Manejo das disfunções temporomandibulares. Parte II: tratamento cirúrgico / Management of temporomandibular joint disorders. Part II: surgical treatment

Objetivo: Apresentar as modalidades de tratamentos cirúrgicas mais usadas disponíveis no arsenal terapêutico das desordens temporomandibulares (DTMs). Revisão da literatura: As DTMs são muito frequentes e são responsáveis ​​por dor e desconforto em um número importante de pacientes. A avaliação e o diagnóstico são as chaves para determinar um plano de manejo adequado dessas doenças. Embora o tratamento conservador seja bem-sucedido na maioria dos pacientes, os tratamentos cirúrgicos podem ser a única opção para aqueles que não respondem ao tratamento conservador ou para casos com indicação cirúrgica inicial como, por exemplo, algumas neoplasias articulares. Dentre as alternativas cirúrgicas, podemos citar a artrocentese, artroscopia, reposicionamento do disco articular por cirurgia aberta, discectomia e tratamentos cirúrgicos para hipermobilidade e anquilose da articulação temporomandibular. Considerações finais: A seleção adequada dos casos é requisito obrigatório para uma intervenção cirúrgica bem-sucedida, a fim de alcançar o resultado desejado do tratamento, como alívio dos sintomas e melhora da função.

Aim: To present the most commonly used surgical treatment modalities available in the therapeutic arsenal for temporomandibular disorders (TMD). Literature review: TMD is very common and is responsible for pain and dysfunction in a significant number of patients. Assessment and diagnosis are key to determining a management plan for these diseases. Although conservative treatment is successful in most patients, surgical treatments may be the only option for those who do not respond to conservative treatment or for some cases with an initial surgical indication, such as some joint neoplasms. Surgical alternatives include arthrocentesis, arthroscopy, repositioning of the articular disc by open surgery, discectomy and surgical treatments for temporomandibular joint hypermobility and ankylosis. Conclusions: Proper case selection is the mandatory requirement for successful surgical intervention in order to achieve the desired treatment outcome, such as symptom relief and improved function.

Perspectivas atuais da Engenharia de Tecidos da articulação temporomandibular / Perspectivas Actuales de la Ingeniería de Tejidos para la Articulación Temporomandibular / Current Perspectives of Tissue Engineering for the Temporomandibular Joint

Introdução: As limitações das terapias atuais para doenças degenerativas da articulação temporomandibular (ATM) levaram ao aumento do interesse em estratégias regenerativas. A engenharia de tecidos (ET), combinando células-tronco, arcabouços e fatores de crescimento, pode fornecer uma substituição biológica funcional e permanente das estruturas da ATM, além de prevenir o avanço de doenças degenerativas. Objetivo: Este artigo descreve as perspectivas atuais da ET das estruturas da ATM em modelos animais. Metodologia: As abordagens da ET foram categorizadas de acordo com as estruturas primárias da ATM: 1) o disco articular, 2) o côndilo mandibular e 3) a fossa glenóide e eminência articular. Resultados: As áreas com a maior quantidade de estudos são o côndilo mandibular e disco articular, em estudos que abordam o uso de arcabouços tridimensionais, de origem sintética e/ou natural, podendo ou não estar associados a células tronco (diferenciadas ou não) e a fatores de crescimento. Conclusão: A ET da ATM ainda é uma área relativamente nova, em desenvolvimento e em constante avanço. Os avanços tecnológicos desenvolvidos nessa área têm o potencial de auxiliar no desenvolvimento de terapias mais eficientes e menos invasivos... (AU)

Introducción: Las limitaciones de las terapias actuales para las enfermedades degenerativas de la articulación temporomandibular (ATM) han llevado a un mayor interés en las estrategias regenerativas. La ingeniería de tejidos, que combina células, andamios y factores de crecimiento, puede proporcionar un reemplazo biológico funcional y permanente de las estructuras de la ATM, además de prevenir el avance de enfermedades degenerativas. Objetivo: Este artículo describe las perspectivas actuales de la ingeniería de tecidos de las estructuras de la ATM en modelos animales. Metodología: Los enfoques de ingeniería de tejidos se clasificaron según las estructuras primarias de la ATM: 1) el disco articular, 2) el cóndilo mandibular y 3) la fosa glenoidea y la eminencia articular. Resultados: Las áreas con mayor número de estudios son el cóndilo mandibular y el disco articular, en estudios que abordan el uso de estructuras tridimensionales, de origen sintético y/o natural, que pueden o no estar asociadas a células (diferenciadas o no) y con factores de crecimiento. Conclusión: La ingeniería de tejidos de la ATM es todavía un área relativamente nueva, en desarrollo y em constante avance. Los avances tecnológicos desarrollados en esta área tienen el potencial de ayudar en el desarrollo de terapias más eficientes y menos invasivas... (AU)

