The ESTMJS (European Society of Temporomandibular Joint Surgeons) Consensus and Evidence-Based Recommendations on Management of Condylar Dislocation.

Although condylar dislocation is not uncommon, terminology, diagnostics, and treatment concepts vary considerably worldwide. This study aims to present a consensus recommendation based on systematically reviewed literature and approved by the European Society of TMJ Surgeons (ESTMJS). Based on the template of the evidence-based German guideline (register # 007-063) the ESTMJS members voted on 30 draft recommendations regarding terminology, diagnostics, and treatment initially via a blinded modified Delphi procedure. After unblinding, a discussion and voting followed, using a structured consensus process in 2019. An independent moderator documented and evaluated voting results and alterations from the original draft. Although the results of the preliminary voting were very heterogenous and differed significantly from the German S3 guideline (p < 0.0005), a strong consensus was achieved in the final voting on terminology, diagnostics, and treatment. In this voting, multiple alterations, including adding and discarding recommendations, led to 24 final recommendations on assessment and management of TMJ dislocation. To our knowledge, the ESTMJS condylar dislocation recommendations are the first both evidence and consensus-based international recommendations in the field of TMJ surgery. We recommend they form the basis for clinical practice guidelines for the management of dislocations of the mandibular condyle.

Nearthrosis in true long-standing temporomandibular joint dislocation; a report on pathogenesis and clinical features with review of literature.

The behavior and function of the condyle are not the same in every type of temporomandibular joint (TMJ) dislocation. Acute displacement or dislocation of the condyle is not a rare incident, and the treatment modalities have been well known by physicians for a long time. Chronic dislocation of the condyle is considered a relatively common entity for which treatment may indispensably be surgical intervention. Type of dislocation, duration and the number of episodes are taken into account while constructing the treatment plan. Chronic dislocation that has been left untreated for a long time is a relatively less often encountered type exhibiting difficult clinical conditions for treatment. This type of dislocation is usually seen in elderly patients with poor general health conditions and can be classified as "long-standing dislocation." In this clinical condition, after having some chronic dislocation episodes, the condyle leaves the original fossa, sits in the anterior part of the eminence permanently, creates a new fossa and never gets back to the original place again. Duration is the most important criterion in classifying long-standing dislocations and has a great effect on decisions regarding the type of management. The relevant literature includes few reports, most of which speculate upon "duration," which varies on a large scale ranging from 5 weeks to 33 years. There has been neither an agreement on time span within which long-standing dislocation develops, nor a universally accepted definition for what "long-standing" is indeed meant to be. On the other hand, in some cases, the condition has been named "true long-standing dislocation" due to some permanent pathological changes that the TMJ undergoes, such as pseudoarticulation/nearthrosis/false joint/neo-joint. In this paper, management of true long-standing/permanent dislocation in two patients, whose conditions lasted more than 1 year and resulted in permanent changes in TMJ anatomy, is presented. Due to the poor general health condition of the two elderly patients, they were treated in the most conservative way possible. In one of the patients, eminectomy and head-gear application were used to attain gradual relocation of the condyles. Rehabilitation of masticatory function of the other patient was improved prosthetically.

A study on etiopathogenesis and clinical features of multi-headed (bifid and trifid) mandibular condyles and review of the literature.

PURPOSE: The formations of second or more condylar heads are considered as rare anomalies. Fourteen multi-headed condyles (MHC) were presented; 13 of these were bifid mandibular condyles (BMC), whereas one exceptionally rare case was a trifid mandibular condyle (TMC). The TMC presented in this paper is the eighth case reported in the literature. In this paper, etiopathogenesis, types, and treatments are discussed. MATERIALS AND METHODS: Patients were classified according to their status, etiologies, gender, functions of the mandible, interocclusal distances, pathological conditions, types, and treatment received. RESULTS: BMCs were classified into two groups: type I BMCs were nontraumatic, nonsymptomatic, mediolateral, presumably developmental, and characterized by shallow grooves. Type II BMCs were traumatic and may have two subgroups. The first group of type II BMCs were mediolateral and Y-shaped. The second group of type II BMCs were characterized by two separate and anteroposteriorly located condyles. CONCLUSION: Treatment depended on patients' complaints. In this study, asymptomatic patients did not receive therapy, whereas patients with temporomandibular join internal derangement received medical treatment, and patients with ankylosis had surgical treatment.

Formation of Condyle-Like Structure after Treatment of Temporomandibular Joint Ankylosis: Literature Review and Long-Term Follow-Up of Two Patients.

