Outcome of eminectomy combined with discectomy and silastic interpositional graft for temporomandibular joint dysfunction: a retrospective study of 20 years

Internal derangement of the temporomandibular joint (TMJ) is usually treated conservatively, but about 5% require surgical treatment. We designed a retrospective study to assess the long-term outcomes of eminectomy combined with discectomy and silastic interpositional graft in 44 patients who had chronic TMJ dysfunction that had not responded to traditional conservative treatment and arthrocentesis. The maximum mouth opening, pain score, Wilkes stage, and clinical dysfunction index were measured before, and two years after, operation. All the patients showed significant improvement in mouth opening and reduced pain scores (p < 0.0001 in each case). There were no long-term operative complications, and postoperative magnetic resonance scans showed that the silastic interpositional graft was in a stable position with no evidence of degenerative changes on the surfaces of the joint and no lymphadenopathy.     

Endoscopically assisted fixation of the custom-made total temporomandibular joint prosthesis in TMJ Yang’s system through a modified preauricular approach

This article describes the experience with the endoscopically assisted fixation of the customized total temporomandibular joint (TMJ) prosthesis in TMJ Yang’s system only through a modified preauricular approach. Twenty patients (23 joints) treated with the custom-made total TMJ prosthesis were retrospectively recruited. An endoscopically assisted technique was used through a modified preauricular approach to fix the mandibular component for all these patients. These reconstructions were evaluated by surgical records, clinical examinations, and radiographic observations. All patients had successful fixation of the prosthesis. No patient had permanent weakness of the facial nerve and malocclusion or any other severe complications. The mean operative time was 111 min per joint (range, 85–133 min). The average surgical bleeding was 195 ml per side. The mean follow-up period was 16.2 months (range, 5–32 months). The mean scores were 8.3 for surgical satisfaction and 9.2 for scar healing evaluation. All patients experienced positive clinical outcomes, with a mean 75.2% reduction in pain and 53.7% increase in mouth opening with significant differences (P < 0.05). The endoscopically assisted TMJ reconstruction with the customized prosthesis in TMJ Yang’s system through the modified preauricular approach could produce good aesthetic and functional results.     

A prospective,single-centre study on patient outcomes following temporomandibular joint replacement using a custom-made Biomet TMJ prosthesis

This study describes the clinical variables in 61 patients following total alloplastic temporomandibular joint reconstruction (TJR) in which the Biomet Microfixation Patient-Patient-Matched TMJ Implant was used. All patients were classified using the Wilkes classification. The visual analogue scale score for jaw pain intensity, the maximum inter-incisal opening (MIO), and the frequency of adverse events were recorded during follow-up; the mean follow-up was 14.2 ± 8.6 months. Significant improvements were found in the MIO (P < 0.0005), except at the 3-year follow-up. Additionally, a significant reduction in pain was observed both short and long term (P < 0.0005). The incidence of adverse events was low (seven of the 81 alloplastic joints); two joints needed revision. TJR appears to be a relevant treatment option in patients with a broad range of temporomandibular joint disorders in whom none of the joint components are salvageable because of significant disease. Our patients gained an almost normal range of mouth opening and experienced a significant reduction in pain. Our results are promising, however TJR is associated with some side effects. TJR should be considered when less invasive procedures fail and a comprehensive presurgical work-up has been performed. Ongoing prospective studies are needed to consolidate the possible significant treatment outcomes.     

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

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

Total reconstruction of the temporomandibular joint. Up to 8 years of follow-up of patients treated with Biomet® total joint prostheses

12 patients underwent temporomandibular joint (TMJ) reconstruction with Biomet total joint prostheses. Indications for TMJ reconstruction included ankylosis, rheumatoid arthritis, degenerative joint disease and condylar resorption. Five patients had unilateral procedures, seven had bilateral. The follow-up ranged between 2 and 8 years. Amongst the ankylotic patients the mean jaw-opening capacity increased from 3.8 mm preoperatively to 30.2 mm 1 year after surgery, and in most of those patients the opening capacity remained stable over the years. The other patients maintained a mean opening capacity of more than 35 mm. Joint related pain and interference with eating were eliminated after TMJ reconstruction. There were no permanent facial nerve disturbance, no postoperative infections and no device related complications. The outcome supports prosthetic TMJ reconstruction as a useful treatment modality in patients with advanced TMJ disease.     

