One- and three-year prospective outcome study of modified condylotomy for treatment of reducing disc displacement

Improvement of the temporomandibular joint symptoms due to the condylar position change following modified L-shaped intraoral vertico-sagittal ramus osteotomy: a single-center, retrospective study

PURPOSE

Intraoral vertico-sagittal ramus osteotomy (IVSRO) was first reported by Choung in 1992 as a surgical procedure to decrease postoperative condylar dislocation. In 2017, Iwanaga et al. developed modified L-shaped IVSRO (mIVSRO) to reduce postoperative nerve dysfunction and achieved favorable outcomes. This study aimed to clarify the effect of mIVSRO on changes in temporomandibular joint (TMJ) symptoms and three-dimensional condylar position.

METHODS

We conducted a retrospective study of thirty sides in fifteen Japanese adults diagnosed with jaw deformities who underwent mIVSRO and sagittal split ramus osteotomy (SSRO). TMJ symptoms were assessed chronologically, and the condylar long axis and the condylar position were analyzed two- and three-dimensionally using axial cephalograms and cone-beam computed tomography.

RESULTS

Postoperative TMJ symptoms improved by 90% (9/10 sides) in the mIVSRO group and by 50% (7/14 sides) in the SSRO group. The mIVSRO group exhibited outward rotation of the condylar long axis, while the SSRO group exhibited inward rotation. Moreover, mIVSRO induced residual anteromedial-inferior deviation of the condyle. The inclination angle of the condylar process was not significantly different between the two procedures pre- and postoperatively.

CONCLUSION

These results clearly demonstrated the effect of mIVSRO on symptomatic TMJ. Residual changes in the position of the condyle following mIVSRO may not affect jaw function.

Treatments for painful temporomandibular disc displacement with reduction: a network meta-analysis of randomized clinical trials

There is currently no consensus on the best treatment for painful temporomandibular disc displacement with reduction (DDwR), and no network meta-analysis of randomized clinical trials (RCTs) comparing all types of treatment for this condition has been conducted. The objective of this study was to compare and rank all treatments for DDwR, including conservative treatments, occlusal splints, low-level laser therapy (LLLT), manual therapy, no treatment (control), arthrocentesis (Arthro) alone, Arthro plus intra-articular injection of platelet-rich plasma (Arthro-PRP) or hyaluronic acid (Arthro-HA), and Arthro plus occlusal splint. Predictor variables were pain intensity and maximum mouth opening (MMO). The mean difference with 95% confidence interval was estimated using Stata software. The GRADE system was used to assess the certainty of the evidence. Twenty RCTs reporting 1107 patients were identified in the literature search; 980 of these patients were included in the network meta-analysis. Direct meta-analysis showed that Arthro-PRP significantly reduced pain intensity compared to Arthro alone, while occlusal splint and manual therapy were superior to conservative treatment (all very low quality evidence). Arthro with intra-articular injection of PRP/HA ranked as the most effective treatment in terms of pain reduction, whereas LLLT ranked the best choice for increasing MMO for patients with DDwR. However, it is important to note that the evidence for the superiority of these treatments is generally of very low quality. Therefore, further high-quality research is needed to confirm these findings and provide more reliable recommendations for the treatment of DDwR.

Step-back anterior repositioning splint retraction for temporomandibular joint disc displacement with reduction in adult patients

BACKGROUND

Anterior repositioning splint (ARS) is used to treat temporomandibular joint (TMJ) disc displacement with reduction (DDwR). However, high recurrence rate remains a problem especially in patients with unstable occlusions.

OBJECTIVE

This study optimised standard ARS therapy and proposed a step-back ARS retraction (SAR) method in adult patients with DDwR.

METHODS

Dental examinations and magnetic resonance imaging of TMJ were obtained before treatment (T0), 1 to 3 months (T1), 3 to 6 months (T2) and 6 to 12 months (T3) during treatment in 48 adults (average age 27.1 ± 5.7 years). After 3 months of basic ARS wearing, personalised treatment for patients with normal disc-condyle relationship was prescribed depending on bilaminar zone adaptations and severity of molar openbite. SAR which required sequential ARS wearing was designed for patients with deep overbite/overjet until retrodiscal tissue adaptations and stable occlusions were achieved.

RESULTS

The maximum interincisal opening was increased from 44.3 ± 6.9 to 45.3 ± 6.3 mm (p < .01), and joint pain was alleviated after ARS treatment. The overall success rate of ARS wearing was 92.1% (58/63) featured by a recaptured disc. Fifteen patients who underwent SAR therapy all showed bilaminar zone adaptations in the end, and one patient had positive condylar bone remodelling.

CONCLUSIONS

ARS treatment could improve mouth opening and joint symptoms in adult DDwR patients. SAR method was suitable for treating DDwR patients with deep overbite and overjet and improved retrodiscal tissue adaptations and condylar bone remodelling.

What are the Effects of Internal Fixation on Trigeminal Neurosensory Function and the Temporomandibular Joints Following Intraoral Vertical Ramus Osteotomy?

PURPOSE

Intraoral vertical ramus osteotomy (IVRO) has, traditionally, been accomplished without internal fixation, necessitating a period of maxillomandibular fixation (MMF). With advances in instrumentation, internal fixation of IVRO is feasible, obviating the need for MMF. The purpose is to investigate the effects of transoral internal fixation on the prevalence of third division trigeminal nerve (CNV3) injury, temporomandibular joint (TMJ) arthralgia, and surgical site bleeding following IVRO.

