Current thinking in open temporomandibular joint surgery. Is this still indicated in the management of articular temporomandibular joint disorder?

Management of temporomandibular disorders (TMD) follows a stepwise approach of conservative management, minimally invasive surgery (arthrocentesis and arthroscopy), open surgery and alloplastic replacement. The majority of patients treated in primary care and managed initially in secondary care have myofascial pain and can be managed conservatively with rest, topical NSAIDs, muscle massage, and a bite orthosis. Those who fail to improve and have articular related pain with limitation of function should initially undergo arthroscopic investigation and arthrocentesis, which is effective at resolving symptoms in 80% of patients. Arthroscopy provides the best diagnostic aid should there be a failure to improve and should enable the surgeon to appropriately plan open surgery. Historically, surgical intervention was based on a 'one size fits all' philosophy with the surgeon carrying out a procedure which they are used to doing regardless of the pathology. Prior to arthroscopy this carried an '80% chance of getting 80% better' regardless of approach. Prior arthroscopy reduced success rates to 50%-60% and a better success rate is needed. Basing surgical intervention on the pathology encountered is a sensible approach to joint management, with the surgeon performing surgery on the articular surfaces or disc as indicated. Having used this approach over the last 15 years the author has achieved success rates of 80% in the longer term and this philosophy, rationale, and technique will be discussed along with analysis of more recent publications in the field.

Recommendations on the Use of Oral Orthotic Occlusal Appliance Therapy for Temporomandibular Joint Disorders: Current Evidence and Clinical Practice.

Background: 'Temporomandibular joint disorders (TMDs)' denote an umbrella term that includes arthritic, musculoskeletal and neuromuscular conditions involving the temporomandibular joint, the masticatory muscles, and the associated tissues. Occlusal devices are one of the common treatment modalities utilized in the conservative management of TMDs. The indications for the available 'oral splints' or 'oral orthotic occlusal devices' remain ambiguous. Methods: A joint international consortium was formulated involving the subject experts at TMJ Foundation, to resolve the current ambiguity regarding the use of oral orthotic occlusal appliance therapy for the temporomandibular joint disorders based on the current scientific and clinical evidence. Results: The recommendations and the conclusion of the clinical experts of the joint international consort has been summarized for understanding the indications of the various available oral orthotic occlusal appliances and to aid in the future research on oral occlusal orthotics. Conclusion: The use of the oral orthotic occlusal appliances should be based on the current available scientific evidence, rather than the archaic protocols.

Post-traumatic management of condylar fracture complications.

Management of issues following condylar fracture is dependent on the effect on joint function and pain and an assessment of the degree of deformity. The following article aims to guide the reader in the assessment of these issues and the preservation of as much as is normal as possible. "First do no harm" is a phrase coined from the writings of Hippocrates, the Greek philosopher and physician. The cases described illustrate examples of where other clinicians have advised joint replacement, but where the author has used orthognathic or less invasive techniques to preserve existing tissues and joint function and to restore facial balance. They serve as a reminder that the complete TMJ surgeon needs a good orthognathic knowledge and expertise.

The ESTMJS (European Society of Temporomandibular Joint Surgeons) Consensus and Evidence-Based Recommendations on Management of Condylar Dislocation.

Although condylar dislocation is not uncommon, terminology, diagnostics, and treatment concepts vary considerably worldwide. This study aims to present a consensus recommendation based on systematically reviewed literature and approved by the European Society of TMJ Surgeons (ESTMJS). Based on the template of the evidence-based German guideline (register # 007-063) the ESTMJS members voted on 30 draft recommendations regarding terminology, diagnostics, and treatment initially via a blinded modified Delphi procedure. After unblinding, a discussion and voting followed, using a structured consensus process in 2019. An independent moderator documented and evaluated voting results and alterations from the original draft. Although the results of the preliminary voting were very heterogenous and differed significantly from the German S3 guideline (p < 0.0005), a strong consensus was achieved in the final voting on terminology, diagnostics, and treatment. In this voting, multiple alterations, including adding and discarding recommendations, led to 24 final recommendations on assessment and management of TMJ dislocation. To our knowledge, the ESTMJS condylar dislocation recommendations are the first both evidence and consensus-based international recommendations in the field of TMJ surgery. We recommend they form the basis for clinical practice guidelines for the management of dislocations of the mandibular condyle.