Is dermis fat arthroplasty better than plain gap arthroplasty? A prospective randomised controlled trial

The aim of the study was to compare interpositional arthroplasty using a dermis fat graft with gap arthroplasty in the management of ankylosis of the temporomandibular joint (TMJ). We organised a prospective randomised study of 22 patients who presented with ankylosis of the TMJ. They were randomised to be treated with either plain gap arthroplasty or dermis fat arthroplasty, and the predictor variable was the method of treatment. The primary outcome variables were mouth opening and pain on jaw exercises. Pain and interincisal opening were measured on day 5, day 14, at the end of one month, and at six months, one year, two years, and three years. There was a significant difference between the two groups on two occasions: postoperative day 5 (p = 0.013) and at one year (p = 0.018). The mean (SD) scores for mouth-opening were higher in the dermis fat group at all times (41.20 (4.69) mm compared with 39.50 (2.46) mm in gap arthroplasty at two years, and 41.40 (3.60) mm compared with 38.9 (2.02) mm at three years). The visual analogue pain scores were also lower in the dermis fat graft group. The groups showed similar results at the end of three years follow up, with no significant difference in mouth opening. We conclude therefore that the two techniques have similar outcomes in the management of ankylosis of the TMJ.     

Reconstruction of the temporomandibular joint: a comparison between prefabricated and customized alloplastic prosthetic total joint systems

The implantation of an alloplastic total temporomandibular joint (TMJ) prosthesis is an innovative approach for the treatment of end-stage TMJ disorders. Two types of system exist: prefabricated (stock) and customized computer-aided design/computer-aided manufacturing (CAD/CAM) devices. A clinical study was performed to evaluate the effectiveness of these two designs. Twenty-eight patients treated between 2015 and 2017 were included and assigned to two groups: stock prostheses (group 1) and customized CAD/CAM prostheses (group 2). Clinical evaluations were performed at five time-points up to 6 months postoperative. Parameters included maximum interincisal opening, pain, diet, complications, and subjective well-being at the end of follow-up. Differences between pre-surgery and 6-month post-surgery values were highly significant (P < 0.001). No patient required a liquid diet at the end of treatment, and 66% of group 1 patients and 100% of group 2 patients reported improved well-being. Complications were observed in 32% of patients and included temporary paralysis of the facial nerve. In conclusion, clinical outcomes of stock and CAD/CAM prostheses suggested great improvements in mouth opening and reduction of pain as a result of the rehabilitation of TMJ function. Results showed comparable data for the two types of prosthesis design at 6 months postoperative.     

Effects of four treatment strategies for temporomandibular joint closed lock

A previous randomized controlled trial (RCT) by Schiffman et al. (2007)¹⁵ compared four treatments strategies for temporomandibular joint (TMJ) disc displacement without reduction with limited mouth opening (closed lock). In this parallel group RCT, 106 patients with magnetic resonance imaging (MRI)-confirmed TMJ closed lock were randomized between medical management, non-surgical rehabilitation, arthroscopic surgery, and arthroplasty. Surgical groups also received rehabilitation post-surgically. The current paper reassesses the effectiveness of these four treatment strategies using outcome measures recommended by the International Association of Oral and Maxillofacial Surgeons (IAOMS). Clinical assessments at baseline and at follow-up (3, 6, 12, 18, 24, and 60 months) included intensity and frequency of TMJ pain, mandibular range of motion, TMJ sounds, and impairment of chewing. TMJ MRIs were performed at baseline and 24 months, and TMJ tomograms at baseline, 24 and 60 months. Most IAOMS recommended outcome measures improved significantly over time (P ≤ 0.0003). There was no difference between treatment strategies relative to any treatment outcome at any follow-up (P ≥ 0.16). Patient self-assessment of treatment success correlated with their ability to eat, with pain-free opening ≥35 mm, and with reduced pain intensity. Given no difference between treatment strategies, non-surgical treatment should be employed for TMJ closed lock before considering surgery.     

