Interdisciplinary Approach to the Temporomandibular Joint Osteoarthritis-Review of the Literature.

Background and objectives: There are an increasing number of patients applying for dental treatment who suffer from temporomandibular joint osteoarthritis (TMJOA). Osteoarthritis may be the cause of the pain in the area of temporomandibular joints, but its course may also be absolutely asymptomatic. The aim of this study was to present an interdisciplinary approach to TMJOA, including current diagnostics and treatment modalities on the basis of the available literature. Materials and Methods: PubMed and Scopus databases were analyzed using the keywords: ((temporomandibular joint AND osteoarthritis) AND imaging) and ((temporomandibular joint AND osteoarthritis) AND treatment). The bibliography was supplemented with books related to the temporomandibular joint. After screening 2450 results, the work was based in total on 98 publications. Results and Conclusions: Osteoarthritis is an inflammatory, age-related, chronic and progressive degenerative joint disease. Magnetic resonance imaging (MRI) and cone-beam computed tomography (CBCT), together with clinical symptoms, play significant roles in TMJOA diagnosis. Current MRI techniques seem to be clinically useful for assessment of bony changes in temporomandibular joint (TMJ) disorders. Treatment of TMJOA requires a complex, interdisciplinary approach. TMJOA treatment includes the cooperation of physiotherapists, rheumatologists, gnathologists, orthodontists and quite often also maxillofacial surgeons and prosthodontists. Sometimes additional pharmacotherapy is indicated. Thorough examination of TMJ function and morphology is necessary at the beginning of any orthodontic or dental treatment. Undiagnosed TMJ dysfunction may cause further problems with the entire masticatory system, including joints, muscles and teeth.

No association between types of unilateral mandibular condylar abnormalities and facial asymmetry in orthopedic-treated patients with juvenile idiopathic arthritis.

INTRODUCTION: Dentofacial asymmetries are often observed in patients with juvenile idiopathic arthritis (JIA) and temporomandibular joint (TMJ) involvements. The aim of this split-face study was to associate types of radiologic TMJ abnormalities with the degree of dentofacial asymmetry in patients with unilateral TMJ involvements assessed with cone-beam computed tomography. METHODS: Forty-seven JIA patients and 19 nonarthritic control subjects were included in the study. Normal condylar radiologic cone-beam computed tomography appearance in at least 1 TMJ was the inclusion criterion for all patients with JIA. The contralateral TMJ was thereafter scored as either "normal," "deformed," or "erosive," consistent with predefined criteria. Based on the bilateral radiologic TMJ appearances, 3 JIA groups were assigned: normal/normal, normal/deformed, and normal/erosive. The severity of the dentofacial asymmetry was compared between the JIA groups and control subjects. Dentofacial asymmetry was expressed as interside ratios and angular measurements. RESULTS: Eighty-seven percent of the JIA patients were being treated or had previously received treatment with a functional orthopedic appliance at the time of the cone-beam computed tomography. Significantly greater dentofacial asymmetries were observed in the 2 groups of JIA patients with unilateral condylar abnormalities (deformation or erosion) than in the other groups. A similar degree of dentofacial asymmetry was observed in JIA patients with bilateral normal TMJs and in the nonarthritic control group. CONCLUSIONS: JIA patients with unilateral condylar abnormalities (deformation or erosion) exhibited significantly more severe dentofacial asymmetries than did the JIA patients without condylar abnormalities and the control subjects. We found the same degree of dentofacial asymmetry when dividing patients with condylar abnormalities into deformation and erosion groups.

Audiological features in congenital bony atresia of external auditory canal with temporal-mandibular joint retroposition.