MATERIALS AND METHODS

A retrospective study was conducted on patients who underwent IVRO at Vanderbilt University Medical Center between January 2017 and December 2020. The primary predictor variable was fixation status-internal fixation versus MMF. The primary outcome variable was postoperative CNV3 neurosensory disturbance. The secondary outcome variables were TMJ arthralgia and surgical site bleeding. Statistical analysis included Fisher's exact test and McNemar's Chi-squared test.

RESULTS

Seventy two subjects (59 IVROs without internal fixation and 65 IVROs with internal fixation) were studied. The frequency of CNV3 neurosensory deficit was 0% in the IVRO without internal fixation group and 3.1% in the IVRO with internal fixation group (P = .49). Within group analysis showed a decreased frequency of postoperative TMJ arthralgia compared to preoperative records in both groups (IVRO without internal fixation group, P = .04 and IVRO with internal fixation group, P = .004). The frequency of active surgical site bleeding controlled with local measures was 1.7% in the IVRO without internal fixation group and 3.1% in the IVRO with internal fixation group (P = 1).

CONCLUSION

Internal fixation of IVRO is associated with low incidence of neurosensory deficit, TMJ arthralgia, and active surgical site bleeding.

The three-dimensional evaluation of positional change in mandibular condyle after intraoral vertical ramus osteotomy

OBJECTIVES

The purpose of this study was to compare the changes of the condylar axis, the anteroposterior condylar position relative to the glenoid fossa, after intraoral vertical ramus osteotomy (IVRO).

STUDY DESIGN

21 patients diagnosed as skeletal class III malocclusion underwent IVRO and were followed according to the authors' postoperative management regimen. The three-dimensional positions of the condyles were evaluated by cone-beam computerized tomography (CBCT) at pre-op, post-op, and at follow-up. CBCT images were referenced to assess the condylar axis change and the anteroposterior condylar position in the glenoid fossa. A repeated-measures analysis of variance (P<0.05) also was performed.

RESULTS

After surgery, both the axial condylar angles and the anteroposterior condylar position were significantly different (P<0.05). The coronal condylar axis rotated outwardly. The anteroposterior condylar position in the glenoid fossa had moved from the concentric to the anterior position. But the condyle changes between post-op and follow-up (P>0.05) were insignificant.

CONCLUSIONS

With postoperative intermaxillary elastic traction, the condyles changed their positions physiologically for newly established jaw movement after IVRO.

Effects of the changes in the condylar long axis angle and condylar position on temporomandibular symptoms after intraoral vertical ramus osteotomy: a preliminary study

OBJECTIVE

This study was conducted to characterize the effects of the changes in the condylar long axis and position on temporomandibular symptoms with respect proximal segment position after intraoral vertical ramus osteotomy (IVRO).

STUDY DESIGN

Twenty Japanese patients with diagnosed jaw deformity underwent IVRO without internal fixation. Long-term changes in condylar long axis and position were assessed during postoperative follow-up examinations by using computed tomography, and t tests were performed for comparison. In addition, changes in temporomandibular symptoms were examined.

RESULTS

The degree of axial rotation of the proximal segment changed significantly when the proximal segment was located laterally. Downward changes in condylar position significantly differed when the proximal segment was located posterolaterally. Forward changes in condylar position significantly differed when the proximal segment was located laterally; moreover, when the proximal segment was located laterally, temporomandibular symptoms disappeared.

CONCLUSIONS

Lateral location of the proximal segment may be an important factor in the positive effects of IVRO, with respect to temporomandibular symptoms.

Condylotomy to Reverse Temporomandibular Joint Osteoarthritis in Rabbits

PURPOSE

Osteoarthritis (OA) of the temporomandibular joint (TMJ) is characterized by local tissue degeneration and pain. Treatments have been aimed at reducing symptoms, and only some can interfere with the progression of pathophysiologic changes caused by OA. Condylotomy is an alternative treatment for patients with OA refractory to conventional treatment. The aim of the present animal study was to investigate the influence of condylotomy on TMJ OA in New Zealand rabbits.

MATERIALS AND METHODS

The 36 rabbits were divided into 3 groups: the osteoarthritis group (OG; induced OA), treatment group (TG; induced OA plus condylotomy), and control group (CG; neither OA nor surgery). OA was induced using intra-articular monosodium iodoacetate injection for 40 days. The rabbits in the TG underwent condylotomy and were killed 20, 40, and 60 days after treatment. The rabbits in the CG and OG were killed at the same points.

RESULTS

The articular joint condition was better in the TG 60 days after surgery (P = .032). A direct comparison revealed regression of TMJ OA over time among the treated rabbits (P = .008). Surgical treatment promoted mandibular condylar remodeling in the TG, reversing the tissue degeneration caused by OA.

CONCLUSIONS

Our findings suggest that condylotomy could be an option for the treatment of OA and prevent damage to TMJ structures. This could be of particular importance for patients without satisfactory responses to more conservative treatment.

A stepped approach for the management of symptomatic internal derangement of the temporomandibular joint

Background

Internal derangement is the clinical and pathological condition of disc displacement of the temporomandibular joint. Management of these cases involve conservative and surgical treatment options. Minimally invasive surgical procedures namely arthrocentesis and arthroscopy are promising techniques in the management of internal derangement. However patient selection algorithms, indications for minimally invasive procedures and details of the techniques should be further studied for safe and cost effective management of these cases.