Gap arthroplasty of temporomandibular joint ankylosis by transoral access: a case series

This article describes a technique of gap arthroplasty in temporomandibular joint (TMJ) ankylosis performed by transoral access. The treatment of TMJ ankylosis by creating an adequate gap is of paramount importance in preventing any future recurrence and this can be achieved only when good access is gained to this complex anatomical joint. Five patients with TMJ ankylosis (eight TMJ) were treated by gap arthroplasty using an intraoral approach. The average mouth opening before surgery was 8.6 mm and the average mouth opening achieved postsurgery was 37.9 mm. The average follow-up time was 13 months and none of the patients had any recurrence or significant complications during or after surgery. Our technique relies on the use of a stable landmark to trace the superior-most extent of the ankylotic mass thereby facilitating the removal of the entire mass including the medial extent. We found that even though transoral access is technically challenging and took an average time of 84 min, it has many advantages over conventional extraoral approaches in terms of facial scars and facial nerve injury. The authors also emphasize the importance of good postoperative physiotherapy and presurgical patient counselling to prevent future recurrences.     

Simultaneous custom-made replacement of the temporomandibular joint and cranioplasty

A 23-year-old man presented with a history of fibrous ankylosis of the left temporomandibular joint (TMJ), scarring and shortening of the left temporalis muscle secondary to transection, and surgically-induced neuropathic pain after previous decompression of the temporal bone. There was evident hollowing of the left temporal fossa, and mouth opening was limited to 5 mm. The aims of the operation were to treat the ankylosis, improve cosmesis, and reduce his medication. His left TMJ was reconstructed with a custom-made alloplastic joint, and a simultaneous custom-made cranioplasty. At follow-up after 2 years he was free of pain and taking no drugs. He had no obvious cranial deformity, and his mouth opening had increased to 35 mm. To our knowledge this is the first reported case of simultaneous custom-made cranioplasty and reconstruction of the TMJ.     

Accuracy of fit analysis of the patient-specific Groningen temporomandibular joint prosthesis

Total joint replacement (TJR) with a prosthesis can be indicated for patients with severe temporomandibular joint (TMJ) dysfunction. Surgical accuracy is necessary for correct translation of the preoperatively predicted functional outcome, wear, and biomechanical behaviour of the patient-specific TMJ-TJR prosthesis. This study describes the first clinical applications of the patient-specific TMJ-TJR prosthesis according to the Groningen principles (G-TMJ-TJR), which was developed and validated in a prior human cadaver test study. The aim of this study was to validate the accuracy of placement of the patient-specific G-TMJ-TJR in the clinical setting. It was hypothesized that a virtual surgical plan (VSP) combined with guided placement of the patient-specific G-TMJ-TJR would be performed as predictably and accurately as in the prior cadaver series. All patients who received a VSP-based patient-specific G-TMJ-TJR between December 2017 and March 2020 were included in this study. The accuracy analysis was based on postoperative cone beam computed tomography (CBCT) data. All 11 prostheses could be inserted using routine pre-auricular and retromandibular surgical approaches. Analysis of the VSPs and postoperative CBCTs showed an average three-dimensional deviation of 1.07 mm (standard deviation 0.46 mm, range 0.33–1.91 mm) for all of the fossa and mandibular components. The patient-specific G-TMJ-TJR can be applied predictably and accurately in a clinical setting.     

