Oral and maxillofacial surgeons' assessment of the role of Pernkopf's atlas in surgical practice.

BACKGROUND: The use of the Pernkopf atlas of human anatomy in surgery presents ethical challenges due to the author's association with the Nazi regime and the potential depiction of victims of this regime. The atlas was of particular utility to two surgical specialties: nerve surgeons and oral and maxillofacial surgeons. The representation of peripheral nerves and complex head and neck anatomy is probably unequaled in any other atlas of anatomy. While the ethical implications of the use of Pernkopf's atlas among nerve surgeons have been previously assessed, this study focuses on the volume dedicated to detailed images of head and neck dissections, and the ethical implications of using this atlas by oral and maxillofacial surgeons. OBJECTIVE: To (1) assess the role of the Pernkopf atlas in oral and maxillofacial surgeons' current practice and (2) determine whether a proposal of four conditions would provide ethical guidance for use in surgery and education. METHODS: Members of three American oral and maxillofacial surgical societies (ACOMS, ASTMJS, AAOMS) were surveyed and 181 responses collected. The survey introduced the historical origin of the Pernkopf atlas, and respondents were asked whether they would use the atlas under specific conditions that could be a recommendation for its ethical handling. An anatomical plate comparison between Netter's and Pernkopf's atlases was performed to compare accuracy and surgical utility. RESULTS: Forty-nine percent of respondents were aware of the Pernkopf atlas, and 9% of respondents were currently using it. Amongst those aware of the historical facts, 42% were comfortable using the atlas, 33% uncomfortable, and 25% undecided. The four conditions involving disclosure, bioethical and religious considerations, and remembrance led to 75% of those "uncomfortable" and "undecided" becoming "comfortable" with use. CONCLUSIONS: Amid recent developments and controversy regarding the Pernkopf atlas, a proposal detailing conditions for an ethical approach may provide guidance in surgical planning and education. Furthermore, this approach has implications for the future preparation and publication of anatomical atlases and their use.

Early Clinical Outcomes of Arthroscopic Management of the Failing Alloplastic Temporomandibular Joint Prosthesis.

PURPOSE: Total joint replacement is the recommended treatment for end-stage temporomandibular joint (TMJ) disease. The goal of treatment is to help the return to acceptable function with improvement of the maximum incisal opening (MIO) and a reduction of pain. When a prosthetic joint shows late complications, surgical management includes an open approach, with debridement, cultures, and prosthetic replacement as options. The purpose of the present study was to evaluate the early outcomes of arthroscopic management of failing prosthetic TMJs (PTMJs). PATIENTS AND METHODS: The inclusion criteria were patients with custom or stock joints with complaints of limitation of mouth opening and pain, who had undergone arthroscopy. The exclusion criteria were patients with radiographic heterotopic bone formation, improvement with antibiotic treatment, and failed hardware found on imaging studies. RESULTS: A total of 9 patients were included in the present study (all women), with 5 unilateral and 4 bilateral PTMJs, for a total of 13 sides that underwent arthroscopy. Their mean age was 40 years (range, 23 to 65 years). The mean preoperative MIO was 25 mm, and the mean preoperative visual analog scale for pain and functional limitation scores were both 8 of 10. The corresponding scores were 4 of 10 and 3 of 10 at 3 months postoperatively. CONCLUSIONS: Arthroscopic management of prosthetic joints has been reported in orthopedic studies, with benefits shown in the diagnosis and management of synovial impingement and arthrofibrosis. The results from the present study demonstrated that the early clinical outcomes of arthroscopic management of PTMJs is promising for decreasing pain and increasing the MIO. Larger studies with longer follow-up are needed to further classify the different causes of prosthetic failure and advance the approaches to management.

Does the Age of a Patient Affect the Outcome of Temporomandibular Joint Arthroscopic Surgery?