Introduction: The limitations of current therapies for degenerative diseases of the temporomandibular joint (TMJ) have led to increased interest in regenerative strategies. Tissue engineering (TE), combining stem cells, scaffolds, and growth factors, can provide a functional and permanent biological replacement of TMJ structures, in addition to preventing the advancement of degenerative diseases. Aim: This article describes current TE perspectives of TMJ structures in animal models. Methods: TE approaches were categorized according to the primary TMJ structures: 1) the articular disc, 2) the mandibular condyle, and 3) the glenoid fossa and articular eminence. Results: The areas with the greatest number of studies are the mandibular condyle and articular disc, in studies that address the use of three-dimensional scaffolds, of synthetic and/or natural origin, which may or may not be associated with stem cells (differentiated or not) and with growth factors. Conclusion: TE of the TMJ is still a relatively new, developing, and constantly advancing area. The technological advances developed in this area have the potential to assist in the development of more efficient and less invasive therapies... (AU)

Acesso cirúrgico ao segmento cervical distal da artéria carótida interna e à bifurcação carotídea alta - revisão integrativa da literatura e proposta de protocolo / Surgical access to the distal cervical segment of the internal carotid artery and to a high carotid bifurcation - integrative literature review and protocol proposal

Resumo Diversas manobras já foram descritas para o acesso ao segmento distal cervical da artéria carótida interna ou à bifurcação carotídea alta; entretanto, há divergências na sistematização dessas técnicas. O objetivo deste estudo é revisar as técnicas descritas e propor um protocolo prático que auxilie na seleção da técnica mais adequada para cada caso. Para isso, foi realizada uma busca nas bases de dados PubMed Central, Biblioteca Virtual em Saúde e SciELO por artigos sobre o tema, em língua inglesa ou portuguesa, publicados entre os anos de 1980 e 2021. Entre as manobras descritas, parece razoável que as duas etapas iniciais sejam a abordagem ao músculo esternocleidomastóideo, seguida pela secção/retração do ventre posterior do músculo digástrico. Caso necessário, a subluxação mandibular temporária unilateral é um recurso adicional e preferível à divisão do aparato estiloide, devido ao menor potencial de morbidade. Exposições ainda mais amplas podem ser obtidas com as osteotomias mandibulares.

Abstract Several different maneuvers have been described for obtaining access to the distal cervical segment of the internal carotid artery or to a high carotid bifurcation. However there are different approaches to systematization of these techniques. The objective of this study is to review the techniques described and propose a practical protocol to support selection of the most appropriate technique for each case. The review is based on the results of database searches on PubMed Central, the Virtual Health Library (BVSalud), and SciELO for articles on the subject published in English or Portuguese from 1980 to 2021. Among the different maneuvers described, it appears reasonable that the first two steps should be to obtain access at the sternocleidomastoid muscle, followed by section or retraction of the digastric muscle posterior belly. If needed, temporary unilateral mandibular subluxation is an additional resource that is preferable to division of the styloid apparatus process, because of its lesser potential for morbidity. Even wider exposure can be obtained using mandibular osteotomies.

Condylar Dislocation for Intracranial Fossa: a Review of the Last 10 Years

The displacement of the mandibular condyle into the cranial fossa is an uncommon event; when it occurs, there is a need for immediate and multidisciplinary surgical intervention. Due to its rare advent, there is still no consolidated service dynamics, as this condition has not yet been described in a sedimented way in the literature databases. In the present article, we performed a literature review of condylar dislocation for the intracranial fossa described in the past 10 years in the PubMed and Lilacs search databases.

Research progress on tissue engineering in repairing tempomandibular joint / 浙江大学学报·医学版

Temporomandibular joint osteoarthritis (TMJOA) is mainly manifested as perforation of temporomandibular joint disc (TMJD) and destruction of condylar osteochondral complex (COCC). In recent years, tissue engineering technology has become one of the effective strategies in repairing this damage. With the development of scaffold material technology, composite scaffolds have become an important means to optimize the performance of scaffolds with the combined advantages of natural materials and synthetic materials. The gelling method with the minimally invasive concept can greatly solve the problems of surgical trauma and material anastomosis, which is beneficial to the clinical transformation of temporomandibular joint tissue engineering. Extracellular matrix scaffolds technology can solve the problem of scaffold source and maximize the simulation of the extracellular environment, which provides an important means for the transformation of temporo joint tissue engineering to animal level. Due to the limitation of the source and amplification of costal chondrocytes, the use of mesenchymal stem cells from different sources has been widely used for temporomandibular joint tissue engineering. The fibrochondral stem cells isolated from surface layer of articular cartilage may provide one more suitable cell source. Transforming growth factor β superfamily, due to its osteochondrogenesis activity has been widely used in tissue engineering, and platelet-rich derivative as a convenient preparation of compound biological factor, gradually get used in temporomandibular joint tissue engineering. With the deepening of research on extracellular microenvironment and mechanical stimulation, mesenchymal stem cells, exosomes and stress stimulation are increasingly being used to regulate the extracellular microenvironment. In the future, the combination of complex bioactive factors and certain stress stimulation may become a trend in the temporomandibular joint tissue engineering research. In this article, the progress on tissue engineering in repairing COCC and TMJD, especially in scaffold materials, seed cells and bioactive factors, are reviewed, so as to provide information for future research design and clinical intervention.