OBJECTIVES: To facilitate the diagnosis, treatment and surgical options for congenital bony atresia of external auditory canal (EAC) with temporal-mandibular joint (TMJ) retroposition by analyzing its audiological features and the morphology of temporal bone on CT scan. MATERIALS AND METHODS: Two cohorts of patients with congenital EAC bony atresia with (n=23) or without (n=21) TMJ retroposition were recruited from September 2012 to July 2014 at Beijing Tongren Hospital, Capital Medical University. The patients with TMJ retroposition were set as the group A and those without as group B. Based on the degree of TMJ retroposition, group A was further divided into two sub-groups A1 (n=13) and A2 (n=10). The temporal bone CT scan, pure tone average (PTA) and air-bone gap (ABG) were obtained for the main outcome measurements. SPSS 17.0 was used for the statistics analysis with t and t test. RESULTS: For group A, the average air conduction (AC) was 55.22±12.53dBHL, the average bone conduction (BC) was 7.07±3.34dBHL, and the average ABG was 50.69±8.60dBHL. For the sub-groups A1 and A2, the average AC was respectively 45.77±8.43dBHL and 59.50±7.43dBHL, BC 7.07±3.34dBHL and 6.89±4.37dBHL, and ABG 47.31±7.92dBHL and 53.00±7.91dBHL. For group B, the average AC was 70.24±5.63dBHL, BC 6.78±4.37dBHL, and ABG 60.19±6.09dBHL. CONCLUSIONS: The degree of TMJ retroposition is negatively related to the severity of hearing loss among patients with congenital EAC bony atresia, and those with TMJ have suffered less severe hearing loss than those without. Although TMJ retroposition might be a disadvantage for patients undergoing EAC plasty and tympanoplasty, it must be considered for its influence on hearing loss severity and auditory canal abnormality when planning the surgical treatment. Different from normal surgical protocol for congenital EAC bony atresia, we commend other hearing reconstruction methods such as BAHA and VSB, even without intervention.

Ectopic external auditory canal and ossicular formation in the oculo-auriculo-vertebral spectrum.

Ear abnormalities in oculo-auricular-vertebral spectrum commonly present with varying degrees of external and middle ear atresias, usually in the expected locations of the temporal bone and associated soft tissues, without ectopia of the external auditory canal. We present the unique imaging of a 4-year-old girl with right hemifacial microsomia and ectopic location of an atretic external auditory canal, terminating in a hypoplastic temporomandibular joint containing bony structures with the appearance of auditory ossicles. This finding suggests an early embryological dysfunction involving Meckel's cartilage of the first branchial arch.

[Frequency of signs and symptoms of temporomandibular joint disorders, vertical orthodontic anomalies and their relationships based on screening of a large population]. / Temporomandibuláris ízületi és vertikális ortodonciai rendellenességek elofordulási gyakorisága, valamint azok összefüggései nagyszámú populáció szurovizsgálata alapján.

Altogether 4606 volunteers (2923 vomen, 1683 men) participated in the representative national epidemiological study to screen the alterations of temporomandibular joint (TMJ). The characteristic clinical signs and subjective complaints according to TMJ were evaluated by medical history taking and physical examination. Regarding the orthodontic anomalies, the vertical abnormalities (deep bite and open bite) were specifically noted. Clinical signs showing functional problems of TMJ were found in 45.19% of the screened population, mainly in the group of 35-44 year olds. The frequency of clicking and crepitation of TMJ was significantly higher in women compared to men (p < 0.05). The highest rate of clinical signs of TMJ disorders was found in the South-Transdanubian region, the lowest rate in the Middle-Transdanubian region, between these regions it was a significant difference regarding the frequency of deviation/deflexion (p < 0.05). Of the vertical abnormalities, deep bite occured most frequently in the 35-44 ys old age group. The prevalence of deep bite was higher among males than females in the whole screened population, but the difference was not statistically significant. Significant relationship was detected between deep bite and TMJ pain, deep bite and noises in the joint in the majority of the population. The most frequent anomaly in the South-Transdanubian region was deep bite, while the open bite occured most frequently in south middle part of Hungary. Conclusion: the Hungarian population needs well organized specific programs to improve the oral health including TMJ and orthodontic aspects.

Clinical Implications of Temporomandibular Condyle Agenesis in a Toddler.

Agenesis of the temporomandibular condyle is a congenital/developmental disorder that can present with the absence of the condyle and an incomplete development of the articular fossa and eminence, resulting in facial asymmetry as well as masticatory dysfunction. The purpose of this report is to present the case of a three-year-old girl with absence of the left temporomandibular condyle. The patient presented with pain and dysfunction in the left masseter muscle, pre-auricular area and ear as well as mild chin deviation to the left. The most common treatment modality is to wait and treat this condition with surgical intervention once the patient is grown. However, oral orthopedic appliances can be considered to promote bone formation prior to surgery. Prompt recognition and early treatment is advisable to take advantage of the child's growth and avoid further facial asymmetry, pain and dysfunction.

