Virtual surgical planning in craniomaxillofacial surgery: a structured review.

Craniomaxillofacial (CMF) surgery is a challenging and very demanding field that involves the treatment of congenital and acquired conditions of the face and head. Due to the complexity of the head and facial region, various tools and techniques were developed and utilized to aid surgical procedures and optimize results. Virtual Surgical Planning (VSP) has revolutionized the way craniomaxillofacial surgeries are planned and executed. It uses 3D imaging computer software to visualize and simulate a surgical procedure. Numerous studies were published on the usage of VSP in craniomaxillofacial surgery. However, the researchers found inconsistency in the previous literature which prompted the development of this review. This paper aims to provide a comprehensive review of the findings of the studies by conducting an integrated approach to synthesize the literature related to the use of VSP in craniomaxillofacial surgery. Twenty-nine related articles were selected as a sample and synthesized thoroughly. These papers were grouped assigning to the four subdisciplines of craniomaxillofacial surgery: orthognathic surgery, reconstructive surgery, trauma surgery and implant surgery. The following variables - treatment time, the accuracy of VSP, clinical outcome, cost, and cost-effectiveness - were also examined. Results revealed that VSP offers advantages in craniomaxillofacial surgery over the traditional method in terms of duration, predictability and clinical outcomes. However, the cost aspect was not discussed in most papers. This structured literature review will thus provide current findings and trends and recommendations for future research on the usage of VSP in craniomaxillofacial surgery.

[Orofacial and musculoskeletal disorders of professional musicians - Frequency and therapy principles]. / Orofaziale und muskuloskelettale Schmerzsyndrome bei professionellen Musikern ­ Häufigkeiten und Therapieprinzipien.

Playing-related musculoskeletal disorders are frequently found in the upper extremety and the spine. Moreover, orofacial pain syndromes and craniomandibular dysfunctions are important in upper string players and wind players. The treatment of musicians is based on a diagnostic process including the evaluation of specific musical aspects, a functional manual medicine examination and an evaluation of postural and movement characteristics while playing the musical instrument.

Effectiveness of the therapeutic laser in the syndrome of dysfunction of the temporomandibular joint of arthrogenic origin / Eficacia del láser terapéutico en el síndrome de disfunción de la articulación temporomandibular de origen artrogénico

Abstract Temporomandibular joint dysfunction syndrome (TMD), is a collective term characterized by symptoms involving chewing muscles, temporomandibular joint and orofacial structures. The efficacy of low intensity laser (LLLT) Gallium arsenide, in combination with a non-steroidal anti-inflammatory drug (NSAID) was evaluated. The main objective was to evaluate the maximum mouth opening without pain (ABM), arthralgia in the joint capsule through visual analog scale (VAS), laterality, protrusion, joint noises and count of tablets ingested per group. A controlled clinical trial (double-blind-randomized) was carried out in 30 subjects, who presented DTM of arthrogenic etiology; 5 applications of LLLT were made with wavelength of 810 nm, output optical power of 100-200 mw, emission PW=Pulsed (1-10,000Hz), dose of 10 jouls-cm², time of 1.44 minutes in mouth closed and with the mouth half open. One more follow-up appointment per month. There were two groups: experimental and control group, where different variables were analyzed (ABM, laterality, protrusion, VAS and sociodemographic). In the control group, a supposed LT application (not active) was made, for later comparison. Pain-free ABM was assessed in all appointments in addition to the other clinical parameters. Repeated measures analysis was performed with mixed models. Thirty patients were included of which 28 finished the treatment, two of them were lost during follow-up. The groups were similar in all their baseline variables. There were no statistically significant differences when applying the final multiple regression analysis, in the ABM, or in any other of the clinical parameters analyzed. LT was not effective in treating arthrogenic DTM.

