Clinical implications of the innervation of the temporomandibular joint

The successful management of temporomandibular joint (TMJ) pain remains elusive. Often, the initial relief of pain is complicated by recurrence of the symptoms. This time frame suggests that the pain may be related to neuromas of the nerves that innervate the TMJ. The current study attempted to define the innervation pattern of the TMJ as identified in 16 embalmed and 8 fresh-frozen specimens. In each specimen, the auriculotemporal nerve, a branch of the mandibular portion (V3) of the trigeminal nerve, was found to innervate the lateral capsule of the TMJ. In 75% of the specimens, the masseteric nerve, a branch of the maxillary portion (V2) of the trigeminal nerve, was found to innervate the anteromedial capsule of the TMJ. In 33% of the specimens, there was a branch coming through the mandibular notch to innervate the anteromedial capsule that was not from the masseteric nerve; this nerve is believed to have passed through the lateral pterygoid muscle after leaving V2. These consistent patterns of innervation of the TMJ suggest that diagnostic nerve blocks can be done to determine the pain pathway in these patients. It is suggested that if the nerve blocks are successful, TMJ denervation may be a future method of pain relief in patients with recalcitrant or recurrent TMJ pain.     

Arthroscopic cauterization of retrodiscal tissue as a successful minimal invasive therapy in habitual temporomandibular joint luxation

Habitual temporomandibular joint (TMJ) luxation is a serious condition for the patient, and is often managed by extensive open joint surgery. Arthroscopic eminoplasty is an alternative, but this technique could also cause concomitant damage to the articular surface. The aim of this study was to evaluate the therapeutic effects and side effects of arthroscopic electrocautery of retrodiscal tissues in habitual TMJ luxation. All patients with habitual TMJ luxations who needed surgical management from 1 January 2000 to 31 December 2009 in the authors’ institution in The Netherlands, were included in this study. All patients were primarily treated with arthroscopic electrocautery. Pre- and postoperative evaluation parameters were: TMJ luxations, maximum mouth opening, translatory capacity, pain and joint noises. Sixteen patients with habitual luxation were treated with arthroscopic electrocautery. Patient reluxation occurred in one. None of the patients had joint pain or mobility restrictions. The overall success rate was 95%. After 86 months there was a high success rate for this therapy. No other morbidity was seen, in contrast with open joint surgery or using sclerosing agents. The authors conclude that arthroscopic eletrocautery of retrodiscal tissues is a highly successful minimal invasive therapy in habitual TMJ luxation without side effects.     

Insurance coverage for the treatment of craniomandibular disorders

The successful dental practitioner must be knowledgeable in all aspects of insurance claims administration. The efficient management of insurance claims for the treatment of temporomandibular joint disorders (TMJ) and myofascial pain dysfunction syndromes should not be considered an exception. The information presented in this article is intended to provide dental practitioners who treat TMJ disorders and myofascial pain dysfunction syndromes with a practical, efficient, and proved method of maximizing insurance reimbursement for their patients' TMJ and myofascial pain therapy.     

Internal derangements of the temporomandibular joint: the role of arthroscopic surgery and arthrocentesis

Arthroscopic surgery appears to be a safe, minimally invasive and effective method for treating internal derangements of the temporomandibular joint (TMJ), reducing pain and increasing mandibular range of motion for approximately 80% of patients. Although these results are encouraging, they are largely based on retrospective, uncontrolled and short-term studies. The landmark observation that lysis and lavage in only the upper compartment of the TMJ produce successful clinical results without repositioning the disc has prompted clinicians to question the importance of disc position as a significant factor in the etiology of TMJ pain dysfunction. Although there are prospective, controlled, randomized short-term studies indicating that arthrocentesis and arthroscopic surgery have comparable success rates in the management of acute TMJ closed lock, similar long-term studies are lacking. Until they have been done, the roles of arthroscopic surgery and arthrocentesis in the management of TMJ internal derangements remain unclear.     