An updated protocol for mandibular reconstruction in nongrowing patients with craniofacial microsomia with temporomandibular joint total prosthesis.

The authors aim to present an updated protocol for mandibular reconstruction in nongrowing patients with Pruzansky/Kaban type IIb/III congenital craniofacial microsomia with customized temporomandibular joint (TMJ) prosthesis to reduce facial nerve (FN) damage and improve surgical accuracy. This is illustrated (using 3 cases) and is based on preoperative mapping of the FN using MRI for better virtual surgical planning of custom-made TMJ prosthesis. Intraoperative FN mapping and monitoring, as well as verification of the final result with intraoperative cone-beam computed tomography (CBCT) and 3D-reconstructed images is also achieved. All 3 patients presented mild transient postoperative facial palsy due to surgical soft tissue stretching which resolved within 2 months of surgery. All patients presented proper occlusion and mouth opening without pain, with an average incisal opening of 38.8 mm (range 35.5-42 mm) at two months of follow-up. Moreover, superposition of intraoperative and preoperative 3D reconstruction images ensured surgical accuracy and avoided the need for a potential reintervention. In conclusion, the proposed surgical protocol for mandibular reconstruction with customized alloplastic TMJ prosthesis in nongrowing patients with type IIb/III Pruzansky-Kaban congenital mandibular hypoplasia may reduce FN morbidity, improve surgical accuracy and final outcomes.

A range of condylar hypoplasia exists in Treacher Collins syndrome.

PURPOSE: Temporomandibular joint malformation is a complex deformity in Treacher-Collins syndrome (TCS); however, it is not well characterized. This study aimed to better clarify this pathology by volumetrically assessing the mandibular condyle in patients with TCS compared with normal controls and the relative contribution of the condyle to hemimandibular volume. MATERIALS AND METHODS: A retrospective, cross-sectional analysis of pediatric patients with TCS and unaffected controls was performed. The study sample was comprised of Treacher Collins patients. The predictor variable in this study was disease status (TCS diagnosis vs control), and the outcome variable was condylar volume. Demographic information was collected, and 3-dimensional computed tomographic data were analyzed by computerized segmentation (Materialise). Volumes were obtained for TCS condyles and compared with age-matched controls using the Student t test. RESULTS: Three-dimensional computed tomographic scans were identified in 10 patients with TCS (20 sides) and 14 control subjects (28 sides). The TCS group included 4 female and 6 male patients (age, 0.3 to 213 mo; average age, 66.5 mo). The control cohort included 7 female and 7 male subjects (average age, 68.8 mo). Evaluation of the mandibular condyle showed that patients with TCS had a significantly smaller condylar volume than control patients (TCS, 178.28 ± 182.74 mm(3); control, 863.55 ± 367.20 mm(3); P < .001). Additional intragroup analysis showed no significant differences between the left and right condylar volumes in the TCS group (P = .267). In addition, the condyle for patients with TCS represented a smaller proportion of hemimandibular volume compared with controls (1.37% vs 4.19%, respectively; P < .001). CONCLUSIONS: The results of the this study suggest that condylar volumes are significantly smaller in patients with TCS compared with age-matched controls, and the condyle represents a smaller fraction of the total mandibular volume for patients with TCS than in unaffected children. In addition, there is considerable variability of condylar size in patients with TCS. These facts portend treatment decisions because a functional temporomandibular joint is necessary and may need to be reconstructed as a first stage before effective implementation of distraction procedures.

Biological reconstruction of the temporomandibular joint by chondro-osseous graft: clinical and experimental study.