Evaluation of mandibular stability and condylar volume after orthognathic surgery in patients with severe temporomandibular joint osteoarthrosis / 北京大学学报(医学版)

OBJECTIVE@#To investigate the effect of preoperative condylar condition for mandible retrognathism deformities with severe temporomandibular joint osteoarthrosis on the stability of the jaw after orthognathic surgery and on the postoperative condylar volume changes.@*METHODS@#In this retrospective study, from 2014 to 2019, 37 patients including 1 male and 36 female, aged between 21 to 34 years old with an average age of (28.03±6.52) years, were diagnosed with mandible retrognathism deformities with severe temporomandibular joint osteoarthrosis by Peking University School and Hospital of Stomatology and received orthognathic surgery, meeting the inclusion criteria were included. According to the preoperative condylar condition. There were divided into smooth group and non-smooth group, the lateral cephalometric films 1 week (T0), 3 months (T1), 6 months (T2) and 1 year (T3) after surgery were used to establish the coordinate system and cephalometric analysis to determine the stability of the jaw after operation. The three-dimensional model of the condyle was segmented by cone beam computed tomography (CBCT) 1 week (T0), 3 months (T1), 6 months (T2) and 1 year (T3) after surgery and the volume was obtained to evaluate the change of the condyle volume after surgery. CBCT image data was used to evaluate the changes of the condylar condition after surgery, and to clarify the correlation between the postoperative condylar condition and jaw stability. SPSS 20.0 statistical software was used for statistical analysis, Fisher's exact probability methods were used to compare whether there were statistically significant differences in the stability of the mandibular joint at stages T1, T2 and T3 with different preoperative condylar condition.Spearman correlation coefficient analysis and Mann-Whitney test were used to compare whether there were statistically significant differences in the volume changes at stages T1, T2 and T3 after surgery between the two groups.@*RESULTS@#The recurrence rates of the mandible in the condylar smooth group were T1 36.85%, T2 47.37% and T3 42.11%, respectively. The recurrence rates in the non-smooth condylar group were T1 27.78%, T2 44.44% and T3 55.56%, respectively. There was no statistical difference in the recurrence rates between the two groups at different time points. There was no significant difference in the condylar volume change between smooth group and non-smooth group.@*CONCLUSION@#For patients with mandible retrognathism deformities with severe temporomandibular joint osteoarthrosis and no significant changes in the condyle observed for one year before surgery, there is no difference in the influence of the preoperative condylar condition on the stability of jaw after operation, and no definite influence on the volume of the condyle after operation. Condylar resorption 3 months after surgery can cause instability of the jaw after orthognathic surgery.

Anquilose da articulação têmporo-mandibular em criança: relato de caso clínico / Temporomandibular joint ankylosis in children: case report

Anquilose da articulação temporo mandibular (ATM) pode ser definida como a fusão das superfícies articulares da mandíbula com o crânio, resultando em severos problemas para seus portadores. Os fatores causais mais comuns são: trauma, infecção e doença sistêmica. Diversos sistemas de classificação têm sido propostos, dentre eles o estabelecido por Sawhney (1986), que divide essa patologia em 4 estágios. Diversas formas de tratamento têm sido empregadas, tais como artroplastia em gap, artroplastia interposicional e reconstrução articular. Kaban estabeleceu um protocolo de tratamento para pacientes pediátricos, muito utilizado na atualidade, apresentando boas taxas de sucesso. O objetivo do trabalho foi relatar um caso de uma criança com anquilose bilateral da ATM, tratada seguindo esse protocolo, com sucesso em seu objetivo de restaurar a função mandibular, apesar da possibilidade de procedimentos complementares futuros para finalização do caso.

Ankylosis can be defined as a fusion of the articular surfaces of the jaw to the skull, resulting in severe problems for its sufferers. The most common causal factors are trauma, infection and systemic disease. Several classification systems have been proposed, among them established by Sawhney (1986), which divides this disease into four stages. Several forms of treatment have been employed, such as gap arthroplasty, interpositional arthroplasty and joint reconstruction. Kaban established a treatment protocol for pediatric patients widely used today with good success rates. The aim of the study was to report a case of a child with bilateral ankylosis, treated according to this protocol with success in the goal to restore jaw function despite the possibility of future additional procedures for completion of the case.

