Who is who in oral cancer?

Great attention has been attached to explore the association between oral bacteria and oral cancer. Recently, four common inhabitants of oral cavity, Porphyromonas gingivalis, Fusobacterium nucleatum, Treponema denticola and Streptococcus anginosus, have been identified as potential etiologic bacterial agents for oral carcinogenesis. They might promote the oncogenesis and progression of oral cancer by induction of chronic inflammation, enhancement of migration and invasiveness, inhibition of cell apoptosis, augment of cell proliferation, suppression of immune system and production of carcinogenic substances. Thus, this review will focus on the possible mechanisms of these oral bacteria contributing to occurrence and development of oral cancer, and the potential clinical implications of utilizing oral bacteria on the diagnosis, prevention and treatment of oral cancer will be discussed.

Multiple Treatment Meta-Analysis of Intra-Articular Injection for Temporomandibular Osteoarthritis.

PURPOSE: The purpose of the present study was to compare the efficacy of intra-articular injections of different agents for temporomandibular osteoarthritis (TMJOA) using a network meta-analysis. MATERIALS AND METHODS: A comprehensive search strategy was performed in multiple English and Chinese language electronic databases. Randomized controlled trials comparing the effect of intra-articular injections of different agents to treat TMJOA were included in accordance with the inclusion and exclusion criteria. The bias of risk in each study was assessed, with data extraction performed independently by 2 reviewers. The primary outcomes included pain intensity and maximal mouth opening. RESULTS: A total of 11 trials were included in the present study, and 10 different agents (ie, hyaluronic acid, dexamethasone, prednisolone, betamethasone, betamethasone plus hyaluronic acid, morphine, tramadol, platelet-derived growth factor [PDGF], placebo, arthrocentesis alone) administered using intra-articular injections were assessed. The evidence from the direct comparisons showed that arthrocentesis plus sodium hyaluronate resulted in significantly better pain relief outcomes compared with arthrocentesis alone. Also, the visual analog scale score was further reduced to 1.27 by PDGF injection after arthrocentesis (arthrocentesis plus PDGF) compared with arthrocentesis alone. Morphine and tramadol had a high probability of being the best treatment for pain control, with PDGF ranked third. When considering pain relief, arthrocentesis plus sodium hyaluronate resulted in a better outcome than arthrocentesis alone, and arthrocentesis plus PDGF was better than arthrocentesis plus placebo. PDGF injections had the greatest probability of being the best treatment for improving joint opening, followed by sodium hyaluronate. CONCLUSIONS: Tramadol, morphine, and PDGF injections after arthrocentesis were effective in the treatment of TMJOA with excellent effects in reducing pain and improving joint opening. Hyaluronic acid injections were effective for improving the maximal mouth opening of patients with TMJOA in the short-term. The combination of a corticosteroid and hyaluronic acid injection reduced the symptoms of TMJOA more than corticosteroid injections alone, but not of hyaluronic acid alone.

Glucosamine oral administration as an adjunct to hyaluronic acid injection in treating temporomandibular joint osteoarthritis.

OBJECTIVE: To investigate the therapeutic effect of oral glucosamine (GS) as an adjunct to hyaluronic acid (HA) injection on patients with temporomandibular joint osteoarthritis (TMJ OA). METHODS: In this clinical trial, 136 participants, diagnosed as TMJ OA clinically and radiographically, were enrolled and randomized into two groups (group GS + HA: oral GS + HA injection; group placebo + HA: oral placebo + HA injection). Pain, maximum interincisal mouth opening (MMO), the levels of IL-1ß, IL-6, and TGF-ß in TMJ synovial were defined as the outcome measurements and conducted before operation, and at 1-month and 1-year follow-up. RESULTS: In both groups, pain scores were decreased and MMOs were increased at 1-month and 1-year follow-up, the changes at 1-year follow-up showed statistically significant intergroup differences. At 1-month follow-up, only IL-6 concentration was lower in group GS + HA than that in group placebo + HA. One year later, TGF-ß concentration was higher and IL-6 and IL-1ß concentrations were lower in group GS + HA than those in group placebo + HA. CONCLUSIONS: Both strategies alleviated symptoms in short term, but the patients treated with GS benefited more than those with placebo in long term, which may be due to the suppression of IL-1ß and IL-6 and the stimulation of TGF-ß.