This study includes 35 children treated by reconstruction of the temporomandibular joint (TMJ) by chondro-osseous graft harvested from iliac crest for management of 2 diseases; the first one was ankylosis of the TMJ. There were 25 cases of 9 girls and 16 boys, and there were 10 cases of hypoplasia of the TMJ of first-arch dysplasia syndrome or hemifacial microsomia, of which 4 were females and 6 were males. Their ages ranged between 4 and 13 years (mean, 8.5 years); follow-up of the patients ranged from 3 to 5 years. All patients showed good result and without recurrence of ankylosis or restriction of mouth opening, and growth of the face was acceptable and without using osteotomies for correction of jaw relationship or distraction techniques.Experimental studies on rabbits were performed to prove the condyle as growth center and after excision of the head of condyle and disk in newly growing rabbits of 3 months of age; after 3 months of follow-up, we observed severe deformity of the rabbits' mandible, and the mandible deviated to the affected side on the first experiment. In the second experiment, reconstruction of the TMJ and condyle of the rabbits by chondro-osseous graft harvested from iliac crest of the same rabbit was carried out in 8 animals to assess the viability and value of chondro-osseous graft to replace the TMJ. After 3 months, all animals were killed. Postmortem studies were done to assess the healing process of the graft or any resorption of the graft. Histological studies of the graft showed 4 layers: the first articular layer was thick because of functional demand of masticatory process for hard food of rabbits; the second layer was the granular mesenchymal stem cells layer, very active and multiple layers that represent the proliferative layer; the third layer showed conversion of cartilage cells to osteoid cells, and the fourth layer was the osteoid layer. On follow-up of clinical cases, the graft was continued for functional demand of growth, repair, and remodeling of the condyle.

Bilateral craniofacial microsomia: orthognathic treatment for an advanced dentofacial deformity.

In this article, we report the combined surgical and orthodontic treatment for a patient with bilateral craniofacial microsomia and facial asymmetry.

Clinical findings in patients with GLI2 mutations--phenotypic variability.

Mutations in the human GLI2 gene were first reported in association with defective anterior pituitary formation, panhypopituitarism, and forebrain anomalies represented by typical holoprosencephaly (HPE) and holoprosencephaly-like (HPE-L) phenotypes and postaxial polydactyly. Subsequently, anophthalmia plus orbital anomalies, heminasal aplasia, branchial arch anomalies and polydactyly have also been incorporated into the general phenotype. Here we described six Brazilian patients with phenotypic manifestations that range from isolated cleft lip/palate with polydactyly, branchial arch anomalies to semi-lobar holoprosencephaly. Novel sequence variants were found in the GLI2 gene in patients with marked involvement of the temporomandibular joint (TMJ), a new clinical finding observed with mutations of this gene. Clinical, molecular and genetic aspects are discussed.

Auriculo-condylar syndrome. Confronting a diagnostic challenge.

Auriculo-condylar syndrome (ACS) is characterized by typical ears malformation (so-called "question mark" ears), prominent cheeks, microstomia, and abnormality of the temporomandibular joint and condyle of the mandible. In this report we describe a new simplex case and a previously unreported family with affected individuals in three generations documenting clinical variability. Linkage study for markers located in candidate region for ACS1 (1p21.1-q23.3) was excluded in our familial case, reinforcing the hypothesis of genetic heterogeneity for this condition. A review of the literature focusing diagnostic criteria and features of ACS was performed.

Craniofacial growth disturbance is related to temporomandibular joint abnormality in patients with juvenile idiopathic arthritis, but normal facial profile was also found at the 27-year follow-up.

OBJECTIVES: To assess the long-term outcome of craniofacial morphology related to disease variables and temporomandibular joint (TMJ) involvement as demonstrated with computed tomography (CT) and magnetic resonance imaging (MRI) in adult patients with juvenile idiopathic arthritis (JIA). METHODS: Sixty of 103 patients participated in a re-examination on average 27 years after baseline. Craniofacial morphology, with emphasis on size and position of the mandible, was assessed in lateral cephalographic images and related to disease variables and TMJ involvement by CT and MRI. Definitions of craniofacial growth disturbances were based on measurements outside 2 SD from the mean of healthy adult controls. RESULTS: Sagittal craniofacial growth disturbances were found in 57% and micrognathia in 27% of the 60 patients. Of those with JIA TMJ involvement, 70% had some form of growth disturbance. Micrognathia occurred only in patients with bilateral TMJ involvement. The bilateral TMJ group had significantly different craniofacial morphology than healthy controls and patients without TMJ involvement. Growth disturbances and TMJ involvement were present in all subtypes of JIA, except for one subtype comprising one patient. Patients with growth disturbances had more severe disease than patients with normal craniofacial growth, regarding both present and previous disease activity. Unexpectedly, half of the patients without craniofacial growth disturbances also had TMJ involvement, many from before the age of 12. CONCLUSIONS: Craniofacial growth disturbances were found to be frequent in adult JIA patients, especially in those with bilateral TMJ involvement. However, growth disturbances did not always follow TMJ involvement, not even when affected early.