Resumen El síndrome de disfunción de la articulación temporomandibular (DTM) es un término colectivo caracterizado por síntomas que involucran músculos de la masticación, articulación temporomandibular y estructuras orofaciales. Se evaluó la eficacia del láser de baja intensidad (LLLT) Arseniuro de galio, en combinación con un antiinflamatorio no esteroideo (AINE). El objetivo principal fue evaluar la apertura bucal máxima sin dolor (ABM), la artralgia en cápsula articular a través de escala visual análoga (EVA), lateralidades, protrusión, ruidos articulares y conteo de tabletas ingeridas por grupo. Se realizó un ensayo clínico controlado (doble ciego-aleatorizado) en 30 sujetos, que presentaban DTM de etiología artrogénica; se les realizaron 5 aplicaciones de LLLT con longitud de onda de 810 nm, potencia óptica de salida de 100-200 mw, emisión PW=Pulsed (1-10,000Hz), dosis de10 jouls-cm², tiempo de1.44 minutos a boca cerrada y con la boca semiabierta. Una cita más de seguimiento al mes. Se tuvieron dos grupos: experimental y grupo control, donde se analizaron diferentes variables (ABM, lateralidades, protrusión, EVA y sociodemográficas). En el grupo control se hizo una supuesta aplicación LT (no activo), para posterior comparación. En todas las citas se valoró la ABM sin dolor además de los otros parámetros clínicos. Se realizó análisis de medidas repetidas con modelos mixtos. Se incluyeron 30 pacientes de los cuales 28 finalizaron el tratamiento, dos de ellos se perdieron en el seguimiento. Los grupos fueron similares en todas sus variables basales. No hubo diferencias estadísticas significativas al aplicar los análisis de regresión múltiple finales, en la ABM, ni tampoco en ningún otro de los parámetros clínicos analizados. El LT no fue eficaz en el tratamiento de la DTM de origen artrogénico.

Desordens hiperostóticas em American Bully / Hiperostotic disorders in american bully

O complexo de desordens hiperostóticas é uma condição rara e autolimitante, que tem as mesmas características histopatológicas, que cursa com proliferação óssea de caráter não neoplásico. Acomete cães jovens de raças distintas, com variabilidade quanto ao tipo de proliferação óssea e quanto aos ossos acometidos. O complexo é composto pela osteopatia craniomandibular, hiperostose da calota craniana e osteodistrofia hipertrófica. Podendo estar presente nos ossos da calota craniana, mandíbulas, coluna cervical e esqueleto apendicular. O presente relato, descreveu o quadro de uma cadela, da raça American Bully, não castrada, três meses de idade, que foi atendida com queixa de aumento de volume doloroso das mandíbulas, hiporexia e sialorreia há 15 dias, apresentando ao exame físico, amplitude de movimento diminuída e sensibilidade dolorosa da articulação temporomandibular, espessamento firme bilateral do crânio em região de fossa temporal, espessamento palpável de consistência firme das mandíbulas e crepitação respiratória. Após avaliação clínica e realização de exames complementares, chegou-se ao diagnóstico presuntivo, de complexo de desordens hiperostóticas. Foi instituído como conduta terapêutica o suporte analgésico, sendo eficaz para a manutenção das necessidades fisiológicas até a paciente alcançar a fase adulta. O prognóstico para esta paciente foi considerado bom, uma vez que não havia indícios de anquilose da articulação temporomandibular e/ou manifestações neurológicas.

The complex of hyperostotic disorders is a rare and self-limiting condition, which has the same histophatological characteristics, which courses with non-neoplastic bone proliferations. It affects young dogs of different breeds, with variability the bones affected. The complex is composed of craniomandibular osteopathy, calvarial hyperostotic syndrome and hypertrophic osteodystrophy. It may be present in the bones of the skullcap, jaws, cervical spine and appendicular skeleton. The present report describes the condition of a female dog, American Bully breed, entire, three months old, with a complaint of painful swelling of the jaws, hyporexia and drooling for 15 days, presenting on physical examination, reduced amplitude and pain of the temporomandibular joint, bilateral firm thickening of the skull in the temporal fossa region, palpable firm-consistent thickening of the mandibles and respiratory crackle. After clinical evaluation and complementary tests, a presumptive diagnosis of hyperostotic disorders complex was reached. It was instituted pain management as a treatment, being effective for the maintenance of physiological needs until the patient reaches the adulthood. The prognosis for this patient was considered good, since there was no evidence of temporomandibular joint ankylosis and/or neurological manifestations.

What factors predict craniomandibular disorders in severe COVID-19 survivors after prolonged intubation?