Is There a Difference in Intra-Articular Injections of Corticosteroids, Hyaluronate, or Placebo for Temporomandibular Osteoarthritis?

PURPOSE: Corticosteroids are widely used for treatment of temporomandibular joint (TMJ) osteoarthritis (OA). This study investigated the effects of corticosteroids on TMJOA compared with placebo or hyaluronate. MATERIALS AND METHODS: The authors designed and implemented a systematic review and meta-analysis to compare the effects of intra-articular injection of corticosteroid, hyaluronate, or placebo for patients with TMJOA. The authors searched related randomized controlled studies electronically in multiple English- and Chinese-language electronic databases. The predictor variable was intra-articular injection with corticosteroid, hyaluronate, or placebo. Primary outcome variables were pain intensity and maximal mouth opening. Other variables included success rate and adverse events. Meta-analyses were performed with Rev Man 5.3. RESULTS: Eight studies met the inclusion criteria. Meta-analysis showed that corticosteroid injections after arthrocentesis were superior to placebo in relieving pain as assessed with the visual analog scale (mean difference [MD], -0.74; 95% confidence interval [CI], -1.34 to -0.13; P = .02; I2 = 0%) in the long-term, but was inferior in increasing maximal mouth opening (MD, -2.06; 95% CI, -2.76 to -1.36; P < .00001; I2 = 28%). Although corticosteroid and hyaluronate injections without arthrocentesis decreased pain and improved maximal mouth opening, the corticosteroid group had a significantly lower success rate (odds ratio = 0.41; 95% CI, 0.17-1.00; P = .05; I2 = 0%) than the hyaluronate group in the short term. CONCLUSION: Corticosteroid injections after arthrocentesis are recommended for patients with TMJOA to relieve joint pain rather than increase maximal mouth opening. Corticosteroid and hyaluronate have marked effectiveness on TMJOA; however, hyaluronate might be the better alternative to some extent.

Deep simulated annealing for the discovery of novel dental anesthetics with local anesthesia and anti-inflammatory properties.

Multifunctional therapeutics have emerged as a solution to the constraints imposed by drugs with singular or insufficient therapeutic effects. The primary challenge is to integrate diverse pharmacophores within a single-molecule framework. To address this, we introduced DeepSA, a novel edit-based generative framework that utilizes deep simulated annealing for the modification of articaine, a well-known local anesthetic. DeepSA integrates deep neural networks into metaheuristics, effectively constraining molecular space during compound generation. This framework employs a sophisticated objective function that accounts for scaffold preservation, anti-inflammatory properties, and covalent constraints. Through a sequence of local editing to navigate the molecular space, DeepSA successfully identified AT-17, a derivative exhibiting potent analgesic properties and significant anti-inflammatory activity in various animal models. Mechanistic insights into AT-17 revealed its dual mode of action: selective inhibition of NaV1.7 and 1.8 channels, contributing to its prolonged local anesthetic effects, and suppression of inflammatory mediators via modulation of the NLRP3 inflammasome pathway. These findings not only highlight the efficacy of AT-17 as a multifunctional drug candidate but also highlight the potential of DeepSA in facilitating AI-enhanced drug discovery, particularly within stringent chemical constraints.

Analysis of dental clinic and dental chair distribution in Sichuan.

OBJECTIVES: To thoroughly understand the current dental chair equipment status of dental clinics in Sichuan Province and provide a reference for administrative departments. METHODS: Data were collected from a health administrative department and a regional social development yearbook. The number of existing dental clinics and dental chairs in Sichuan Province was investigated. RESULTS: In Sichuan Province, 7 103 dental clinics were determined to be equipped with 21 760 dental chairs. The Gini coefficients of per capita dental clinics in the province were 0.50, 0.22, and 0.06, and the Gini coefficients of per capita dental chairs were 0.68, 0.31, and 0.15; these coefficients had the same distribution as that reflected by the Lorenz curve. In consideration of geographic distribution, the Theil index for the distribution of dental clinics and dental chairs among cities and states were 0.690 7 and 0.822 3, respectively. The overall Theil index va-lues for the distribution of dental clinics and dental chairs in the province were 0.902 4 and 1.079 4, respectively. The difference in the distribution of dental clinics and dental chairs among cities and states in the province contributed 0.765 4 and 0.761 8 to the total difference, respectively. CONCLUSIONS: The allocation of oral health resources in Sichuan Pro-vince is relatively equitable in terms of population and economic distribution but uneven in geographical distribution.