Neurosensory assessment in patients with total reconstruction of the temporomandibular joint

Somatosensory sensitivity and postoperative endogenous pain modulation have not been investigated in temporomandibular joint (TMJ) prosthesis patients. The objectives of this study were to assess somatosensory function at the TMJ and examine possible differences in conditioned pain modulation (CPM) between patients with total TMJ prostheses (n = 7) and a reference group of healthy controls (n = 20). Somatosensory abnormalities were assessed using quantitative sensory testing (QST), which encompasses thermal and mechanical testing procedures. CPM was tested by comparing pressure pain thresholds (PPT) before (baseline), during, and after the application of painful and non-painful cold stimuli. PPTs were measured at the TMJ and thenar eminence (control). The effect of CPM on PPT values was tested with analysis of variance. Three patients exhibited mixed somatosensory loss (i.e., decreased thermal and mechanical detection) with mixed hyperalgesia (i.e., increased sensitivity to thermal and mechanical pain) and two patients exhibited mixed loss with only mechanical hyperalgesia. There was a significant decrease in pressure pain sensitivity at both sites during painful cold application in healthy controls (P < 0.001) but not in patients (P = 0.476). In conclusion, QST measures demonstrated somatosensory abnormalities in patients with total TMJ prostheses. Noxious conditioning cold stimuli evoked CPM-like effects in healthy subjects but not in patients with TMJ reconstruction.     

A ten-year experience and follow-up of three hundred patients fitted with the Biomet/Lorenz Microfixation TMJ replacement system

The purpose of this paper is to present the postoperative results obtained after full temporomandibular joint (TMJ) reconstruction employing the Biomet/Lorenz Microfixation TMJ replacement system (Jacksonville, FL, USA) in 300 patients (201 unilateral, 99 bilateral). Objective data (maximum inter-incisal opening; MIO) and subjective data (function and speech, diet, and pain) were collected preoperatively and at postoperative evaluations performed over a 10-year period (mean 3.5, standard deviation 2.1 years). The MIO measures were obtained using a calliper rule. Subjective data were evaluated using a visual analogue scale with scores ranging from 0 to 5 for each variable. The results were analyzed with the paired t-test (two-sided, α = 5%). Each patient showed significant improvements for all of the variables at evaluation on postoperative day 7. The results for MIO, function and speech, and diet, showed improvements at each postoperative evaluation over a maximum of 3 years, with stabilization of the results from the fourth year. Complaints of pain decreased considerably up to the 1-month postoperative evaluation, and no patient reported severe pain at 6 months after surgery. The results presented show that the reconstruction of the TMJ through the installation of the Biomet/Lorenz system prosthesis is a safe and effective option for proper reestablishment of the joint and stomatognathic system function; significant long-term improvements in mandibular range of motion are promoted and pain levels decrease.     

Treatment modalities of TMJ ankylosis: experience in Delta Nile,Egypt

The study reports the authors’ experience in managing TMJ ankylosis in Delta Nile, Egypt (1995–2006) and compares the surgical modalities used. 101 patients (109 joints) were reviewed in this retrospective study. Pre- and postoperative assessment included history, radiological and physical examination, and mouth opening. Age, sex, aetiology, joint(s) affected, surgical modality, complications and follow up periods were evaluated. Various types (fibrous, fibro-osseous and bony) of TMJ ankylosis were diagnosed; trauma was the commonest aetiology. The patients’ age range was 2–41 years, 62% were female, and the follow up period ranged from 14 to 96 months. Average mouth opening was significantly increased from 5.3 mm pre-operatively to 32.9 mm 12 months postoperatively (P = 0.0001). Marked improvement in mouth opening was documented when the ramus-joint complex was reconstructed using distraction osteogenesis (34.7 mm), costochondral graft (34.4 mm) and Surgibone (34.6 mm). Gap arthroplasty showed least satisfactory mouth opening compared with other techniques (P = 0.001). Minor and major complications were encountered in 33% of cases, including 5% recurrence rate. Early release of TMJ ankylosis; reconstruction of the ramus height with distraction osteogenesis or bone grafting combined with interpositional arthroplasty, followed by vigorous physiotherapy is successful for managing TMJ ankylosis.     

