Osteoarthritis of the temporomandibular joint: a review of aetiology and pathogenesis.

The aim of this review was to assess the level of evidence for genetic, biological, and functional predictive and predisposing factors for end-stage temporomandibular joint arthritis within the published literature. A comprehensive review based upon PRISMA guidelines was performed from all literature relevant to the topic. Case series and animal studies were included given the rare nature of the disease and goal of finding root-cause predictive factors. Clinical and radiographic measures were used specifically to identify factors which may have contributed to disease onset and progression. A total of 249 abstracts were identified based on search terms of major databases. After application of exclusion and inclusion criteria, 63 full-text articles were included in the analysis of this paper. There were few factors that could be reliably used to predict end-stage temporomandibular joint disease. Limited evidence is available to adequately predict end-stage temporomandibular joint osteoarthritis. No descriptive process exists that explains how and why this process can occur in younger adults. A better understanding of the aetiology and pathogenesis of TMJ-OA may lead to prevention and more effective management strategies that may reduce the need for drastic surgical intervention, particularly in young adults.

Microbiological investigation of the mandibular condyle in patients with advanced osteoarthritis of the temporomandibular joint.

PURPOSE: The aim of this study was to investigate the presence of bacteria in samples of the temporomandibular joint taken from patients suffering from advanced osteoarthritis of the temporomandibular joint (TMJ). MATERIALS AND METHODS: 25 fresh mandibular condyle samples were taken from 17 consecutive patients undergoing mandibular condylectomy (8 bilateral) for advanced TMJ osteoarthritis (Dimitroulis Category 5 joints). The joint samples were stained and cultured for the presence of microorganisms following a standardised joint culture protocol. RESULTS: No evidence of bacteria was found on staining or solid culture mediums. Late growth (day 12) of commensal skin organisms (P. Acnes, S. Epidermitis, S. Capitis) were identified in enriched broth samples in 5 joint samples. No statistically significant associations were noted between positive broth samples and age or previous joint intervention (p > 0.05) CONCLUSIONS: Within the limitations of this study, we have failed to identify meaningful bacterial growth in tissues (i.e. condylar head) of the TMJ that would suggest a contributory bacterial pathogenesis for arthritis of the TMJ.

Surgical management of recurrent TMJ dislocation-a systematic review.

PURPOSE: Recurrent temporomandibular joint (TMJ) dislocation can be challenging to treat and the current understanding regarding aetiology and management of this condition is limited. The aim of this paper was to conduct a systematic review regarding the management of recurrent TMJ dislocation. METHODS: A literature review was conducted using PRISMA guidelines to identify papers published between 2006 and 2016. The resultant papers were analysed. RESULTS: A total of 33 papers were found relevant to the study. Minimally invasive techniques described included autologous blood injection, which was associated with an overall success of 80% at 12 months. Other modalities investigated included OK-432 sclerotherapy, laser capsulorrhaphy, botulinum toxin of the lateral pterygoid muscle or modified dextrose. These publications show promising success rates. Surgical techniques described included disc plication, eminoplasty and eminectomy. These modalities had a similar success rate, although numbers were limited. The true incidence of recurrent TMJ dislocation is unknown and aetiology is limited to expert opinion. CONCLUSION: The current understanding of management for recurrent TMJ dislocation is limited to case series and case reports. This paper compiles the current understanding of management of recurrent TMJ dislocation. Compared to previous reviews, this paper describes some novel minimally invasive techniques with promising success in the management of recurrent TMJ dislocation.

Surgical management of recurrent dislocation of the temporomandibular joint: a new treatment protocol.

Recurrent dislocation of the temporomandibular joint (TMJ) is rare. It is distinct from acute or chronic dislocation and is associated with considerable morbidity and deterioration in quality of life. To formulate a practical surgical treatment algorithm, we retrospectively reviewed the management and long-term outcomes of 14 patients who presented to a single hospital department over a period of six years (2010-2016), and collected data on demographics, clinical features, operation, and outcome. Patients were followed up for a minimum of 12 months and a maximum of seven years. Results showed effective long-term resolution of symptoms after a combination of eminectomy and disc plication (meniscopexy). Patients whose symptoms had resulted from dystonia of the lateral pterygoid muscle also benefitted from additional lateral pterygoid myotomy. A combination of eminectomy and disc plication (meniscopexy) effectively provides successful long-term outcomes in this group of patients.