PURPOSES: To estimate and identify predictors of craniomandibular disorders (CMDs) in severe COVID-19 survivors after prolonged intubation ≥ 1 week (SCOVIDS-PI). METHODS: This retrospective study enrolled two cohorts of SCOVIDS-PIs with vs. without CMD during a one-year period. The predictor variables were demographic, dental, anesthetic, and laboratory parameters. The main outcome was presence of CMD until six post-PI months (yes/no). Appropriate statistics were computed with α = 95%. RESULTS: The sample comprised 176 subjects aged 59.2 ± 17.2 years (range, 27-89; 11.9% with CMDs; 30.1% females). CMDs were significantly associated with (1) bilateral posterior tooth loss (P = 0; number needed to screen [NNS] = 1.6), (2) dentofacial skeletal class II/convex face (P = .01; NNS = 2.2), and (3) peak CRP during intensive care ≥ 40 mg/l (P = .01; NNS = 3.5). With combined predictors, NNS became 2 to 4.3. CONCLUSIONS: Three predictors of CMDs in SCOVIDS-PIs: bilateral molar loss, convex face, and CRP ≥ 40 mg/l, indicate CMD screening and/or referral to a CMD specialist, regardless of patients' age, gender, underlying CMDs, or previous dental checkups. Screening ∼2 to 4 "SCOVIDS-PIs with ≥ one predictor" will identify one CMD events/patients during the first six post-PI months.

Influence of craniocervical and craniomandibular dysfunction to nonrestorative sleep and sleep disorders.

Objective: Nonrestorative sleep and sleep disorders are commonly reported in patients suffering from craniomandibular (CMD) and craniocervical dysfunctions (CCD). This study aimed to investigate polysomnographic characteristics and the reduction of pain before and after treatment in these patients.Methods: Seventy-four patients with sleep disorders and evident CMD and CCD were included. Manual therapy and an Aqualizer® were used in the therapeutic group. Polysomnographic measurements were conducted pre- and post-therapy.Results: The number of sleep stage alterations and the sleep stage index differed significantly between pre- and post-therapeutic measurements. Between both groups, these parameters were significantly different, as well (p = .001 and p = .012). The subjective perception of sleep quality improved in 81.6% post-therapy (p < .001).Discussion: Manual therapy and the application of an Aqualizer® may improve sleep quality in patients suffering from CMD and CCD. Pain may not be the main cause for the sleep disorders in CMD and CCD.

Cytokines, Masticatory Muscle Inflammation, and Pain: an Update.

Cytokines are proteins secreted by diverse types of immune and non-immune cells and play a role in the communication between the immune and nervous systems. Cytokines include lymphokines, monokines, chemokines, interleukins, interferons, colony stimulating factors, and growth factors. They can be both pro- and anti-inflammatory and have autocrine, paracrine, and endocrine activities. These proteins are involved in initiation and persistence of pain, and the progress of hyperalgesia and allodynia, upon stimulating nociceptive sensory neurons, and inducing central sensitization. The objective of this review is to discuss several types of pro- and anti-inflammatory mediators and their relation with inflammatory pain in masticatory muscles.

Association of decrease in insula fMRI activation with changes in trait anxiety in patients with craniomandibular disorder (CMD).

Patients with chronic pain and especially with craniomandibular disorder (CMD) show specific psychopathology in trait anxiety. In a previous longitudinal functional imaging study on CMD we found that the anterior insula was modulated by successful therapy intervention and pain relief. We here intended to investigate possible associations between anterior insula fMRI-activation during occlusal movements and trait anxiety over a splint therapy approach in patients with CMD. Three fMRI-investigations of a craniomandibular occlusion task were performed together with pain score evaluations and scoring of trait anxiety (State -Trait Anxiety Inventory; STAI) before, after two weeks and after three months of a DIR-mandibular splint therapy in a small group (n = 9) of CMD patients. Patients showed increased anxiety levels before therapy assessed with the STAI and the depression and anxiety scale (DASS). Besides of relevant reduction in pain the STAI decreased over time. Reduction in STAI was associated with anterior insular fMRI-activation reduction on both hemispheres. We conclude that the anxiety driven anticipation of pain related to occlusal trigger is processed in the anterior insula and might therefore be a main driver of therapeutic intervention by the splint therapy in CMD.

What Role Does Synovitis Play in Craniomandibular Dysfunction (CMD)? A 3T-MRI Study. / Welche Rolle spielt die Synovialitis bei der kraniomandibulären Dysfunktion (CMD)? Eine 3T-MRT-Studie.

