[Minimally invasive treatments and open joint surgery for disorders of the temporomandibular joint]. / Minimaal invasieve behandelingen en opengewrichtschirurgie voor aandoeningen van het kaakgewricht.

The initial treatment of symptomatic disorders of the temporomandibular joint typically consists of a conservative approach, in which medication (painkillers and muscle relaxants), orofacial physiotherapy and splints are most important. In most cases, minimally invasive treatment options, such as arthrocentesis, arthroscopy or joint injections, are only considered when conservative methods provide insufficient symptom reduction. There is, however, an ongoing debate about the optimal treatment strategy due to an increasing body of evidence concerning the superior effectiveness in symptom reduction of minimally invasive treatment options with regard to conservative treatments. If these minimally invasive treatment options are also ineffective, open joint surgery may be considered as a last option for a select group of patients.

Arthroscopy versus arthrocentesis and versus conservative treatments for temporomandibular joint disorders: a systematic review with meta-analysis and trial sequential analysis.

The aim of this systematic review was to assess the efficacy of arthroscopy compared to arthrocentesis and to conservative treatments for temporomandibular joint disorders. Thirteen controlled studies on various patient outcomes were included after a systematic search in seven electronic databases. Meta-analyses were conducted separately for arthroscopic surgery (AS) and arthroscopic lysis and lavage (ALL), and short-term (<6 months), intermediate-term (6 months to 5 years), and long-term (≥5 years) follow-up periods were considered. No significant differences in pain reduction and complication rates were found between AS or ALL and arthrocentesis. Regarding improvement in maximum mouth opening (MMO), both AS at intermediate-term and ALL at short-term follow-up were equally efficient when compared to arthrocentesis. However, at intermediate-term follow-up, ALL was superior to arthrocentesis for MMO improvement (mean difference 4.9 mm, 95% confidence interval 2.7-7.1 mm). Trial sequential analysis supported the conclusion of the meta-analysis for MMO improvement for ALL versus arthrocentesis studies at intermediate-term follow-up, but not for the other meta-analyses. Insufficient evidence exists to draw conclusions regarding other patient outcomes or about comparisons between arthroscopy and conservative treatments. Due to the low quality of the primary studies, further research is warranted before final conclusions can be drawn regarding the management of temporomandibular joint disorders.

Arthrocentesis versus non-surgical intervention as initial treatment for temporomandibular joint arthralgia: a randomized controlled trial with long-term follow-up.

Arthrocentesis for arthralgia of the temporomandibular joint (TMJ) is often only indicated when conservative, non-surgical interventions have failed. However, performing arthrocentesis as initial therapy may facilitate earlier and better recuperation of the joint. The aim of this study was to assess the efficacy of this therapy with a long-term follow-up. Eighty-four patients were randomly allocated to receive either arthrocentesis as initial treatment (n = 41) or non-surgical intervention (n = 43). Pain (100-mm visual analogue scale, VAS) and mandibular function impairment questionnaire scores (MFIQ, 0-100) were recorded at 3, 12, and 26 weeks, and ≥ 5 years (median 6.2, interquartile range 5.6-7.4 years). Univariable analyses were performed and linear mixed-effect models were constructed. Patients in the arthrocentesis group experienced significantly lower TMJ arthralgia compared to those treated non-surgically (pain during movement: -10.23 mm (95% confidence interval -17.86; -2.60); pain at rest: - 8.39 mm (95% confidence interval -13.70; -3.08)), while mandibular function remained similar in the two groups (MFIQ -2.41 (95% confidence interval -8.61; 3.78)). Of the final sample, 10 patients (10/39, 26%) in the non-surgical intervention group and two patients (2/34, 6%) in the arthrocentesis group received additional treatment during follow-up. Thus, initial treatment with arthrocentesis reduced TMJ arthralgia more efficaciously than non-surgical intervention in the long term, while maintaining similar mandibular function.

Accuracy of fit analysis of the patient-specific Groningen temporomandibular joint prosthesis.