Treatment of ankylosis is one of the greatest challenges in temporomandibular joint (TMJ) surgery. To provide a satisfactory mouth opening, as well as normal jaw function, and to prevent reankylosis in the long term are the most important principles in the treatment of TMJ ankylosis. These functions have been attained in both of the presented patients in the long term. It is known that heterotopic bone formation is rare in the maxillofacial area, but rapid bone regeneration which reconstitutes a new condyle is rarer. The purpose of the presented paper is to reveal the existence of an inherent capability of the mandible, rapid bone growth of the ramus mandible, and reformation of a previously nonexisting condyle after resection of the ramus in patients with TMJ ankylosis. In this paper, two unusual cases of unexpected condyle-like structure formation after treatment of ankylosis were presented.

Relationship between activity of gluthatione peroxidase and nitric oxide in synovial fluid and the progression of temporomandibular joint internal derangement.

The purposes of this study were to measure the activity of glutathione peroxidase (GPX) and nitric oxide (NO) in the synovial fluid of patients with temporomandibular joint (TMJ) internal derangement (ID) and to indicate the relationship between the activity of GPX and NO and the progress of the ID. Twenty-six patients with TMJ ID were identified and classified according to Wilkes staging through clinical and radiologic examinations. Levels of GPX were determined indirectly by a coupled reaction with glutathione reductase. Levels of NO were measured colorimetrically. The activity of GPX and NO was observed to be progressively increasing as the stage of the TMJ ID progressed. There were significant correlations between the 2 substances and the Wilkes stages. Oxidative stress may have a role in the pathogenesis of TMJ ID. In synovial fluid, GPX and NO activities are increased as the stage of the disease increased. Increase in the activities of GPX might not be enough to prevent progression of the TMJ ID.

Tumor necrosis factor-alpha levels in the synovial fluid of patients with temporomandibular joint internal derangement.

PURPOSE: The purpose of this study was to investigate the level of tumor necrosis factor-alpha (TNF-α) in the synovial fluid (SF) of patients with temporomandibular joint (TMJ) internal derangement and to show the relationship between the level of TNF-α and the severity of the disease. MATERIALS AND METHODS: Arthrocentesis was performed on 32 female and five male patients (aged between 17 and 45) referred to our clinic with the complaint of TMJ pain and discomfort. TNF-α levels were determined in the SF samples obtained during arthrocentesis. As a measure of pain, visual analog scale (VAS) scores were also evaluated. RESULTS: There were statistically significant differences in VAS scores between the stages. VAS scores were found to be elevated as the stage of disease progressed. Increased levels of TNF-α were found in progressive stages of internal derangement. CONCLUSION: In our study, both SF TNF-α levels and pain levels (VAS scores) were found to be increased in patients with internal derangement as the stage of the disease progresses. TNF-α might contribute to the pathogenesis of synovitis and the degeneration of the TMJ cartilage and bone.

A clinical study on survival rate of patients with squamous cell carcinoma of the lower lip in Kosovo.

OBJECTIVE: The aim of this study is to find out the survival rate of patients with squamous cell carcinoma of the lower lip in Kosovo and to see the effect of stage of disease on the success of surgical treatment. PATIENTS AND METHODS: 789 patients with SCCLL who were referred to the Department of Maxillofacial Surgery, University Clinical Centre of Kosovo, were examined during a period of 20 years (between 1993 and 2013). 614 (77.82%) of these patients received treatment and have regularly visited the department once every 3 months for post-operative controls. Data have been collected from these 614 patients for 10 years; thus the follow-up period lasts for 10 years for every patient under control. The collected data were analysed using Chi square test. Patients were classified by sex, aetiology, stage of the disease, location of the disease, the treatment patients received, metastasis rate and survival rate. RESULTS: The most susceptible patients were those at ages between 50 and 70. The youngest patient was 8 years old whereas the oldest was 92. The male-female ratio was 5:1. 57% of the patients had been working outdoors and had been exposed to sunlight. Ten years survival rate for the Stages I, II, III and IV was 91.7%, 83.7%, 28% and 11.4% respectively. CONCLUSION: It was found that the success of the surgery was closely related with the stage of disease and early diagnosis. Training the relevant parties (i.e., the people, family doctors etc.) on early diagnosis would improve the survival rate.

Zygomaticocoronoid ankylosis: a rare clinical condition leading to limitation of mouth opening.