Reconstrucción mandibular con injerto costocondral en microsomía hemifacial: reporte de un caso / Mandibular reconstruction with a costochondral graft in hemifacial microsomia: report of a case

La reconstrucción de la articulación temporomandibular (ATM) es una de las cirugías más demandantes para el cirujano maxilofacial y su equipo. Sus objetivos no sólo incluyen la rehabilitación del complejo mecanismo normal de la articulación, sino también la restauración de la simetría facial, mejorar la oclusión y a la vez la masticación. Las funciones de la ATM pueden verse afectadas por diferentes en enfermedades: tumorales, infecciosas, traumáticas y displasias. Éstas son las que constituyen la mayor indicación para la reconstrucción de la ATM, siendo las congénitas asociadas a síndromes las más difíciles de tratar. La microsomía hemifacial es el segundo defecto craneofacial más común, después de la fisura labio palatina. Es un síndrome que, a diferencia de otros, presenta una gran diversidad de opciones de tratamiento, los cuales van a ser aplicados con un enfoque multidisciplinario, ya que los tratamientos pueden ir desde los conservadores o no quirúrgicos como los de ortopedia funcional hasta los quirúrgicos que comprenden la reconstrucción de la ATM y rama mandibular, los cuales en su mayoría se realizan con injertos libres costocondrales. Se presenta el caso de un paciente femenino de cinco años de edad, la cual acude referida al Hospital Central ®Dr. Ignacio Morones Prieto¼ con diagnóstico de microsomía hemifacial severa. Este trabajo se enfoca en describir el protocolo utilizado en nuestra institución para la reconstrucción mandibular de este síndrome desde edades tempranas, lo que beneficiará tanto la función articular como la estética facial.

Temporomandibular joint (TMJ) reconstruction is one of the most demanding surgical procedures performed by maxillofacial surgeons and their teams, whose aim is not only to rehabilitate the complex normal mechanism of the joint but also to restore facial symmetry, and to improve occlusion and chewing. TMJ functions can be affected by various types of maladies: tumors, infectious diseases, trauma, and dysplasias, which constitute the main indicators for TMJ reconstruction, being those associated with congenital syndromes the most difficult to treat. Hemi-facial microsomia is the second most common craniofacial defect after cleft lip and palate. Unlike other syndromes, it presents a wide range of treatment options, all involving a multidisciplinary approach as that they can range from conservative or nonsurgical procedures to functional orthopedics, and surgical procedures in which the TMJ and the mandibular ramus are reconstructed...

Interpositional Arthroplasty with Temporomyofascial Flap to Correct TMJ Reankylosis in Child: A Case Report.

Temporomandibular joint ankylosis (TMA) is a highly distressing condition in which the temporomandibular joint (TMJ) is replaced by scar tissue. Most frequently reported complications after surgical treatment are limited mouth opening and re-ankylosis. Reankylosis happens due to inadequate bone removal, lack of sufficient interpositional material, fibrous tissue adhesions and elongation of coronoid process and regrowth of bone in the sigmoid notch area. In gap arthroplasty treatment chances to recurrence is 53% than interpositional arthroplasy. We treated a case of right sided TMJ reankylosis by interpositional arthroplasty with temporomyofacial flap and physiotherapy was started 3 days after surgery and maintained for 6 months. In 2 years follow-up, no signs of recurrence and maximum mouth opening 45 mm were observed. The success in preventing reankylosis after TMJ interpositional arthroplasty with temporomyofacial flap is relatively better than gap arthroplasty alone.

Cirugía endoscópica de la articulación temporomandibular: condromatosis sinovial / Endoscopic surgery of the temporomandibular joint: synovial chondromatosis / Cirurgia endoscópica de la articulação temporomandibular: condromatose sinovial

La condromatosis sinovial es una metaplasia cartilaginosa del tejido sinovial de las articulaciones. Es una enfermedad de etiología desconocida e infrecuente. Su localización en la articulación temporomandibular es más rara aún. Se describe el caso clínico de una paciente con diagnóstico de condromatosis sinovial de la articulación temporomandibular tratada con éxito mediante un abordaje quirúrgico combinado: externo y con endoscopios de 4 mm. Se realizó una revisión de la bibliografía sobre la información existente de la condromatosis sinovial.

Synovial chondromatosis is a cartilaginous metaplasia of the synovial tissue of joints. It is a disease of unknown etiology and infrequent. Its location in the temporomandibular joint is still more unusual. The case of a patient is described with a diagnosis of synovial chondromatosis of the temporomandibular joint successfully treated with a combined surgical approach: external and with 4 mm endoscopes. A review of the literature was conducted on the existing information on synovial chondromatosis.

A condromatose sinovial é uma metaplasia cartilaginosa do tecido sinovial das articulações. É uma doença de etiologia desconhecida e pouco frequente. A sua localização na articulação temporomandibular é ainda mais rara. Descreve-se o caso clínico de uma paciente com diagnóstico de condromatose sinovial da articulação temporomandibular tratada com sucesso mediante uma abordagem cirúrgica combinada: externa e com endoscópios de 4 mm. Realizou-se uma revisão da bibliografia sobre a informação existente da condromatose sinovial.