Total joint replacement (TJR) with a prosthesis can be indicated for patients with severe temporomandibular joint (TMJ) dysfunction. Surgical accuracy is necessary for correct translation of the preoperatively predicted functional outcome, wear, and biomechanical behaviour of the patient-specific TMJ-TJR prosthesis. This study describes the first clinical applications of the patient-specific TMJ-TJR prosthesis according to the Groningen principles (G-TMJ-TJR), which was developed and validated in a prior human cadaver test study. The aim of this study was to validate the accuracy of placement of the patient-specific G-TMJ-TJR in the clinical setting. It was hypothesized that a virtual surgical plan (VSP) combined with guided placement of the patient-specific G-TMJ-TJR would be performed as predictably and accurately as in the prior cadaver series. All patients who received a VSP-based patient-specific G-TMJ-TJR between December 2017 and March 2020 were included in this study. The accuracy analysis was based on postoperative cone beam computed tomography (CBCT) data. All 11 prostheses could be inserted using routine pre-auricular and retromandibular surgical approaches. Analysis of the VSPs and postoperative CBCTs showed an average three-dimensional deviation of 1.07mm (standard deviation 0.46mm, range 0.33-1.91mm) for all of the fossa and mandibular components. The patient-specific G-TMJ-TJR can be applied predictably and accurately in a clinical setting.

Biodegradable versus titanium osteosynthesis in maxillofacial traumatology: a systematic review with meta-analysis and trial sequential analysis.

Titanium osteosynthesis is currently the fixation system of choice in maxillofacial traumatology. Biodegradable osteosynthesis systems have the ability to degrade in the human body. The aim of this study was to conduct a systematic review, with meta- and trial sequential analyses, to assess the efficacy and morbidity of biodegradable versus titanium osteosynthesis after maxillofacial trauma. MEDLINE, Embase, and CENTRAL were searched for randomized controlled trials and prospective and retrospective controlled studies. Five time periods were studied: perioperative, short-term (0-4 weeks), intermediate (6-12 weeks), long-term (>12 weeks), and overall follow-up. After screening 3542 records, 24 were included. All had a high risk of performance and detection bias due to the nature of the interventions. Meta-analysis showed no differences in efficacy or morbidity between biodegradable and titanium osteosynthesis. The risk of perioperative screw breakage was significantly higher (risk ratio 17.13, 95% confidence interval 2.19-34.18) and the symptomatic plate removal rate lower in the biodegradable group (risk ratio 0.11, 95% confidence interval 0.02-0.57), which was confirmed by the trial sequential analysis. The quality of evidence ranged from very low to moderate. Based on the narrative review and meta-analyses, current evidence shows that biodegradable osteosynthesis is a viable alternative to titanium osteosynthesis when applied in the treatment of maxillofacial trauma, with similar efficacy but significantly lower symptomatic plate removal rates. Perioperative screw breakage occurred significantly more often in the biodegradable group compared to the titanium group.

Comparison of the long-term clinical performance of a biodegradable and a titanium fixation system in maxillofacial surgery: A multicenter randomized controlled trial.

BACKGROUND: Biodegradable fixation systems could reduce or eliminate problems associated with titanium removal of implants in a second operation. AIM: The aim of this study was to compare the long-term (i.e. >5 years postoperatively) clinical performance of a titanium and a biodegradable system in oral and maxillofacial surgery. MATERIALS AND METHODS: The present multicenter Randomized Controlled Trial (RCT) was performed in four hospitals in the Netherlands. Patients treated with a bilateral sagittal split osteotomy (BSSO) and/or a Le Fort-I osteotomy, and those treated for fractures of the mandible, maxilla, or zygoma were included from December 2006 to July 2009. The patients were randomly assigned to either a titanium (KLS Martin) or a biodegradable group (Inion CPS). RESULTS: After >5 years postoperatively, plate removal was performed in 22 of the 134 (16.4%) patients treated with titanium and in 23 of the 87 (26.4%) patients treated with the biodegradable system (P = 0.036, hazard ratio (HR) biodegradable (95% CI) = 2.0 (1.05-3.8), HR titanium = 1). Occlusion, VAS pain scores, and MFIQ showed good and (almost) pain free mandibular function in both groups. CONCLUSION: In conclusion, the performance of the Inion CPS biodegradable system was inferior compared to the KLS Martin titanium system regarding plate/screws removal in the abovementioned surgical procedures. TRIAL REGISTRATION: http://controlled-trials.com ISRCTN44212338.

