Disk position before and after modified condylotomy in 80 symptomatic temporomandibular joints

Predisposing conditions for condylar sag after intraoral vertical ramus osteotomy

Intraoral vertical ramus osteotomy (IVRO) is used to treat mandibular prognathism and temporomandibular disorders. However, the improvement of temporomandibular disorders after IVRO is considered to be due to the anterior and downward movement of the mandibular condyle, which may lead to condylar sag, and in the worst case, condylar luxation. In this retrospective cohort study, we examined factors potentially associated with condylar sag. Univariate analysis indicated that condylar sag was significantly associated with the following factors: magnitude of setback (P = 0.001), less than 3 mm setback (P < 0.001), presence of temporomandibular joint (TMJ) symptoms (P = 0.002), Wilkes classification (P = 0.039), occlusal cant correction ≥ 2 mm (P = 0.018), and mandibular condyle deformation (P < 0.001). Setback magnitude (P = 0.032) and TMJ symptoms (P = 0.007) remained significant in the multivariate analysis. In the receiver operating characteristic curve, the setback magnitude cut-off value for condylar sag after IVRO was 3.25 mm. Thus, the incidence of condylar sag after IVRO is increased with a smaller setback magnitude (≤ 3.25 mm) and the presence of TMJ symptoms. These factors should be evaluated by surgeons during treatment planning for IVRO to estimate condylar sag, and it may be possible to predict the risk of condylar luxation.

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.

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.

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.

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.

Meniscopexy for internal derangement of temporomandibular joint

The term internal derangement was first adopted to describe any pathologic entity that interfered with the smooth function of the temporomandibular joint (TMJ). The term is currently used exclusively to describe alterations in disc-fossa relations. Internal derangement of the TMJ does not always cause pain, although when the disc becomes displaced, noises and locking can occur and ligamentous, capsular or retrodiscal pain may dominate the clinical picture. Meniscopexy of TMJ was done in ten patients where clinical features suggest true internal derangement of the TMJ refractory to conservative treatment with restricted movement and pain identified as arising primarily from the joint. Magnetic resonance imaging was done to identify the cause of problem.

Quantification of disc displacement in internal derangement of the temporomandibular joint using magnetic resonance imaging

Many measures have been developed to determine the extent of disc displacement in internal derangements of the temporomandibular joint (TMJ) using magnetic resonance imaging. The purpose of this study was to develop a quantitative method of analyzing disc position and to evaluate the positions of the disc in internal derangements of the TMJ (group 1, with reduction; group 2, without reduction). Magnetic resonance images of 150 TMJs in 20 healthy volunteers and 55 patients with internal derangements were evaluated. The anatomical points of interest of the TMJ, including the anterior (DA) and posterior (DP) points of the disc, were marked on parasagittal magnetic resonance images of the TMJ disc taken in both the closed- and the open-mouth positions. All points were recorded using an x-y coordinate system, with reference to a referral line. In the closed-mouth position, the DP in patients in group 1 was situated in a more-anterior direction than the DP in volunteers. The DP in group 2 was located further anterior and inferior than the DP in group 1. However, the position of the DA did not differ between group 1 and group 2. In the open-mouth position, the DP was displaced anteroinferiorly to a greater extent in group 2 than in group 1 (one-way ANOVA, followed by Scheffe's test; P < 0.0001). The distance between the disc points in the closed- and open-mouth positions was also evaluated. Comparison of the disc point position in the closed- and open-mouth positions in symptomatic and asymptomatic displaced TMJ discs revealed no significant difference. In conclusion, most of our results quantitatively support previously reported findings in imaging, surgical, and histopathological studies of TMJ internal derangement. We suggest that our measure of disc position of the TMJ would be useful to assess the status and response to treatment of internal derangements of the TMJ.

A biomechanical basis for primary arthroplasty of the temporomandibular joint

Biomechanical principles of temporomandibular joint (TMJ) loading are unique, particularly in an orthopedic system that exhibits curvilinear general plane motion. Certain type-specific derangements can be surgically challenging and may primarily require open arthrotomy techniques rather than arthroscopy. This article discusses the basic biomechanical principles in normal and pathologic function. Three-dimensional preoperative imaging of TMJs is necessary for appropriate assessment of all patients and when open techniques are necessary as the initial surgical procedure.

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.