Management of temporomandibular joint disorders: A surgeon's perspective.

Disorders of the Temporomandibular joint (TMJ) may clinically present with jaw pain and restricted mouth opening that may limit a patient's access to comprehensive dental care. The aim of this article is to provide a general overview of the current treatment strategies available in the management of disorders of the TMJ. Both conservative and surgical treatment options will be discussed as there is no one treatment for temporomandibular disorders (TMD) which encompasses a wide range of diagnoses. A multidisciplinary team approach to management is essential in the fundamental care of all TMD patients so that treatment can be specifically tailored to individual patient needs.

Comparison of the outcomes of three surgical treatments for end-stage temporomandibular joint disease.

The aim of this study was to determine whether there are any differences between condylectomy, rib grafts, and prosthetic joints (Biomet TMJ stock prosthesis) with regard to outcomes for patients with end-stage temporomandibular joint (TMJ) disease. Fifty-six of a total 127 patients who presented with category 5 end-stage TMJ disease over 3 years (2010-2013) agreed to participate in this retrospective, comparative, cohort study. Patients were divided into four groups: preoperative (n=16), condylectomy (n=8), rib graft (n=16), and prosthetic joint (n=16). They were assessed for major postoperative complications (i.e., return to theatre) and maximum range of mandibular motion, and all completed a specific quality of life (QOL) questionnaire. Whilst the condylectomy group demonstrated the best mandibular range of motion (P<0.01), rib graft patients were more likely to experience complications (43.8%) necessitating a return to theatre. The prosthesis group recorded the best mean aggregate QOL score, but the difference compared to the rib graft and condylectomy groups was not statistically significant. The results of this study suggest that for dentate patients, prosthetic joints are highly dependable with no returns to theatre and favourable QOL outcomes. For edentulous patients, condylectomies alone also appear to work well. Future TMJ prosthetic designs should focus on improving mandibular range of motion, as the current stock prosthesis allows only a restricted range, no better than that achieved with rib graft (P>0.05) and far less than that achieved with condylectomy (P<0.01).

A new surgical classification for temporomandibular joint disorders.

The role of temporomandibular joint (TMJ) surgery is ill-defined, so a universal classification is needed to collate the evidence required to justify the surgical interventions undertaken to treat TMJ disorders. The aim of this article is to introduce a new classification that divides TMJ disorders into 5 categories of escalating degrees of joint disease that can be applied to TMJ surgery. Using a category scale from 1 to 5, with category 1 being normal, and category 5 referring to catastrophic changes to the joint, the new classification will provide the basis for enhanced quantitative and descriptive data collection that can be used in the field of TMJ surgery research and clinical practice. It is hoped that this new classification will form the basis of what will eventually become the universal standard surgical classification of TMJ disorders that will be adopted by both researchers and clinicians so that ultimately, the role of TMJ surgery will be based on evidence rather than conjecture.

Microbiological investigation of retrodiscal tissues from patients with advanced internal derangement of the temporomandibular joint.

The aim of this study was to investigate the presence of bacteria in samples of retrodiscal tissues taken from patients suffering from advanced internal derangement of the temporomandibular joint (TMJ). 12 fresh retrodiscal tissue samples were taken from 12 consecutive patients who underwent unilateral TMJ discectomy for advanced TMJ internal derangement (Wilkes stage IV). The retrodiscal tissue samples were stained and cultured for the presence of micro-organisms in microbiology laboratories. No evidence of bacteria or other micro-organisms was found in any of the tissue specimens procured from the TMJ. This study failed to identify the presence of bacteria or other micro-organisms in fresh retrodiscal tissue specimens of the TMJ in patients with advanced TMJ internal derangement.

Getting published in peer-reviewed journals.

Writing a paper for publication in a peer-reviewed journal is a rewarding experience but a very difficult undertaking that requires years of experience, determination and patience. The exponential rise of knowledge has resulted in the exponential rise of manuscripts submitted for publication in the various peer-reviewed journals all over the world. Potential authors are not only having to write high-quality papers to get published, but also have to compete with other authors for the limited journal space available to publish their papers. The purpose of this article is to highlight some of the ways of making the task of getting published in peer-reviewed journals easier to achieve.