Changes in temporomandibular joint dysfunction after orthognathic surgery.

PURPOSE: We sought to evaluate the effects of orthognathic surgery on temporomandibular joint (TMJ) dysfunction in patients with known presurgical TMJ internal derangement who underwent double-jaw surgery for the treatment of dentofacial deformities. Patients and Methods: Treatment records of 25 patients with magnetic resonance imaging and clinical verification of preoperative TMJ articular disc displacement who underwent double-jaw surgery only were retrospectively evaluated, with an average follow-up of 2.2 years. Signs and symptoms of TMJ dysfunction, including pain, range of mandibular motion, and presence/absence of TMJ sounds, were subjectively (visual analog scales) and objectively evaluated at presurgery (T1), immediately postsurgery (T2), and at longest follow-up (T3). Surgical change (T2-T1) and long-term stability of results (T3-T2) were calculated using the superimposition of lateral cephalometric and tomographic tracings. RESULTS: Presurgery, 16% of the patients had only TMJ pain, 64% had only TMJ sounds, and 20% had both TMJ pain and sounds. Postsurgery, 24% of the patients had only TMJ pain, 16% had only TMJ sounds, and 60% has both TMJ pain and sounds. Thus, presurgery 36% of the patients had TMJ pain, and postsurgery, 84% had pain. Average visual analog scale pain scores were significantly higher postsurgery and none of the patients with presurgery TMJ pain had relief of pain postsurgery. In addition, 6 patients (24%) developed condylar resorption postsurgically, resulting in the development of Class II open bite malocclusion. CONCLUSIONS: Patients with preexisting TMJ dysfunction undergoing orthognathic surgery, particularly mandibular advancement, are likely to have significant worsening of the TMJ dysfunction postsurgery. TMJ dysfunction must be closely evaluated, treated if necessary, and monitored in the orthognathic surgery patient.     

改良耳屏切口颞下颌关节盘复位固定术手术入路介绍及效果评价

目的: 介绍一种改良耳屏切口颞下颌关节盘复位固定术术式并初步评价其临床效果。方法: 选取符合条件的颞下颌关节盘不可复性前移位患者6例（7侧关节）,依据Wilkes-Bronstein分期,纳入IV~V期患者,采用改良耳屏切口行颞下颌关节盘复位固定术。结果: 术中术区视野显露充分,术后MRI显示全部7侧关节盘复位良好,面神经功能保存良好。结论: 经改良耳屏切口行颞下颌关节盘复位固定术,术中暴露关节区充分,术后短期疗效可靠,且具有切口美观,手术创伤小,面神经受损程度轻等优点。可作为颞下颌关节手术的入路之一。     

Cryoanalgesia in the management of intractable pain in the temporomandibular joint: a five-year retrospective review

Cryoanalgesia is a controversial adjunct to the management of chronic pain, but we know of no studies that have investigated its effect in the management of temporomandibular joint (TMJ) pain. In this five-year retrospective study we treated 17 patients who had severe pain that had failed to respond to all forms of conventional conservative treatment and were not appropriate for simple open operation. None had a clear indication for open operation on the joint or had too severe disease to warrant a simple procedure. Preliminary diagnostic injections of bupivacaine to the TMJ relieved the pain. We applied the cryoprobe in the region of the auriculotemporal nerve and TMJ capsule. There was a small but insignificant improvement in mean mouth opening together with a significant (p = 0.000) improvement in visual analogue pain scores (VAS) from 6.8 (range 4–10) to 2.0 (range 0–7). Two patients had no change in their pain scores, and 2 had complete resolution of their pain. The mean number of pain-free months after treatment was 7 (IQR 3–15). Three patients had long-term pain relief, and 12 temporary relief; 6 of these subsequently had successful relief after total replacement of the TMJ. One patient had further cryoanalgesia, one was referred for specialist pain management, and one controlled the pain with nortriptyline. Of the 17 cases studied, 2 had temporary complications after cryoanalgesia. Cryoanalgesia is a useful adjunct to the management of intractable pain in the TMJ. Short-term pain relief can be achieved, and long-term relief is possible in some, deferring more complex and costly treatments.     