Management of the temporomandibular joint in inflammatory arthritis: Involvement of surgical procedures.

Many conditions may affect the temporomandibular joint (TMJ), but its incidence in individual joint diseases is low. However, inflammatory arthropathies, particularly rheumatoid and psoriatic arthritis and ankylosing spondylitis, appear to have a propensity for affecting the joint. Symptoms include pain, restriction in mouth opening, locking, and noises, which together can lead to significant impairment. Jaw rest, a soft diet, a bite splint, and medical therapy, including disease-modifying antirheumatic drugs (DMARDs) and simple analgesia, are the bedrock of initial treatment and will improve most symptoms in most patients. Symptom deterioration does not necessarily follow disease progression, but when it does, TMJ arthroscopy and arthrocentesis can help modulate pain, increase mouth opening, and relieve locking. These minimally invasive procedures have few complications and can be repeated. Operations to repair or remove a damaged intra-articular disc or to refine joint anatomy are used in select cases. Total TMJ replacement is reserved for patients where joint collapse or fusion has occurred or in whom other treatments have failed to provide adequate symptomatic control. It yields excellent outcomes and is approved by the National Institute of Health and Care Excellence (NICE), UK. Knowledge of the assessment and treatment of the TMJ, which differs from other joints affected by inflammatory arthritis due to its unique anatomy and function, is not widespread outside of the field of oral and maxillofacial surgery. The aim of this article is to highlight the peculiarities of TMJ disease secondary to rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis and how to best manage these ailments, which should help guide when referral to a specialist TMJ surgeon is appropriate.

Prospective outcome analysis of total replacement of the temporomandibular joint with the TMJ Concepts system in patients with inflammatory arthritic diseases.

We report the outcomes of patients with rheumatoid arthritis, psoriatic arthritis, or ankylosing spondylitis, who had total replacement of the temporomandibular joint (TMJ) using the TMJ Concepts system between 2005 and 2014. We prospectively measured mouth opening (mm), and pain and dietary function (visual analogue scale (VAS), 1 - 100) before operation, and at 6 weeks, 6 months, one year, and beyond. Forty-six joints were replaced in 26 patients (mean age 40, range 16 - 71), 22 of whom were female. Most had rheumatoid (n=17) or psoriatic arthritis (n=7). At one year the mean (SD) pain scores had fallen from 55 (36) to 2 (7) on the left, and from 62 (31) to 2 (5) on the right (p<0.001). Mean (SD) scores for dietary function had increased from 48(25) to 95(9) (p<0.001), and mouth opening had increased from a mean (SD) of 23(10) mm to 35(5) mm (p<0.001). The joints dislocated during the operation in 5 patients, and 4 had temporary weakness of the facial nerve. Outcomes after replacement of the TMJ with the TMJ Concepts system were good in patients with inflammatory arthritis, which further validates the procedure, as damage to the joint is severe in this group.

UK temporomandibular joint replacement database: report on baseline data.

Our goal is to establish the long-term collection of data on temporomandibular joint replacement from all centres in the UK where this is done. Currently, 16 surgeons have been identified, and 13 of them had entered data when this paper was being prepared. Data are entered online through the Snap Survey and then analysed annually. We report on 402 patients (332 (83%) female and 70 (17%) male) who had 577 joints inserted between 1994 and 2012. The main diagnoses that resulted in total joint replacement were osteoarthritis, failed operation, ankylosis, and seronegative arthritis. Preoperatively, the median (IQR) maximal incisal opening was 20 (15-26)mm (mean 20) and the median pain scores on the visual analogue scale (VAS 0-10) were 8 for both joints. The median (IQR) baseline dietary score (liquid 0 - solid 10) was 4 (3-6). A total of 173 (43%) patients had had one or more open procedure(s) before total replacement, 177 (44%) had not had open operation, and 52 (13%) had no data entered. The 3 primary systems used were the TMJ Concepts System (Ventura, USA), the Biomet System (Biomet/Lorenz Microfixation, Jacksonville, USA), and the Christensen System (TMJ Implants, Golden, USA). The median (IQR) duration of inpatient stay was 3 (2-4) days (mean 3). Follow-up data will be collected to assess patient recorded outcome measures (PROM) and objective measurements of total joint replacements in the UK from 1994 onwards.