Changes in the temporomandibular joint after mandibular setback surgery in monkeys: intraoral vertical versus sagittal split ramus osteotomy

OBJECTIVE

This study was to investigate the changes in condylar position and structure of the temporomandibular joint (TMJ) after mandibular setback using 2 forms of the ramus osteotomy.

STUDY DESIGN

Twelve adult male rhesus monkeys were randomly divided into groups A (n = 6) and B (n = 6) for mandibular setback surgical procedure. An intraoral vertical ramus osteotomy (IVRO) was performed in group A, whereas a sagittal split ramus osteotomy (SSRO) was performed in group B. Changes in condylar position were quantified by computed tomography (CT) preoperatively and postoperatively. All animals in groups A and B were killed at 12 weeks after surgical procedure. The TMJ specimens were harvested and processed for histological examination.

RESULTS

In group A, the CT examinations showed a significant anteroinferior displacement of the condyle after surgical procedure. In group B, slight posterior displacement and lateral tilting of the condyle were noted after surgical procedure. Thickened cartilage layer and endochondral ossification were seen in the condyles of group A, but only minimal alteration in articular cartilage was found in group B.

CONCLUSIONS

Both SSRO and IVRO can be biologically sound procedures for correction of mandibular prognathism. Intraoral vertical ramus osteotomy procedure leads to condylar adaptive remodeling, which may have favorable effects on TMJ, and it could be considered as a preferred surgical treatment for those patients with preoperative TMJ disorders.

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.

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.

Long-term results of functional open surgery for the treatment of internal derangement of the temporomandibular joint

We studied 20 consecutive patients with internal derangements of the temporomandibular joint (TMJ), a median of 51 months after open operation on the joint and a rehabilitation programme. The design was a retrospective clinical study. The maximal opening and lateral active movements and the presence of clicking and joint pain were recorded preoperatively, after complete rehabilitation, and at the time of follow-up. Patients completed visual analogue scales of pain before operation and at the time of follow-up. Operation and postoperative rehabilitation reduced the variability of the opening and lateral movements, significantly increased maximal opening, and reduced clicking and pain.

Transitional joint effusion in the mandibular prognathic surgery patient: intraoral vertical ramus osteotomy versus sagittal split ramus osteotomy

PURPOSE

The purpose of this study was to examine the cause of joint effusion (JE) appearing postoperatively in the temporomandibular joint (TMJ) of patients with mandibular prognathism on T2-weighted magnetic resonance (MR) images.

PATIENTS AND METHODS

MR imaging was performed before and after surgery in 30 TMJs of 15 subjects with mandibular prognathism who underwent intraoral vertical ramus osteotomy (IVRO) and in 20 TMJs of 10 subjects with mandibular prognathism who underwent sagittal split ramus osteotomy (SSRO). The preoperative MR imaging was performed 1 month before surgery, and postoperative MR imaging was performed during maxillomandibular fixation.

RESULTS

Preoperatively, none of SSRO and IVRO groups had JE. Postoperatively, 12 TMJs (40%) of the IVRO group and only 1 TMJ (5%) of the SSRO group had JE. As for the TMJs in the IVRO group, on MR imaging, the degree of downward movement of the condyle after surgery was larger in TMJs with JE (3.8 +/- 2.3 mm) than in TMJs without JE (1.8 +/- 1.6 mm). JE diminished within about 4 months after removal of the maxillomandibular fixation.

CONCLUSION

JE appearing postoperatively in the TMJ of patients with mandibular prognathism might be relation to the degree of downward movement of the condyle.

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.

Condylar and temporomandibular joint disc positions after mandibular osteotomy for prognathism

PURPOSE

The purpose of this study was to compare the changes in temporomandibular joint (TMJ) morphology and clinical symptoms after sagittal split ramus osteotomy (SSRO) and intraoral vertical ramus osteotomy (IVRO) with and without a Le Fort I osteotomy.

PATIENTS AND METHODS

Of 43 patients with a diagnosed jaw deformity, 20 underwent IVRO without internal fixation and 23 underwent SSRO with rigid internal fixation. Some operations were performed in combination with a Le Fort I osteotomy. The TMJ symptoms and joint morphology, including the disc position, were assessed preoperatively and postoperatively using magnetic resonance imaging (MRI) and axial cephalography.