Physiotherapy as an adjuvant therapy for treatment of TMJ disorders

Physiotherapy has long been used to cure joint and muscle diseases. It has also been used to treat various diseases without inflicting mental trauma or the pain of surgery. This adjunctive therapeutic modality is widely used for patients with orofacial disorders, especially in the prevention or treatment of temporomandibular joint (TMJ) disorder, hypomobility, or ankylosis. Physiotherapy has a particular importance in the treatment of TMJ disorders such as myofascial pain and internal derangement. This review article highlights the importance of physiotherapy as an emerging adjuvant therapy in the treatment of TMJ disorders.     

Concomitant temporomandibular joint and orthognathic surgery: a preliminary report.

PURPOSE: In the present study, we evaluated the outcome of concomitant temporomandibular joint (TMJ) and orthognathic surgery in patients with TMJ articular disc dislocation and coexisting dentofacial deformities. PATIENTS AND METHODS: The records of 70 patients treated with TMJ articular disc-repositioning surgery and concomitant orthognathic surgery (double jaw or only mandibular surgery) were retrospectively evaluated. Patients were divided into the following 3 groups: group 1 patients had mandibular advancement, group 2 patients had mandibular setback, and group 3 patients had a mandible that remained in the original position. Lateral cephalometric radiographs and lateral cephalometric tomograms were assessed at the following intervals: before surgery (T1), immediately after surgery (T2), 6 to 12 months after surgery (T3), and at the longest follow-up (T4). Lateral cephalometric tracings were superimposed to calculate surgical change (T2 - T1), short-term stability (T3 - T2), and long-term stability (T4 - T3) of the orthognathic surgery procedures. Maximum interincisal opening (MIO) and subjective TMJ pain (visual analog scales) were comparatively evaluated at T1 and T4. RESULTS: Subjective TMJ pain levels and MIO improved in all 3 groups after surgery. Before surgery, 56 of 70 patients (80%) had pain and 14 of 70 patients (20%) had no pain. At the longest follow-up, 42 of 70 patients (60%) reported complete relief of TMJ pain. Only 5 of 70 patients (7%) had severe pain after surgery compared with 37 of 70 patients (53%) before surgery. At the longest follow-up, 6 of 70 patients (9%) showed less than 35 mm MIO, residual severe pain, or both. One patient had significant condylar resorption after surgery. The orthognathic procedures were found to be stable in the long term. Concomitant TMJ and orthognathic surgery had an overall success rate of 91.4% based on a greater than 35 mm MIO and a decrease in pain. CONCLUSIONS: When indicated, TMJ and orthognathic surgery can be concomitantly performed with predictable results and a good success rate. Strong consideration should be given to early surgical intervention because the success rate decreases significantly with pre-existing TMJ dysfunction of greater than 48 months' duration.     

Will they fit? Determinants of the adaptability of stock TMJ prostheses where custom TMJ prostheses were utilized

Currently only two alloplastic temporomandibular joint (TMJ) total joint replacement (TJR) systems are available in the United States. The aim of this study was to define variables that determine whether a Biomet stock prosthesis could have been used to reconstruct a TMJ previously reconstructed with a TMJ Concepts patient-fitted prosthesis. All of the TMJ Concepts prostheses placed between 2010 and 2018 at the University of Texas – Health at San Antonio were analyzed retrospectively. There were 128 cases (241 joints) with intact stereolithographic models analyzed for successful adaptation of the Biomet stock TMJ prosthesis. Anatomical, demographic, etiological, and perioperative data were gathered for each joint to investigate possible causes of failure of stock adaptation. The majority of joints, 74% (178/241), could have had a stock prosthesis adapt. All joints with ≥40 mm gap arthroplasty failed stock prosthesis adaptation. Only 50% (32/64) of the joints with at least one previous open TMJ surgery and 60% (58/96) of the joints with concomitant orthognathic surgery could have had a stock TMJ prosthesis. The stock prosthesis could not be adapted for any of the patients requiring TMJ replacement for congenital disorders or those requiring TMJ salvage. Overall, the majority of cases treated with a patient-specific TMJ TJR could have been treated with a stock prosthesis.     