PURPOSE: The purpose of the present study was to investigate the degree and clinical relevance of synovitis in craniomandibular dysfunction. MATERIALS AND METHODS: In total, 140 temporomandibular joints were examined using a 3 T MRI scanner. Quantitative analysis of synovial enhancement was performed and interrelated with arthrosis deformans, degenerative disc disease, joint effusion, bone marrow edema and restriction of motion. RESULTS: We found a statistically high and significant correlation between the degenerative changes as mentioned above and the intensity of synovial enhancement. CONCLUSION: The study shows that typical MRI findings in CMD patients are often combined with signs of synovitis. Presumably joint inflammation has an effect on the clinical signs and symptoms and also the prognosis of CMD. These results should be taken into consideration when selecting treatment. KEY POINTS: · 3T-MRI using a dedicated coil is the method of first choice in the examination of CMD syndrome.. · MR imaging allows quantification of increased synovial enhancement.. · There is a highly significant correlation between degenerative changes of the disc or cartilage and synovitis.. · Results of the study are relevant for the clinical assessment and therapy of CMD syndrome.. CITATION FORMAT: · Stimmer H, Ritschl L, Goetz C et al. What Role Does Synovitis Play in Craniomandibular Dysfunction (CMD)? A 3T-MRI Study. Fortschr Röntgenstr 2019; 191: 924 - 931.

Complex segregation analysis of craniomandibular osteopathy in Deutsch Drahthaar dogs.

This study investigated familial relationships among Deutsch Drahthaar dogs with craniomandibular osteopathy and examined the most likely mode of inheritance. Sixteen Deutsch Drahthaar dogs with craniomandibular osteopathy were diagnosed using clinical findings, radiography or computed tomography. All 16 dogs with craniomandibular osteopathy had one common ancestor. Complex segregation analyses rejected models explaining the segregation of craniomandibular osteopathy through random environmental variation, monogenic inheritance or an additive sex effect. Polygenic and mixed major gene models sufficiently explained the segregation of craniomandibular osteopathy in the pedigree analysis and offered the most likely hypotheses. The SLC37A2:c.1332C>T variant was not found in a sample of Deutsch Drahthaar dogs with craniomandibular osteopathy, nor in healthy controls. Craniomandibular osteopathy is an inherited condition in Deutsch Drahthaar dogs and the inheritance seems to be more complex than a simple Mendelian model.

Fibromyalgia in patients with chronic CCD and CMD - A retrospective study of 555 patients.

OBJECTIVE: Craniomandibular dysfunction (CMD) and craniocervical dysfunction (CCD) are clearly defined musculoskeletal pain syndromes. Relationships with fibromyalgia syndrome (FMS) have not yet been investigated. The aim of the present study is to establish possible relationships between FMS and CMD/ CCD. METHODS: In a retrospective study, 555 patients with CCD and CMD were investigated with respect to the diagnostic criteria of FMS. In addition to otolaryngologic and dental examination, an instrumental functional analysis for the diagnosis of CMD/CCD was performed. RESULTS: Three hundred fifty-one (63%) of the 555 patients evaluated met the diagnostic criteria for FMS. Seventy-two percent of the patients had a widespread pain index of at least 7 and a severity scale score of at least 5. Twenty-nine percent had a widespread pain index of 3-6 and a severity scale score of at least 9. Using myocentric bite splint therapy and therapy with oral orthesis in combination with neuromuscular relaxation measures, a good to very good improvement of physical symptoms was seen in 84% of CMD-FMS patients, and an improvement of the symptoms in the jaw was achieved in 77% of cases. DISCUSSION: The substantial proportion of CMD and CCD patients who meet the criteria for FMS emphasizes the complexity of the two diseases. It must be assumed that FMS is a crucial factor for the formation of CMD and CCD. Conversely, CMD/ CCD could also be responsible for diverse clinical pictures of the FMS. FMS patients with synchronous CCD/CMD benefit from an interdisciplinary CMD/CCD treatment.