Cost-Effectiveness of a Biodegradable Compared to a Titanium Fixation System in Maxillofacial Surgery: A Multicenter Randomized Controlled Trial.

BACKGROUND: Biodegradable fixation systems could reduce/delete the problems associated with titanium plate removal. This means less surgical discomfort, and a reduction in costs. AIM: The aim of the present study was to compare the cost-effectiveness between a biodegradable and a titanium system in Maxillofacial surgery. MATERIALS AND METHODS: This multicenter RCT was performed in the Netherlands from December 2006 to July 2009. Included were 230 patients who underwent a bilateral sagittal split osteotomy (BSSO), a Le Fort-I osteotomy, or a bi-maxillary osteotomy and those treated for fractures of the mandible, maxilla, or zygoma. The patients were randomly assigned to a titanium group (KLS Martin) or to a biodegradable group (Inion CPS). Costs were assessed from a societal perspective. Health outcomes in the incremental cost-effectiveness ratio (ICER) were bone healing (8 weeks) and plate removal (2 years). RESULTS: In 25 out of the 117 patients who were randomized to the biodegradable group, the maxillofacial surgeon made the decision to switch to the titanium system intra-operatively. This resulted in an Intention-To-Treat (ITT-)analysis and a Treatment-Received (TR-) analysis. Both analyses indicated that operations performed with titanium plates and screws had better health outcomes. In the TR-analysis the costs were lower in the biodegradable group, in the ITT-analysis costs were lower in the titanium group. CONCLUSION AND DISCUSSION: The difference in costs between the ITT and the TR analyses can be explained by the intra-operative switches: In the TR-analysis the switches were analysed in the titanium group. In the ITT-analysis they were analysed in the biodegradable group. Considering the cost-effectiveness the titanium system is preferable to the biodegradable system in the regular treatment spectrum of mandibular, Le Fort-I, and zygomatic fractures, and BSSO's, Le Fort-I osteotomies and bimaxillary osteotomies. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN 44212338.

Comparison of the long-term skeletal stability between a biodegradable and a titanium fixation system following BSSO advancement - a cohort study based on a multicenter randomised controlled trial.

Biodegradable fixation systems could reduce or eliminate the problems associated with removal of titanium plates. A multicenter randomised controlled trial (RCT) was performed in the Netherlands from December 2006-July 2009, and originally 230 injured and orthognathic patients were included. The patients were randomly assigned to either a titanium control group (KLS Martin) or to a biodegradable test group (Inion CPS). The aim of the present study was to compare the long-term skeletal stability of advancement bilateral sagittal split osteotomies (BSSO) of a biodegradable system and a titanium system. Only patients from the original RCT who were at least 18 years old and who had a BSSO advancement osteotomy were included. Those who had simultaneous Le Fort I osteotomy or genioplasty were excluded. Analysis of skeletal stability was made by digital tracing of lateral cephalograms. Long-term skeletal stability in BSSO advancement did not differ significantly between patients treated with biodegradable plates and screws and those treated with titanium plates and screws. Given the comparable amount of relapse, the general use of Inion CPS in the treatment of BSSO advancement should not be discouraged. On the basis of other properties a total picture of the clinical use can be obtained; the short-term stability, the intraoperative switches, the number of plates removed and cost-effectiveness. Trial registration of original RCT: http://www.controlled-trials.com; ISRCTN 44212338.