Temporomandibular joint surgery: what does it mean to the dental practitioner?

A poor appreciation of the role of surgery in the management of temporomandibular disorders (TMD) may result in some patients being denied access to appropriate care. While surgery is often considered as an option of last resort, there are instances where surgery is the definitive and sometimes the only treatment option. The aim of this paper was to review the role of temporomandibular joint (TMJ) surgery and its place in the treatment armamentarium of temporomandibular disorders. Indications, rationale for surgery, risks vs. benefits are discussed and complemented with examples of clinical cases treated by the author. All dental practitioners should be aware of the benefits of TMJ surgery so that patients do not suffer unnecessarily from ongoing non-surgical treatments that ultimately prove to be ineffective in the management of their condition.

A critical review of interpositional grafts following temporomandibular joint discectomy with an overview of the dermis-fat graft.

The aim of this critical review is to determine what constitutes an ideal disc replacement material and whether any of the existing materials reported in the literature satisfy the requirements of an effective disc substitute following temporomandibular joint (TMJ) discectomy. Over the last half century a myriad of interpositional materials have been used in the TMJ but nearly all have been less than successful. The disasters that followed the early use of alloplastic interpositional implants in the 1980s prompted the increased use of autogenous grafts in the 1990s. Whilst studies by the author on the use of dermis-fat grafts have been largely positive, there are still concerns that make the dermis-fat graft a less than ideal interpositional material for use in discectomized joint cavities. In reviewing the literature, it is clear that there is still no ideal interpositional material that satisfies all the criteria for replacement of a missing articular disc following TMJ discectomy.

Surgical management of persistent oromandibular dystonia of the temporalis muscle.

A rare case of unifocal oromandibular dystonia of the temporalis muscle is presented. It was treated with surgical myotomy when initial botulinum toxin A therapy failed after 3 years of repeated injections.

Histological fate of abdominal dermis-fat grafts implanted in the temporomandibular joint of the rabbit following condylectomy.

The histological fate of abdominal dermis-fat grafts implanted into the temporomandibular joint (TMJ) following condylectomy was studied. 21 rabbits underwent left TMJ discectomies and condylectomies; 6 were controls (Group A; no graft used); 15 (Group B) had autogenous abdominal grafts transplanted into the left TMJ. Animals were killed after 4, 12 and 20 weeks. Specimens of the TMJ were histologically and histomorphometrically evaluated. At 4 weeks, fat necrosis was clear in all specimens. The dermis component survived and formed cysts with no necrosis. By 12 weeks, viable fat deposits appeared with no evidence of necrotic fat. At 20 weeks, large amounts of viable fat were present in Group B specimens. Group A had no fat, although the missing condyles regenerated. In the presence of viable fat, Group B showed little condyle regeneration 20 weeks after condylectomy. Non-vascularised fat grafts do not survive transplantation, but stimulate neoadipogenesis. The fate of the dermis component of the graft is independent of the fat component. Fat in the joint space disrupts the regeneration of a new condylar head. Neoadipogensis inhibits growth of new bone and cartilage. This has clinical implications for TMJ ankylosis management and preventing heterotopic bone formation around prosthetic joints.

The radiological fate of dermis-fat grafts in the human temporomandibular joint using magnetic resonance imaging.

The purpose of this study was to investigate the radiological fate of the dermis-fat graft within the temporomandibular joint (TMJ) using magnetic resonance imaging (MRI). Fifteen patients with dermis-fat grafts placed in 17 TMJs following discectomy for severe internal derangement were divided into 3 equal groups according to the time lapse between TMJ surgery and the MRI investigation: 0-6 months, 7-23 months and 2 or more years. The radiological presence of fat was found within the joint or surrounding the condyle in all 17 operated joints. The interpositional material found within the radiologically defined joint space was mainly grey (Grade 3, 12 joints), suggesting tissue change to other than fat, i.e. scar or granulation tissue. Two joints showed interpositional material entirely composed of fat (Grade 1), while 3 joints showed heterogeneous material composed of fat interspersed with grey tissue (Grade 2). There was no statistically significant difference in size of fat graft between the time intervals studied. Fat was present in similar quantities within or surrounding all joints regardless of the time lapse since surgery. Intermittent compressive forces of the joint may act as a negative influence on the growth and maintenance of fat tissue within the joint space itself.