Paresthesia in dentistry: The ignored neurotoxicity of local anesthetics.

Local anesthetics are frequently used by dentists to relieve localized discomfort of the patient and improve treatment conditions. The risk of paresthesia after local anesthesia is frequently encountered in dental clinics. The neurotoxicity of local anesthetics is a disregarded factor in paresthesia. The review summarizes the types of common local anesthetics, incidence and influencing factors of paresthesia after local anesthesia, and systematically describes the neurotoxicity mechanisms of dental local anesthetic. Innovative strategies may be developed to lessen the neurotoxicity and prevent paresthesia following local anesthesia with the support of a substantial understanding of paresthesia and neurotoxicity.

Carcinosarcoma of the deep lobe of the parotid gland in the parapharyngeal region: A case report.

BACKGROUND: Salivary carcinosarcoma is an extremely rare tumor containing both malignant epithelial and mesenchymal constituents. This article reports a rare case of carcinosarcoma with salivary duct carcinoma and osteosarcoma as the tumor components. The clinicopathological characteristics, treatment, and prognosis are discussed in conjunction with the literature. CASE SUMMARY: A 48-year-old man presented with a complaint of a mass in the right parotid region. Osteosarcoma was first considered for assessment by fine-needle aspiration cytology. Physical examination revealed a mass measuring approximately 4 cm × 3.5 cm × 3 cm. The mass, the whole lobe of the right parotid gland, and the right mandible were completely removed during surgery. Postoperative histopathology confirmed carcinosarcoma of the salivary gland. CONCLUSION: A definite diagnosis of salivary gland carcinosarcoma can only be obtained after complete surgical resection.

Temporomandibular custom hemijoint replacement prosthesis: prospective clinical and kinematic study.

PURPOSE: To evaluate the clinical and functional outcomes of a custom temporomandibular hemijoint fossa/eminence implant prosthesis. MATERIALS AND METHODS: This prospective cohort study enrolled patients with osteoarthritis of the temporomandibular joint. The primary study variables were pain experience, pain intensity, chewing ability, jaw opening, joint noise, and overall satisfaction of the surgical outcome at 3, 6, and 13 months after surgery. Pre- and postsurgical kinematic analyses measured maximum incisal opening, operated and unoperated condyle translations, and mandibular body axis rotation using mandibular kinematic data combined with patient-specific computed tomographic data. The primary analysis of interest concerned preoperative versus postoperative changes. RESULTS: The study sample was composed of 36 subjects (mean age, 46 years; 94% female; 40 joints). There were statistically significant improvements between pre- and postoperative measurements for each study variable. The kinematic data documented preservation or an increase of bilateral condylar motion, mandibular axis rotation, and mandibular incisor motion. CONCLUSIONS: Temporomandibular joint hemiarthroplasty with a custom metal fossa/eminence prosthesis provides satisfactory clinical and functional outcomes when used for advanced osteoarthritis in patients with focal joint pain secondary to computed tomographically documented joint pathology.

Maxillofacial injuries caused by the 2008 Wenchuan earthquake in China.

PURPOSE: To describe the pattern of maxillofacial injuries sustained by survivors of the 2008 Wenchuan earthquake in the West China Hospital of Stomatology from May 12 to June 23, 2008. PATIENTS AND METHODS: Cross-sectional data were analyzed using hospital-based records of earthquake survivors admitted to the West China Hospital of Stomatology. A self-designed form to record information about variables such as the gender and age of the survivors and type of location of soft and hard tissue injuries was used. RESULTS: The age of earthquake survivors of maxillofacial injuries ranged from 4 to 84 years. Fractures and soft tissue injuries were the most common of all injuries in the maxillofacial region, constituting 40.7% and 38.9%, respectively. Thirteen patients (11.5%) had dental injuries and 9 (8.0%) also had other organ injuries. CONCLUSION: During the Wenchuan earthquake, the incidence of maxillofacial injuries in survivors was relatively low compared with injury in other organs. However, because most injuries were maxillofacial fractures and facial soft tissue damage, special attention was paid to maxillofacial injury when planning and providing emergency treatment. The effective management of earthquake injuries and those caused by other types of disaster requires a multidisciplinary approach, and maxillofacial surgeons should form an integral part of this multidisciplinary team.

