Botulinum toxin: new treatment for temporomandibular disorders.

BACKGROUND: Temporomandibular disorders (TMDs) affect the face and jaws, and cause chronic pain and dysfunction in many people. As in other conditions involving the musculoskeletal system, controlling the myogenous component is an integral part of treatment. In this study, we evaluated subjective and objective responses to treatment with botulinum toxin A (BTX-A) in a group of 46 patients with TMDs. METHODS: 46 subjects with TMD were enrolled in this uncontrolled study and treated with BTX-A 150U. Both masseter muscles were injected with 50 U each and both temporalis muscles with 25 U each under electromyographic guidance. Subjects were assessed at two-week intervals for eight weeks. Outcome measures included subjective assessment of pain by visual analogue scale (VAS), measurement of mean maximum voluntary contraction (MVC), interincisal oral opening, tenderness to palpation, and a functional index based on multiple VAS. Medians of the data were taken for each outcome measure at each time point and subjected to Duncan's multiple range test. RESULTS: There were significant (P<0.05) differences in all median outcome measures between the pre-treatment assessment and the four follow-up assessments except for MVC. Although MVC was significantly reduced midway through the study, it had returned to pretreatment values by the final two assessments. All other outcome measures remained significantly different from the pretreatment findings. Paired correlation of variables including age, sex, diagnosis, depression index, and time of onset showed no significant differences. CONCLUSIONS: BTX-A injections produced significant improvements in pain, function, mouth opening, and tenderness to palpation. MVC initially diminished then returned to the initial values. Although the study was uncontrolled, the results strongly suggest that BTX-A reduces severity of symptoms and improves functional abilities for patients with TMD and that these extend beyond its muscle-relaxing effects.

Experimental study of bone growth around a dental implant after Surgibone grafting.

Histologic and histomorphometric results of bone growth around titanium alloy screw-type implants after Surgibone grafting in New Zealand white rabbits are presented. At 21 days, new bone was formed along the surface of the implant. At 84 days, newly formed bone replaced almost all of the trabecular bone of the graft and reached the shoulder level of the implant. There was a higher percentage of host bone area at 84 days than at any of the earlier experimental periods (P < .01). The average mineral apposition rates ranged from 1.82 to 2.35 microns/day in original bone and 2.55 to 2.80 microns/day in newly formed bone. The results suggest that Surgibone grafting in combination with dental implants can be used to increase the height of the recipient bone and therefore aid in the fixation of the implant in this animal model.

The use of botulinum toxin for the treatment of temporomandibular disorders: preliminary findings.

PURPOSE: The aim of this study was to evaluate the response of patients with temporomandibular disorders to Botulinum toxin A (BTX-A) therapy. METHODS: The 15 subjects enrolled in this uncontrolled study were diagnostically categorized and treated with 150 units of BTX-A. Both masseter muscles received 50 units each under eletromyographic (EMG) guidance. Similarly, both temporalis muscles were injected with 25 units each. Subjects were assessed at 2-week intervals for 8 weeks. Outcome measures included subjective pain by visual analog scale (VAS), measurement of bite force, interincisal opening, tenderness to palpation, and a functional index based on multiple VAS. RESULTS: All mean outcome measures, with the exception of bite force, showed a significant (P = .05) difference between the preinjection assessment and the four follow-up assessments. No side effects were reported. CONCLUSIONS: BTX-A injections produced a statistically significant improvement in four of five measured outcomes, specifically pain, function, mouth opening, and tenderness. No statistically significant changes were found in mean maximum voluntary contraction or in paired correlation of factors such as age, sex, diagnosis, depression index, or time of onset.

[Experimental study of cattle bone grafting in combination with implant insertion].

OBJECTIVE: To study the effect of cattle bone grafting in combination with implant insertion. METHODS: Twenty cattle bone blocks were onlayed on the rabbit tibial metaphysis, which were fixed by dental implants. Triple fluorochromes were sequentially given to animals following the operation. New bone formation was histologically and histomorphometrically evaluated. RESULTS: The fluorochrome-labelled new bone gradually replaced almost all the spongy bone and the partial cortical bone of the graft at the end of the experiment. There was a significant higher percentage of bone area at the first four thread levels at 84 days than at 21 days. The average mineral apposition rates ranged from 1.90 microns/d to 2.75 microns/d. CONCLUSION: The onlay cattle bone grafting in conjunction with screw-type dental implants can be used to increase the volume of the recipient bone.

A clinical trial of a new dental implant.

This paper presents the results of a clinical trial of a new dental implant after two years of loading. The design and the technical details of the surgical and prosthodontic phases of treatment are discussed. The implant's success was measured using Health Canada (Health Protection Branch) criteria. Patients with less than optimal clinical situations were not excluded from the study. The study shows survival rates in the lower jaw of 85.6 per cent and in the upper jaw of 86.7 per cent. Bleeding and oral hygiene indices and bone loss (less than 0.2 mm/yr) all fall within generally accepted limits.

Effect of drill speed on bone temperature.