Efeitos das terapias para disfunção temporomandibular sobre a postura craniocervical / Effects of therapies for temporomandibular disorders on craniocervical posture

O objetivo do presente estudo foi avaliar se as terapias de placa oclusal, fisioterapia e aconselhamento, empregadas para o tratamento da disfunção temporomandibular (DTM), alteram a postura craniocervical e quadro de dor. Trata-se de um ensaio clínico randomizado controlado cego, onde foram incluídos sujeitos previamente diagnosticados com DTM por meio do RDC/TMD (Research diagnostic criteria for temporomandibular disorders). Os pacientes foram sorteados entre quatro grupos de tratamento: placa oclusal (PO, n=17), fisioterapia (F, n= 19), aconselhamento (AC, n=15) e placa associada ao aconselhamento (PAC, n= 14), totalizando 65 indivíduos. Para a análise postural, uma teleradiografia foi realizada no baseline e após 1 mês da aplicação da terapia a fim de observar a distância occiptoatlas (DOA), a relação craniocervical (ACR) e o posicionamento do osso hioide (TH). Os traçados foram realizados nas imagens utilizando-se o Software CorelDraw X6 (2012 Corel Corporation, Canadá). Para análise da variável dor, a escala visual analógica foi aplicada antes e 1 mês após as terapias. Os dados obtidos foram submetidos a diversos testes T pareado (α=5%) e para a variável dor o teste SPANOVA foi aplicado. Com exceção do grupo PAC na variável ACR (p=0,003), os resultados mostraram que não houve diferença estatisticamente significativa para as variáveis analisadas quanto as diferentes terapias ao longo do tempo. Porém pode-se observar que todos os grupos de tratamento possibilitaram uma redução do quadro de dor dos pacientes (p=0.013) ao longo do tempo. Conclui-se que as terapias aplicadas pouco influenciam na postura craniocervical, mas são eficazes para o alivio da sintomatologia dolorosa (AU).

The objective of the present study was to evaluate whether the occlusal plaque, physiotherapy and counseling therapies used in the treatment of temporomandibular disorders (TMD) alter the craniocervical posture and the pain picture. This is a controlled, randomized, blinded study that included individuals previously diagnosed with TMD through the RDC / TMD (Research criteria criteria for temporomandibular disorders). The patients were randomly selected from four treatment groups: occlusal (OP, n = 17), physiotherapy (MT, n = 19), counseling (C, n = 15) and counseling, totaling 65 individuals. For the postural analysis, a teleradiography was performed at the baseline and 1 month after the application of the therapy, in order to observe the occipito-atlas distance (DOA), the craniocervical relationship (ACR) and the positioning of the hyoid bone. Traits were performed on the images using CorelDraw X6 software (2012 Corel Corporation, Canada). To analyze the pain variable, the visual analogue scale was applied before and 1 month after the therapies. The data obtained were submitted to several paired T tests (α = 5%) and for the pain variable the SPANOVA test was applied. With the exception of the PAC group in the ACR variable (p = 0.003), the results showed that there was no statistically significant difference for the analyzed variables regarding the different therapies over time. However, it can be observed that all the treatment groups allowed a reduction of the patients' pain picture (p = 0.013) over time. It's concluded that the therapies applied have little influence on craniocervical posture, but are effective for the relief of painful symptoms (AU).

Prevalencia de los trastornos temporomandibulares y factores asociados más comunes presentados en las clínicas de la Universidad Santo Tomás en el segundo periodo del año 2016 / Prevalence of the temporomandibular disorders and most common associated factors presented in the ninth and tenth semester clinics of the Universidad Santo Tomás in the second period of the year 2016

Objetivo: Establecer la prevalencia de los trastornos temporomandibulares (TTM) presentados por los pacientes que acudieron a las clínicas odontológicas de noveno y décimo semestre de la Universidad Santo Tomás en el segundo período de 2016. Materiales y Métodos: Se realizó un estudio observacional descriptivo de corte transversal, con una muestra de 113 historias clínicas, se recolectó la muestra de historias clínicas ya diligenciadas de las clínicas de noveno y décimo semestre de la Universidad Santo Tomás en el segundo periodo del año 2016. Usando estadística descriptiva para el análisis Univariado. En el análisis bivariado, se estableció relación entre TTM y las variables de interés mediante la prueba t-student y Chi-cuadrado donde un valor de p≤0,05 fue considerado estadísticamente significativo. Resultados: De las 113 historias clínicas se obtuvieron 131 diagnósticos, la prevalencia de uno o más TTM fue del 55,7%, de los cuales el 30,1% fueron mujeres diagnosticadas con TTM; el TTM más prevalente fue la subluxación unilateral en el 11,4% de los casos. De los factores asociados, predominó el ruido articular con 43,4% donde el tipo predominante de ruido fue el clic con 91,8%, seguido por el dolor muscular. Conclusiones: La prevalencia de TTM fue alta, representada en el 55,7% de la población. El TTM más común fue la Subluxación unilateral con un 11,4%. Se encontró asociación estadísticamente significativa entre al menos un factor de tipo signo y síntoma, los factores dentales y uno o más TTM.