The maintenance of an oral epithelial barrier.

Oral epithelial barrier consists of closely controlled structure of the stratified squamous epithelium, which is the gateway to human bodies and encounters a huge burden of microbial, airborne and dietary antigens, as well as masticatory damage. Once this barrier is destroyed, it will trigger bone loss, tissue damage and microbial dysbiosis and lead to diseases, such as periodontitis, oral mucosal diseases and oral cancer. Recently, increasing evidences showed that different factors including microorganism, saliva, proteins and immune components have been considered to play a critical role in the disruption of oral epithelial barrier. Herein, we discussed mechanisms governing the maintenance of oral epithelial barrier. Besides, the role of oral epithelial barrier failure in oral carcinogenesis will also be talked about.

Molecular Layer Deposition-Modified 5A Zeolite for Highly Efficient CO2 Capture.

Effective pore mouth size of 5A zeolite was engineered by depositing an ultrathin layer of microporous TiO2 on its external surface and appropriate pore misalignment at the interface. As a result, a slightly bigger N2 molecule (kinetic diameter: 0.364 nm) was effectively excluded, whereas CO2 (kinetic diameter: 0.33 nm) adsorption was only influenced slightly. The prepared composite zeolite sorbents showed an ideal CO2/N2 adsorption selectivity as high as ∼70, a 4-fold increase over uncoated zeolite sorbents, while maintaining a high CO2 adsorption capacity (1.62 mmol/g at 0.5 bar and 25 °C) and a fast CO2 adsorption rate.

Porphyromonas gingivalis Promotes 4-Nitroquinoline-1-Oxide-Induced Oral Carcinogenesis With an Alteration of Fatty Acid Metabolism.

Microbiota has been widely considered to play a critical role in human carcinogenesis. Human papilloma virus, hepatitis B and C virus, and Helicobacter pylori are implicated in the pathogenesis of cancer of uterine cervix, liver, and stomach, respectively. However, whether Porphyromonas gingivalis (P. gingivalis), a common Gram negative oral bacteria, is associated with oral carcinogenesis still remains unclear and its underlying mechanism needs to be addressed. Here, we established a combined experimental system of 4NQO-induced oral carcinoma model and chronic periodontitis model and investigated the effects of P. gingivalis infection on oral carcinogenesis and fatty acid metabolism during oral carcinogenesis. The data showed that in this animal model, P. gingivalis infection induced mice periodontitis, increased the tongue lesion size and multiplicity of each mouse and promoted oral cancer development. P. gingivalis treatment significantly increased the level of free fatty acids and altered the fatty acid profile in tongue tissues and the serum of mice. And P. gingivalis induced the formation of fatty liver of the mice. Besides, immunohistochemical analysis and qRT-PCR showed that the expression of fatty-acid synthase and acetyl-CoA carboxylase 1 were increased in the tongue and liver tissues of 4NQO-treated mice infected with P. gingivalis. These results showed that P. gingivalis promoted oral carcinogenesis and aggravated disturbance of fatty acid metabolism, indicating a close association among P. gingivalis, lipid metabolic and oral carcinogenesis.

Regulation of plasminogen activator activity and expression by cyclic mechanical stress in rat mandibular condylar chondrocytes.

To investigate the mechanism of cartilage degradation induced by overloading in the temporomandibular joint (TMJ), the effect of cyclic mechanical compressive stress on the activity of plasminogen activator (PA) and the expression of the predominant components of the PA system were analyzed in cultured mandibular condylar chondrocytes (MCCs) in rats. MCCs were exposed to cyclic mechanical compressive stress (2000, 4000 and 6000 µ strain) at 0.5 Hz by a four­point bending system. The activity of PA was determined by hydrolysis of the chromogenic substrate H­D-Val-Leu-Lys­pNA (S­2251). The mRNA and protein expression levels of urokinase­type PA (uPA), tissue­type PA (tPA), uPA receptor (uPAR) and PA inhibitor 1 (PAI­1) were detected by qPCR and western blot analysis, respectively. Cyclic mechanical stress at 4000 and 6000 µ strain induced the expression of uPA, tPA and uPAR, and increased the activity of PA. Furthermore, cyclic mechanical stress at 6000 µ strain also inhibited the expression of PAI­1. Analysis of pericellular proteolytic activity demonstrated that PA functioned as the active enzyme in excessive mechanical stress responsiveness (e.g., 4000 and 6000 µ strain) largely via uPAR, not PAI­1. Cyclic mechanical stress at 2000 µ strain induced the expression of tPA and PAI­1; however, it did not change the activity of PA. These results suggested that the mechanical induction of uPA, tPA and uPAR upregulated PA activity, which may provide a proteolytic environment of extracellular matrix components and subsequently contribute to the cartilage degradation in TMJ osteoarthritis.