This manuscript aims to retrospectively analyze the significance of a stepped surgical treatment approach (arthrocentesis under local anaesthesia as the first line of treatment, followed by arthroscopic lysis and lavage under general anaesthesia in unresolving cases) of internal derangement with or without osteoarthritis.

Methods

This is a retrospective cohort study. Case notes of 1414 patients that were managed with a standard protocol were reviewed. Appropriate inclusion and exclusion criteria were set. Thirty-three patients were eligible for inclusion. Parameters recorded were pain-free inter-incisal opening, spontaneous pain, pain on function, difficulty on chewing, and perceived disability on jaw movements. Pre-operative and post-operative (at the end of the follow up period) pain free maximum interincisal opening values were compared with paired t test and the subjective parameters were evaluated with Chisquare analysis. Treatment outcome and success rate according to American Association of Oral and Maxillofacial Surgeons were descriptively shown.

Results

Interincisal opening values increased, and the number of patients with severe or medium rated subjective parameters were reduced at discharge. These improvements were found to be statistically significant. Clinical (Wilkes) staging of internal derangement pre-operatively and at discharge remained either unchanged or was lower. Treatment outcome and success according to American Association of Oral and Maxillofacial Surgeons criteria was 94%.

Conclusion

The stepped approach for the management of symptomatic internal derangement with or without osteoarthritis is a successful treatment strategy with favourable therapeutic outcomes.

Complications after intraoral vertical ramus osteotomy: relationship to the shape of the osteotomy line

Intraoral vertical ramus osteotomy (IVRO) is used widely to correct mandibular prognathism. However, several disadvantages of this procedure have been reported, such as condylar luxation and bony interference at the osteotomy site. The aim of this study was to survey the incidence of complications (condylar luxation and bony interference) based on the shape of the osteotomy line. One hundred and eighty-five rami in 118 patients with jaw deformities, which were treated with IVRO, were examined retrospectively. The shape of the osteotomy line and the postoperative complications were examined on panoramic radiographs. Osteotomy lines were classified into three types: vertical, C-shaped, and oblique. Of the 185 osteotomy sites, 98 were vertical, 37 C-shaped, and 50 oblique. Condylar luxation was found in six rami (3.2%); four had undergone vertical osteotomy and two had undergone C-shaped osteotomy. Bony interference occurred in seven rami (3.8%), all with vertical type osteotomy lines. Most complications occurred in the vertical type cases and no complications were found in oblique type cases. Condylar luxation was found mainly in unilateral IVRO cases and bony interference was found in bilateral IVRO cases. These results suggest that the oblique type of osteotomy line has the advantage of avoiding complications.

Orthognathic surgery and temporomandibular joint symptoms

The aim of this article is to review temporomandibular joint symptoms as well as the effects of orthognathic surgery(OGS) on temporomandibular joint(TMJ). The causes of temporomandibular joint disease(TMD) are multifactorial, and the symptoms of TMD manifest as a limited range of motion of mandible, pain in masticatory muscles and TMJ, Joint noise (clicking, popping, or crepitus), myofascial pain, and other functional limitations. Treatment must be started based on the proper diagnosis, and almost symptoms could be subsided by reversible options. Minimally invasive options and open arthroplasty are also available following reversible treatment when indicated.

TMD manifesting in a variety of symptoms, also can apply abnormal stress to mandibular condyles and affect its growth pattern of mandible. Thus, adaptive developmental changes on mandibular condyles and post-developmental degenerative changes of mandibular condyles can create alteration on facial skeleton and occlusion. The changes of facial skeleton in DFD patients following OGS have an impact on TMJ, masticatory musculature, and surrounding soft tissues, and the changes of TMJ symptoms. Maxillofacial surgeons must remind that any surgical procedures involving mandibular osteotomy can directly affect TMJ symptoms, thus pre-existing TMJ symptoms and diagnoses should be considered prior to treatment planning and OGS.

Unilateral intraoral vertical ramus osteotomy and sagittal split ramus osteotomy for the treatment of asymmetric mandibles

In surgery for facial asymmetry, mandibles can be classified into two types, rotational and translational, according to the required mandibular movements for surgery. During surgery for rotational mandibular asymmetry, a bilateral sagittal split ramus osteotomy (BSSRO) may cause a large bone gap between the proximal and distal segments as well as condylar displacement, resulting in a relapse of the temporomandibular joint disorder, especially in severe cases. The intraoral vertical ramus osteotomy has an advantage, in this respect, because it causes less rotational displacement of the proximal segment on the deviated side and even displaced or rotated condylar segments may return to their original physiologic position. Unilateral intraoral vertical ramus osteotomy (UIVRO) on the short side combined with contralateral SSRO was devised as an alternative technique to resolve the spatial problems caused by conventional SSRO in cases of severe rotational asymmetry. A series of three cases were treated with the previously suggested protocol and the follow-up period was analyzed. In serial cases, UIVRO combined with contralateral SSRO may avoid mediolateral flaring of the bone segments and condylar dislocation, and result in improved condition of the temporomandibular joint. UIVRO combined with contralateral SSRO is expected to be a useful technique for the treatment of rotational mandibular asymmetry.

