Does Surgical Release of TMJ Bony Ankylosis Increase the Risk of Trigeminocardiac Reflex? A Retrospective Cohort Study.

PURPOSE: The exact frequency of the trigeminocardiac (TGC) reflex in temporomandibular joint (TMJ) surgery is still controversial. The purpose of the present report was to estimate the frequency of and identify the risk factors for TGC reflex among patients undergoing operative management of TMJ ankyloses. PATIENTS AND METHODS: A retrospective cohort study was conducted of patients who had undergone gap arthroplasty for TMJ ankyloses at Al-Azhar University Hospital, Cairo, Egypt, from 2001 to 2015. The predictor variables were patient demographic data (age and sex), ankylosis type, and surgery type. The outcome variable was the occurrence of the TGC reflex (yes vs no). The data analysis included descriptive statistics and χ2 tests to compare the categorical variables. Binary regression logistic model analysis was performed to identify the associated predictor variable. P values were considered statistically significant at ≤ .05. RESULTS: The sample included 55 subjects. The mean ± standard deviation age of the patients was 21.3 ± 9.855 years, and 43.6% were males. The frequency of TGC reflex was 12.7%. The factors associated with an increased risk of TGC reflex were type IV bony ankylosis (P = .012) and the need for repeat surgery (P = .016.). A multivariable binary regression model analysis demonstrated that the recurrence of surgery was the most significant predictor factor affecting the frequency of the TGC reflex. The computed variance ranged from 13 to 25%. However, other variables, including age, gender, side, and ankylosis type, were not associated with reflex onset (odds ratio, 0.028; 95% confidence interval, 0.001 to 0.911; P = .044). CONCLUSIONS: Recurrent ankylosis surgery carries a high risk of TGC reflex. Preoperative risk factor identification and close monitoring are crucial to prevent the occurrence of this reflex in susceptible patients. Future research projects should include more variables in the study.

Outcome of Surgical Protocol for Treatment of Temporomandibular Joint Ankylosis Based on the Pathogenesis of Ankylosis and Re-Ankylosis. A Prospective Clinical Study of 14 Patients.

PURPOSE: Trauma is the leading cause of temporomandibular joint (TMJ) ankylosis, and the treatment of this condition poses a considerable challenge because of the high incidence of recurrence. The author hypothesized that a treatment of ankylosis based on pathogenesis would result in a better outcome and a lower recurrence rate. MATERIALS AND METHODS: The author designed and implemented a prospective clinical study. The sample was composed of patients with TMJ ankylosis. The predictor variables were the affected side and patient age and gender. The outcome variable was maximal interincisal opening (outcome MIO). Descriptive and bivariate statistics were computed, and the P value was set at less than .05. The protocol consisted of the following steps: 1) perioperative indomethacin for 2 weeks; 2) the creation of a minimal gap of 5 to 10 mm; 3) ipsilateral coronoidectomy and (if required) contralateral coronoidectomy; 4) pterygomasseteric sling and temporalis muscle release; 5) interpositional dermis fat graft fixed to the condylar stump; 6) insertion of a suction drain; 7) immediate aggressive physiotherapy for at least 6 months; 8) regular long-term follow-up; and 9) delayed reconstruction using distraction osteogenesis. RESULTS: The sample was composed of 14 patients (3 male and 11 female). Of these patients, 9 and 5 exhibited unilateral and bilateral ankylosis, respectively, and their ages ranged from 12 to 38 years (median, 18.5 yr). The follow-up period ranged from 24 to 48 months (mean, 32.5 months). Intraoperative MIOs ranged from 38 to 52 mm (mean, 45.7 mm). Postoperative MIOs exhibited a minor decrease in mouth opening (mean, 43.5 mm). The outcome MIOs ranged from 35 to 55 mm (mean, 43.5 mm). Of all patients, 21.4% developed temporary facial nerve paresis (grade II). CONCLUSIONS: The results of the present study suggest that this surgical protocol is effective in the treatment of the TMJ ankylosis and the prevention of re-ankylosis.

Platelet-Rich Plasma Injection as an Effective Treatment for Temporomandibular Joint Osteoarthritis.