How accurate is arthroscopy of the temporomandibular joint? A comparison of findings in patients who had open operations after arthroscopic management failed.

We examined the accuracy of arthroscopy to diagnose disease in the temporomandibular joint (TMJ) and to allocate an appropriate Wilkes' stage. We compared findings made during arthroscopy with those at subsequent open operation in the same patient. Overall, arthroscopy had 87% sensitivity and 99% specificity in diagnosing disease in the TMJ, and it also accurately allocated the Wilkes' stage (sensitivity 94%, specificity 98%).

Outcomes of open temporomandibular joint surgery following failure to improve after arthroscopy: is there an algorithm for success?

We reviewed the results of one surgeon's experience of open surgical management of the temporomandibular joint (TMJ) in patients who fail to respond to arthroscopy and aimed to identify groups of patients that may or may not benefit from the intervention. Over a 7-year period (2005-2012) we retrospectively collected data from the medical notes of patients who underwent discectomy, disc plication, eminectomy, eminoplasty, and adhesiolysis, according to the clinical findings for joint pain, restriction, and locking. A total of 22 patients (71%) reported improvement in pain score and 19 (61%) reported an improvement in mouth opening 12 months postoperatively. Overall, 12 patients (39%) ultimately needed TMJ replacement. This group included 5/6 patients in Wilkes' stage IV and 6/15 in stage V, 5/7 patients with a preoperative pain score of 90-100, and half of those with preoperative mouth opening of 20-29 mm (7/14). Open surgical management of the TMJ can benefit patients despite the previous failure of arthroscopy to manage pain, restriction, and locking. Arthroscopy seems to reduce the percentage of patients that need open TMJ surgery, but also the success of subsequent operations compared with previous studies. TMJ replacement is increasingly being done successfully to treat end-stage disease. These results may be used when obtaining a patient's consent for open TMJ surgery, particularly if they are in the groups considered to have a high risk of subsequently requiring a replacement joint.

How do I manage restricted mouth opening secondary to problems with the temporomandibular joint?

Restricted mouth opening is a common problem that presents to secondary care, and management depends on the primary cause. The most common differential diagnoses related to the temporomandibular joint (TMJ) include muscle spasm secondary to pain, anchored disc phenomenon, irreducible anterior disc displacement, rheumatoid diseases, and ankylosis. In this paper each is considered in turn.

Management of recurrent ankylosis in arthrogryposis: new solutions to a rare problem.

Arthrogryposis is a rare condition that comprises contracture of the joints, muscular weakness, and fibrosis. Restricted mouth opening caused by coronoid hyperplasia has been reported but to our knowledge, ankylosis of the temporomandibular joint (TMJ) has not. Standard management of ankylosis includes creation of a gap arthroplasty and possible reconstruction with autogenous or alloplastic materials. We describe management of a patient with arthrogryposis who developed ankylosis for a second time after satisfactory gap arthroplasty and total replacement of the TMJ with a custom-made prosthesis. The original prosthesis was removed, the ankylosis resected, and the prosthesis replaced. This has given an excellent outcome at 12 months.

Botulinum injection for the management of myofascial pain in the masticatory muscles. A prospective outcome study.