Ankylosis, between the coronoid process and the zygoma, is a rare occurrence. A review of the literature has disclosed 15 reported cases of this disorder. True incidence of this condition might be even higher. Zygomaticocoronoid ankylosis might have been encountered by many surgeons, and yet it has been misdiagnosed or overlooked.In this article, the treatment of a 14-year-old patient with zygomaticocoronoid ankylosis is presented. With regard to treatment, there are various opinions as to whether the coronoidectomy be performed intraorally or extraorally. In this study, treatment of the patient has been performed via intraoral approach.

Malondialdehyde levels in dental follicles of asymptomatic impacted third molars.

PURPOSE: Increased levels of reactive oxygen species lead to oxidative stress and tissue damage. Malondialdehyde (MDA) is one of many low-molecular-weight endproducts of lipid peroxidation that increases with oxidative stress. The aim of this study was to determine oxidative stress in dental follicles (DFs) of radiologically asymptomatic impacted third molars (ITMs) using MDA. MATERIALS AND METHODS: This study involved 40 DFs of 40 patients referred for clinically and radiographically asymptomatic ITMs. Forty healthy gingival tissues in the same patients were obtained during surgical removal of teeth as a control group. DF widths on periapical radiographs narrower than 2.5 mm were included in the study. All tissues samples were analyzed for MDA as an indicator of oxidative stress. RESULTS: Levels of MDA were significantly higher in DFs from ITMs than those from healthy gingival tissues of the same patients (P < .01). CONCLUSION: The results suggest that significant oxidative stress may occur in DFs of asymptomatic ITMs. The findings suggest that increased MDA may play an important role in oxidative stress in DFs. In light of these preliminary findings of the present study, further investigations and comprehensive studies are required to determine the role of antioxidants that scavenge free radicals in DFs.

Surgical and prosthetic rehabilitation of edentulous adult cleft palate patients by dental implants.

Adult patients who did not receive proper treatment for cleft palate are challenging for clinicians in terms of prosthetic rehabilitation. Moreover, during the late stages of adulthood when patients become edentulous, prosthetic reconstruction becomes even more challenging. This clinical report describes the prosthetic rehabilitation of 2 edentulous geriatric patients with unrepaired cleft palate by placement of dental implants after closure of the oronasal communications.

Surgical and prosthodontic rehabilitation in a patient with Freeman-Sheldon syndrome.

Dental and prosthetic rehabilitation possess significant challenges in patients who have Freeman-Sheldon syndrome. Microsomia is one of the main diagnostic criteria for Freeman-Sheldon syndrome, and it creates difficulty in working in the intraoral cavity. Most patients with small orifice often have difficulties in oral hygiene maintenance, and it gives rise to loss of some of the teeth. It incurs the need for dental and oral treatment. In the presented study, the patient with limited mouth opening that disabled the dentists to perform dental treatment was given prosthodontic therapy after having commissuroplasty and implant placement simultaneously.

Bidirectional temporomandibular joint ankylosis: a rare, disabling condition of mastication.

Temporomandibular joint (TMJ) ankylosis is characterized by a bony mass that generally creates difficulty in 1 direction, opening the mouth. In this paper, the patient who presented was experiencing difficulty in 2 directions, both in opening and closing the mouth. A rare disabling condition of mastication and bidirectional ankylosis and its surgical treatment have been presented. Bidirectional temporomandibular joint ankylosis is a rare condition that disables the patient both to open and close the mouth. The left side of type 2 ankylosis (Sawhney, Plast Reconstr Surg 1986;77:29-38) was treated conservatively. Disc was preserved and used as interpositional material. In treatment of the right side, which was type 4 ankylosis (Sawhney, Plast Reconstr Surg 1986;77:29-38), a gap was created, and then, a titanium fossa implant was placed to prevent ankylosis.

Management of chronic recurrent temporomandibular joint dislocations: a retrospective study.