Tratamento de anquilose da articulação temporomandibular subsequente à trauma mandibular em paciente pediátrico / Management of temporomandibular joint bony ankylosis as sequel of mandibular trauma in pediatric patient

A anquilose da articulação temporomandibular (ATM), refere-se à união intracapsular do complexo discocôndilo à superfície articular do osso temporal, com restrição dos movimentos articulares, e consequente limitação da abertura bucal, restrição da capacidade mastigatória, dificuldade de fonação, higiene bucal precária, além dos transtornos psicológicos como dificuldade de interação social. O presente estudo tem por objetivo relatar um caso clínico de anquilose unilateral na ATM direita em uma paciente do gênero feminino, com nove anos de idade e discutir os aspectos envolvidos no seu tratamento, como a utilização de artroplastia interposicional com enxerto costocondral e retalho de músculo temporal na cirurgia reconstrutiva da ATM. Conclui-se que a artroplastia interposicional com retalho do músculo temporal e enxerto costocondral representa uma excelente alternativa para o tratamento de paciente com anquilose da ATM em fase de crescimento, pois o enxerto costocondral possui características morfológicas semelhantes ao côndilo mandibular, potencial de crescimento, que possibilita que o enxerto acompanhe o surto de crescimento no caso de pacientes pediátricos. O resultado satisfatório do tratamento deve ser atribuído à correta escolha da técnica cirúrgica e ao acompanhamento fisioterápico e fonoaudiológico rigoroso... (AU)

Ankylosis of the temporomandibular joint (TMJ) refers to the fusion of the complex intracapsular disc-condyle and the articular fossa of the temporal bone, with restriction of joint movement and consequent limitation of mouth opening, restricted masticatory capacity, difficulty in speech, and poor oral hygiene, in addition to psychological disorders such as difficulty with social interaction. This study aims to report a case of unilateral TMJ ankylosis. A 9-year-old female patient and discuss the issues involved in treatment by means of interpositional arthroplasty with costochondral graft and muscle flap temporal reconstructive surgery on the TMJ. We conclude that treatment using interpositional arthroplasty with temporalis muscle flap and costochondral graft is an excellent alternative for treating patients with TMJ ankylosis during growth because the costochondral graft has morphological characteristics similar to the mandibular condyle growth potential, which allows the graft to track the growth spurt in the case of pediatric patients. The satisfactory outcome of treatment should be attributed to the correct choice of surgical technique and to follow-up including rigorous physical therapy and speech therapy... (AU)

Anquilosis de ATM: riesgos anatómicos y potencialidad del sistema piezoeléctrico / TMJ ankylosis: anatomical risk and piezoelectric system potentiality

El objetivo de este trabajo es presentar los riesgos anatómicos en el abordaje de la anquilosis de la articulación temporo mandibular (ATM) y el uso del sistema piezoeléctrico para realizar la resección de la misma. La paciente sexo femenino, 12 años, presento una anquilosis de la ATM derecha, previamente operada en base a reconstrucción con un injerto costocondral. Luego de 4 años de realizada la primera reconstrucción se presentó con una nueva anquilosis del área presentando una masa de tejido óseo de 31 mm en sentido latero-medial, que abarcaba hasta el foramen oval en la base de cráneo y de 28 mm en sentido anteroposterior. La lesión fue abordada con un acceso preauricular y posterior resección con sistema piezoeléctrico, utilizando una técnica de resección en bloque. Se presenta la técnica y se discute la potencialidad de realizar este procedimientos con los nuevos sistemas piezoeléctrico.

The aim of this report is to present the anatomical risk for to treat the temporo mandibular joint (TMJ) ankylosis and the use of the piezoelectric system for to make the bone resection. Female patient, 12 years old, presented a right TMJ ankylosis, that was previously operated with a costocondral graft reconstruction. After 4 year from these reconstructive surgery the patient was involved in a new TMJ anklylosis of the same side showing a bone mass with 31mm in an meddle-lateral direction, with compromise until to oval foramen in the skull base and 28mm in the anterior-posterior direction. The lesion was operated by a preauricular approach and then a bone resection with the piezoelectric system, using a block resection technique. In this report it´s present the technique and is discusses the potentiality of the new piezoelectric system for these procedures.

Sistema TMJ Concepts: Próteses personalizadas e de estoque para reconstrução total da articulação temporomandibular / TMJ Concepts System: Custom-made and off-the-shelf prostheses for temporomandibular joint reconstruction

Certas lesães que afetam a articulação temporomandibular (ATM) podem ser severas necessitando de uma reconstrução efetiva dessa estrutura, mas a reconstrução artificial da ATM com qualquer tipo de implantes que não apresente décadas de sucesso, deve ser considerada como a última alternativa para os pacientes que estão sofrendo de lesões severas. As proteses TMJ Concepts© quando usadas em pacientes que tiveram múltiplas cirurgias da ATM resultação em melhora da função, mas em geral, não reduzirão significativamente as dores. A reconstrução da ATM tem indicações específicas e precisas que serão abordadas neste artigo, bem como os benefícios e riscos. O autor recomenda os dispositivos da firma TMJ Concepts Inc., Califórnia - EUA depois de mais de uma década de excelente experiência pessoal com esse produto