Computer-assisted surgical planning and simulation for condylar reconstruction in patients with osteochondroma.

We describe the use of computer-assisted three-dimensional surgical planning in condylar reconstruction by vertical ramus osteotomy for patients with osteochondroma, and its clinical effects. Seventeen patients with osteochondroma of the mandibular condyle who were seen from March 2005 to March 2009 were divided into 2 groups treated by condylectomy and condylar reconstruction using vertical sliding osteotomy of the mandibular ramus with and without three-dimensional simulation using Surgicase CMF Materialise software. Clinical examination, radiographs, photographs, and details of operation and outcome were used postoperatively to evaluate the clinical effects of the technique. Satisfactory mouth opening was achieved in all cases. Mean (SD) osteotomy and fixation time, duration of intermaxillary fixation, and degree of postoperative numbness of the lower lip were considerably reduced among patients who had three-dimensional simulation. The combined use of computer-assisted three-dimensional surgical planning and simulation with vertical ramus osteotomy to reconstruct the condyle for patients with osteochondroma after excision of the tumour makes the operation more accurate and more convenient, and avoids damage to vital structures.

Rapid silica atomic layer deposition on large quantities of cohesive nanoparticles.

Conformal silica films were deposited on anatase titania nanoparticles using rapid silica atomic layer deposition (ALD) in a fluidized bed reactor. Alternating doses of tris(tert-pentoxy)silanol (TPS) and trimethylaluminum (TMA) precursor vapors were used at 175 degrees C. In situ mass spectroscopy verified the growth mechanism through a siloxane polymerization process. Transmission electron microscopy revealed highly conformal and uniform silica nanofilms on the surface of titania nanoparticles. A growth rate of approximately 1.8 nm/cycle was achieved for an underdosed and incomplete polymerization reaction. Primary nanoparticles were coated despite their strong tendency to form dynamic agglomerates during fluidization. Methylene blue oxidation tests indicated that the photoactivity of anatase titania particles was mitigated with the ALD films.

Maxillofacial space infection experience in West China: a retrospective study of 212 cases.

OBJECTIVES: Our objectives were to analyze the clinical features of maxillofacial space infection (MSI) patients admitted to the West China Hospital of Stomatology over a five-year period, and to identify potential risk factors associated with life-threatening complications. METHODS: A retrospective medical chart review was performed and the sociodemographic and clinical characteristics of patients with MSI were evaluated. RESULTS: A total of 212 patients were enrolled in this study, including 125 males (59.0%) and 87 females (41.0%), with an age range of 1-88 years (median 47.5 years). The most common cause of MSI was odontogenic infection (56.1%). The submandibular space was the space most commonly involved in both single space and multiple space infections (37.5% and 29.1%, respectively). One hundred and two patients (48.1%) self-medicated before admission, and the time from onset of symptoms until presentation was longer in those who self-medicated compared with those who did not (p=0.028). Fifty-seven patients (26.9%) had life-threatening complications and six died (2.8%). In multivariate analysis, age, self-medication, admission temperature, respiratory difficulty, and underlying diseases were found to be risk factors for life-threatening complications. The most common occupation of the patients was farmer (54.7%). Among the farmers, 72.4% had an odontogenic etiology; however, 91.7% of the farmers with odontogenic space infections had not undergone dental treatment before admission. CONCLUSIONS: Our experience suggests that the management of MSI should be more aggressive when the above risk factors are present, in order to avoid life-threatening complications. In addition, considering the poor medical conditions in the rural areas of West China, standard dental care and services should be provided in the future to replace self-medication.

Analysis of 46 maxillofacial fracture victims in the 2008 Wenchuan, China earthquake.

