Prospective study of the long-term outcomes and complications after total temporomandibular joint replacement: analysis at 10 years.

This prospective analysis was performed to assess the long-term benefits of the TMJ Concepts joint replacement system in the UK. All patients who had replacement temporomandibular joints (TMJ) with at least 10 years of follow-up were included. The most common primary diagnoses were trauma, multiple previous operations, psoriatic arthritis, rheumatoid arthritis, degenerative disease, and ankylosis. A total of 43 patients (62 joints) were followed up for 10 years (mean age 45, range 22-70 years); 39 were female and four were male. The mean number of previous TMJ procedures was 2.5 (range 0-10). Over the 10 years of follow-up, there were significant improvements in pain score (10-point scale; decreased from 7.4 to 1.7), maximum mouth opening (increased from 21.0 mm to 34.7 mm), and dietary score (10-point scale; increased from 4.1 to 9.5). Joints in two patients failed, one secondary to a local dental infection and one due to reankylosis. None failed due to wear of the prosthesis, whether the prosthesis was standard cobalt-chrome or all-titanium. Total TMJ replacement gives good long-term improvements, both lessening pain and improving function, and is an effective form of management for irreparably damaged joints.

Quality of life outcomes one year after replacement of the temporomandibular joint using a modified SF36 questionnaire.

The aim of this study was to assess the quality of life (QoL) of patients who had total replacement of the temporomandibular joint (TMJ) using a modified short form 36 (SF36) questionnaire, which is validated for use in this context. A total of 36 patients (32 female, 4 male, mean (range) age at the time of operation 44.5 (19-74) years) who had TMJ replacements between 2013 and 2016 were evaluated. Each completed a questionnaire preoperatively and at one year postoperatively. Postoperatively there were significant reductions in scores for pain and anxiety, and improvements in mood, diet, and the ability to chew. There were no significant differences between the preoperative and postoperative scores in terms of speech or recreation, although most reported an overall improvement in general well-being. Our results suggest that TMJ replacement is associated with a better QoL in terms of pain and function, and that the modified questionnaire is suitable for the appraisal of outcomes after this type of operation.

Analysis of outcomes after revision replacement of failed total temporomandibular joint prostheses.

End-stage disease of the temporomandibular joint (TMJ) can be managed successfully with alloplastic total replacements, but these can fail because of allergy, infection, wear, fracture, and heterotopic development of bone. We prospectively reviewed the outcome data of all patients who required revision of previously placed replacement joints between 2004 and 2016. Data included pain and diet scores using 100mm visual analogue scales (VAS), and interincisal distance recorded before, and at six weeks, six months and 12 months after operation. The reasons for failure and the number of previous procedures were also noted. Twenty patients (26 joints) had revisions. The reasons included infection (n=9), reankylosis (n=5), wear of the existing prosthesis (n=2), fracture of the prosthesis (n=2), foreign body reaction (n=1), and allergy to the prosthesis (n=1). The mean (range) age of the patients was 53.3 (47-68) years, and 15 were female and five male. Preoperatively, the mean (SD) pain score was 73.1 (22.4), mouth opening was 20.9 (10.2) mm, and diet score 41.7 (23.6). At 12-month follow up, all the measurements had improved significantly (p≤0.05), with the pain score improving to a mean (SD) of 18.4 (25.2), mouth opening to 32.2 (9.3) mm, and diet score to 89.4 (18.5). Revision replacements done by an experienced team result in considerably improved outcomes with limited complications, but the improvements in function and pain are not as marked as they are after primary replacement.

UK temporomandibular joint replacement database: a report on one-year outcomes.

Alloplastic temporomandibular joint (TMJ) replacements are increasingly subspecialised, and supraregional centres that treat sufficient numbers to ensure high standards are emerging. Having recently reported the introduction of a national TMJ joint replacement database that is endorsed by the British Association of TMJ Surgeons (BATS), we now present the first-year outcomes. This was a review of all data in the BATS National Case Registration of TMJ Replacement as of June 2014. A total of 252 one-year outcome records were available. Key outcomes were median (IQR) improvements in interincisal distance of 9 (4-15) mm (p<0.001) and worst-sided pain score of 6 (4-8) (p<0.001). Pain scores improved or remained static at one year in all but 3 (2%) patients. There was a significant improvement in the proportion of patients who reported a good, very good, or outstanding quality of life at one year (38% at baseline to 87% at one year; p<0.001). While outcome reports from single centres for alloplastic TMJ replacements have already been published in the United Kingdom, this is the first dedicated national database in this country that will yield valuable longitudinal follow-up data. Outcomes were comparable with smaller published series and showed improvements in pain, dietary intake, quality of life, and function, with few outliers. The database has recently moved to a new software system and we hope to publish three-year and five-year outcomes in due course.