We prospectively analysed the outcome after botulinum injection in patients who did not recover after conservative measures to manage masticatory myofascial pain, and who were not willing to take low dose tricyclic antidepressants as a muscle relaxant. We prospectively 62 patients were assessed with visual analogue scores (VAS) for pain on the affected side before, and 6 weeks after botulinum injection(s) (50 units Dysport in up to 3 sites), and measured mouth opening in mm. Of those treated 49 (79%) showed at least some improvement (pain reduced by more than 25%). Patients reported more than a 90% reduction in the VAS for 25 (30%) of the 84 sides of the face treated. Only 22 of the 62 patients had more than one course of treatment to the same side. Interincisal distance improved by a mean/median of 0.9 mm (p<0.03) after treatment. Side effects included 3 cases of temporary weakness of a facial muscle. Ranking the VAS pain scores using the Wilcoxon test before and after injection showed a significant reduction in pain (median change -29.5, interquartile range -53 to -16, p<0.0001). The treatment significantly improved patients' pain scores and the overall mean/median reduction in pain was 57%. Botulinum injection does not guarantee complete resolution of myofascial pain, but it usually has some beneficial effect in improving the symptoms, and should be considered as an alternate treatment for masticatory myofascial pain if conservative methods have failed.

The TN Chawla Lecture - The current management of midfacial trauma.

The management of mid-facial trauma has changed very little in the last decade with minor modifications related to orbital trauma and minimal access approaches particularly related to secondary reconstruction. In the UK the introduction of major trauma centres has tended to concentrate the management of polytrauma patients to individual regional sites. From a maxillofacial perspective this increases craniofacial cases treated in these units. It also requires a collaborative team approach and a thorough understanding of ATLS principles. Imaging has progressed to include rapid CT scans, individualised CBCT scans and the use of rapid prototyping models to aid in both visualisation, planning and construction of customised implants. Finally the industry has managed to develop smaller implants with equal strength to facilitate low profile fixation which is less likely to be prominent in the midface. These also facilitate the use of endoscopic assisted procedures, which tend to be used in secondary reconstruction of the upper 1/3 and osteotomy surgery.

TMJ pain and cryoanalgesia.

Temporomandibular (TMJ) joint pain is a complex issue involving several factors in a spectrum including myofascial pain, internal derangement and degenerative disease, all of which are reciprocally affected by psychological factors. Current assessment of TMD (temporomandibular disorder) can be assisted by standardised protocols, but often there is a combination of disease processes which each need to be addressed. Initial management should always be conservative with a preference for non-invasive measures which do no harm and have evidential support. Subsequent management of myofascial pain could involve tricyclic anti-depressants or botulinum injection into areas of muscle spasm. Joint related pain is diagnosed by relief of pain following intra-articular local analgesia. Where this is successful arthroscopy/arthrocentesis are successful in relieving the pain in up to 90% of cases. In addition arthroscopy is an accurate diagnostic tool. Where this fails, open surgery is less successful and ultimately joint replacement may be required. Where the latter are not indicated, but pain is relieved by LA, cryoanalgesia to the joint capsule may be beneficial.

Alloplastic or autogenous reconstruction of the TMJ.

Reconstruction of the irreparably damaged temporomandibular joint (TMJ) is dependent on the cause of damage and the patient's age. In childhood the current preference is for autogenous reconstruction which can potentially "grow" with the child. This is either with soft tissue interposition (temporalis fascial interposition), local osteotomy, distraction osteogenesis, non-vascularised tissue (costochondral, sternoclavicular) or vascularised tissue (second metatarsal). Current debate centres around the possibility of alloplastic reconstruction particularly where autogenous tissue has failed. The resultant failure of growth - if this occurs, can be dealt with in late adolescence with either osteotomy, distraction osteogenesis or replacement of the condylar component of the prosthesis. In the adult the choice is currently in favour of alloplastic reconstruction as this gives a more stable long term result and facilitates early mobilisation. Initial cost is clearly an issue, but when weighted against the reduced length of stay and reduced morbidity, often the costs are equivalent in the short term and come to benefit alloplasts in the medium term. Their long term outcomes beyond 15 years are however not clear.