RESULTS

A significant difference in the direction of condylar rotation was seen in horizontal axial cephalography images (P <.01). Fewer or no TMJ symptoms were reported postoperatively by 88% of the patients who underwent IVRO with or without a Le Fort I osteotomy and by 66.7% of patients who underwent SSRO with or without a Le Fort I osteotomy. In sagittal images, no change was seen in anterior disc displacement after SSRO; however, improvement was seen in 44.4% of patients with anterior disc displacement who underwent IVRO with or without a Le Fort I osteotomy.

CONCLUSION

These results suggest that SSRO does not improve anterior disc displacement; IVRO improves anterior disc displacement in the initial postsurgical period, and both procedures may improve TMJ symptoms.

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.

The incidence of reoperation after temporomandibular joint arthroscopic surgery: a retrospective study of 450 consecutive joints

PURPOSE

The purpose of this study was to investigate the incidence of reoperation after temporomandibular joint arthroscopic surgery in 315 consecutive patients (488 joints).

STUDY DESIGN

The clinical data and operative reports of all patients who underwent arthroscopic procedures from 1995 to 2000 were reviewed retrospectively. Patients had a preoperative clinical and panoramic radiographic evaluation. Most of the patients had disk displacement without reduction. In the remaining patients, the intra-articular pathologic conditions ranged from disk displacement with reduction to degenerative joint disease. The outcome assessment was based on reduction in pain, improvement in vertical dimension of mouth opening, and mandibular excursions. The same surgical team performed all arthroscopic procedures. Before surgery, all patients received at least 3 to 6 months of nonsurgical therapy consisting of anti-inflammatory medications, muscle relaxants, splint therapy, physiotherapy, exercise, moist heat, cold laser, ultrasound, and soft diet or a combination thereof. Patients were monitored postoperatively for as long as 5 years.

RESULTS

Results showed that approximately 20% of those patients who had temporomandibular joint arthroscopic surgery underwent further temporomandibular joint procedures ranging from repeat arthroscopic surgery to open-joint arthrotomy.

CONCLUSION

Temporomandibular joint surgical arthroscopy is an appropriate therapeutic modality for patients with temporomandibular joint internal derangements, with reoperation required for only 20% of patients.

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.

Clinical versus magnetic resonance imaging findings with internal derangement of the temporomandibular joint: an evaluation of anterior disc displacement without reduction

PURPOSE

The purpose of this study was to investigate whether the clinical finding of anterior disc displacement without reduction (ADWOR) and pain in the temporomandibular joint (TMJ) is correlated to the magnetic resonance imaging (MRI) findings of TMJ internal derangement (ID).

PATIENTS AND METHODS

The TMJ group was composed of 55 TMJ pain patients who were assigned a clinical diagnosis of unilateral ADWOR. The control group consisted of 58 nonpainful TMJ patients. Sagittal and coronal MR images were obtained to establish the incidence and type of ID.

RESULTS

Using chi-square analysis, the results showed a significant relationship between the presence of pain and the MRI diagnosis of ID (P =.000) and its type (P =.000). Use of the kappa statistical test indicated poor diagnostic agreement between the presence of pain and the MRI diagnosis of ID (kappa = 0.37) and disc displacement with reduction (kappa = 0.20). The diagnostic agreement for disc displacement without reduction was 78.8%, with a corresponding kappa-value of 0.58, indicating fair agreement between the clinical and the MRI diagnosis.

CONCLUSION

The results suggest that TMJ pain associated with ADWOR is correlated with MRI diagnoses of ID and the ID type. These data confirm the use of the clinical diagnostic criteria for disc displacement without reduction as a reliable method of predicting similar MRI diagnoses.

Relationship between temporomandibular joint pain and magnetic resonance imaging findings of internal derangement