PURPOSE: The purpose of this study is to evaluate the clinical results of patients who received surgical treatment for chronic recurrent dislocations (CRD). In our clinical practice CRD patients were classified into 5 types depending upon their aetiology. These patients were treated by two different surgical techniques, eminectomy or augmentation of the eminence by autograft depending on their classification. MATERIALS AND METHODS: Nineteen patients with CRD attended the clinic for surgical treatment. Patients were classified accordingly into 5 types of CRD. Eminoplasty was used in the treatment of twelve patients with type I and II disease. An oblique osteotomy of the eminence was carried out. Harvested chin graft was contoured to a wedge form and inserted tightly into the osteotomy site. The augmentation of the eminence was provided by an inlay cortical bone graft without using any of the conventional fixation materials. The remaining 7 patients with type III, IV and V disease were treated by eminectomy. The factors evaluated were pre- and post-operative maximal incisor opening, sex, age, number and type of previous operations, cause and type of the CRD, and the previous treatment of the patients. RESULTS: The survey is based on nineteen patients who were treated in the same department. Patients age ranged from 22 to 80 years. Females are dominated in the study. The follow-up period ranged from 1 to 12 years. Free excursions of the condyles were achieved in the patients treated by two different techniques. On the other hand, maximum interincisal openings were higher in the patients treated by eminectomy when compared with the patients who had eminoplasty. CONCLUSION: So far as the quality of life for the patients with CRD is concerned, the most appropriate technique (whether it be to confine the condyle or allow its free movement) to be employed should be decided by following an comprehensive evaluation of the patients' history.

A clinical study on temporomandibular joint ankylosis in children.

Temporomandibular joint (TMJ) ankylosis is a disabling condition of the masticatory system and is most commonly due to trauma, infections, and some systemic diseases. Hypomobility affects the surrounding structures as well as the joint itself. Ankylosis arising in early childhood usually leads to facial asymmetry. Ankylosis in children usually occurs from an intracapsular compression fracture or rarely from a suppurative arthritis of middle ear infection.Treatment of the ankylosis is probably one of the greatest challenges in TMJ surgery, and the treatment of TMJ ankylosis in children is much more challenging than in adults because of high recurrence and the probable change in the unpredictable growth of the mandible. In treatment of TMJ ankylosis in children, to maintain a normal growth and the development of the face is as important as to provide a satisfactory mouth opening with free movement of the mandible.A variety of techniques and various success rates in the treatment of TMJ ankylosis both in adults and in children have been reported. However, no single method has produced uniformly successful results. In this study, gap arthroplasty was applied in 6 patients, and 2 different types of fossa implants were used as interpositional material in the other 8 patients, and the results of the treatments have been evaluated retrospectively.

A clinical study on treatment of temporomandibular joint chronic recurrent dislocations by a modified eminoplasty technique.

Various augmentation techniques have been proposed to incarcerate the condyle for the treatment of temporomandibular joint chronic recurrent dislocation (CRD). Some of them have been used successfully, whereas some of them failed. The purpose of this study was to present an alternative eminoplasty technique, more specifically an inlay augmentation technique of articular eminence in the treatment of temporomandibular joint CRD. Twelve patients, 11 of whom had bilateral and the remaining 1 of whom had unilateral CRD, were evaluated. The same technique was used in the treatment of all patients. An oblique osteotomy of the eminence was carried out. Harvested chin graft was contoured in wedge form and inserted tightly into the osteotomy site. The augmentation of the eminence was provided by an inlay cortical bone graft without using any of the conventional fixation materials used to secure the bone graft. All of the symptoms of CRD have disappeared in the postoperative stage. Long-term follow-up revealed satisfactory mouth opening and augmentation of the eminence. None of the fixation materials such as wire, screw, or miniplate were used to keep the bone graft in proper place, and yet, patients had no further episode. It provided shorter operating time for surgeon and satisfactory postoperative results.

Superoxide dismutase activity in synovial fluids in patients with temporomandibular joint internal derangement.

PURPOSE: To measure the activity of superoxide dismutase (SOD) in the synovial fluid of patients with temporomandibular joint internal derangement and to show the relationship between the activity of SOD and the severity of the disease. MATERIALS AND METHODS: Twenty patients with internal derangement were classified according to Wilkes by clinical radiological examinations. SOD activity was measured by the method based on nitrobluetetrazolium reduction rate. RESULTS: The activity of SOD seemed to be progressively decreased as the stage of the disease increased. CONCLUSION: The reduction of SOD activity observed may result from insufficient scavenging capacity of free radicals. Further investigation and longitudinal studies are required to determine the role of antioxidants that scavenge the free radicals in temporomandibular joint disorders.

Rehabilitation of severely atrophied mandible using free iliac crest bone grafts and dental implants: report of two cases.