PURPOSE: Although temporomandibular joint (TMJ) disorders encompass all age groups, it is generally considered to affect young to middle-age adults. The aim of this investigation was to study patients who met the criteria for TMJ arthroscopy and to determine whether there was a difference in outcomes between younger and older patients. MATERIALS AND METHODS: This was a retrospective chart review of patients who underwent TMJ operative arthroscopy. The primary variable studied was patient age. Major outcome variables included changes in subjective pain measured by a visual analog scale (VAS) and changes in maximum interincisal opening (MIO) after arthroscopic surgery. Other variables of interest included the presence of systemic disease, synovitis, and osteoarthritis diagnosed arthroscopically. Data analysis included the Student t test, regression analysis (R Studio, Boston, MA), and χ2 test with a P value less than .05 indicating statistical significance. RESULTS: The study population consisted of 103 patients diagnosed with internal derangement and severe inflammatory or degenerative TMJ disease (Wilkes stages II to V) who underwent operative arthroscopy. Patients were divided into 2 groups based on age (group Y, <40 yr old, n = 51, mean age, 26 yr; group O, >40 yr old, n = 52, mean age, 56 yr). The presence of osteoarthritis diagnosed arthroscopically was significantly greater in group O than in group Y (P < .01). There was significant postoperative improvement in pain (VAS) and MIO in group Y (P < .01) and group O (P < .01). Although the 2 groups showed substantial improvement after arthroscopy, when comparing differences in outcomes between the groups, the absolute postoperative pain level for group O was significantly lower than for group Y (P < .05). Comparison of postoperative MIO did not show a significant difference between group Y and group O (P = .286). CONCLUSIONS: Groups Y and O showed substantial improvement in pain (VAS) and mandibular mobility (MIO) after surgical TMJ arthroscopy. Group O had a higher prevalence of arthroscopically diagnosed osteoarthritis and lower postoperative pain levels compared with group Y. Older patients with advanced TMJ disease responded well to TMJ arthroscopy.

Internal Derangement of the Temporomandibular Joint: New Perspectives on an Old Problem.

Internal derangement is caused by loss of the structure and function of the intra-articular tissues, leading to a failure in the biomechanics of the temporomandibular joint. This tissue failure is usually caused by joint overload, leading to an inflammatory/degenerative arthropathy of the temporomandibular joint. The intra-articular changes associated with internal derangement of the temporomandibular joint can also be caused by a systemic arthropathy or a localized atypical arthropathy involving the temporomandibular joint. Clinicians must be diligent in establishing the correct diagnosis and cause of the internal derangement, which ultimately leads to the appropriate management of patients with these disorders.

Minimally Invasive Treatment of Temporomandibular Joint Ankylosis and Fibrosis of Temporalis Muscle.

A case of severe mandibular hypomobility due to fibrosis of the left temporalis tendon, combined with ankylosis of the temporomandibular joint, is presented. This case emphasizes the importance of reconstructing the historical timeline to establish a correct diagnosis, ultimately leading to appropriate treatment. The use of minimally invasive surgical techniques and the importance of postoperative rehabilitation are emphasized.

The essential role of the otolaryngologist in the diagnosis and management of temporomandibular joint and chronic oral, head, and facial pain disorders.

This article clarifies the current state of knowledge of chronic oral, head, and facial pain (COHFP) conditions with the inclusion of temporomandibular joint disorders as just one component of the variety of conditions that can cause head and facial pain. Obtaining an accurate diagnosis in a timely manner is extremely important because COHFP symptoms can be caused by a variety of pathologic conditions that can be inflammatory, degenerative, neurologic, neoplastic, or systemic in origin. The essential role of the specialty of otolaryngology in the diagnosis and management of patients with these complex COHFP conditions is emphasized.

Diagnosis and treatment of temporomandibular disorders.

Current concepts and recommended treatment for temporomandibular disorders (TMDs) and temporomandibular joint pain and dysfunction have evolved over time. This article attempts to distill the current information for this often confusing topic into relevant clinical issues that will allow the general dental practitioner to be better able to diagnose and interpret clinical findings, and institute a therapeutic regimen that will provide needed relief to patients suffering from TMD dysfunction. Current management methods, both surgical and nonsurgical, are reviewed and discussed.

Rationale for early versus late intervention with arthroscopy for treatment of inflammatory/degenerative temporomandibular joint disorders.