Current thinking about the management of dysfunction of the temporomandibular joint: a review.

Increasingly the management of TMJ pathology is becoming a subspecialist interest. The number of patients having TMJ joint replacement had steadily increased over the last decade and there is now NICE guidance on this matter. Whilst the evidence of the management of TMJ disease is limited and there are few randomised controlled trials, the incidence of TMJ pathology has not changed and there is a requirement for guidance on the management. Whilst previously patients with TMJ pain were managed surgically, this is changing, and the vast bulk of initial management is non-surgical/medical. This paper will review the literature on TMD and provide guidance for management.

Medium-term outcomes and complications after total replacement of the temporomandibular joint. Prospective outcome analysis after 3 and 5 years.

In this prospective analysis, we assess the medium-term benefits, efficacy, and safety of the TMJ Concepts joint replacement system in the United Kingdom. Outcome measures of pain, maximum mouth opening, and diet were recorded preoperatively and at intervals up to 3 and 5 years. All patients who had replacement temporomandibular joints (TMJ) within a 6-year period were included. A total of 58 patients (84 joints) were followed up for 3 years (mean age 47, range 19-72) and 26 (42 joints) for 5 years (mean age 46, range 27-70). The female to male ratio was 52:6 at 3 years and 23:3 at 5 years. The most common diagnosis was degenerative disease, and the mean number of previous TMJ procedures was 2.4 (range 0-14). There were significant improvements in pain scores (7.4 reduced to 0.6 at 3 years and 0.8 at 5 years), maximum mouth opening (21.0-35.5mm at 3 years and 23.8-33.7mm at 5 years), and dietary scores (4.1-9.7 at 3 years and 3.7-9.6 at 5 years). Revision operations were required in 2 patients (not included in the outcome data) for biofilm infection of the prosthesis secondary to local infection in the head and neck. One patient had weakness of the temporal branch of the facial nerve that needed correction. TMJ replacement is an effective form of management for an irreparably damaged joint, particularly in cases of ankylosis. It lessens pain and improves function with minimal long-term morbidity.

Prospective comparison study of one-year outcomes for all titanium total temporomandibular joint replacements in patients allergic to metal and cobalt-chromium replacement joints in patients not allergic to metal.

We aimed to ascertain whether there are any early differences in outcome between all titanium temporomandibular joint (TMJ) prostheses in patients allergic to metal and standard cobalt-chromium prostheses in patients not allergic to metal. All patients who had primary TMJ prostheses placed with one-year follow-up between March 2003 and February 2011 were included. We reviewed the basic characteristics of patients. The outcome variables measured included disease, pain, mouth opening, and diet. A total of 55 patients with 77 joint replacements fulfilled the inclusion criteria. Forty patients had standard cobalt-chromium alloy (Co-Cr-Mo) prostheses (20 unilateral and 20 bilateral), and 15 had all titanium prostheses (13 unilateral and 2 bilateral). Osteoarthritis was the most common disease in both groups. There was significant improvement in pain score at reviews at 6 weeks (p=0.001) and 12 months (p=0.03). Values between groups were not significant (p=0.48 at 6 weeks, and p=0.10 at 1 year). Mouth opening in each group improved significantly with continued gains between assessments at 6 weeks and 12 months (p=0.001) but there were no significant differences between groups. Diet scores were significantly improved one year postoperatively in both groups (p=0.001), but differences between groups were not significant (p=0.90). At one year, outcomes for all titanium prostheses in patients allergic to metal were similarly favourable to those in patients who had no hypersensitivity to metal and had standard prostheses. No patient developed a hypersensitivity reaction, and no all titanium prosthesis failed during the one-year follow-up period.

Prospective analysis of the incidence of metal allergy in patients listed for total replacement of the temporomandibular joint.

