UK temporomandibular joint replacement database: report on baseline data

Our goal is to establish the long-term collection of data on temporomandibular joint replacement from all centres in the UK where this is done. Currently, 16 surgeons have been identified, and 13 of them had entered data when this paper was being prepared. Data are entered online through the Snap Survey and then analysed annually. We report on 402 patients (332 (83%) female and 70 (17%) male) who had 577 joints inserted between 1994 and 2012. The main diagnoses that resulted in total joint replacement were osteoarthritis, failed operation, ankylosis, and seronegative arthritis. Preoperatively, the median (IQR) maximal incisal opening was 20 (15–26) mm (mean 20) and the median pain scores on the visual analogue scale (VAS 0–10) were 8 for both joints. The median (IQR) baseline dietary score (liquid 0 – solid 10) was 4 (3–6). A total of 173 (43%) patients had had one or more open procedure(s) before total replacement, 177 (44%) had not had open operation, and 52 (13%) had no data entered. The 3 primary systems used were the TMJ Concepts System (Ventura, USA), the Biomet System (Biomet/Lorenz Microfixation, Jacksonville, USA), and the Christensen System (TMJ Implants, Golden, USA). The median (IQR) duration of inpatient stay was 3 (2–4) days (mean 3). Follow-up data will be collected to assess patient recorded outcome measures (PROM) and objective measurements of total joint replacements in the UK from 1994 onwards.     

Predictive risk factors for persistent pain following total prosthetic temporomandibular joint replacement

The aim of this study was to determine the rate of persistent pain following total TMJ replacement and to identify potential predictive risk factors. A retrospective review of case notes treated by a single surgeon in a tertiary unit was performed. For each patient a number of variables were recorded including visual analogue pain scores (0 to 10) and opioid usage pre surgery and at 12 months or last follow up beyond 12 months. Persistent pain scores of 5 to 7 were regarded as moderate and 8 to 10 as severe. The mean pain score at last follow-up was significantly lower than preoperatively (2.1 vs. 6.3, p < 0.001) with a mean follow-up time of 40.1 months (range 12–44). 16.4% of the patients reported moderate to severe pain and 13.7% were still on regular opioids at the last follow-up. Therefore 15 patients (20.5%) suffered from chronic postoperative pain after TMJ replacement surgery. Patients reporting severe preoperative pain scores (p = 0.04), regular opioid use (p = 0.001) or multiple previous open TMJ surgeries (p = 0.03) were more likely to suffer from chronic persistent pain and these should be regarded as predictive risk factors. The identification of these factors allows for better risk stratification of patients, informed consent and the agreement of expected outcomes. Patients with true articular disease and a single failed surgery should be considered for early total TMJ replacement to minimise multifactorial persistent pain.     

Retrospective comparison of autogenous cosotochondral graft and coronoid process graft in the management of unilateral ankylosis of the temporomandibular joint in adults

We retrospectively compared the clinical outcomes of autogenous coronoid process grafts (n = 32) and costochondral grafts (n = 28) in condylar reconstruction for the treatment of unilateral ankylosis of the temporomandibular joint (TMJ) in adults. Preoperative and postoperative assessments included diet scores, cone-beam computed tomography (CT), maximal interincisal opening, lateral excursion, and mandibular deviation on opening the mouth. There were no significant differences between the 2 groups in the measurements before and after the operation with respect to incisal opening, lateral excursion, mandibular deviation, diet scores, or recurrence rate, but in both the postoperative incisal opening, lateral excursion, and diet scores had improved significantly compared with preoperatively. After costochondral graft 3 patients developed intraoperative plural tears, and 6 had temporary pain at the donor site. The frontal branch of the facial nerve was temporarily affected in 5 patients after costochondral graft and 3 after coronoid process grafts, all of which recovered in 3–6 months. There was no recurrence after coronoid process grafting, and one after costochondral grafting. The clinical outcomes in both groups were satisfactory and comparable. Autogenous coronoid process grafting may therefore be a good alternative for condylar reconstruction in patients with ankylosis of the TMJ.     

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.     

Is the risk of chronic pain after total temporomandibular joint replacement independent of its indications? A prospective cohort study

Chronic pain is a possible long-term complication after alloplastic temporomandibular joint reconstruction (TMJR). This study was developed to evaluate various subjective and objective measurements to determine the presence and degree of TMJ pain in patients treated with TMJR regardless of the indication for the operation. A prospective, single-centre study was performed. Data on 36 patients (56 TMJR) were collected preoperatively and at follow up two to three years postoperatively. The primary outcome variable was subjective TMJ pain (none/mild, moderate/severe) at follow up. The predictor variables were objective pressure pain thresholds (PPTs) at the ipsilateral joint(s) and muscle(s), functional parameters (incisal range of motion, maximum voluntary clenching), subjective oral health-related quality of life (OHRQoL), and demographic and surgical variables. The number of patients with moderate/severe pain decreased from 17 preoperatively to 10 at follow up. Self-reported TMJ pain was significantly reduced in the entire group (p = 0.001). Patients with moderate/severe pain at follow up were more restricted in their OHRQoL but did not differ in PPT and functional parameters from the no/mild pain group. Moderate/severe TMJ pain at follow up was associated with unilateral TMJR and more preoperative pain. This study provides preliminary evidence that despite good pain reduction in most patients, persistent pain after TMJR is common and, in rare cases, may even worsen regardless of the original diagnosis. At follow up there was a close relation between OHRQoL and TMJ pain. TMJ pain after TMJR cannot be confirmed by objective measurement methods (PPTs and functional parameters).     