In terms of clinical decision-making in instances of temporomandibular disorders (TMD) and orofacial pain, there is controversy in the literature over the diagnostic significance of the temporomandibular joint (TMJ)-related variable disk-condyle relationship (DCR). The purpose of this study was to investigate whether in patients with TMJ-related pain, the variable of TMJ pain may be linked to magnetic resonance (MR) imaging findings of internal derangement (ID). The study comprised 163 consecutive TMJ pain patients. Criteria for including a patient were report of orofacial pain referred to the TMJ, and the presence of uni- or bilateral TMJ pain during palpation, during function, and/or during unassisted or assisted mandibular opening. Bilateral sagittal and coronal MR images were obtained to establish the prevalence of TMJ ID types. Analysis of the data revealed the presence of TMJ pain to be associated with significantly more MR imaging diagnoses of ID than an absence of ID (P<0.001), and disk displacement without reduction than disk displacement with reduction (P<0.001). Using chi-square analysis, the results showed a significant relationship between the presence of TMJ-related pain and the MR imaging diagnosis of TMJ ID (P=0.001), and TMJ ID type (P=0.000). Use of the Kappa statistical test indicated poor diagnostic agreement between the presence of TMJ pain and the MR imaging diagnosis of ID (K=0.16). The results suggest that the clinical variable of TMJ pain may have a significant effect on the prevalences of MR imaging diagnoses of TMJ ID. The data confirm the biological concept of DCR as a diagnostic approach in patients with signs and symptoms of TMJ-related pain.

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.

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

PURPOSE

This outcomes study was designed to provide a comprehensive evaluation of modified condylotomy for the treatment of the painful temporomandibular joint with reducing disc displacement (Wilkes stage II, early III).

PATIENTS AND METHODS

A prospective study of 48 consecutive patients (79 joints) was conducted. All reducing disc displacements were verified by disc imaging. Independent evaluations were performed to assess pain, dysfunction, and progression of disease before modified condylotomy and at intervals up to 1 year after operation. Thirty-one patients (50 joints) completed the examination before the operation and 1 year later. Patient-based assessments were made for pain and diet in 22 patients (35 joints) 3 years after operation.

RESULTS

The mean (+/- SE) visual analog scale (VAS) score for pain improved from 6.9+/-0.4 before modified condylotomy to 2.0+/-0.4 1 year later (P < .001). Serious pain (VAS score greater than 4) after operation was 7 times more likely (P < .04) when there was persistent disc displacement. The mean frequency of pain each day decreased from 14.6+/-1.4 hours to 4.8+/-1.3 hours (P < .001). Dietary restrictions improved from a mean VAS score of 6.1+/-0.5 before operation to 8.8+/-0.3 at 1 year (P < .001). Small differences between mean VAS scores for pain at 1 (2.0+/-0.5) and 3 (2.7+/-0.5) years and diet at 1 (8.6+/-0.4) and 3 (8.4+/-0.5) years after operation were not significant. Mean maximal incisal opening was 41.7+/-1.2 mm before operation and 43.5+/-1.1 mm 1 year later, but the difference was not statistically significant. Mean contralateral movement improved from 8.1+/-0.3 mm to 8.9+/-0.3 mm 1 year after operation (P < .05). Clicking was reduced from 64% of joints to 16% 1 year after operation (P < .001). The disc was reduced in 72% of joints, healing of an incipient degenerative lesion occurred in 1 joint, and there was no evidence of progression to nonreducing disc displacement (Wilkes late III, IV, V) or DJD (Wilkes IV, V) in any joint 1 year after modified condylotomy. The rate for reoperation was 4%. Complications occurred in 4 patients after operation and were resolved 1 year later. When these outcomes were judged by 7 AAOMS assessment indices for internal derangement, the mean rate of favorable outcome was 94%.

CONCLUSION

Modified condylotomy is an effective operation for treating pain and diminished function of temporomandibular joints with reducing disc displacement. It is also an effective treatment for slowing and, in some cases, reversing the progression of internal derangement.

Results of reoperation after failed modified condylotomy

PURPOSE

This retrospective study reports the reoperation rate for failure after modified condylotomy.

MATERIALS AND METHODS

A consecutive series from each of two surgeons constituted the study group of 361 joints in 235 patients. Reoperation rates were calculated for all joints and by type of disc displacement.

RESULTS

A second operation occurred in 4.2% of all joints. However, the cumulative rate of reoperation was 4.4%, because one of the joints required a third operation. Although the rate of reoperation varied (0% to 6.5%) according to the type of disc displacement, the differences were not statistically significant. All joints requiring reoperation had a displaced disc, and more than half had lost nearly all the joint space gained by the primary operation.

CONCLUSION

The rate of reoperation for modified condylotomy is low. Risk factors for reoperation appear to be recurrent or residual disc displacement and loss of joint space after the first operation. Bilateral operation was not a risk factor.

