Juvenile idiopathic arthritis of the temporomandibular joint - no longer the forgotten joint.

Juvenile idiopathic arthritis (JIA) of the temporomandibular joint (TMJ) is common in children, with an increasing awareness of the condition in all healthcare professionals. TMJ involvement presents a challenge in both diagnosis and treatment, as late presentation can still occur as the disease often develops asymptomatically. This can result in facial deformity and/or functional difficulties including obstructive sleep apnoea. Early diagnosis is therefore essential, requiring a high index of clinical suspicion coupled with the judicious use of gadolinium contrast magnetic resonance imaging (MRI). Long-term management is best provided by a multidisciplinary team as patients often need a combination of pharmacological management, surgical interventions, orthodontics, and psychological support. End stage deformity can be treated by different surgical options, each with their own risks and benefits, however recently there is increasing recognition for the role of total alloplastic TMJ replacement. This review focuses on the diagnosis and management of TMJ arthritis and aims to highlight the important role of maxillofacial surgeons in JIA treatment.

Predictive risk factors for facial nerve injury in temporomandibular joint replacement surgery.

The objective of this study was to determine the prevalence of temporary and permanent facial nerve injury in total temporomandibular joint (TMJ) replacement surgery and to identify potential predictive risk factors. We made a retrospective review of case notes and opportunistic review of patients treated in a single tertiary referral unit by a single surgeon. For each patient a number of potential risk factors were determined, and the presence or absence of nerve injury recorded at 2 week follow up and a minimum of 12 months follow up. At 2-week review, facial nerve weakness was noted in 38/133 cases (28%) and at last follow up there were 4/133 cases (3%) with continuing (permanent) facial nerve weakness. Bilateral surgery, revision TMJ replacement, primary diagnosis, the number of previous surgeries and a history of recovered facial nerve injury all significantly increased the likelihood of temporary facial nerve injury, but not the likelihood of permanent facial nerve injury. Factors which increase the risk of temporary facial nerve injury are relatively predictable and include bilateral surgery, revision TMJ replacement, and multiple open TMJ surgeries. Risk factors associated with permanent injury are less predictable but are likely to be similar. The identification of such factors allows for the risk stratification of patients and improve informed consent. We also recommend that patients with a single, previously failed open TMJ surgery should be considered for early TMJ replacement and in multiply operated patients a subfascial plane of dissection is adopted.

Simultaneous custom-made replacement of the temporomandibular joint and cranioplasty.

A 23-year-old man presented with a history of fibrous ankylosis of the left temporomandibular joint (TMJ), scarring and shortening of the left temporalis muscle secondary to transection, and surgically-induced neuropathic pain after previous decompression of the temporal bone. There was evident hollowing of the left temporal fossa, and mouth opening was limited to 5mm. The aims of the operation were to treat the ankylosis, improve cosmesis, and reduce his medication. His left TMJ was reconstructed with a custom-made alloplastic joint, and a simultaneous custom-made cranioplasty. At follow-up after 2 years he was free of pain and taking no drugs. He had no obvious cranial deformity, and his mouth opening had increased to 35 mm. To our knowledge this is the first reported case of simultaneous custom-made cranioplasty and reconstruction of the TMJ.

Dental foundation year 2 training in oral and maxillofacial surgery units - the trainees' perspective.

Most dental foundation year 2 (DF2) training takes place in oral and maxillofacial surgery (OMFS) units. We did a survey of DF2 trainees in these units by telephone interviews and an online questionnaire to find out about their experience of training and their career aspirations. A total of 123 responded, which is roughly 41% of the total estimated number of trainees. Trainees applied for these posts mainly to improve their dentoalveolar skills (50%), and this was cited as the best aspect of the training. Most (81%) were on-call at night and this was generally thought to be a valuable training experience (77%), but 20% thought that it was the worst aspect of the job. Most did not regret taking up the post although the experience had caused 75% to alter their intentions about their future career; general dental practice was the commonest choice. In conclusion, trainees are generally satisfied with their training and these positions have guided their choices about future careers.