Three-Dimensional Reconstruction of TMJ MR Images: A Technical Note and Case Report

MR images of the temporomandibular joint at occlusion and at various stages of mouth opening were registered and reconstructed three-dimensionally before and after a modified condylotomy in a patient with painful disk displacement. Following the condylotomy, the condyle/disk relationship had become normalized in all three planes of space at closed mouth and during mouth opening. The post-operative distances of the condylar and diskal paths had increased when compared with the preoperative distances. The three-dimensional visualizing method may, besides providing diagnostic advantages, be a valuable tool for qualitative and quantitative documentation of the efficiency of different treatment methods for normalization of the disk/condyle relationship in patients with TMJ disk displacement.

Alterations of the Temporomandibular Joint on Magnetic Resonance Imaging according to Growth and Development in Schoolchildren

The paper explains the alterations of the temporomandibular joint (TMJ) visualized by magnetic resonance imaging (MRI) according to the growth and development of schoolchildren. Appearance and disappearance of a "double contour-like structure" (DCLS) of the mandibular condyle on MRI according to the growth and development of schoolchildren were demonstrated. In addition, possible constituents of DCLS and the significance of detection of DCLS on MRI were also speculated. The relationship between red marrow and yellow marrow in the articular eminence of temporal bone, the disappearance of DCLS, and alterations of the mandibular condyle have been elucidated.

A critical review of Dr. Charles S. Greene's article titled "Managing the Care of Patients with Temporomandibular Disorders: a new Guideline for Care" and a revision of the American Association for Dental Research's 1996 policy statement on temporomandibular disorders, approved by the AADR Council in March 2010, published in the Journal of the American Dental Association September 2010

Dr. Charles Greene's article, "Managing the Care of Patients with TMDs A New Guideline for Care," and the American Association for Dental Research's (AADR) 2010 Policy Statement on Temporomandibular Disorders, published in the Journal of the American Dental Association (JADA) September 2010, are reviewed in detail. The concept that all temporomandibular disorders (TMDs) should be lumped into one policy statement for care is inappropriate. TMDs are a collection of disorders that are treated differently, and the concept that TMDs must only be managed within a biopsychosocial model of care is inappropriate. TMDs are usually a musculoskeletal orthopedic disorder, as defined by the AADR. TMD orthopedic care that is peer-reviewed and evidence-based is available and appropriate for some TMDs. Organized dentistry, including the American Dental Association, and mainstream texts on TMDs, support the use of orthopedics in the treatment of some TMDs. TMDs are not psychological or social disorders. Informed consent requires that alternative care is discussed with patients. Standard of care is a legal concept that is usually decided by a court of law and not decided by a policy statement, position paper, guidelines or parameters of care handed down by professional organizations. The 2010 AADR Policy Statement on TMD is not the standard of care in the United States. Whether a patient needs care for a TMD is not decided by a diagnostic test, but by whether the patient has significant pain, dysfunction and/or a negative change in quality of life from a TMD and they want care. Some TMDs need timely invasive and irreversible care.

Reoperative temporomandibular joint surgery

TMJ surgeries are not always successful. Many potential pitfalls can occur during any phase of the treatment and can lead to complications, less than desirable results, and short- or long-term failures. Unsatisfactory results can occur for multiple reasons, including misdiagnosis of the original pathologic condition, incorrect selection of surgical technique, technical failures, complications, systemic disease, and unrealistic expectations. This article focuses on the reoperation of the TMJ primarily in cases of internal derangement and discusses TMJ arthrocentesis, arthroscopy, modified condylotomy, and open joint procedures.

Avoiding condylar displacement after intraoral vertical ramus osteotomy

The intraoral vertical osteotomy is a versatile and simple technique usually applied to correct mandibular prognathism. Its greatest advantages include ease of performance and minimum neurosensory disturbances, whereas maxillomandibular fixation is pointed as its major disadvantage. Another important concern about this technique is condylar displacement, which may lead to temporomandibular dysfunction. Technical notes to avoid condylar luxation are discussed after 15 years of experience using this osteotomy as the technique of choice to correct mandibular prognathism. Three similar cases are presented, where 1 condyle was displaced from the glenoid fossa, resulting in mandibular deviation during function in patients requiring small mandibular setback.

The effects of changing position and angle of the proximal segment after intraoral vertical ramus osteotomy

The authors evaluated changes in position and angle of the proximal segment, including the condyle, after intraoral vertical ramus osteotomy (IVRO) with and without a Le Fort I osteotomy to verify whether displacement of the proximal segment could induce postoperative complications. Changes in condylar angle, ramus angle, and displacement of proximal segment were measured pre- and postoperatively. The position of the temporomandibular joint (TMJ) disc was examined pre- and postoperatively. Trigeminal nerve hypoesthesia in the lower lip was assessed bilaterally. The postoperative horizontal condylar angle was significantly smaller than the preoperative one on the deviated and non-deviated sides (P<0.0001). The postoperative coronal condylar angle was significantly larger than the preoperative one on the deviated side (P=0.0483). The postoperative sagittal ramus angle was larger than the preoperative one on the deviated (P<0.0001) and non-deviated (P=0.00005) side. Most joints with an anteriorly-displaced disc with and without reduction improved on the non-deviated side; 5 of 16 joints improved on the deviated side. Results suggest the position and angle of the proximal segment, including the condyle, could change after IVRO. This could be associated with symptomatic improvement in TMJ, and extreme medial displacement of the proximal segment could delay recovery from lower lip hypoesthesia.