Nasal implants following nasectomy.

A case of a 63-year-old female who was reconstructed with an implant-supported nasal prosthesis following nasectomy is reported. The technique and advantages of this treatment modality are discussed.

The prevalence of osteoarthrosis in cases of advanced internal derangement of the temporomandibular joint: a clinical, surgical and histological study.

INTRODUCTION: The articular disk has a central role in the pathology of internal derangement of the Temporomandibular Joint (TMJ). What is less clear is the role of osteoarthrosis in the development of internal derangement. The aim of this study is to determine the prevalence of osteoarthrosis in cases of advanced and recalcitrant TMJ internal derangement that were treated by diskectomy. MATERIALS AND METHODS: This study involved 22 joints in 18 patients who underwent surgery for the treatment of advanced and recalcitrant internal derangement of the TMJ. All patients included in the study failed to respond to at least 6 months of pre-operative conservative treatment and the clinical diagnoses of advanced TMJ internal derangement were confirmed on pre-operative MRI's. Tissue specimens were obtained from all 22 joints for histopathology. The specimens included articular disks that were excised from all 22 joints which were found to have severely displaced and deformed disks that were judged to be irreparable at the time of surgery. Also included were eight tissue samples from the mandibular condyles that were judged to be diseased on pre-operative tomograms and at the time of surgery. All samples were prepared in serial sections in the standard way and examined under light microscopy by two experienced Oral Pathologists. RESULTS: There were 22 specimens of articular disk examined together with 8 specimens from the mandibular condyle. All 22 joints (100%) showed histological evidence of disk pathology and eight of the 22 joints (34.4%) were found to have condylar pathology. The most common disk pathology was hyalinization indicative of disk degeneration (12/22). The most common condylar pathology found was articular surface degeneration indicative of osteoarthrosis (8/22). CONCLUSION: The clinical and radiological diagnoses of advanced TMJ internal derangement correlated with histological findings of degeneration and inflammation of the articular disk in all 22 specimens. The 8 specimens obtained from the condylar head showed histological features consistent with osteoarthrosis. This study showed that osteoarthrosis and internal derangement were found to co-exist in the same joint in about one-third of cases. The fact that osteoarthrosis was not found in all cases suggests that perhaps the widely held view that subclinical osteoarthrosis may lead to pathologic tissue responses in the form of internal derangement will need to be re-examined.

The role of surgery in the management of disorders of the temporomandibular joint: a critical review of the literature. Part 2.

The literature is unequivocal in its support for surgery in the management of certain disorders of the Temporomandibular joint (TMJ). Unfortunately, the literature on TMJ surgery is based more on observation than science since randomised clinical trials comparing surgical treatment of the TMJ with medical treatment and no treatment (i.e., placebo) do not exist. Because the application of scientific principles in clinical studies which involve surgical intervention are ethically unfeasible, the true benefit of surgical intervention for Temporomandibular Disorders (TMD) may never be conclusively established. Waiting for properly designed, placebo controlled, random clinical trials will only impede the progress of surgical experience and frustrate the decision making for both clinicians and patients. Therefore, the current recommendations for surgery must rely on the best available evidence. The aim of this, the second of two papers, is to scrutinize the role of TMJ surgery in light of the controversies that have appeared in the literature in recent years.

The role of surgery in the management of disorders of the Temporomandibular Joint: a critical review of the literature. Part 1.

Despite the controversy surrounding the role of surgery in the management of Temporomandibular Disorders (TMD), studies in peer review journals continue to support the role of surgery as a legitimate means of treating pain and dysfunction in the Temporomandibular Joint (TMJ). To better understand the role of surgery in the management of TMJ disorders, a critical review of the literature will be presented in two parts. Part 1 reviews the evolution of TMJ surgery together with the biological evidence for surgical disease. History teaches us that we are destined to repeat the mistakes of the past if we fail to properly reflect on what has already been achieved and where the failures have occurred. With the help of molecular biology, the future of TMD management may comprise more carefully targeted and less radical treatment modalities.