Certain dysfunctions affecting temporomandibular joint (TMJ) may be severe and might need an effective reconstruction. However artificial replacement of the TMJ with any type of implants that have not presented decades of treatment success is to be considered the last resort for patients suffering from severe TMJ diseases. The TMJ Concepts© prostheses when used in patients submitted to multiple TMJ surgeries will improve jaw function but in general they will not reduce pain significantly. TMJ reconstruction has specific and precise indications which will be addressed on this article as well as its benefits and risks. The author endorses TMJ Concepts© devices after more than a decade of excellent personal experience with this product

Criterio de diagnóstico para el tratamiento quirúrgico de los Meniscopatias de la Articulación Temporomandibular / Diagnostic criteria for the surgical treatment of temporomandibular joint disorders

La alteración en el normal funcionamiento de la Articulación Temporomandibular (ATM), puede tener repercusiones en forma aguda o crónica, con especial énfasis en los músculos de la masticación y/o inflamación de la articulación, que conecta la mandíbula con el cráneo. La principal causa es la hiperfunción o parafunción muscular, como en el caso del bruxismo, con repercusión en el sistema musculo-esqueletal de la cavidad oral, como también diferentes tipos de desplazamientos del disco en la ATM. El desorden trasciende los límites entre diferentes disciplinas de la salud, en particular, odontología y neurología que tienen diferentes enfoques de tratamiento. La ATM es susceptible a muchas otras afecciones que afectan a otras articulaciones del cuerpo, incluyendo anquilosis, artritis, trauma, luxaciones, desarrollo de anomalías, neoplasias y lesiones recidivantes. La decisión para intervenir una ATM debería ser tomada con cautela y basada en un análisis racional y apropiado de la enfermedad subyacente. En csos selectos, la cirugía de ATM es el tratamiento de elección para un subconjunto de desordenes Temporomandibulares, incluyendo trastornos articulares internos, enfermedad degenerativa de la articulación, artritis reumatoide, artritis infecciosa, luxación mandibular, anquilosis e hiperplasia o hipoplasia condilar. El objetivo del presente trabajo es enmarcar la cirugía de ATM como un ámbito indiscutible de la cirugía oral y maxilofacial, que bajo un diagnóstico certero y criterio quirúrgico apropiado lleva a una resolución definitiva del cuadro patológico.

Temporomandibular joint disorder a term covering acute or chronic pain, especially in the muscles of mastication and/or inflammation of the temporomandibular joint, which connects the mandible to the skull. The primary cause is muscular hyper or parafunction, as in the case of bruxism, with secondary effects on the oral musculoskeletal system, like various types of displacement of the disc in the temporomandibular joint. The disorder transcends the boundaries between several health-care disciplines in particular, dentistry and neurology there are a variety of treatment approaches. The temporomandibular joint is susceptible to many of the conditions that affect other joints in the body, including ankylosis, arthritis, trauma, dislocations, developmental anomalies, enoplasia and rective lesions. The decision to perform temporomandibularjoint (TMJ) surgery should be made carefully and must be based on a rational and appropiate analysis of the underlying disease. In selected cases, TMJ surgery is the preferred treatment for a subset of temporomandibular disorders (TMDs), incluiding internal derangement, degenerative joint disease, rheumatoid arthritis, infectious arthritis, mandibular dislocation, ankylosis, and condylar hyperplasia or hypoplasia. The aim of this article is to establish that TMJ surgery is the undisputed purview of the maxillofacial surgeon, thatunder accurate diagnosis and adquate surgical criteria leads to a definitive resolution of the pathology.

Bifocal distraction in patient with rheumatoid arthritis and severe condylar degeneration: report of case / Distracción bifocal en paciente con artritis reumatoide y degeneración condilar severa: reporte de un caso

Facial involvement in patients with rheumatoid arthritis is variable depending on the type, onset, and duration of the disease. The treatment of patients with open bite resulting from degenerative changes on the condyles can be a challenge for the surgeon. Rheumatoid arthritis is a systemic disorder of unknown etiology characterized by chronic inflammation and proliferation of synovial tissue. Studies showed that patients with rheumatoid arthritis can developed progressive osteoarthrosis that result in gross radiographic changes in the condyles. With the development of distraction osteogénesis for treatment of mandible hypoplasia a new chapter has been opened in the surgical management of patients with rheumatoid arthritis associated with skeletal deficiency. The aim of this paper is to evaluate osteogenesis distraction for treatment of anterior open bite in patients with rheumatoid arthritis and severe condylar degeneration.