Modified condylotomy versus conventional conservative treatment in painful reciprocal clicking--a preliminary prospective study in eight patients

Modified condylotomy may be relevant in severe painful reciprocal clicking of the temporomandibular joint (TMJ) where conservative treatment is insufficient. The effect of the modified condylotomy was analyzed and compared with conventional nonsurgical treatment in a randomized pilot study of eight patients, 19-44 years of age, with severe painful reciprocal clicking. Before and after treatment, assessments were performed by subjective reports, clinical recordings, and blinded evaluations of radiography and magnetic resonance imaging (MRI). Based on the clinical evaluations before treatment, all conditions were disc displacements with reduction and arthralgia (Research diagnostic criteria for temporomandibular disorders), but based on MRI, one patient had disc displacement without reduction and another had normal disc position. The treatment effect was significantly better and the disorders were significantly more reduced with condylotomy than with conventional nonsurgical treatment (P < 0.05, Mann-Whitney U test). In the surgical group, the clicking and locking had disappeared, the pain during function was significantly reduced (P < 0.05, Friedman ANOVA), and in two patients the disc position was normalized. The clicking still persisted in the nonsurgical patients and the disc position was unchanged. Our conclusion is that modified condylotomy is a promising option to reduce symptoms and signs in severe painful reciprocal clicking.

Condylar luxation following bilateral intraoral vertical ramus osteotomy

OBJECTIVE

The intraoral vertical ramus osteotomy (IVRO) is widely used to treat mandibular prognathism and some forms of temporomandibular joint disorder (TMD). This retrospective report evaluated the incidence of condylar luxation following bilateral IVRO.

STUDY DESIGN

Clinical records and radiographs of 319 patients seen during a 13-year period between 1992 and 2005 were evaluated. The mean age of the patients (232 females, 87 males) at the time of surgical procedure was 26.1 years. All patients underwent a bilateral IVRO to treat mandibular prognathism or TMD. Postoperatively, the condylar position was evaluated from lateral and anteroposterior cephalograms and tomograms of the temporomandibular joint (TMJ).

RESULTS

An IVRO was performed on 638 sides in 319 patients. In 8 sides in 8 patients, the proximal segments were dislocated, and the condylar heads were located beyond the articular eminence. One patient underwent a closed reduction under local anesthesia, and 4 patients underwent an open reduction under sedation or general anesthesia. The average follow-up period was 4.3 years (1.2-9 years). Six of the 8 patients did not complain of any TMJ dysfunction. The objective clinical evaluation also did not reveal any dysfunctional patterns. A TMJ click on the affected side was observed in 1 patient, and mandibular deviation to the affected side upon opening the mouth was observed in 1 patient.

CONCLUSION

Although condylar sag is a consistent finding after IVRO, the mandibular condyles tend to return their preoperative positions. In this study, condylar luxation was observed in 1.3% (8/638) of the joints after bilateral IVRO. However, there were no severe clinical problems in these patients during a relatively long follow-up period.

Disc derangements of the temporomandibular joint

Disc-related derangement of the temporomandibular joint is common and epidemiological research has found that about 20% of the population may be affected. Although very few of these people have the more prominent symptoms, recent data indicate that the numbers who need treatment is increasing. The two clinical variants of disc derangement, reciprocal clicking and closed lock, have long been recognized, but the association between them and their aetiology and pathogenesis is still unclear. As a consequence, there is still uncertainty on how to treat the conditions, and this is even more evident when surgery is involved. This paper describes new tissue research related to disc derangement. A simplified scheme is presented and implications for surgical treatment are discussed.

Relationship between cortical bone formation on mandibular condyles and alternation of the magnetic resonance signals characteristic of growth

INTRODUCTION

The purpose of this study was to elucidate the significance of double contour-like structures (DCLS) relative to the maturity of mandibular condyles and the possible constituents of DCLS. We evaluated the relationship between the alternation of DCLS and the ossification on the top of mandibular condyles.

METHODS

In 36 subjects, aged 9 to14 years at the first examination, magnetic resonance imaging characteristics of the mandibular condyles were obtained from fast spin echo intermediate-weighted images and T2-weighted images; 2 or 3 years later, magnetic resonance images were again obtained from 23 of the same 36 subjects.

RESULTS

A significant relationship was found between the absence of DCLS and the continuity of void-signal lines on the tops of the mandibular condyles. DCLS disappeared, and the void-signal lines on the tops of the mandibular condyles became continuous as the children grew. The top of DCLS was seen as a hypersignal on T2-weighted images.

CONCLUSIONS

Alternations of DCLS might be a useful criterion for evaluating the maturity of mandibular condyles in children. Possible constituents of DCLS might be hypervascular loose fibrous tissue and a proliferation of cartilage accompanied by active ossification on the tops of the mandibular condyles.