PURPOSE: Emerging evidence has suggested that platelet-rich plasma (PRP) might be of assistance in the treatment of degenerative conditions of the joints. The aim of the present study was to compare the use of PRP and hyaluronic acid (HA) in the treatment of temporomandibular joint (TMJ) osteoarthritis (OA) with long-term follow-up data. PATIENTS AND METHODS: Patients meeting the Research Diagnostic Criteria for TMJ-OA were randomly assigned to 1 of 2 study groups that received either PRP or HA. The outcome variables were maximum nonassisted (voluntary) mouth opening (MVMO), joint sounds, and pain index scores. Other variables, including patient age and gender, were evaluated in relation to the outcomes. Descriptive and bivariate statistics were computed, and the P value was set at .05. RESULTS: A total of 50 patients with TMJ-OA were enrolled in the study (29 women and 21 men, age range 31 to 49 years, mean age 38.6). In group I, 25 patients received 3 injections of 1 mL of PRP. In group II, 25 patients received 3 injections of 1 mL of low-molecular-weight HA. Between-group comparisons of the outcome variables over time revealed significant improvements in group II at 1 and 3 months. At 6 and 12 months, the PRP group exhibited better performance compared with the HA group in terms of the recurrence of pain and joint sounds. The improvements obtained with the PRP injections in group I were maintained during the follow-up period. At the end of the follow-up period, the median MVMO in group I was 41.0 mm. In group II, the median MVMO was 39.0 mm. CONCLUSION: PRP performed better than HA acid in the treatment of TMJ-OA during long-term follow-up in terms of pain reduction and increased interincisal distance. Future studies will focus on the synergistic actions of HA and PRP in the treatment of TMJ-OA.

Synergistic effect of platelet rich plasma with hyaluronic acid injection following arthrocentesis to reduce pain and improve function in TMJ osteoarthritis.

Increasing evidence supports the use of platelet-rich plasma (PRP) combined with hyaluronic acid (HA) for the treatment of knee osteoarthritis, which effectively promotes cartilage repair. This study aimed to determine whether injection of PRP+HA following arthrocentesis reduces pain and improves maximum incisal opening. This was a single-blind, prospective, randomized control study. The patients were selected based on the Hegab classification: Group I: patients treated with arthrocentesis followed by a single PRP injection; Group II (Control): patients treated with arthrocentesis followed by a single HA injection; and Group III: patients treated with arthrocentesis followed by a single PRP+HA combination injection. The primary predictor variable was the medication used for injection. The primary outcome variables were the maximum voluntary mouth opening and pain index scores. The secondary outcome variable was joint sounds. All outcome variables were assessed and compared among the three groups at baseline and at 1-, 3-, 6-, and 12-month intervals. Other variables, including patients' age and sex, were evaluated in relation to the patient outcomes. Injecting PRP+HA showed statistically significant improvement in the primary and secondary treatment outcomes over PRP or HA injection throughout the study period (P<0.005). Injection of PRP+HA following arthrocentesis had significant long-term clinical efficacy regarding pain relief that considered the main concern of both the patient and clinician.

Closure of the alveolar cleft by bone segment transport using an intraoral tooth-borne custom-made distraction device.

PURPOSE: The fact that bone transportation generates not only bone but also surrounding soft tissues makes it an ideal technique for tissue regeneration. This study evaluates bone segment transport using an intraoral tooth-borne distraction device for alveolar cleft closure. MATERIALS AND METHODS: Patients with an alveolar cleft were enrolled in the study. They were treated at the Al-Azhar University Hospital, Cairo, Egypt, between 2004 and 2007. Anterior transportation of the posterior dentoalveolar segment was performed by use of an intraoral tooth-borne custom-made distractor. Clinical evaluations included the following: preoperative and postoperative intraoral photographs, vitality testing of the teeth in the transport segment, cast analysis, and measurement of tooth mobility. Radiographic evaluations included occlusal films, orthopantomography, and computed tomography and 3D computed tomography for volumetric and densitometric evaluations of the distracted bone. RESULTS: After distraction was completed, the transported segments were positioned 1 to 4 mm superior to the occlusal plane. The radiographic evaluation showed residual triangular bone deficits that were closed through gingivoperiosteoplasty or bone grafting. Once the transported segments came in contact with the alveolar bone of the normal side, the intervening fibrous tissue at the docking site was removed, and docking-site surgery was then performed. The results obtained from both clinical examinations and radiographic imaging showed complete closure of the alveolar clefts. CONCLUSIONS: Maxillary alveolar bone transport offers an alternative technique in the latest treatment of the alveolar cleft.