Aim: To establish the prevalence of temporomandibular disorders (TMD) presented by patients who attended the dental clinics of the ninth and tenth semester of the Santo Tomas University in the second period of 2016. Materials and Methods: A cross - sectional, observational, descriptive study was carried out, with a sample of 113 clinical records. The sample was collected from clinical records already completed from the clinics of ninth and tenth semester of the University Santo Tomas in the second period of the 2016. Using descriptive statistics for the univariate analysis. In the bivariate analysis, a relationship between TMD and the variables of interest was established using the t-student and Chi-square test, where a value of p≤0.05 was considered statistically significant. Results: Of the 113 clinical records, 131 diagnoses were obtained. The prevalence of one or more TMD was 55.7%, of which 30.1% were women diagnosed with TMD. The most prevalent TTM was the unilateral subluxation in 11.4% of the cases. Of the associated factors, joint noise predominated with 43.4% where the predominant type of noise was the click with 91.8%, followed by muscle pain. Conclusions: The prevalence of TMD was high, represented in 55.7% of the population. The most common TMD was unilateral Subluxation with 11.4%. We found a statistically significant association between at least one sign and symptom type factor, dental factors and one or more TMD.

[Painful temporomandibular dysfunctions: diagnosis and -treatment]. / Pijnlijke temporomandibulaire disfuncties: diagnose en behandeling.

Painful temporomandibular disorders (TMD pain) are common among the general population. The most common sub diagnoses are myalgia (jaw-muscle pain) and arthralgia (temporomandibular joint pain). The aetiology of TMD pain has a multifactorial nature, and its diagnosis and possible treatment often require a multidisciplinary approach. The most recent insights in the diagnosis and treatment of TMD pain are based on the multidisciplinary guideline 'Chronic Orofacial Pain' that was developed by the Dutch Society of Headache Patients and was published in 2013. Dentists are required to follow the recommendations of this guideline. The authorisation of the guideline by the relevant academic and professional associations in the Netherlands implies that restraint is advised when adopting diagnostic procedures and treatment modalities that are not or are insufficiently based on solid evidence.

Evaluation of total alloplastic temporo-mandibular joint replacement with two different types of prostheses: A three-year prospective study

BACKGROUND: Temporo-Mandibular Joint (TMJ) replacement has been used clinically for years. The objective of this study was to evaluate outcomes achieved in patients with two different categories of TMJ prostheses. MATERIAL AND METHODS: All patients who had a TMJ replacement (TMJR) implanted during the study period from 2006 through 2012 were included in this 3-year prospective study. All procedures were performed using the Biomet Microfixation TMJ Replacement System, and all involved replacing both the skull base component (glenoid fossa) and the mandibular condyle. RESULTS: Fifty-seven patients (38 females and 19 males), involving 75 TMJs with severe disease requiring reconstruction (39 unilateral, 18 bilateral) were operated on consecutively, and 68 stock prostheses and 7 custom-made prostheses were implanted. The mean age at surgery was 52.6 ± 11.5 years in the stock group and 51.8 ± 11.7 years in the custom-made group. In the stock group, after three years of TMJR, results showed a reduction in pain intensity from 6.4 ±1.4 to 1.6 ± 1.2 (p < 0.001), and an improvement in jaw opening from 2.7±0.9 cm to 4.2 ± 0.7 cm (p < 0.001). In the custom-made group, after three years of TMJR, results showed a reduction in pain intensity from 6.0 ± 1.6 to 2.2 ± 0.4 (p < 0.001), and an improvement in jaw opening from 1.5 ± 0.5 cm to 4.3 ± 0.6 cm (p < 0.001). No statistically significant differences between two groups were detected. CONCLUSIONS: The results of this three-year prospective study support the surgical placement of TMJ prostheses (stock prosthetic, and custom-made systems), and show that the approach is efficacious and safe, reduces pain, and improves maximum mouth opening movement, with few complications. As such, TMJR represents a viable technique and a stable long-term solution for cranio-mandibular reconstruction in patients with irreversible end-stage TMJ disease. Comparing stock and custom-made groups, no statistically significant differences were detected with respect to pain intensity reduction and maximum mouth opening improvement