PURPOSE: The goal of this study was to determine if there were differences in outcomes of arthroscopic surgery in patients with inflammatory/degenerative temporomandibular joint (TMJ) disease who underwent early surgical intervention versus late surgical intervention. MATERIALS AND METHODS: The study population included 44 consecutive patients who met the criteria for TMJ operative arthroscopy who were divided into early and late intervention groups. The time between the onset of symptoms and the performance of arthroscopy was used to determine entry into the early versus late intervention group. All groups were evaluated for changes in preoperative versus postoperative pain levels based on visual analog scale (VAS) scores and maximum interincisal opening distance. Statistical analyses included the Student t test to determine if there were significant differences between preoperative and postoperative assessments in the early and late intervention groups. RESULTS: The mean time between onset of symptoms in the early intervention group (21 patients) was 5.4 months compared with 33 months in the late intervention group (23 patients). All patient groups had statistically significant decreases in pain and improvement in maximum interincisal opening distance after arthroscopy. The early intervention group had a mean decrease in VAS pain scores of 5.14 compared with the late intervention group with a mean decrease in VAS pain scores of 2.84, and this difference was significant (P = .012). The early intervention group had a mean increase in maximum interincisal opening of 12.38 mm compared with the late intervention group with a mean increase of 7.70. Although statistical significance was not achieved for increases in maximum interincisal opening between the early and late intervention groups (P = .089), the difference between the 2 groups was suggestive of a trend. There were no surgical complications for either group; however, 2 patients in the late intervention group developed persistent chronic neuropathic pain, requiring pain management. CONCLUSIONS: TMJ arthroscopy reliably decreased pain and increased the maximum interincisal opening distance in the early and late intervention groups. The early intervention group had better surgical outcomes than the late intervention group. Arthroscopic surgery should be considered early in the management of patients with inflammatory/degenerative TMJ disease.

Dental premedication protocols for patients with knee and hip protheses.

In 1997, the American Dental Association (ADA) and the American Academy of Orthopaedic Surgeons (AAOS) published an advisory statement regarding antibiotic prophylaxis for patients with total joint replacements undergoing dental treatment. The first periodic update of these guidelines was published in 2003. Nevertheless, confusion exists among dentists and physicians as to the clinical indications for premedication in this patient population. This article serves as an overview of current recommendations for use of chemoprophylaxis in the dental treatment of patients ith prosthetic joints.

Dental premedication protocols for patients with knee and hip prostheses.

In 1997, the American Dental Association (ADA) and the American Academy of Orthopaedic Surgeons (AAOS) published an advisory statement regarding antibiotic prophylaxis for patients with total joint replacements undergoing dental treatment. The first periodic update of these guidelines was published in 2003. Nevertheless, confusion exists among dentists and physicians as to the clinical indications for premedication in this patient population. This article serves as an overview of current recommendations for use of chemoprophylaxis in the dental treatment of patients with prosthetic joints.

The relationship between temporomandibular joint synovitis and adhesions: pathogenic mechanisms and clinical implications for surgical management.

PURPOSE: The purpose of this investigation was to determine the relationship between arthroscopically diagnosed synovitis and adhesions in a population of patients with significant limitation of mandibular opening and temporomandibular joint pain. PATIENTS AND METHODS: Temporomandibular joint arthroscopy was performed on 126 joints in 80 patients (female:male = 5.7:1; mean age = 35.5 years; mean duration of symptoms = 50 months). All patients were diagnosed with severe temporomandibular joint disease recalcitrant to conservative therapy. Each joint was evaluated arthroscopically for the presence of synovitis and adhesions. Chi-squared analysis was performed to determine if there was a significant relationship between the presence of synovitis and adhesions. RESULTS: Diagnostic arthroscopic examination showed the following: no synovitis and no adhesions in 18/126 joints (14%), no synovitis with adhesions present in 33/126 joints (26%), synovitis with no adhesions in 13/126 joints (10%), and synovitis and adhesions present in 62/126 joints (49%). Statistical analysis showed a significant relationship between arthroscopically diagnosed synovitis and adhesions. CONCLUSION: Synovitis and adhesions are commonly present in the temporomandibular joints of patients requiring arthroscopic surgery due to painful limitation of mandibular movement. Excessive mechanical stress on the temporomandibular joint leads to maladaptive responses in the articular and synovial tissues, ultimately leading to synovitis, osteoarthritis and the formation of adhesions. An understanding of the pathogenic mechanisms that lead to synovitis, osteoarthritis and adhesions has important clinical implications for the nonsurgical as well as surgical management of patients suffering from these disorders.

Analysis of inflammatory mediators in temporomandibular joint synovial fluid lavage samples of symptomatic patients and asymptomatic controls.