Classification of temporomandibular joint internal derangement based on magnetic resonance imaging and clinical findings of 435 patients contributing to a nonsurgical treatment protocol.

This prospective clinical study aimed to establish a new classification system for TMJ internal derangement based on MRI in correlation with clinical findings contributing to a nonsurgical treatment protocol. A consecutive sample of 435 internal derangement patients was enrolled in the study. Clinical and MRI studies were used to establish the new classification system. A total of 747 joints were classified according to our staging system and received treatment according to the associated nonsurgical treatment protocol. The primary outcome variables were maximum voluntary mouth opening and visual analogue scale pain scores. The secondary outcome variable was joint sound. Statistical analysis of the differences between pretreatment and posttreatment measurements showed an increase in mouth opening throughout the study period (P < 0.001 at 12 m posttreatment). Statistical analysis of the VAS scores showed a statistically significant decrease in all study groups during all study periods, with P < 0.0001 at 12 months posttreatment. Statistical analysis of joint sounds showed significant improvement during all study periods. The new classification system is a simple, & reasonable including a detailed description of all the pathologic changes of the joint. The nonsurgical treatment protocol was Simple, effective and specific depending on the pathological changes in joint.

MRI-based determination of occlusal splint thickness for temporomandibular joint disk derangement: a randomized controlled clinical trial.

OBJECTIVE: This prospective study examined a method using magnetic resonance imaging (MRI) to assess the appropriate effective occlusal splint vertical thickness in the management of disk derangement. STUDY DESIGN: Patients were diagnosed as having internal disk displacement of the temporomandibular joint and were divided into 2 groups. Group I (disk displacement with reduction) was subdivided randomly into 2 subgroups: subgroup IA (control group) comprising patients treated with 3-mm-thick splints; and subgroup IB (study group) comprising patients treated with MRI-based splint thickness. Group II (disk displacement without reduction) was subdivided randomly into 2 subgroups: subgroup IIA (control group) comprising patients treated with 3-mm-thick splints; and subgroup IIB (study group) comprising patients treated with MRI-based splint thickness. The primary outcome variables were maximum voluntary mouth opening and visual analogue scale scores for pain. The secondary outcome variable was joint sound. The final sample was composed of 162 patients (Group I = 90 and Group II = 72). RESULTS: Statistical analysis showed significant improvement of the clinical outcomes in subgroups IB and IIB compared with that in subgroups IA and IIA. CONCLUSIONS: On the basis of MRI measurements and clinical outcome, the present study we recommend 4-mm and 6-mm vertical splint thickness for disk displacement with reduction and disk displacement without reduction, respectively, for 1 year.

Treatment of chronic recurrent dislocation of the temporomandibular joint with injection of autologous blood alone, intermaxillary fixation alone, or both together: a prospective, randomised, controlled clinical trial.

Our aim was to evaluate the efficacy of autologous blood injection in the treatment of chronic recurrent dislocation of the temporomandibular joint (TMJ) in a prospective randomised controlled clinical study. Forty-eight patients (11 men and 37 women) with chronic recurrent dislocation of the TMJ were randomly assigned to 1 of 3 equally sized groups. Patients in the first group were treated with injection of autologous blood (ABI) alone into the superior joint space and the pericapsular tissues. Those in the second group were treated with intramaxillary fixation (IMF) alone for 4 weeks, and those in the third group were treated with ABI and IMF for 4 weeks. Interincisal distance, digital panoramic radiograph, incidence of recurrent dislocation, and pain in the TMJ were assessed postoperatively at 2 weeks and at 1, 3, 6, and 12 months. The mean (SD) reduction in interincisal distance in the group treated with both techniques was 11.0 (1.9), which was significantly higher than in either the group treated with ABI, which was 8.5 (2.4) or IMF, which was 9.1 (2.1). The results in the ABI group and the IMF group did not differ significantly. The combined group showed the biggest decrease. The ABI alone group had the most recurrences (n=8, which were treated by repeated injections with no recurrence after the third). The IMF alone group had only 3 and there were none in the combined group. We conclude that ABI is a simple and safe technique for the treatment of dislocation of the TMJ in the outpatient clinic. Recurrence can be overcome by multiple injections. However, the best clinical results are given by a combination of ABI and IMF.