Modified arthroscopic anterior myotomy for internal derangement of the temporomandibular joint: clinical and radiological results

The role of the holmium laser in increasing the success rate of temporomandibular joint arthroscopic discopexy

The purpose of this study was to compare the effects of anterior releasing of the temporomandibular joint disc during arthroscopic discopexy surgery with a holmium laser versus manual instrumentation. A total of 80 patients (139 joints), divided into two groups. Anterior releasing surgery was performed using manual surgical instruments in 40 patients (70 joints) and with holmium laser assistance in the other 40 patients (69 joints). Statistical analyses, including χ2 tests and multivariate analysis, assessed factors impacting surgical success. The results showed that discopexy success was significantly higher with holmium laser use compared to manual instruments (odds ratio 4.41, P = 0.003). In addition, a preoperative diagnosis of anterior disc displacement with reduction (ADDwR) was found to be significantly more likely to result in surgical success compared to anterior disc displacement without reduction (ADDwoR) or idiopathic condylar resorption (odds ratio 5.91, P = 0.001). This study found that the use of holmium laser assistance, as compared to manual surgical instruments, significantly enhanced the success rate of arthroscopic discopexy in the temporomandibular joint. Furthermore, patients classified as ADDwR exhibited a notably higher surgical success rate compared to those classified as ADDwoR or idiopathic condylar resorption.

Arthroscopic anatomy of the anteromedial wall of the temporomandibular joint: Implications in articular disc displacement

Numerous anatomical and imaging studies have established a close relation between disc displacement of the temporomandibular joint (TMJ) and the medial wall of the TMJ. These studies have revealed a direct association between disc displacement without reduction (DDWoR) and the occurrence of fatty degeneration within the superior fascicle of the lateral pterygoid muscle (SPLM). While the aetiology of this phenomenon remains unclear, it has been suggested that it stems from the interaction between this muscle fascicle and the bony surface of the medial wall of the joint.

Imaging evaluation of disc position and status after temporomandibular joint arthroscopic disc repositioning and suturing surgery

Objective

This study aimed to explain the change of disc position at different over-corrected place after arthroscopic disc repositioning and suturing surgery.

Study design

Patients treated with temporomandibular joint arthroscopic disc repositioning and suturing surgery were reviewed. All patients underwent magnetic resonance imaging (MRI) before, immediately after surgery and at 2-year follow-up. The position of disc was checked and the change was compared.

Results

133 patients were included in the final analysis with 203 TMJ sides. The incidence rate for anterior movement of the disc after surgery was 33.0 %. Disc repositioned between 12 and 1 o'clock showed smaller movement rate of 22.6 %, while higher movement rate of 53.6 % was seen when repositioned between 2 and 3 o'clock.

Conclusions

After arthroscopic disc repositioning and suturing surgery for ADD patients, the repositioned disc showed tendency to move forward. 12 to 1 o'clock was optional disc site for repositioning while excessive over-correction was not recommended.

Effect of TMJ disc position on condylar bone remodeling after arthroscopic disc repositioning surgery

PURPOSE

The objective of this study was to analyze the effect of TMJ disc position on condylar bone remodeling after arthroscopic disc repositioning surgery.

METHODS

Nine patients with anterior disc displacement without reduction (ADDWoR, 15 sides) who underwent arthroscopic disc repositioning surgery were included. Three-dimensional (3D) reconstruction of the articular disc and the condyle in the closed-mouth position was performed using cone-beam computed tomography (CBCT) and magnetic resonance imaging (MRI) data. Then, the CBCT and MRI images were fused and displayed together by multimodal image registration techniques. Morphological changes in the articular disc and condyle, as well as changes in their spatial relationship, were studied by comparing preoperative and 3-month postoperative CBCT-MRI fused images.

RESULTS

The volume and superficial area of the articular disc, as well as the area of the articular disc surface in the subarticular cavity, were significantly increased compared to that before the surgical treatment（P < 0.01）. There was also a significant increase in the volume of the condyle (P < 0.001). All condyles showed bone remodeling after surgery that could be categorized as one of two types depending on the position of the articular disc, suggesting that the location of the articular disc was related to the new bone formation.

CONCLUSIONS

The morphology of the articular disc and condyle were significantly changed after arthroscopic disc repositioning surgery. The 3D changes in the position of the articular disc after surgery tended to have an effect on condylar bone remodeling and the location of new bone formation.

Arthroscopic assisted release of lateral pterygoid versus scarification of retrodiscal tissue in management of internal derangement of temporomandibular joint-A randomized clinical trial

The purpose of this study was to compare the effectiveness of arthroscopic-assisted lateral pterygoid muscle release versus scarification of retrodiscal tissues in the treatment of temporomandibular joint internal derangement. A prospective, comparative, randomized clinical trial involved 16 patients with TMJ internal derangement. Arthroscopic assisted release of lateral pterygoid muscle was assigned to one group of patients (Group I). Group II patients received arthroscopic assisted scarification of retrodiscal tissues. Data collected through functional examination including visual analogue scale (VAS), maximum mouth opening, lateral excursion, and clicking sound immediately and after 3, 6, and 12 months. Pre- and post-operative MRI was used to assess disc position. The VAS scores decreased in both groups at the end of the follow-up period (0.45 vs 6.75, and 1.13 vs 6.50 in group I and II respectively; P<0.001). The maximum mouth opening improved to 32.9.50 ± 1.69 mm in group I, and 30.49 ± 0.93 in group II (P<0.001). Lateral excursion improved in both groups (P<0.001). Clicking sounds disappeared in all patients. Within the limitations of the study, it seems that arthroscopic assisted release of lateral pterygoid and scarification of retrodiscal tissues may be beneficial in management of anteriorly displaced discs that don't respond to conservative treatments.