The purpose of this study was to reveal the improvement in facial esthetics and maintenance of mastication in severely atrophied mandibles with inadequate alveolar ridges in 2 patients. Bone graft harvested from iliac crest was used for the reconstruction in the first case, followed by the application of 2 dental implants after 6 months. A free iliac bone graft and 2 dental implants were also used simultaneously with a 1-stage surgery in the second case; the patient had previously had a mandibular reconstruction with a rib graft. Both of the patients achieved remarkably functional and esthetic improvements after treatment. Free iliac bone graft is considered to be a favorable alternative for the maintenance of satisfactory functional and esthetic results in patients with severely atrophied alveolar ridges.

Healing of bone defects by an osteopromotion technique using solvent-dehydrated cortical bone plate: a clinical and radiological study.

Osseous defects of the jaws following trauma, cysts, infection or congenital deformity may show poor osteogenesis and the affected area may never be completely filled with bone. It is widely accepted in guided tissue regeneration that physically halting soft connective tissue proliferation into bone allows bone regeneration. This concept is called the "osteopromotion principle." The purpose of the present study was to evaluate the effect of solvent-dehydrated cortical bone plates as a barrier to allow bone regeneration by assessing the osteopromotion principle. 30 patients (18 male, 12 female) with cystic lesions of the jaws were assigned to two different groups. The patients in Group A were treated by enucleation. In Group B, were treated by removal of the lesion and placing a solvent-dehydrated cortical bone plate on top of the cyst cavity to avoid ingrowth of connective tissue. Both groups were evaluated radiographically using spiral-computed tomography (CT) before surgery and 12 months postoperatively. In group B, all cystic cavities showed complete bone healing in 12 months. At the same period, invasion of the soft connective tissue were observed in the patients treated only by enuclation. This study demonstrates that solvent-dehydrated cortical bone plates can be used as a barrier in treatment of cyst cavities and they hinder ingrowth of connective tissues and promote successful bone healing.

Inappropriate treatments in temporomandibular joint chronic recurrent dislocation: a literature review presenting three particular cases.

Chronic recurrent dislocation (CRD) is characterized by a condyle that slides over the articular eminence, catches briefly beyond the eminence, and than returns to the fossa. A variety of techniques have been proposed for the treatment of CRD involving tightening of the capsule with sclerosing agents, capsular plication, open condylotomy, eminectomy, and eminoplasty. In eminoplasty, to produce a barrier and eventually to incarcerate the condyle, zygomatic down-fracture, and autografts were used. Studies incorporating the use of screws and wires in the treatment of CRD have never been published. In this article, complications in three patients with CRD who were previously treated by screw eminoplasty and their treatment are presented. Three of the patients were referred to the author's clinic with reports of spontaneous and severe pain around the TMJ area. All of the patients reported in the article were treated previously by other surgeons by fixing screws on articular eminences in an attempt to limit the excursion of the condyle. Placement of materials such as screws with the purpose of creating a barrier, erosion of the articular eminence, and the anterior wall of the condyle are the major problems for this type of surgical option. The other option, as it is applied in treatment of the three cases presented, is to remove the barrier to enable spontaneous reduction, a process that is accomplished best by eminectomy.

Changes in pharyngeal airway space and hyoid bone positions after body ostectomies and sagittal split ramus osteotomies.

UNLABELLED: Although mandibular setback might lead to possible pharyngeal narrowing, the development of obstructive sleep-related breathing disorders may occur because of multiple factors. In this study, the changes in the pharyngeal airway space (PAS) and the hyoid bone position have been evaluated before and after surgery in patients who underwent body ostectomy (BO) and sagittal split ramus osteotomy (SSRO). In addition, the effects of the BO on PAS and on hyoid bone position have been compared with the effects of the SSRO. MATERIAL AND METHODS: Thirty patients with mandibular prognathism underwent mandibular setback osteotomy. The patients were divided into two groups: BO group, 15 patients (5 men, 10 women) who underwent BO; and SSRO group, 15 patients (11 men, 4 women) who underwent SSRO. Changes in PAS and hyoid bone position were analyzed throughout the preoperative and early and long-term postoperative periods via lateral cephalometric radiographs. RESULTS: A decrease has been observed in the PAS area and the anteroposterior dimension of the PAS detected in all patients in the long-term period. Hyoid bone revealed backward and downward movement during the early postoperative period; however, it showed a tendency to return to its original anatomic position during the long-term postoperative period. None of the patients had disturbances in respiration. CONCLUSION: After BO and SSRO, a decrease in PAS area was observed, and this decrease also continued in the long-term period. Our results revealed a decrease in PAS area after BO, but the decrease was less than that in cases having SSRO.