PURPOSE: At 14:28 hours on May 12, 2008, a massive earthquake wracked most areas of Sichuan, China, causing catastrophic human loss. The aim of this study was to delineate the characteristics of victims with maxillofacial fractures in this disaster. PATIENTS AND METHODS: A descriptive analysis was conducted based on the medical records of earthquake maxillofacial injuries casualties transferred to West China Hospital of Stomatology, Sichuan University, after the earthquake. Data regarding demographic details, psychological status, patterns, anatomic sites, etiology, concomitant injuries, and management of earthquake maxillofacial fractures were evaluated. RESULTS: A total of 46 maxillofacial fracture patients' records of 28 (60.9%) males and 18 (39.1%) females were included in this study, with peak incidence (32.6%) in the elderly age group (older than 50 years). The most common etiology of earthquake maxillofacial fractures was building collapse (71.7%). The mandible (65.2%) was the most frequent site of the maxillofacial fracture, followed by the zygomatic complex (21.7%) and maxilla (13.0%). The most prevalent of maxillofacial fracture pattern was multiple and/or comminuted fractures (56.5%), which accounted for 72.7% (24/33) in building collapse injury group. There were 9 (19.6%) patients with significant concomitant injuries and the most common site of concomitant injuries was the head (4 cases) and extremity (4 cases). Four (8.7%) patients' maxillofacial fractures were treated conservatively, 16 (34.8%) underwent closed reduction and fixation, and 26 (56.5%) underwent open reduction and rigid internal fixation (RIF). Apart from 3 patients (6.5%) who showed infection, all patients with facial fractures achieved successful bony union with an acceptable occlusion and facial form. Additionally, it is noteworthy that all patients in our study presented the symptoms of posttraumatic stress disorder (PTSD). CONCLUSION: There is a variation of mechanism of injuries, age group, severity, patterns, concomitant injuries, and management of earthquake maxillofacial fractures. Knowledge of these characteristics provides useful strategies for patient care and prevention of further complications. A multidisciplinary and coordinated approach is important for optimum stabilization and ongoing treatment of victims of building collapse injury. The high percentage of PTSD confirms that psychologists should form an integral part of this multidisciplinary team.

Biocompatible interface films deposited within porous polymers by Atomic Layer Deposition (ALD).

Ultrathin ceramic films were deposited throughout highly porous poly(styrene-divinylbenzene) (PS-DVB) particles using a low-temperature atomic layer deposition (ALD) process. Alumina and titania films were deposited by alternating reactions of trimethylaluminum and H2O at 33 degrees C and of titanium tetrachloride and H2O2 (50 wt % in H2O) at 100 degrees C, respectively. Analytical characterization revealed that conformal alumina and titania films were grown on internal and external polymer surfaces. The improved bioactivity of the polymer substrates was revealed on the basis of the formation of hydroxyapatite (HA) in simulated body fluid. The accelerated formation of HA on the ALD-modified polymer surface was caused by the negatively charged surface provided by the ultrathin ceramic interface. The potential for ALD films to support cell attachment was demonstrated.

Free grafting of autogenous coronoid process for condylar reconstruction in patients with temporomandibular joint ankylosis.

OBJECTIVE: This article describes the clinical effects of condylar reconstruction by free grafting of autogenous coronoid process in patients with temporomandibular joint (TMJ) ankylosis. STUDY DESIGN: Fifteen cases of uni- or bilateral TMJ ankylosis during a 3-year period from March 2004 to March 2007 were surgically treated, and the average observation period was 22 months. All patients were treated by condylar reconstruction of immediate autogenous coronoid process grafts. Temporal muscle myofascial flaps or native articular disc was used as an interpositional tissue. Clinical examination, radiographs, and photographs were used postoperatively to evaluate the grafts and TMJ function. RESULTS: Satisfactory mouth opening was achieved in 14 cases, and 1 patient showed signs of reankylosis of the joint (20 mm mouth opening). Radiographic examination showed that bone union occurred between the grafts and the ramus in all cases. Some bony resorption of the grafted coronoid process was observed in all patients, but no occlusal changes were noted. CONCLUSION: Satisfactory clinical outcomes are obtained after the condylar reconstruction by free grafting of autogenous coronoid process. Therefore, autogenous coronoid process may be a suitable bone resource for condylar reconstruction in patients with TMJ ankylosis.