the 6 week post-surgery assessment, DI and total CMI scores of the treatment group were significantly lower (P < 0.05) than those of the non-treatment group. On the assessment performed 7 months after surgery, all variables were significantly lower (P < 0.05) for the treatment group compared with those of the non-treatment group. The findings of the study indicate that physiotherapy has a positive effect in relieving pain and restoring TMJ function after surgery.

The incidence of reoperation after temporomandibular joint arthroscopic surgery: a retrospective study of 450 consecutive joints.

PURPOSE: The purpose of this study was to investigate the incidence of reoperation after temporomandibular joint arthroscopic surgery in 315 consecutive patients (488 joints). STUDY DESIGN: The clinical data and operative reports of all patients who underwent arthroscopic procedures from 1995 to 2000 were reviewed retrospectively. Patients had a preoperative clinical and panoramic radiographic evaluation. Most of the patients had disk displacement without reduction. In the remaining patients, the intra-articular pathologic conditions ranged from disk displacement with reduction to degenerative joint disease. The outcome assessment was based on reduction in pain, improvement in vertical dimension of mouth opening, and mandibular excursions. The same surgical team performed all arthroscopic procedures. Before surgery, all patients received at least 3 to 6 months of nonsurgical therapy consisting of anti-inflammatory medications, muscle relaxants, splint therapy, physiotherapy, exercise, moist heat, cold laser, ultrasound, and soft diet or a combination thereof. Patients were monitored postoperatively for as long as 5 years. RESULTS: Results showed that approximately 20% of those patients who had temporomandibular joint arthroscopic surgery underwent further temporomandibular joint procedures ranging from repeat arthroscopic surgery to open-joint arthrotomy. CONCLUSION: Temporomandibular joint surgical arthroscopy is an appropriate therapeutic modality for patients with temporomandibular joint internal derangements, with reoperation required for only 20% of patients.