Decision-making considerations in application of biodegradable fixation systems in maxillofacial surgery--a retrospective cohort study.

In a recent RCT comparing biodegradable (Inion CPS) with titanium (KLS Martin) plates and screws for fixation of osteotomies or fractures, we found that in 21% of the cases the surgeon decided intra-operatively to switch from biodegradable to titanium. The aim of the current retrospective cohort study was to analyse the reasons for these switches in order to find predictor variables that may be helpful in the decision to use biodegradable devices or not. The surgeons' opinion about the biodegradable system, and if there was a learning curve in the application of the biodegradable system were also investigated. All variables were assessed during the original RCT by using a questionnaire that was completed by the OMF surgeon directly post-operatively. For the outcome variable "surgeons' opinion" a separate questionnaire was used. Regarding the predictor variables a mandibular fracture had a higher risk of switching compared to a BSSO. However, looking at the reasons for these switches no firm conclusions can be drawn. There was a subjective learning curve to acquire the application-skills for the biodegradable system. There were no changes in isolated Le-Fort-I osteotomies despite the fact that the biodegradable system seems more difficult to apply in the midface. Inadequate stability was the main reason for switching. This can be material-related, or related to inexperience with or lack of confidence in the system, or impatience of the surgeon. A learning curve and personal preferences probably play an important role in the decision to switch. We think that with more patience and more experience it should be possible to increase both user comfort and confidence in the biodegradable system of Inion CPS, which likely will decrease the number of intra-operative switches.

Comparison of biodegradable and titanium fixation systems in maxillofacial surgery: a two-year multi-center randomized controlled trial.

Biodegradable osteosynthesis could reduce/delete the problems associated with titanium plate removal. The aim of the present study was to compare the clinical performance in the first 2 post-operative years between a biodegradable and a titanium system in oral and maxillofacial surgery. The multicenter randomized controlled trial (RCT) was performed in the Netherlands from December 2006 to July 2009. Included were 230 patients who underwent a bilateral sagittal split osteotomy (BSSO) and/or a Le Fort-I osteotomy and those treated for fractures of the mandible, maxilla, or zygoma. The patients were randomly assigned to a titanium group (KLS Martin) or to a biodegradable group (Inion CPS). Plate removal was necessary in 16 of the 134 patients (11.9%) treated with titanium and in 21 of the 87 patients (24.1%) treated with the biodegradable system within the first 2 post-operative years [p = .016, HR biodegradable (95% CI) = 2.2 (1.1-4.2), HR titanium = 1]. Occlusion, VAS, and MFIQ scores showed that both groups had good mandibular function and were (almost) free of pain 1 and 2 years post-operatively (http://controlled-trials.com ISRCTN 44212338).

A randomized clinical trial of biodegradable and titanium fixation systems in maxillofacial surgery.

Biodegradable fixation systems could reduce or delete the problems associated with metallic systems, since removal is not necessary. The aim of this study was to establish the effectiveness and safety of biodegradable plates and screws as potential alternatives to metallic ones. This multi-center randomized controlled trial was conducted from December 2006 to July 2009. Included were patients who underwent mandibular and/or Le Fort I osteotomies and those with fractures of the mandible, maxilla, and zygoma. The patients were assigned to a titanium control group (KLS Martin) or to a biodegradable test group (Inion CPS). The primary outcome measure was 'bone healing 8 weeks post-operatively'. The Intention-To-Treat (ITT) analysis of 113 patients in the titanium group and 117 patients in the biodegradable group yielded a significant difference (p < 0.001), primarily because in 25 patients (21%) who were randomized to the biodegradable group, the surgeon made the decision to switch to titanium intra-operatively. Despite this 'inferior' primary outcome result, biodegradable plates and screws could be safely used when it was possible to apply them. The benefits of using biodegradable systems (fewer plate removal operations) should be confirmed during a follow-up of minimally 5 years (Controlled-trials.com ISRCTN number 44212338).