Condylar and disc positions after intraoral vertical ramus osteotomy with and without a Le Fort I osteotomy

The purpose of this study was to examine the changes in temporomandibular joint (TMJ) morphology and clinical symptoms after intraoral vertical ramus osteotomy (IVRO) with and without a Le Fort I osteotomy. Of 50 Japanese patients with mandibular prognathism with mandibular and bimaxillary asymmetry, 25 underwent IVRO and 25 underwent IVRO in combination with a Le Fort I osteotomy. The TMJ symptoms and joint morphology, including disc tissue, were assessed preoperatively and postoperatively by magnetic resonance imaging and axial cephalogram. Improvement was seen in just 50% of joints with anterior disc displacement (ADD) that received IVRO and 52% of those that received IVRO with Le Fort I osteotomy. Fewer or no TMJ symptoms were reported postoperatively in 97% of the joints that received IVRO and 90% that received IVRO with Le Fort I osteotomy. Postoperatively, there were significant condylar position changes and horizontal changes in the condylar long axis on both sides in the two groups. There were no significant differences between improved ADD and unimproved ADD in condylar position change and the angle of the condylar long axis, although distinctive postoperative condylar sag was seen. These results suggest that IVRO with or without Le Fort I osteotomy can improve ADD and TMJ symptoms along with condylar position and angle, but it is difficult to predict the amount of improvement in ADD.

Temporomandibular joint surgery for internal derangement

Surgery of the temporomandibular joint (TMJ) plays a small, but important, role in the management of patients who have temporomandibular disorders (TMDs). There is a spectrum of surgical procedures for the treatment of TMD that ranges from simple arthrocentesis and lavage to more complex open joint surgical procedures. It is important to recognize that surgical treatment rarely is performed alone; generally, it is supported by nonsurgical treatment before and after surgery. Each surgical procedure should have strict criteria for which cases are most appropriate. Recognizing that scientifically proven criteria are lacking, this article discusses the suggested criteria for each procedure, ranging from arthrocentesis to complex open joint surgery. The discussion includes indications, brief descriptions of techniques, outcomes, and complications for each procedure.

Prospective Multicenter Comparison of 4 Temporomandibular Joint Operations

PURPOSE

This study was designed to compare the outcomes of 4 operations used for the treatment of painful temporomandibular joints with an internal derangement.

PATIENTS AND METHODS

A prospective, controlled study of arthroscopy, condylotomy, discectomy, and disc repositioning was conducted at 3 sites. All sites used the same inclusion and exclusion criteria. Trained, independent examiners assessed pain, diet, and range of motion before operation and 1 month and 1 year after operation.

RESULTS

There were statistically significant reductions in the amount of pain ( P < .001) and daily time in pain ( P < .001) that were similar for all 4 operations 1 month and 1 year after the procedures. The degrees of change after each of the 4 procedures were not statistically different from each other (amount: P = .453 and time: P = .416). Ability to chew, as measured by diet visual analog scale, was substantially improved 1 year after operation ( P < .001). The degrees of change for diet at 1 year also were not different from each other ( P = .314). There were, however, statistically significant differences ( P < .05) in range of motion that varied with procedure.

CONCLUSIONS

All 4 operations were followed by marked improvements in pain and diet. The amounts of improvement varied slightly by operation, but these differences were not statistically significant. There were small but statistically significant differences between procedures for range of motion. If these findings are confirmed, they have an important implication for procedure selection.

Histologic evaluation of temporomandibular arthritis induced by mild mechanical loading in rabbits

BACKGROUND

We still lack knowledge of causative factors in arthritis related to temporomandibular disorders (TMD). The goal of the present study was to investigate whether applying a mechanical loading on the glenoid fossa can induce arthritis.

METHODS

Coil springs were placed in 24 rabbits so as to exert a force of 100 g between the orbital edge and the antegonial notch. At 1, 2, 4 and 8 weeks after the surgery, six samples of the temporomandibular joint (TMJ) were removed for histologic examination.

RESULTS

The results showed that mild synovitis began 1-2 weeks after the start of loading, and the degree of synovitis was significant at 4 weeks, and that morphologic changes occurred in the articular eminence and condyle, while type II collagen in the cartilage of the articular eminence degraded prior to that in the condyle.

CONCLUSIONS

Our results revealed that mild, continuous mechanical loading to the glenoid fossa induces synovitis of the articular capsule, and induces organic changes of the articular cartilage without destroying these tissues.

Comparison of the clinical outcomes of patients having sounds in the temporomandibular joint with skeletal mandibular deformities treated by vertico-sagittal ramus osteotomy or vertical ramus osteotomy

OBJECTIVE

This article describes the effects of the intraoral vertico-sagittal ramus osteotomy (IVSRO) procedure on the jaw of patients with temporomandibular joint (TMJ) disorders.

STUDY DESIGN

IVSRO was performed on 15 patients (30 sides) who had mandibular protrusion or asymmetry with TMJ dysfunction. IVRO was performed on another 15 patients (30 sides). All of the 30 patients had sounds in the TMJ uni- or bilaterally. The relative positions of the condyle and disc and the range of motion of the condyles were determined by magnetic resonance imaging (MRI) before and 12 months after the operations.

RESULTS

Sounds such as clicking improved in 92% (24/26) of the joints in the IVSRO group, and in 83% (20/24) of the joints in the IVRO group 12 months after the operation. The positional relationship between the condyle and disc on the MR images improved in 82% (9/11) of the joints with reduction of the anterior disc displacement; in 60% (3/5) of the joints without reduction of the anterior disc displacement in the IVSRO group; in 75% (9/12) of the joints with reduction of the anterior disc displacement; and in 40% (2/5) of the joints without reduction of the anterior disc displacement in the IVRO group. Immediately after the operation, the condyle was displaced anterio-inferiorly in all joints in both groups, but gradually returned to close to the preoperative position. There were no significant differences between the 2 groups regarding the extent of shift of the condylar head at 2 weeks and 12 months after the operation.