Prospective study of five-year outcomes and postoperative complications after total temporomandibular joint replacement with two stock prosthetic systems

To evaluate and compare outcomes and complications associated with reconstruction of the temporomandibular joint (TMJ), we prospectively analysed the data of 70 patients who had their joints replaced with stock prostheses during the period 2004-14 and who had been followed up for five years. We used two types of stock prostheses: the metal-on-metal Christensen system (CS), and the ultra-high-molecular-weight-polyethylene-on-metal Biomet® system (BS). Data were collected at 3, 6, 12, 24, 36, 48, and 60 months postoperatively and compared with preoperative measurements. Five years after the replacement there was an increase in mean (SD) mouth opening from 2.0 (0.6) to 4.0 (0.5 cm) (p = 0.012) in the CS, and from 2.5 (1.0) cm to 4.1 (0.6) cm (p = 0.018) in the BS. The mean (SD) reductions in visual analogue pain scores were from 6.9 (1.6) to 2.0 (1.4) (p = 0.001) in the CS, and 6.5 (1.4) to 1.5 (1.1) (p = 0.001) in the BS. There were no significant differences in improvements in mouth opening or reduction in pain between the two groups. However, there were differences in the number of implants that failed, which led to removal and replacement of 2/14 prostheses in the CS group and 3/77 in the BS group (p = 0.06). The results supported the placement of stock prostheses, as evidenced by a low incidence of complications and adverse events, and a long-term improvement in function and reduction in pain in the TMJ. The BS group had significantly fewer prosthetic failures than the CS group.     

Total alloplastic temporomandibular joint reconstruction using Biomet stock prostheses: the University of Florida experience

The purpose of this study was to report the subjective and objective outcomes of temporomandibular joint (TMJ) replacement with Biomet stock prostheses at a single institution in Florida. In this retrospective study, patients who underwent TMJ replacement using a Biomet stock prosthesis from 2005 to 2012 were analyzed. Subjective (pain, diet) and objective (maximal incisal opening) information was obtained. In addition, a quality of life measure was obtained pre- and postoperatively. Significance was set at <0.01. Thirty-six patients (26 bilateral, 6 left, and 4 right) who underwent TMJ replacement using a Biomet stock prosthesis were eligible for the study. Maximal incisal opening improved from 26.1 mm preoperatively to a mean of 34.4 mm postoperatively. The pain score decreased from 7.9 preoperatively to a mean of 3.8 postoperatively. Diet restriction decreased from 6.8 preoperatively to a mean of 3.5 postoperatively. Quality of life improved from a median of 4 preoperatively to a postoperative median of 2. Four implants were removed/replaced because of heterotopic bone formation, infection, and/or loose hardware. Follow-up ranged from 6 to 83 months. Overall, TMJ reconstruction using the Biomet stock joint is effective and safe in this patient population.     

Evaluation of the efficacy of different treatment modalities for painful temporomandibular disorders

The purpose of this study was to clinically evaluate the efficacies of three treatment methods and to compare their outcomes in patients with painful disc displacement. The study group comprised 45 patients with unilateral temporomandibular disorders who fell into Axis I group II (with limited mouth opening) of the Research Diagnostic Criteria for Temporomandibular Disorders. Magnetic resonance imaging was used for definitive diagnosis. The patients were divided randomly into three groups according to the treatment method: splint therapy, splint therapy with ultrasound-guided arthrocentesis, and splint therapy with low-level laser therapy. Patients were followed up after treatment for 6 months. The groups were compared in terms of pain and functional jaw movements (unassisted mouth opening without pain, maximum unassisted mouth opening, and contralateral movements). At the end of treatment, functional jaw movements were significantly increased while pain values were significantly decreased in all groups (P < 0.05). Group 2 had a quicker improvement in terms of mouth opening scores at the end of the first month, and unassisted mouth opening without pain was found to be more than 35 millimetres in all groups at the end of 6 months. All treatment modalities showed effective results on pain and functional jaw movements in the treatment of temporomandibular disorders.     