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

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

Clinical Indications for Simultaneous TMJ and Orthognathic Surgery

Abstract

There are many temporomandibular joint (TMJ) conditions that can cause pain, TMJ and jaw dysfunction, and disability. The most common of these conditions include: 1. articular disk dislocation; 2. reactive arthritis; 3. adolescent internal condylar resorption; 4. condylar hyperplasia; 5. osteochondroma or osteoma; and 6. end-stage TMJ pathology. These conditions are often associated with dentofacial deformities, malocclusion, TMJ pain, headaches, myofascial pain, TMJ and jaw functional impairment, ear symptoms, etc. Patients with these conditions may benefit from corrective surgical intervention. Open joint surgery provides direct access to the TMJ allowing manipulation, repair, removal and/or reconstruction of the anatomical structures that cannot be accomplished by other treatment methods. TMJ surgery and orthognathic surgery can be predictably performed during one operation with high success rates. This paper discusses the most common TMJ pathologies and presents the surgical management considerations to correct the specific TMJ conditions and associated jaw deformities.     

Clinical indications for simultaneous TMJ and orthognathic surgery

There are many temporomandibular joint (TMJ) conditions that can cause pain, TMJ and jaw dysfunction, and disability. The most common of these conditions include: (1) articular disk dislocation; (2) reactive arthritis; (3) adolescent internal condylar resorption; (4) condylar hyperplasia; (5) osteochondroma or osteoma; and (6) end-stage TMJ pathology. These conditions are often associated with dentofacial deformities, malocclusion, TMJ pain, headaches, myofascial pain, TMJ and jaw functional impairment, ear symptoms, etc. Patients with these conditions may benefit from corrective surgical intervention. Open joint surgery provides direct access to the TMJ allowing manipulation, repair, removal and/or reconstruction of the anatomical structures that cannot be accomplished by other treatment methods. TMJ surgery and orthognathic surgery can be predictably performed during one operation with high success rates. This paper discusses the most common TMJ pathologies and presents the surgical management considerations to correct the specific TMJ conditions and associated jaw deformities.     

Total temporomandibular joint replacement: A clinical case with a proposal for post-surgical rehabilitation

OBJECTIVE: The literature on total alloplastic temporomandibular joint (TMJ) reconstructions is encouraging, and studies on total alloplastic TMJ replacements' outcomes showed acceptable improvements in terms of both pain levels and jaw function. Nevertheless, a better standardization of both surgical and post-surgical phases should further improve the efficacy of treatment. MATERIALS AND METHODS: The case report describes the surgical and post-surgical phases of treatment in a patient who underwent a total unilateral joint replacement for TMJ ankylosis, along with a proposal for a post-surgical rehabilitation protocol providing strong passive and active physiotherapy and hyaluronic acid injections to the contralateral joint. RESULTS: The post-operative (PO) course was uneventful. The patient showed a marked improvement up to about 60% in mouth opening and had no pain on either side at the 1-year follow-up. CONCLUSION: In a patient with unilateral TMJ ankylosis, total TMJ replacement was successful. A carefully tailored post-surgical rehabilitation protocol helped the patient to gain a clinically significant improvement in jaw function. Longer follow-up periods are needed to assess the long-term maintenance of results. Clinical trials are strongly recommended to assess the relative efficacy of different PO protocols.     