We prospectively analysed the incidence of metal allergies in patients listed for total replacement of the temporomandibular joint (TMJ) and the efficacy of patch testing to prevent rejection phenomena. All patients (n=101) that required a prosthetic TMJ between March 2004 and August 2012 were tested preoperatively. A total of 39% had an allergy to one or more metals and they were given all-titanium prostheses. Following the introduction of this protocol no patients have shown signs of an allergic rejection within 6 months of operation. We suggest that all patients listed for total TMJ replacement should have patch tests for metal allergies and that all-titanium prostheses are used when allergy is detected.

Prospective assessment of outcomes following disposable arthroscopy of the temporomandibular joint.

Temporomandibular disorder (TMD) is a common cause of chronic facial pain that is often treated successfully without operation, but when no improvement is seen arthroscopy may be considered as a therapeutic and diagnostic tool. We prospectively assessed the outcome of 115 arthroscopic procedures to assess the effectiveness and reliability of a 1.2mm disposable arthroscope (OnPoint, Biomet Microfixation, Jacksonville, USA). All patients included had not improved after standard conservative management. Discharge from clinic was classed as a successful outcome. Measurements taken before, during, and after operation included mouth opening and lateral deviations (mm). Pain was assessed before and after operation using a 10 cm visual analogue scale. Mean improvement in pain scores was 69% and in mouth opening was 19%, and overall success was 76%. Compared with a previous study using a 1.9 mm scope there were fewer complications after arthroscopy with the small diameter scope.

One-year prospective outcome analysis and complications following total replacement of the temporomandibular joint with the TMJ Concepts system.

Total replacement of the temporomandibular joint (TMJ) is increasingly accepted as the gold standard for reconstruction of irreparably damaged or ankylosed joints. The TMJ Concepts system (TMJ Concepts, Ventura, USA) has the longest follow-up of the 2 systems used in the UK. A total of 74 patients had placement of TMJ Concepts prostheses. The primary diagnoses were degenerative disease, multiple previous operations, injury, rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and ankylosis. Of these, 12 were revisions of previous replacements (3 after multiple operations). Over the year there was a significant mean (SD) reduction in pain score (10 cm visual analogue scale) from 72 (2.5) to 8 (1.7) (p<0.0001), and mean (SD) improvements in mouth opening from 22.4 mm (9.4) to 33.7 mm (6.2) (p<0.0001), and dietary consistency (10 cm analogue liquid 0 to solid 100) from 38 (23) to 93 (16) (p<0.0001). No patient had worse symptoms postoperatively. Joints in 2 patients failed because of biofilm infections. Two patients required blood transfusion and one required ligation of the external carotid artery. Five had perioperative dislocation, which responded to elastic intermaxillary fixation for one week. A total of 31 patients had partial, and 2 had total weakness of the facial nerve. All resolved fully except weakness of the temporal branch in one patient, which required brow lift. Total TMJ replacement gives good early improvements in function and pain with few complications. Of the 74 patients, 71 were very pleased to have had the procedure. One was dissatisfied despite complete pain relief and improvement in mouth opening from 3 to 30 mm, and 2 were ambivalent (one had infection, revision, and permanent weakness of the temporal branch of the facial nerve).

Is the 3-D CT model useful to our anaesthetists?

A case report of a nasal spur detected on pre-operative 3-D Cad-Cam models illustrating the use of these models in predicting and preventing anaesthetic difficulties.

Role of botulinum toxin A injection into the submandibular salivary glands as an assessment for the subsequent removal of the submandibular glands in the management of children with sialorrhoea.

Sialorrhoea is caused by an excessive production of saliva or a lack of muscular coordination at the initiation of the swallowing reflex during the voluntary phase. In children with neuromuscular disorders it can cause excoriation and social embarrassment. In adults, repeated injections of botulinum have been shown to be beneficial in the control of sialorrhoea, but in children, lack of cooperation necessitates general anaesthesia, and repeated injections would not be appropriate. We aimed to assess outcome after injection of botulinum into the submandibular glands to find out whether subsequent removal of the glands would reduce salivary flow to an acceptable level. We assessed 30 children with various neuromuscular disorders that caused a lack of muscular coordination when swallowing. Under general anaesthesia, they all had injection of 1 unit/kg/gland of botulinum toxin A (Dysport™, Ipsen Ltd., Slough, UK) into each submandibular gland either by bimanual palpation or under ultrasound guidance. They were reassessed at 6 weeks to find out whether the flow had reduced adequately or whether the mouth was too dry. Twenty-one had improved and of these, 20 went on to have the glands removed successfully with no neurological or surgical complications. The mouth of one patient had become too dry after injection and the parents declined further surgery. The remaining 9 did not improve noticeably and continued to be managed medically. Injection of botulinum into the submandibular glands gives a reliable assessment of how much the salivary flow will be reduced after the submandibular gland has been removed.