Arthroscopic osteoplasty of the medial and anteromedial wall of temporomandibular joint: surgical technique and anatomical considerations

The anterior displacement of the articular disc is the most frequent cause of pathological alterations in the TMJ. Although it is an extremely common pathology, there is no certainty about the aetiopathogenesis of this disease. The main aim of the present report is to describe new anatomical findings that could help clarifying the aetiopathogenesis of this disease and determine a typology of treatment based on the cause of the disease. All the operative records of patients who underwent arthroscopic osteoplasty of the medial TMJ wall in our centre from January 2021 to September 2021 were reviewed and analysed to identify specific anatomical features observed in every procedure. Fifty-two joints were included for analysis in this study. Twenty-two joints were classified as Wilkes stages II-III and 30 as Wilkes stages IV-V. The most common complication observed in our sample was the dysaesthesias found in the temporal and preauricular regions. Other complications observed were frontal branch paresis (n = 2), intraoperative bleeding (n = 1), and postoperative malocclusion (n = 1). The compression of the superior head of pterygoid lateral muscle (SPLM) on the medial bony wall and the consequent muscle atrophy could be key for the aetiology of the anterior TMJ disc displacement. Therapeutic actions on the osseous and muscular component in this anatomical area could improve the outcomes of patients affected by TMJ internal derangement. A meticulous dissection of the fascia of the superior fascicle of the lateral pterygoid muscle allows a remodelling of the bone surfaces with minimal complications.

Temporomandibular Joint Arthroscopic Surgical Techniques: Electrocoagulation and Myotomy Indications

Temporomandibular joint (TMJ) surgical arthroscopy has become a usual operation to treat different pathologies such as internal derangements and degenerative joint diseases and osteoarthritis. Although many instruments such as palpators, forceps, scissors, scrapers, scalpels, and motorized terminals are needed to perform different arthroscopic surgical procedures, it is of paramount importance to have devices that allow the surgeon to cut and coagulate tissues safely. Coblation (cold ablation) is a process that using a radiofrequency electrical energy passing through saline solution and produces plasma that can be applied precisely to tissues to break molecular bonds within cells. This surgical technique has become the best surgical option to perform different arthroscopic surgical techniques. Coblation of synovitis areas, lysis of adhesions, disc mobilization techniques with the anterior release (capsulotomy or myotomy), and posterior coagulation of the retro discal tissues are the most common procedures performed. Disc perforations, bone chondromalacia, synovial chondromatosis (SC), and joint hypermobility can also be treated using coblation technologies.

Prognostic indicators of arthroscopic discopexy for management of temporomandibular joint closed lock

In order to optimize patient selection for temporomandibular joint (TMJ) arthroscopic discopexy to achieve favorable outcomes, prognostic indicators impacting the results are important to analyze. This longitudinal retrospective study aimed to analyze various prognostic factors impacting surgical outcomes following arthroscopic discopexy for management of TMJ closed lock using success criteria based on pain, maximal interincisal opening, diet, and quality of life. Furthermore, a quantitative MRI assessment was performed pre- and post-operatively. Multivariate analysis was used to evaluate various prognostic variables including gender, age, side, duration of illness, Wilkes staging, parafunctional habits, splint therapy and orthodontic treatment. A total of 147 patients (201 joints) were included. The outcome was categorized as excellent (n = 154/76.61%), good (n = 34/16.91%), or poor (n = 13/6.46%) with a success rate of 93.54%. Patients aged > 30 years old (p = 0.048), longer duration of illness (12–24 months: p = 0.034) and (> 24 months: p = 0.022), and patients with Wilkes stage IV (p = 0.002) were all significantly more likely to be in the poor outcome group. Finally, orthodontic treatment showed a significant association with excellent outcomes (p = 0.015). Age, duration of illness, Wilkes staging, and orthodontic treatment are considered significant prognostic factors that can predict the outcomes following the arthroscopic discopexy for management of TMJ closed lock.

Is Arthroscopic Disk Repositioning Equally Efficacious to Open Disk Repositioning? A Systematic Review

PURPOSE

Temporomandibular joint disc repositioning surgery is 1 of the treatment modalities used for treating anterior disc displacement of the temporomandibular joint. The procedure can be arthroscopic disc repositioning or open disc repositioning. This systematic review measured and compared the efficacy of arthroscopic and open disc repositioning procedures.

MATERIALS AND METHODS

The authors conducted a systematic review without meta-analysis by performing a literature search electronically and manually covering arthroscopic and open disc repositioning studies published up to July 2020 in Pubmed, Embase, and Cochrane databases. Surgical outcomes such as changes in maximal incisal opening (MIO) and pain scores, temporomandibular joint noises, diet consistency, malocclusion, and postoperative complications were extracted and analyzed.

RESULTS

A total of 28 studies were included in the review and split into those assessing open disc repositioning (n = 13) and those assessing arthroscopic disc repositioning (n = 15). The average age of the study patients in the included studies was 31.5 ± 6.8 years, and women represented 83.3% of the study population. Both arthroscopic and open disc repositioning showed to be efficacious in reducing pain and increasing MIO. Due to heterogeneity in study designs and data reporting between the studies, no quantitative analysis was performed, and the groups were not directly compared.

CONCLUSIONS

Both arthroscopic and open disc repositioning led to significant improvements in clinical outcomes based on pain scores and MIO. This study highlights the need for comparative studies of the 2 techniques with well-documented case selection including standardized diagnosis based on Wilkes stages and rigorous outcomes assessment including patient reported outcomes.