Delays in emergency oral and maxillofacial operations: 5 years later.

Delays in emergency oral and maxillofacial operations lead to prolonged discomfort for patients and increase the burden on acute hospital services. A published prospective study in our unit in 2003-2004 identified appreciable delays, which were primarily attributed to general surgical cases taking priority (system delay). Our aim in the present study was to assess progress since then by making a prospective audit of delays in emergency oral and maxillofacial operations over a 6-month period. Data collected included duration and reason for delays, and these were correlated with type of operation, and compared to the performance in the same hospital 5 years previously.A total of 222 patients were booked on to the emergency list, which indicated that the workload had doubled during the 5 years. Mean delay had also increased, with 60% of patients waiting more than 12h, and 29% more than 24h. Fractured mandibles were most likely to be left. System delay accounted for 83% of delays. There had been no lessening of the delays in emergency operating, despite increased use of elective lists for emergencies. This may be attributed to the large increase in workload without matching increases in the number of staff or availability of theatres. In addition, problems with communication between specialties, the number of staff in theatre and recovery, and over-running of elective lists, contributed to the use of theatres that did not match their capacity. Since the end of the audited period there have been signs of improvement as a result of an interspecialty initiative to improve the productivity of emergency theatres, and the addition of a dedicated trauma list for oral and maxillofacial surgery.

Oral cancer: delays in referral and diagnosis persist.

Oral cancer accounts for around 1% of all new cancers diagnosed in the United Kingdom every year. Mortality rates remain relatively high and prognosis is worst in cases of more advanced disease at time of diagnosis. Early identification of malignant lesions and speedy referral to a specialist for treatment are therefore important. The reasons and extent of the delays at the different stages between a patient first noticing an oral lesion and attending a health care professional and then being referred for specialist care have previously been studied and consistently found to be longer than desired. The National Oral Cancer Awareness Week (NOCAW), first run in 1995, aimed to increase the awareness of oral cancer amongst health care professionals and the public. It has since been repeated and is now an annual event. Alongside publications by the British Dental Association and guidelines circulated by the Department of Health on oral cancer diagnosis and referral, it is hoped this will lead to a decrease in the delay between the onset of oral cancer and patients receiving appropriate treatment. We looked at the previously published data on referral delay in oral cancer both in the United Kingdom and overseas and then identified delays in referral of oral cancer patients in a region that had been studied before NOCAW was introduced, to see if this was having any effect on referral delays. We found that despite the great publicity raised by NOCAW and the other publications and courses on oral cancer since the original audit, patient delay and referral delay have not improved. We conclude that more needs to be done to transfer guidelines to everyday practice.

Reconstruction of the temporomandibular joint by the transfer of the free vascularised second metatarsal.

We present our experience of a series of patients who presented for salvage reconstruction of the temporomandibular joint (TMJ) for relief of pain. Reconstruction was achieved by transfer of the free vascularised second metatarsal. This technique has been used for a total of seven TMJ reconstructions in five patients. We describe the surgical anatomy, technique and results during the last 18 years. One joint failed but the other six surviving joints continue to provide adequate pain-free function. We advocate this technique for autogenous salvage reconstruction in joints that have been previously operated on unsuccessfully.

Angina bullosa haemorrhagica presenting as acute upper airway obstruction.

We report a case of acute upper airway obstruction caused by a rapidly expanding blood-filled bulla in the oropharynx (angina bullosa haemorrhagica), requiring tracheal intubation. The larynx could not be visualized by either awake fibreoptic laryngoscopy or direct laryngoscopy under anaesthesia. Surgical tracheostomy was therefore performed under general anaesthesia.

A retrospective study of the costochondral graft in TMJ reconstruction.