Initial TMJ disk recapture with anterior repositioning appliances and relation to dental history

Fifty-eight consecutive patients in a referral based practice seeking treatment for complex chronic painful temporomandibular joint (TMJ) disease were enrolled in a prospective study to assess the recapture of displaced disks by anterior repositioning appliances (ARA) and the improvement in disk position in those disks that did not fully recapture. After standard clinical workup, including assessment of pain, maxillary and mandibular ARAs were constructed which repositioned condyles to the Gelb 4/7 position as determined by cephalometrically-corrected linear tomograms. Multi-planar magnetic resonance imaging (MRI) was performed immediately before and after insertion of the mandibular ARA, showing three-dimensional recapture of disks in 85% and improved disk position in 6% of reducing displacements. Disk position was improved in 28% of nonreducing joints, but none were totally recaptured. Recapture or improvement was achieved in 91% of reducing, 28% of nonreducing, and 63% of all joints with internal derangements. Initial disk position, reduction on opening and recapture by ARA were statistically independent of patient age, number of teeth missing, number of third molars missing, malocclusion (Angle's class), overjet, overbite, prosthetic appliances, and previous orthodontic treatment. It was concluded that ARA therapy provided effective recapture of displaced TMJ disks that reduce upon mouth opening. In this population of patients with chronic TMJ pain, previous dental treatment had no statistically significant effect on the incidence of internal derangement or on disk recapture by ARA therapy. There was no evidence of adverse effect from orthodontics, prosthetics, or any other dental care.

Modification of the modified condylotomy

PURPOSE

This article describes the results of modification of the condylotomy procedure for treating painful internal derangements of the temporomandibular joint.

MATERIALS AND METHODS

Data on postoperative disc position, joint space, and pain were evaluated in patients who underwent either the original modified condylotomy or the newly modified procedure.

RESULTS

Less anterior and inferior sag of the condyle was produced by the new technique. Pain relief and disc reduction were about the same with both procedures.

CONCLUSIONS

The new modifications make the operation quicker and easier, while producing outcomes similar to those obtained with the original modified procedure.

Long-term follow-up of modified condylotomy for internal derangement of the temporomandibular joint

OBJECTIVES

The purpose of this study was to evaluate disk position and patient response 10 years after modified condylotomy for symptomatic reducing disk displacement.

STUDY DESIGNS

Questionnaires and invitations to return for examination and temporomandibular joint magnetic resonance imaging were mailed to 39 consecutive patients 10 years after modified condylotomy.

RESULTS

On a 10-point scale the mean pain experienced by the 17 respondents (27 joints) to the questionnaire was 2.0. Ninety percent of 20 joints (12 patients) examined were free of tenderness to palpation. Magnetic resonance imaging in 10 patients (17 joints) showed disk reduction in 59%, displacement with reduction in 29%, and displacement without reduction in 12%. Eighty-five percent of the joints met American Association of Oral and Maxillofacial surgeons criteria for a successful therapeutic outcome.

CONCLUSIONS

The study suggests a role for modified condylotomy in the long-term management of symptoms associated with reducing disk displacement. Further, modified condylotomy can frequently reverse an internal derangement and seems to protect against the natural progression of osteoarthrosis.

Recapture of temporomandibular joint disks using anterior repositioning appliances: an MRI study

Thirty consecutive patients seeking treatment for painful temporomandibular joint (TMJ) disease were enrolled in a prospective study to assess the relationship between the recapture of displaced disks by anterior repositioning appliances (ARA) and the relief of symptoms. After standard clinical workup including assessment of pain, maxillary and mandibular ARAs were constructed that repositioned condyles to the Gelb 4/7 position. Magnetic resonance imaging (MRI) was performed before and immediately after the insertion of ARAs. Initial MRI findings showed 26 joints with reducing disk displacements in 17 patients, seven partially-reducing joints in four patients, 14 nonreducing joints in 11 patients, and 13 normal joints in eight patients. Postinsertion MRI showed recapture of disks in 25 of 26 reducing displacements (96%), but no recapture in partially-reducing or nonreducing joints. All but one of the normal joints remained unchanged. Pain assessment showed significant relief of symptoms in all three categories. The degree of pain relief was significantly greater in recaptured reducing disks than the other categories (p < 0.05). ARA therapy provides effective pain relief regardless of disk status, although a greater degree of relief may be achieved in recaptured reducing internal derangements.