Management of the temporomandibular joint in rheumatoid disorders.

This article summarises the rheumatoid diseases that particularly affect the temporomandibular joint (TMJ): psoriatic arthropathy, ankylosing spondylitis, and rheumatoid arthritis. Management is by a joint approach between rheumatologists and maxillofacial surgeons with a specific interest in diseases of the TMJ who give early surgical advice. Steroid injections, whilst useful in the short term, are not useful for long term or repeated treatment, and may lead to collapse of the joint and development of a deformed anterior open bite. These disorders should be managed primarily using standard conservative regimens, and failure to respond should lead to diagnostic or therapeutic arthroscopy and appropriate surgical treatment. When ankylosis develops or the joint collapses, a replacement joint should be considered and patients should be referred to an appropriately trained surgeon.

Cryoanalgesia in the management of intractable pain in the temporomandibular joint: a five-year retrospective review.

Cryoanalgesia is a controversial adjunct to the management of chronic pain, but we know of no studies that have investigated its effect in the management of temporomandibular joint (TMJ) pain. In this five-year retrospective study we treated 17 patients who had severe pain that had failed to respond to all forms of conventional conservative treatment and were not appropriate for simple open operation. None had a clear indication for open operation on the joint or had too severe disease to warrant a simple procedure. Preliminary diagnostic injections of bupivacaine to the TMJ relieved the pain. We applied the cryoprobe in the region of the auriculotemporal nerve and TMJ capsule. There was a small but insignificant improvement in mean mouth opening together with a significant (p=0.000) improvement in visual analogue pain scores (VAS) from 6.8 (range 4-10) to 2.0 (range 0-7). Two patients had no change in their pain scores, and 2 had complete resolution of their pain. The mean number of pain-free months after treatment was 7 (IQR 3-15). Three patients had long-term pain relief, and 12 temporary relief; 6 of these subsequently had successful relief after total replacement of the TMJ. One patient had further cryoanalgesia, one was referred for specialist pain management, and one controlled the pain with nortriptyline. Of the 17 cases studied, 2 had temporary complications after cryoanalgesia. Cryoanalgesia is a useful adjunct to the management of intractable pain in the TMJ. Short-term pain relief can be achieved, and long-term relief is possible in some, deferring more complex and costly treatments.

Foreign body response around total prosthetic metal-on-metal replacements of the temporomandibular joint in the UK.

Replacements for the temporomandibular joint were developed in the early 1960s. Problems with various prostheses, notably the Kent VK1, led to detailed analysis of their risks and complications. In 1999 one type of prosthesis (the Christensen) was converted from an acrylic condyle on cobalt-chromium fossa to metal-on-metal cobalt-chrome condyle and fossa. This has been popular for the last 15 years in the UK, but since it was converted to the metal-on-metal variant there have been several cases of foreign body giant-cell reactions to the prosthesis. Of the 9 cases seen (out of 106 placed), 4 were found retrospectively to be sensitive to one of the metal components of the prosthesis; the others have not been tested to date. Other potential causes of this reaction are point contact, micromovement, or a lymphocyte-mediated response to the prosthesis.

Prospective comparison of methods of closure of the coronal flap after craniofacial surgery in children.

The coronal flap in children may be closed with clips or sutures. The results of closure with clips in patients treated during 1 year at the paediatric craniofacial unit, Liverpool, UK, were audited. Eight of 43 required a further general anaesthetic for removal of clips. A prospective audit the following year of patients whose wounds were closed with a rapidly-absorbed polyglactin suture (Vicryl rapide) showed that 3 out of 39 required re-suture of the wound in theatre (two following trauma from falls). There was one infection in each group. Neither of these patients required formal debridement of the wound in theatre. Rapidly-absorbed polyglactin is a safe alternative to clips for wound closure after craniofacial surgery in children and the morbidity is less because fewer patients have to return to theatre than closure with surgical clips.