A retrospective review of 76 costochondral grafts (57 patients) was undertaken to determine outcome with respect to the extent of previous surgery (none, disc surgery or soft tissue graft, alloplastic disc, alloplastic joint, previous graft) and to initial and preoperative diagnosis. The minimum follow up period was 2 years and for each patient both subjective (pain and dietary interference scores) and objective (interincisal distance) data was recorded. Collectively there was improvement in pain (mean 6.7 to 3.5) and diet (mean 2.2 to 3.0) scores with a moderate increase in interincisal distance (mean 21 to 24mm). In patients with no previous surgery, arthritic disease or congenital deformity the costochondral graft performed well but in patients with previous alloplastic discs and/or total joints the results were less predictable. A preoperative diagnosis of ankylosis was associated with a high complication and further surgery rate suggesting caution in this group of patients.

Castleman's disease presenting as a midline neck mass.

We report the case of a 13-year-old girl who presented with a painless midline submental mass. Excision biopsy confirmed Castleman's disease of the hyaline-vascular type. This unusual condition needs to be considered in the differential diagnosis of masses arising in the neck.

Temporomandibular joint replacement in rheumatoid-induced disease.

We report a series of seven patients with rheumatoid arthritis whose temporomandibular joints were replaced using the Christensen joint system. Patients were assessed before and after operation both subjectively (pain and dietary interference) and objectively (interincisal distance). Patient's satisfaction with the outcome of operation was also recorded. All patients showed improved visual analogue scores for pain and dietary interference after their operations and an improvement in interincisal distance was recorded in five of the patients (the remaining two having had the operation for anterior open bite). Overall satisfaction was high and no patient has rejected the prosthesis or had any substantial complications. The mean follow up period is 30 months (range 8-50). We suggest that patients with severe, rheumatoid-induced temporomandibular disease should be considered for arthroplasty as it is possible to restore some normal function and appearance.

Internal derangement of the temporomandibular joint treated by discectomy and hemi-arthroplasty with a Christensen fossa-eminence prosthesis.

Patients with internal derangement of the temporomandibular joint (TMJ) who have failed to respond to conservative treatment can be treated by discectomy and insertion of a Christensen fossa-eminence prosthesis, provided there is no clinical or radiological evidence of condylar disease (such as avascular necrosis). A total of 42 patients who had significant symptoms related to internal derangement of the TMJ, despite nonsurgical treatment, had discectomies and fossa-eminence prostheses inserted. Preoperative and postoperative measurements were recorded for Gape, Pain and restriction of feeding. All but one of the 34 patients showed improvements in their symptoms postoperatively. There were no serious postoperative complications.

Temporomandibular joint capsule prolapse: a technique of repair using autograft cartilage.

Loss of bony integrity of the temporomandibular joint may result in prolapse of the joint capsule into the external auditory canal. This in turn gives rise to arthralgia, trismus and earache and a risk of septic arthritis. We describe a technique of repair which is simple, uses autologous tissue and has an acceptable cosmetic and functional result.

The oral surgery/orthodontic interface: 2. Local causes of malocclusion.

This is the second of two articles discussing the minor oral surgery/orthodontic interface. The vital role played by the general dental practitioner in monitoring the normal development of the occlusion and the early diagnosis of the local causes of malocclusion was emphasized in the first article. Part 2 discusses the problems associated with the prominent labial frenum, supernumerary teeth and submerged deciduous molars.

The oral surgery/orthodontic interface: 1. Ectopically positioned teeth.

The number of patients seeking orthodontic treatment has increased over the last decade. A proportion of these patients present with minor irregularities due to the so-called 'local causes' of malocclusion, many of which require surgical treatment. Some general dental practitioners have taken up the challenge of correcting these causes and the resulting malocclusion themselves; however, all practitioners must be aware of the treatment options available and the surgical and orthodontic considerations to be taken into account. This will allow informed discussion with patients. In this, the first of two papers, the management of ectopically positioned teeth is discussed.