CONCLUSION

The clinical outcomes of the IVSRO procedure are similar to those of the IVRO procedure. Therefore, IVSRO may be a suitable procedure for patients having TMJ dysfunction with skeletal mandibular deformities, particularly when an IVRO is unsuitable.

Advantages of intraoral verticosagittal ramus osteotomy in skeletofacial deformity patients with temporomandibular joint disorders

PURPOSE

This preliminary study was performed to clarify the usefulness of intraoral verticosagittal ramus osteotomy (IVSRO) in patients with temporomandibular joint (TMJ) disorders.

PATIENTS AND METHODS

We examined 34 sides in 19 consecutive patients with dentofacial deformities with TMJ dysfunction undergoing IVSRO. Preoperatively, 15 patients had TMJ sounds bilaterally and 4 had sounds unilaterally. Five sides in 3 patients had pain in the TMJ, and 4 sides in 3 patients had masticatory muscle pain. The TMJ symptoms, including TMJ sounds, pain in the TMJ, and masticatory muscle pain in each patient, were assessed clinically before and approximately 12 months after IVSRO. Magnetic resonance imaging was also performed to determine joint status, including determination of the positions of the condyle and disc.

RESULTS

The symptoms of the TMJ after 12 months of orthodontic treatment showed marked improvements, with the disappearance of the TMJ sounds in 94% of the sides examined. Pain in the TMJ improved in 4 of 5 sides, and pain of the masticatory muscle improved in 3 of 4 sides. With regard to the relative positions of the condyle and disc on magnetic resonance imaging, 6 of 8 joints and 5 of 7 joints showed improvement in anterior disc displacement with and without reduction, respectively. The direction and mean amount of movement in the distal segment were 8 mm in setback, 4 mm in advance, and 5 mm counterclockwise.

CONCLUSION

IVSRO is potentially as useful for the treatment of TMJ disorders in orthognathic surgery patients as is intraoral vertical ramus osteotomy, and IVSRO can be used selectively in cases in which intraoral vertical ramus osteotomy is contraindicated.

Detection and significance of the characteristic magnetic resonance signals of mandibular condyles in children

OBJECTIVE

We sought to determine the magnetic resonance imaging (MRI) characteristics of mandibular condyles in still-growing children. In addition, we also evaluated the significance of the double-contour-like structure and the conversion from red to yellow marrow characteristic of this age.

METHODS

The MRI characteristics of mandibular condyles were determined by means of fast spin-echo intermediate-weighted images in subjects 9 to 14 years old. In 1 subject who developed temporomandibular joint-related clinical symptoms 1 year later, MRI was re-performed at that time.

RESULTS

With the use of MRI, a total of 17 double-contour-like structures were detected in 42 temporomandibular joints of 9- to 14-year-olds, but neither 50 healthy joints of youths nor adults. In terms of bone marrow signal changes, the turning point was found to be 11 years old. In 1 subject, the double-contour-like structures were not visible on the MR images obtained 1 year after the first examination.

CONCLUSION

The double-contour-like structure and the periods of conversion from red to yellow marrow may be able to be used as part of the criteria for the staging of mandibular condyle development in children.

Natural course of disc displacement with reduction of the temporomandibular joint: changes in clinical signs and symptoms

PURPOSE

The goal of this study was to examine the natural course of disc displacement with reduction in the temporomandibular joint (TMJ).

PATIENTS AND METHODS

This retrospective study involved 24 patients who had been diagnosed with disc displacement with reduction of the TMJ, but who had not undergone any treatment. The extent of maximal mouth opening, protrusion, lateral excursions, noise of the TMJ, pain of the TMJ, and tenderness of masticatory muscles were recorded monthly for a mean of 25.8 months.

RESULTS

Maximal mouth opening, protrusion, and lateral excursions remained unchanged during follow-up. TMJ pain decreased by 15.7% (P >.05). Clicking decreased by 20.8% (P <.05), and tenderness of masticatory muscles decreased by 33.3% (P <.05). Reciprocal clicking remained unchanged in 19 patients (79.2%) and disappeared in 5 patients (23.8%). Four patients (16.7%) in whom clicking disappeared had a normal mouth opening, but locking developed in 1 patient (4.2%).

CONCLUSIONS

In patients with disc displacement with reduction who do not undergo treatment, range of movement remains unchanged over time. Tenderness of masticatory muscles tended lessen, but reciprocal clicking and TMJ pain tended to remain. Clicking did not progress to locking in most patients.

Treatment of painful temporomandibular joint dysfunction with the sagittal split ramus osteotomy

PURPOSE

We describe a new indication for the sagittal split ramus osteotomy with rigid fixation to treat patients with painful dysfunction of the temporomandibular joint.

PATIENTS AND METHODS

Ten patients for whom nonsurgical management failed were found to have a mandibular condyle positioned postero-superior within the glenoid fossa with reduced joint space on corrected-axis tomograms. The sagittal split ramus osteotomy was used to reposition the proximal segment and to increase joint space. Preoperative and long-term postoperative (average, 44.7 months) symptoms and tomographic findings were retrospectively compared.