Relationship between degree of malocclusion and occlusal interference in mice that spontaneously develop anterior transverse crossbite.

INTRODUCTION: Mice with brachymorphism (bm) have defective chondrogenesis, including abnormal growth of the spheno-occipital synchondrosis. Malocclusion (anterior transverse crossbite) sometimes spontaneously occurs in inbred BALB/c-bm/bm mice, before the mandibular incisors erupt and make contact with the maxillary incisors. The aim of this study was to determine whether functional lateral loads to incisors promote anterior transverse crossbites in BALB/c-bm/bm mice. METHODS: BALB/c-bm/bm mice with normal occlusion (normal group), BALB/c-bm/bm mice with malocclusion in which the incisors were not cut (mal group), and BALB/c-bm/bm mice in which the incisors had been cut to eliminate the functional lateral load during continued growth (mal-cut group) were used. We examined the amounts of shift of the maxillary and mandibular incisors in each group using radiographic images. RESULTS: The amount of shift of the maxillary incisors in the mal group was significantly greater than that in normal group. The total amount of shift from the maxilla to the mandible in the mal group was significantly greater than in the normal and mal-cut groups. CONCLUSIONS: The results suggest that a continuous functional lateral load to the incisors is strongly related to promoting and worsening anterior transverse crossbite in BALB/c-bm/bm mice.

[Reconstruction of the TMJ and ramus in otomandibular dysplasia, by grafting of TMJ and homologous bone branch]. / Reconstruction de l'a.t.m. et du ramus dans les dysplasies otomandibulaires par greffe d'articulation temporomandibulaire et de branche montante d'os homologue.

INTRODUCTION: Otomandibular dysplasia is a syndrome of deformities that can affect all latero-facial structures, although the main clinical manifestations include maxillary and mandibular hypoplasia and possibly the absence of the temporo-mandibular joint. OBSERVATION: A 18-year-old man with otomandibular dysplasia was treated by grafting in a homologous joint and bone branch. DISCUSSION: There is no consensus on the best age to treat the syndrome and on treatment for mandibular hypoplasia and to reconstruct the temporo-mandibular joint. An alternative to the suggested treatments consists in reconstructing the joint and the branch affected by hypoplasia by grafting in a homologous joint and bone branch.

Effect of a syndromic diagnosis on mandibular size and sagittal position in Robin sequence.

PURPOSE: Despite its pathogenic heterogeneity, it is often assumed that the small mandible in a neonate with Robin sequence will not grow normally. The purpose of this study was to determine mandibular length and position in patients with nonsyndromic versus syndromic Robin sequence. PATIENTS AND METHODS: Lateral cephalograms of 51 children with Robin sequence were analyzed. Group I consisted of nonsyndromic (NS) subjects and group II consisted of subjects with the 4 most common syndromic (S) diagnoses. Cephalometric measurements included sella-nasion-A point (SNA), sella-nasion-B point (SNB), sella-nasion-pogonion (SNPg), articulare-gonion-pogonion (ArGoPg), temporomandibular joint-pogonion (TmPg), articulare-gonion (ArGo), and gonion-pogonion (GoPg). Differences between groups and subgroups were compared using t test. RESULTS: There were 26 NS patients (mean age, 6.8 yrs) and 25 S patients (mean age, 8.7 yrs); mean age was statistically different between groups (P = .04); therefore, cephalometric measurements were compared with age-matched normal values. Syndromes included Stickler (n = 10), bilateral facial microsomia (n = 8), velocardiofacial (n = 4), and Treacher Collins (n = 3). SNA was statistically different from normal in both groups (NS, P = .017; S, P = .007); however, SNB was not different from normal for either group (NS, P = .175; S, P = .537). SNPg (0.007) was significantly greater than normal in NS (P = .007) but not in S (P = .702) patients. SNA, SNB, and SNPg were not significantly different between groups. In both groups, mandibular length was short (P = .00), especially in S patients (P = .049), mandibular body was small (NS, P = .00; S, P = .00), and the gonial angle more obtuse (NS, P = .006; S, P = .000) than normal. Ramus length was significantly shorter than normal only in S patients (P = .019). Mandibular length (TmPg) was smaller than normal in all S subgroups but with wide variability. There were statistically significant differences among S subgroups with respect to mandibular sagittal position (SNB, P = .00; SNPg, P = .00) and mandibular length (TmPg, P = .008). There were no differences in S subgroups with respect to age, SNA, ArGo, GoPg, and ArGoPg. CONCLUSION: Mandibular morphology and position are variable in Robin sequence, based on the presence and type of associated syndromic diagnosis.