El compromiso facial en pacientes con artritis reumatoide es variable dependiendo del inicio, tipo y duración de la enfermedad. El tratamiento del paciente con mordida abierta resultante de procesos degenerativos condilares son desafiantes para los cirujanos. La artritis reumatoide es una enfermedad sistémica de etiología desconocida caracterizada por inflamación crónica y proliferación del tejido sinovial. Algunos estudios han demostrado que pacientes con artritis reumatoide pueden desarrollar osteoartrosis progresiva que resulta en importantes cambios condilares. Con el desarrollo de la distracción osteogénica para el tratamiento de la hipoplasia mandibular se abrió un nuevo capítulo en el manejo quirúrgico de pacientes con artritis reumatoide asociada a deficiencias esqueletales. El objetivo de este artículo es evaluar la aplicación de distracción osteogénica en un caso de mordida abierta anterior en paciente con artritis reumatoide y degeneración condilar severa.

Discopexia con anclaje: estudio retrospectivo de 190 casos / Discopexia with anchor: a retrospective study of 190 cases

Las disfunciones de la articulación temporomandibular pueden causar graves dolores en la cabeza y cuello. Según la etapa de la disfunción que presentan los pacientes, el tratamiento clínico en sí mismo puede no resultar en respuestas satisfactorias y el tratamiento quirúrgico puede ser considerado como parte del tratamiento. Este trabajo presenta un estudio retrospectivo de 190 pacientes que presentaban desplazamiento discal tratados a través de discopexia quirúrgica y anclaje posterior del disco articular en el cóndilo después de un tratamiento clínico sin respuesta adecuada. El dolor, la distancia interincisal, la extensión del movimiento mandibular, la movilidad y los sonidos del disco articular fueran evaluados clínicamente y por exámenes de imagen en los períodos pre y pos-operatorio, con un seguimiento de 5 años. Los resultados obtenidos fueron favorables para todos los signos y síntomas evaluados. El tratamiento quirúrgico, cuando se indica correctamente, puede ser muy beneficioso para los pacientes que no responden a los tratamientos clínicos de las disfunciones temporomandibulares

The malfunctions of the temporomandibular joint can cause serious pains in the head and neck. According to the stage of the malfunction that the patients present, the clinical treatment by itself cannot result in satisfactory responses and the surgical treatment can be considered to be a part of the treatment. This work presents a retrospective study of 190 patients who were presenting discal displacement agreements across discopexis surgical and later anchoring of the disc to articulate in the condile after a clinical treatment without suitable response. The pain, the interincisal distance, the extension of the jaw movement, the mobility and the sounds of the disc to articulate were evaluated clinically and for examinations of image in the periods pre and post-operatively, with a pursuit of 5 years. The obtained results were favorable for all the signs and evaluated symptoms. The surgical treatment, when it is indicated correctly, can be very beneficial for the patients who do not answer to the clinical treatments of the temporomandibular malfunctions

Anquilose da ATM em crianças: aspectos de interesse cirúrgico / TMJ ankylosis in children: aspects of surgical interest

A anquilose da ATM em crianças gera problemas funcionais, tais como, abertura bucal reduzida, deficiência na fonação, dificuldade de mastigação, higiene bucal pobre, cáries dentais, assimetria facial, distúrbios de crescimento facial e mandibular, maloclusão e comprometimento agudo das vias respiratórias. Essa patologia está mais comumente associada ao trauma, infecções locais ou sistêmicas, doenças sistêmicas, como a espondilite anquilosante, artrite reumatoide, psoríase, fraturas condilares não tratadas ou tratadas de forma inadequada. Várias técnicas têm sido preconizadas para o tratamento da anquilose temporomandibular, e três delas são as mais comumente empregadas: 1) Artroplastia em "gap"; 2) Artroplastia interposicional 3) Excisão e reconstrução da articulação. O manejo da anquilose da ATM continua a ser um tópico de recorrente interesse devido a dificuldades encontradas nas técnicas cirúrgicas empregadas e na alta incidência de recorrência, principalmente quando se trata de pacientes pediátricos. Sabendo-se que a literatura é dinâmica em relatar várias técnicas para o tratamento da anquilose da ATM, este trabalho se propõe a fazer uma revisão acerca do assunto, objetivando discutir os aspectos de interesse cirúrgico no tratamento dessa patologia em crianças.

Temporomandibular joint ankylosis in children causes functional problems such as restricted mouth opening, impairment of speech, difficulty in mastication, poor oral hygiene, rampant caries, facial asymmetry, disturbances in facial and mandibular growth, malocclusion and acute airway involvement. This pathological condition is most commonly associated with trauma, local and systemic infections. Besides, it is also associated with systemic diseases such as ankylosing spondylitis, psoriasis, rheumatoid arthritis, and untreated or improperly treated condylar fractures. Various techniques have been advocated for the treatment of temporomandibular joint ankylosis and three of them are currently employed: 1) Gap arthroplasty; 2) Interpositional arthroplasty; 3) Excision and joint reconstruction. The management of TMJ ankylosis remains a topic continued interest due to difficulties encountered in surgical approaches and the high recurrence of the disease, particularly when it comes to pediatric patients. Bearing in mind that new techniques for the treatment of the TMJ ankylosis are constantly being reported in the literature, this paper set out to review the subject and discuss the aspects of surgical interest in the management of this pathology.