Simplified anesthesia blocking of the temporomandibular joint

The general dentist's ability to perform an anesthesia block of the temporomandibular joint (TMJ) can be very beneficial, especially when trying to diagnose or treat patients with temporomandibular dysfunction who have joint and/or muscle pain. There are three common types of internal joint disorders--orthopedic, inflammatory, and degenerative--producing pain in the ligaments, TMJ capsule, or retrodiscal tissues. Secondary muscle splinting also may be involved. Subjects with these disorders can have pain, limited opening, or difficulty with extended opening. Dentists providing care for these individuals may need to schedule longer appointments and deal with mid-treatment facial or TMJ pain as well as more postoperative discomfort. An anesthesia block for the TMJ can reduce pain and protective muscle splinting, increase the mandibular range of motion, and assist in providing a more manageable treatment.     

Alloplastic temporomandibular joint replacement: rationale for the use of custom devices

The essential life functions of mastication, speech, airway support and deglutition are supported by temporomandibular joint (TMJ) function and form. Over a lifetime, this puts the TMJ complex under more cyclical loading and unloading than any other joint. Therefore, to provide long-term effective outcomes, the TMJ total joint replacement (TJR) device selected must be capable of managing the anatomical, functional and aesthetic discrepancies that dictated its use. The primary goal of TMJ TJR is the restoration of mandibular function and form. Outcomes data confirm that any pain relief attained must be considered of only secondary benefit. Despite persistent but reduced chronic pain, increased mandibular function and form improvement have been reported, resulting in quality of life improvement for 85% of custom TMJ TJR patients studied long-term. Based on the literature and the accepted orthopaedic criteria for the development and utilisation of successful TJR devices, this paper presents a rationale for the use of custom TMJ TJR devices as a 'fitting' management option for end-stage TMJ disorders.     

Arthroscopic treatment of temporomandibular joint locking resulting from disc derangement: two-year results

This article reports 2-year postarthroscopic surgical treatment data for 18 subjects (17 female and 1 male) who had a diagnosis of restricted mandibular movement due to an internal derangement of the temporomandibular joint (TMJ). These subjects had been treated by an average of 2.1 +/- 1.1 doctors for their TMJ problem before seeing the surgeon for arthroscopic treatment. The subjects' mean pain score at the final time point (21 to 30 months after surgery) was decreased by 57% in usual pain intensity. Jaw function showed an average improvement of 67%. These subjects also showed a 13-mm mean increase in their maximum active opening ability at the 2-year postsurgical time point. Slight to definite clicking noises were present presurgically in 11 of 18 patients, and similar joint noises were reported in 14 of 18 patients postsurgically. The mean overall improvement was rated as 8.18 +/- 2.4, with 10 the highest possible rating. One subject rated her improvement as 0, two subjects rated their improvement as 6 out of 10. No significant morbidity was reported by the subjects as a result of their surgery.     

Internal derangements of the temporomandibular joint. III. Anterior repositioning splint therapy

A bstract — Over a four-year period, anterior repositioning (REPO) splint therapy was used to treat 241 temporomandibular joint pain patients for whom a clinical diagnosis of anterior disc displacement had been made. Following an initial six months of active REPO therapy, the response to treatment over the ensuing twelve months was generally encouraging, control of joint noise and discomfort being achieved in 70 per cent of the treated sample. This figure had decreased to 53 per cent at the two-year follow-up and, by the end of three years, only 36 per cent were considered successfully treated.
It is suggested that REPO splint therapy for anterior disc displacement should not be lightly undertaken by the general dental practitioner but that a more conservative approach should be adopted for the vast majority of TMJ pain patients.     

The effect of temporomandibular joint arthroscopy on ear function

Many patients with temporomandibular joint (TMJ) dysfunction also complain of subjective symptoms of ear dysfunction. This study was undertaken to evaluate preoperatively patients with ear complaints associated with TMJ pain and dysfunction and to examine the effect of essentially uncomplicated TMJ arthroscopy on subsequent ear function. Fourteen patients (22 joints) were examined arthroscopically. The patients were evaluated by an otologist, and hearing tests were obtained pre- and post-operatively. All patients had normal audiometric studies preoperatively, and these remained unchanged postoperatively. It was concluded that uncomplicated arthroscopy of the TMJ does not cause ear dysfunction.