RESULTS

Significant pain relief occurred postoperatively in all patients. One patient had a relapse after initial improvement. No patient developed a malocclusion. The long-term radiographic condyle-fossa relationship tended to return to its preoperative position with no relapse of clinical symptoms, except in the 1 patient.

CONCLUSION

The sagittal split ramus osteotomy with rigid fixation is another procedure that can be used to treat painful temporomandibular joint dysfunction by changing the position of the mandibular condyle in the glenoid fossa.

Long-term results of different condylotomy designs for the management of temporomandibular joint disorders

OBJECTIVE

The purpose of this study was to compare the long-term results of the condylotomy techniques.

STUDY DESIGN

Twenty-two patients (mean age, 20.8 years; occlusion: Class I in Angle's classification of malocclusion) were studied. All showed Wilkes stage II or early stage III. The Visual Analogue Scale (VAS), maximum mouth opening (MMO), and the positional change of the condylar segment were recorded preoperatively and postoperatively. The difference in each criterion according to the operative techniques was evaluated by means of a 1-way analysis of variance, and the difference between the preoperative value and the value in the long-term follow-up was evaluated by means of a paired t test.

RESULTS

Six patients underwent an extraoral vertical ramus osteotomy (EVRO), 6 patients underwent a sagittal split ramus osteotomy (SSRO), and 10 patients underwent an intraoral vertico-sagittal split ramus osteotomy (IVSRO). The preoperative value of the maximum mouth opening (MMO) was 33.0 +/- 8.3 mm, 46.1 +/- 7.0 mm, or 40.0 +/- 7.4 mm for patients undergoing EVRO, IVSRO, or SSRO, respectively. In the long-term follow-up period, the MMO was 49.3 +/- 14.6 mm, 47.3 +/- 3.2 mm, or 48.7 +/- 5.1 mm for patients undergoing EVRO, IVSRO, or SSRO, respectively. There were no differences in the amount of the MMO among the operative techniques (P >.05). The preoperative VAS in the operated-on joints was 3.9 +/- 2.4, 5.0 +/- 1.6, or 4.7 +/- 1.4 for patients undergoing EVRO, IVSRO, or SSRO, respectively. In the long-term follow-up period, it was 1.4 +/- 2.2, 2.5 plus minus 2.0, or 3.7 +/- 1.7 for patients undergoing EVRO, IVSRO, or SSRO, respectively. There were no differences in the VAS among the operative techniques (P >.05). When each measurement preoperation was compared with the long-term follow-up, the difference was statistically significant (P =.018 in the MMO, P =.004 in the VAS).

CONCLUSION

The curative effect of a condylotomy on the internal derangement of the temporomandibular joint was acceptable in the long-term follow-up, but the osteotomy procedure used may be only a minor contributing factor to the long-term results.

Prospective study of modified condylotomy for treatment of nonreducing disk displacement

OBJECTIVE

This study was performed to provide an objective assessment of the outcome of modified condylotomy for treatment of the painful temporomandibular joint with nonreducing disk displacement (Wilkes late stage III, IV, V).

STUDY DESIGN

A prospective study of 31 consecutive patients (43 joints) was conducted. All patients had nonreducing disk displacement verified by means of disk imaging. Independent evaluations were performed to assess pain, dysfunction, and progression of disease. The examinations were performed before modified condylotomy and at intervals up to 1 year after the operation. Eighteen patients (26 joints) completed the required examinations. Patient-based assessments were completed for pain and diet on 15 of these 18 patients (23 joints) 3 years after the operation.

RESULTS

Visual analog scale (VAS) scores (mean +/- SE) for pain improved from 7.4 +/- 0.4 before modified condylotomy to 2.4 +/- 0.5 1 year later (P <. 001). Joints with degenerative joint disease (Wilkes stage IV, V) had less satisfactory pain relief compared with stage III joints (3. 6 +/- 0.9 vs 1.1 +/- 0.4, P =.05) and an 11-fold higher risk (P <. 04) for serious residual pain (VAS score >4). Dietary restrictions improved from a mean VAS score of 5.3 +/- 0.7 before the operation to 7.7 +/- 0.5 1 year later (P =.02). Minor differences between mean VAS scores at 1 (2.1 +/- 0.5) and 3 (2.1 +/- 0.5) years for pain, and 1 (7.4 +/- 0.6) and 3 (8.1 +/- 0.6) years for diet, were not significant. Mean maximal interincisal opening was 36.7 +/- 2.0 mm before the operation, and this improved to 40.1 +/- 2.0 mm 1 year later (P <.02). Mean contralateral movement was 8.3 +/- 0.5 mm before the operation and 8.4 +/- 0.6 mm 1 year after the operation (P >.05). None of the 12 Wilkes late III joints progressed to Wilkes IV or V, and none of the 14 Wilkes IV, V joints showed evidence of further bone resorption. The rate for reoperation was 4%. Minor complications occurred in 5 patients and were resolved in all but 1 a year later. When these outcomes were judged by 7 American Association of Oral and Maxillofacial Surgeons assessment indices for internal derangement, the mean rate of favorable outcome was 87%.

CONCLUSION

Modified condylotomy is a safe and effective operation for treating pain and diminished function of temporomandibular joints with nonreducing disk displacement. It also seems to be an effective treatment for slowing further progression of the internal derangement and associated pathologic conditions.