PURPOSE: It was our purpose to study IgA, IgG, and beta-glucuronidase levels in temporomandibular joint fluid lavage samples in order to find a correlation between biochemical markers and joint pathology. MATERIALS AND METHODS: Our patient population included 20 patients (18 female and 2 male) with severe pain and limitation of mandibular movement that failed to improve with at least 3 months of a full course of nonsurgical therapy. After institutional review board approval, 13 control subjects (6 female and 7 male), with no history of temporomandibular joint pain/dysfunction, were obtained. Arthroscopic examination of the patient and control groups involved classification of joints for osteoarthritis and synovitis using a visual grading system. All synovial fluid samples were analyzed for beta-glucuronidase, IgA, and IgG using fluorometric assay and enzyme-linked immunosorbent assay. RESULTS: beta-Glucuronidase was significantly elevated (P<.05, t test) in the patient group compared with the control group (4.13+/-8.30 versus 0.9+/-0.83 [mean+/-SD]). The difference in the IgG level was also statistically significant (31,638+/-70,714 versus 4,407+/-1,324) (P<.05, t test). IgA level showed a similar trend between the patient and control groups (6,315+/-19,037 versus 425+/-192) (P=.10, t test). CONCLUSIONS: Quantitative synovial fluid analysis of beta-glucuronidase, IgA, and IgG demonstrates elevated levels of inflammatory mediators in diseased joints compared with asymptomatic nondiseased joints. We hypothesize that high levels of IgA, IgG, and beta-glucuronidase in the TMJ synovial fluids are due to infiltration from the sera and chronic inflammatory cells residing in the synovium. High levels of immunoglobulins in a closed joint space can elicit strong inflammatory reaction and cause destruction to the joint tissues via complement activation and immune complex deposition. Complement activation increases blood vessel permeability to enable recruitment of neutrophilic leukocytes, which then liberate various lysosomal enzymes and damage the articular cartilage.

Oral and maxillofacial surgery in patients with chronic orofacial pain.

PURPOSE: In this investigation, we evaluated a population of patients with chronic orofacial pain who sought treatment at a pain center in an academic institution. These patients were evaluated with respect to 1) the frequency and types of previous oral and maxillofacial surgery procedures, 2) the frequency of previous significant misdiagnoses, and 3) the number of patients who subsequently required surgical treatment as recommended by an interdisciplinary orofacial pain team. The major goal of this investigation was to determine the role of oral and maxillofacial surgery in patients with chronic orofacial pain. PATIENTS AND METHODS: The study population included patients seen at the Center for Oral, Facial and Head Pain at New York Presbyterian Hospital from January 1999 through April 2001. (120 patients; female-to-male ratio, 3:1; mean age, 49 years; average pain duration, 81 months; average number of previous specialists, 6). The patient population was evaluated by an interdisciplinary orofacial pain team and the following characteristics of this population were profiled: 1) the frequency and types of previous surgical procedures, 2) diagnoses, 3) the frequency of previous misdiagnoses, and 4) treatment recommendations made by the center team. RESULTS: There was a history of previous oral and maxillofacial surgical procedures in 38 of 120 patients (32%). Procedures performed before our evaluation included endodontics (30%), extractions (27%), apicoectomies (12%), temporomandibular joint (TMJ) surgery (6%), neurolysis (5%), orthognathic surgery (3%), and debridement of bone cavities (2%). Surgical intervention clearly exacerbated pain in 21 of 38 patients (55%) who had undergone surgery. Diagnoses included myofascial pain (50%), atypical facial neuralgia (40%), depression (30%), TMJ synovitis (14%), TMJ osteoarthritis (12%), trigeminal neuralgia (10%), and TMJ fibrosis (2%). Treatment recommendations included medications (91%), physical therapy (36%), psychiatric management (30%), trigger injections (15%), oral appliances (13%), biofeedback (13%), acupuncture (8%), surgery (4%), and Botox injections (1%) (Allergan Inc, Irvine, CA). Gross misdiagnosis leading to serious sequelae, with delay of necessary treatment, occurred in 6 of 120 patients (5%). CONCLUSIONS: Misdiagnosis and multiple failed treatments were common in these patients with chronic orofacial pain. These patients often have multiple diagnoses, requiring management by multiple disciplines. Surgery, when indicated, must be based on a specific diagnosis that is amenable to surgical therapy. However, surgical treatment was rarely indicated as a treatment for pain relief in these patients with chronic orofacial pain, and it exacerbated and perpetuated pain symptoms in some of them.