Treatment of temporomandibular joint ankylosis with gap arthroplasty and temporal muscle/fascia graft: a case report with five-year follow-up / Tratamento de anquilose da articulação temporomandibular com artroplastia e enxerto de músculo temporal: Relato de caso com cinco anos de acompanhamento

Purpose: Temporomandibular joint ankylosis (TMA) is a highly distressing condition in which the Temporomandibular Joint (TMJ) is replaced by scar tissue. The most commonly surgical approach used to restore normal joint functioning is a gap arthroplasty associated with the temporal muscle flap (TMF) as interpositional material. This paper aimed to present a modification of the conventional vascularized temporal muscle flap, and describe an alternative procedure using a muscle/fascia temporal graft as interpositional tissue for the gap arthroplasty. Case description: We report a case of TMA treated using a gap arthroplasty and a variation of the TMF technique as interpositional material, performing a temporal muscle/fascia graft. The technique described is associated with adequate bone removal and excellent intraoperative joint mobilization. Physiotherapy was started 2 days after surgery and maintained for 4 months. During the five years of follow-up, no signs of ankylosis recurrence were observed; maximum mouth opening is currently 35 millimeters. Conclusion: The success in preventing reankylosis after TMJ gap arthroplasty is related primarily to the early postoperative physiotherapy, maintained long-term. A free graft harvested from temporal muscle and used as interpositional material is easy to obtain, reliable, and effective. Another advantage is minimal damage to the temporal muscle and low morbidity.

Objetivo: A anquilose da articulação temporomandibular (AATM) é uma condição altamente angustiante aonde a articulação é substituída por tecido cicatricial. A técnica cirúrgica mais comumente usada é a artroplastia associada a um retalho de músculo temporal como um material de interposição entre côndilo/fossa glenóide. Este manuscrito relata um caso de anquilose da articulação temporomandibular tratada pela técnica da artroplastia com uma variação da técnica do retalho do músculo temporal como material interposicional. Descrição do caso: Relatou-se um caso de AATM que foi tratada usando artroplastia com enxerto livre do músculo temporal e fáscia como material interposicional. A técnica descrita está associada a adequada remoção de osso e excelente imobilização articular transoperatória. A fisioterapia foi iniciada 2 dias após a cirurgia e mantida por 4 meses. Durante os 5 anos de controle não houve sinais de recidiva de anquilose; a abertura máxima bucal atualmente é de 35 mm. Conclusão: O sucesso na prevenção da recidiva de anquilose após artroplastia da ATM está primariamente relacionado com fisioterapia pós-operatória precoce, mantida por longo período. Um enxerto livre do músculo temporal usado como material interposicional é fácil de ser obtido, confiável e efetivo. Outra vantagem é dano mínimo ao músculo temporal e baixa morbidade.

Antibiotic prophylaxis for orthognathic surgery: a prospective, comparative, randomized study between amoxicillin-clavulanic acid and penicillin.

OBJECTIVE: The present study was designed to evaluate the prophylactic efficacy after the correction of dentofacial deformities between short- and long-term penicillin and amoxicillin-clavulanic acid. MATERIAL AND METHOD: The present study was prospective, randomized, and double blinded. Patients were separated into four groups randomly: short-term and long-term (5 days) penicillin and short-term and long-term (5 days) amoxicillin-clavulanic acid. RESULTS: One hundred twenty two patients were assigned randomly into the four groups. Infection developed in a patient in the short-term amoxicillin-clavulanic acid group and in a patient in the long-term penicillin group. CONCLUSION: There were no differences in infection between the two groups of antibiotics. Based on the present study, short-term penicillin is still the most appropriate choice for prophylactic antibiotic in orthognathic surgery.

Reemplazo temporomandibular. ¿Autógeno o aloplástico?: revisión de la literatura / Temporomandibular replacement. Autogenous or alloplastic?: a review of the literature

En algunos casos la patología articular produce la destrucción estructural, por lo que el reemplazo de los componentes de la articulación temporomandibular (ATM) es necesario. Las técnicas quirúrgicas pueden consistir en el reemplazo del cóndilo, la cavidad glenoidea y su eminencia articular, o ambos elementos. En los pacientes en crecimiento con asimetría deben emplearse los injertos costocondrales. La reconstrucción aloplástica es útil en pacientes adultos que han sido sometidos a múltiples operaciones en las que los injertos autógenos han fracasado.

In some cases joint pathology produces the destruction of structures so that replacement of components of temporomandibular joint (TMJ) is necessary. Surgical techniques may consist in replacement of the condyle, fossa components, or both elements. In growing individuals with asymmetry, costochondral grafts should be used. The alloplastic reconstruction is specially useful in adult patients who have undergone multiple operations in which autogenous grafts have failed.