Effectiveness of treatment with viscosupplementation in temporomandibular joints with or without effusion

The objective of this study was to determine whether the effectiveness of viscosupplementation with hyaluronic acid (HA) in patients with temporomandibular joint (TMJ) degenerative disorders depends on the presence of intra-articular effusion. In this study of case–control design, two groups of 25 patients were recruited: patients with a clinical diagnosis of painful chronic TMJ osteoarthritis and magnetic resonance imaging (MRI) signs of TMJ degeneration, with (effusion group) or without (no effusion group) MRI evidence of TMJ effusion. All patients underwent five weekly single-needle arthrocenteses plus medium molecular weight HA and 6 months of follow-up. Several clinical outcome parameters were assessed. For all variables, analysis of variance (ANOVA) for repeated measures was performed to assess the existence of significant within-group and between-group treatment effects. Over time, both groups showed significant improvements in all outcome parameters, which were maintained at the 6-month follow-up (P < 0.05). Between-group comparisons showed that the treatment effects did not differ significantly for either the primary outcome variable (pain levels: F = 0.849, P = 0.548) or secondary outcome variables (chewing efficiency: F = 0.854, P = 0.544; functional limitation: F = 1.35, P = 0.226; mouth opening: F = 0.658, P = 0.707). The null hypothesis that there are no differences in treatment effectiveness between patients with and without effusion could not be rejected.     

Temporomandibular joint replacement: a New Zealand perspective

Alloplastic total temporomandibular joint replacement (TMJ TJR) has been performed in New Zealand utilizing the TMJ Concepts patient-fitted system since 2000. The data analysed in this study were collected retrospectively from questionnaires sent to all maxillofacial surgeons in New Zealand who had implanted TMJ Concepts devices between 2000 and 2011. A total of 63 devices were implanted in 42 patients (13 males, 29 females) during this 12-year period. The primary indication for TMJ TJR was end-stage joint disease resulting from ankylosis and arthritis. The mean age of the patients was 47 years (range 7–80 years). The most common complication reported was transient facial nerve impairment in 4.8% of the patients. Objective results, measured as the maximal incisional opening, improved by a mean of 17.3 mm (P < 0.01); 90% of patients reported improved quality of life. New Zealand oral and maxillofacial surgeons have concluded that TMJ TJR using the TMJ Concepts prosthesis is a reliable treatment option for the management of end-stage TMJ disease.     

Relationship between temporomandibular joint pain and magnetic resonance imaging findings in patients with temporomandibular joint disorders

The purpose of this study was to evaluate abnormal magnetic resonance imaging (MRI) findings related to temporomandibular joint (TMJ) pain. This study included 245 joints of 152 patients with temporomandibular disorders with anterior disc displacement; of these, 129 joints had joint pain whereas 116 joints had no joint pain. MRI was used to evaluate the reduction of anterior disc displacement, joint effusion, mandible condylar morphology, bone marrow oedema of the mandibular condyle, and signal intensity of the posterior disc attachment (PDA) on fat-suppressed T2-weighted images. The odds ratio (OR) for each MRI variable for the pain group versus the no pain group was computed using logistic regression analysis. Univariate logistic regression analysis showed significant correlations between TMJ pain and all MRI findings. Multivariate logistic regression analysis showed significant correlations with joint effusion (P = 0.03, OR 2.21), bone marrow oedema (P < 0.001, OR 11.75), and signal intensity of the PDA (P < 0.001, OR 6.21). These results suggest that bone marrow oedema, high signal intensity of the PDA on fat-suppressed T2-weighted images, and joint effusion, in descending order of influence, are factors related to TMJ pain.