Measurements of bone temperature rise were recorded during drilling of bovine cortical bone specimens. A surgical drill (Stryker-100) was fitted with a custom-designed speedometer for monitoring the rotational speed during the drilling, and the drill was mounted on a specially constructed drill press. The tests were conducted in 36 specimens at variable speeds (20000-100000 rpm) and at different constant forces (1.5-9.0 N) which were applied by placing weights on the drill platform. The results revealed that the temperature rise and the duration of temperature elevation decreased with speed and force, suggesting that drilling at high speed and with large load is much more desirable than previously thought.

Clinical prosthodontic management of a new implant system.

Just prior to the advent of the branemark implant, the Harvard consensus on implantology condemned all maxillary implants. While implant utilization has skyrocketed in the last few years integration of implants in the maxilla is a persistent problem and even the branemark implant enjoys a lower success rate in this bone. These observations underscore the higher failure rate of the maxillary implant and suggest the need for development of a new implant design configuration that would favour long term successful integration despite the attenuated maxillary attributes. Such is the intent of the ostial implant. The basic considerations concerning this device, its bioengineering, experimental performance and clinical trials are discussed elsewhere. The purpose of this paper is to describe clinical prosthodontic applications of this implant system.

Postoperative computed tomography study of pterygomaxillary separation during the Le Fort I osteotomy.

Computed tomography (CT) was used postoperatively to assess the pterygomaxillary region in 12 orthognathic surgery patients who had had a Le Fort I osteotomy. Although pterygomaxillary separation was successful in all cases, in only 41.6% of the sides did fractures of the plate not occur. The incidence of low pterygoid plate fracture was 37.5% and that of high pterygoid plate fracture was 25%; 4.2% of sides showed a maxillary tuberosity fracture. Multiple fractures were observed in 8.3% of separated plates. Of 17 pterygoid plates judged clinically to be intact, only 10 were intact as assessed by CT. The significance of these findings and application of CT to evaluation of modifications to the Le Fort I osteotomy is discussed.

Rhabdomyosarcoma of the maxillary sinus: review of the literature and report of a case.

A case of rhabdomyosarcoma of the maxillary sinus is reported. A brief review of the origin, histomorphology, classification, clinical presentation, behavior, prognosis, and treatment is given relative to occurrence in the maxillary antrum. Misinterpretation of the microscopic findings can delay the histologic diagnosis. An error in tissue diagnosis may be minimized by awareness of a chance encounter with this lesion.

A bone chamber for investigation of gas pressure. Oxygen tension measured in rabbits.

Titanium implants containing a chamber that allowed ingrowth of bone were modified from a previous design to allow the use of oxygen microelectrodes. The modification consisted of the placement of ports in the superior surface of the implant for the insertion of oxygen electrodes into the tissue within the bone growth chamber. Forty titanium bone growth chambers were inserted into the proximal tibial metaphyses of 20 rabbits. From 2 to 20 days, oxygen tension was measured inside the chambers of 2 rabbits immediately prior to death. The oxygen tensions increased, declined, and increased again. Our results indicate that oxygen tensions fluctuate during the initial period of healing reflecting cellular changes in the callus.

Osseointegrated dental implants in conjunction with bone grafts.

This paper relates to the experience with 12 patients who received osseointegrated dental implants of the Branemark design associated with bone grafts. 4 patients had iliac crest grafts, 2, of which were inserted together with the implants. Two had metatarsal reconstruction of the anterior mandible with the implants installed at a later date. 2 patients had particulate marrow grafts with immediate installation of the implants. Of the remainder, 1 had a late implantation of a myo-osseous flap utilizing the clavicle and the other delayed implantation of a split rib graft. The mean age of the patients in this series is 49.5 years. The mean loading time for completed cases is 18 months. 7 patients have had their dentition successfully restored, 3 lost the initial implants, 2 of which have been re-operated. One patient died prior to loading and one awaits the final surgical procedure. The results of the particulate marrow and split rib grafts were disappointing. The remainder suggest that osseointegrated dental implants may be utilized with appropriate bone grafting techniques to restore the dentition in patients with severe bone loss or following the surgical ablation of malignant disease.

Dental emergencies.

Patients with dental emergencies sometimes present to their physician. This article outlines the role of the physician in the management of dental patients who have suffered traumatic injuries, postoperative hemorrhage, pain, and infection. It deals with those difficulties for which the physician may easily prescribe treatment and outlines the treatment that would be undertaken by a dentist who receives such a patient on referral.

Interface between titanium 6,4 alloy implants and bone.

This paper presents the results of animal studies on the interface between 6 aluminum, 4 vanadium, titanium alloy and bone. 7 New Zealand white rabbits were anaesthetised and a new design of threaded implant inserted into the tibial metaphysis of each leg. 3 further animals had fine lathe turnings inserted in the same site. The animals were sacrificed 7 weeks later and the implants removed together with the surrounding bone. After suitable processing of the specimens, they were subjected to scanning and transmission electron microscope studies. Compact bone was found in close proximity to the surface of the metal. With higher magnifications, the bone was found to be in intimate contact with the metal. There was no suggestion of the presence of cells or uncalcified collagen fibres between the bone and the implant. At the highest magnification, there was the appearance of a homogenous transition from the bone to the metal, suggesting a biological adhesion.