[Computed tomography investigation of temporomandibular joint in surgery of dento-maxillary anomalies]. / Metoda de evaluare tomografica a articulatiei temporo-mandibulare in chirurgia anomaliilor dento-maxilare scheletale severe.

The aim of this study was to evaluate changes in the temporomandibular joint morphology, regarding the relation between mandibular condyle and fossa, after bilateral sagittal split osteotomy in Angle class III dentomaxillary anomalies. Preserving the preoperative position of the condyle during sagittal split osteotomy is considered important to obtain skeletal and occlusal stability. Cone-beam computed tomography of 20 class III patients with mandibular prognathism were assessed before and 6 weeks after operation to evaluate changes of the condylar position. We propose a protocol for head posture and computed tomography investigation, which makes possible the comparison between cone-beam computed tomography (CBCT) in different moments at the same patient. There are no significant changes after bilateral sagittal split osteotomy regarding joint relations.

Congenital deformities and developmental abnormalities of the mandibular condyle in the temporomandibular joint.

The temporomandibular joint (TMJ) consists of the mandibular condyle and the articular eminence of the temporal bone. The morphological development of the TMJ during prenatal life lags behind other joints in terms of both the timing of its appearance and its progress. At birth, the joint is still largely underdeveloped. There are many causes of the various growth disturbances and abnormalities of the mandibular condyle and related structures. Growth disturbances in the development of the mandibular condyle may occur in utero late in the first trimester and may result in disorders such as aplasia or hypoplasia of the mandibular condyle. Meanwhile, hyperplasia of the mandibular condyle is not visible at birth and seems to be gradually acquired during growth. In the present review article, the congenital abnormalities of the mandibular condyle are classified morphologically into three major groups and two subgroups from a clinical standpoint: (1) hypoplasia or aplasia of the mandibular condyle, including (i) primary condylar aplasia and hypoplasia, (ii) secondary condylar hypoplasia; (2) hyperplasia; and (3) bifidity. In addition, the molecular-based etiology of anomalies of the mandibular condyle is also discussed.

Congenital Abnormalities of the Temporomandibular Joint.

Congenital deformities of the temporomandibular joint (TMJ) complex can present as a heterogeneous continuum of growth disturbances of the mandibular condyle, articular eminence, and temporal bone. This article describes several syndromes with congenital condylar deformity, including mandibulofacial dysostosis (Treacher Collins syndrome), hemifacial microsomia, oculoauriculovertebral syndrome, oculomandibulodyscephaly (Hallermann-Streiff syndrome), and Nager syndrome. Variations in the extent of TMJ deficiency seen in each individual case influence the timing and techniques of TMJ reconstruction.

Acquired Abnormalities of the Temporomandibular Joint.

Mandibular growth is a complex process that involves the "functional matrix," an interaction of the muscles of mastication, occlusion, and jaw function. Although not a typical growth center, the mandibular condyle has a significant effect on the ultimate size, shape and function of the mandible and secondarily on overall facial form. Acquired temporomandibular joint (TMJ)/condylar abnormalities, such as juvenile idiopathic arthritis, idiopathic condylar resorption, TMJ ankylosis, and condylar hyperplasia, often result in facial deformity and functional deficits. Accurate diagnosis is critical for the clinician to assess potential progression of deformity, predict prognosis, and plan treatment.