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.     

关节源性颞下颌关节痛患者关节内窥镜检查结果

目的　探讨颞下颌关节紊乱病伴关节源性关节痛患者的关节腔内状况。方法　对20例颞下颌关节紊乱 病伴关节源性关节痛患者(按Truelove等关于颞下颌关节紊乱病的诊断分类标准确定)的23侧颞下颌关节先后进 行X线片检查和关节内窥镜检查。结果　关节镜下23侧关节内至少存在1种不同程度的腔内病变,最多有6种病 变共存。结论　局限于颞下颌关节的关节痛可能与关节腔内病理改变有关,可能是炎症(滑膜炎)引起疼痛。     

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.     

颞下颌关节疼痛冲洗疗效及关节液中TNFα含量变化

目的　探讨关节上腔冲洗术对颞下颌关节疼痛的影响及疼痛变化与关节液中TNFα含量的关系。方法　在关节上腔冲洗治疗前 ,抽取 4 0名关节源性疼痛TMD患者 4 6侧关节液标本 ,4名患者 6侧关节液标本因血污染被舍弃 ,记录治疗前关节疼痛的VAS值 ;治疗一周后 4 0名患者复诊 36人 ,再次抽取关节液标本 38例 ,并记录VAS值 ;采用双抗体夹心酶联免疫法 (ABC ELASA)检测治疗前后关节液中TNFα的水平。结果　治疗前患者关节液中TNFα检出率为 6 7 5 % (2 7/40 ) ,含量为 (6 4 7 5 6± 4 6 8 75 )pg/mgprotein ,VAS值 :(46 .0 3± 19.6 9)mm ;治疗后患者关节液中TNFα均未检出 ,VAS值 :(17 75± 7 33)mm ,与治疗前相比显著降低。结论　关节疼痛与关节液内TNFα水平密切相关 ;关节上腔冲洗术对缓解患者关节疼痛疗效肯定。     

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.     

Prospective outcome assessment of the therapeutic benefits of arthroscopy and arthrocentesis of the temporomandibular joint

Patients who fail to respond to routine conservative measures to treat pain, restriction, and locking in the temporomandibular joint (TMJ) may have therapeutic arthroscopy or arthrocentesis, both of which are associated with symptomatic improvement in 86% of patients. To our knowledge there are no current data on improvements in mouth opening and lateral deviations after these procedures. This prospective audit includes 244 patients treated between 2005 and 2010 from one surgeon's practice, who were followed up at least once at 6 weeks after arthroscopy or arthrocentesis. They had various conditions but all had tender joints. Measurements of interincisal opening, left and right lateral excursions, and protrusion were taken before and during operation with callipers (mm). Opening and pain scores were also recorded on 10 cm analogue scales before operation and at 6 weeks. Pain scores improved with intervention from a mean score of 37.1–16.1 (range 0–100). The improvement in mouth opening ranged from 0 to 78% (as some patients had locking or pain with normal opening before operation), and 86% had improved enough to be discharged at 6 weeks. Temporary forehead weakness in two patients resolved within the timescale of the study. The study shows improvements in mouth opening, and confirms that pain scores can be improved after arthroscopy or arthrocentesis when conservative approaches have failed. In the hands of a skilled practitioner, arthroscopy can be a useful diagnostic and therapeutic adjunct, which can be used repeatedly with low morbidity.     

Questionable effect of lavage for treatment of painful jaw movements at disc displacement without reduction: a 3‐year randomised controlled follow‐up

The present randomised controlled study compared the 3‐year outcome of local anaesthetics with anaesthetics and lavage in patients suffering from painful temporomandibular joint (TMJ) locking. The study included 45 patients referred for treatment of temporomandibular disorders (TMD) to the Department of Orofacial Pain and Jaw Function, Faculty of Odontology, Malmö University, Malmö, Sweden. All patients received a history questionnaire and clinical examination according to the Research Diagnostic Criteria for TMD, panoramic radiographs and magnetic resonance imaging at baseline. Twenty‐five patients were randomised to anaesthetics alone and 20 patients to anaesthetics and lavage. Three years after treatment, we sent the 37 patients who were available for follow‐up a questionnaire that evaluated pain intensity, physical and emotional functioning, and global improvement. Thirty‐four patients responded. The primary outcome was defined as ≥ 30% pain relief. In an intention‐to‐treat analysis, 28 of 45 patients (62%) reported ≥ 30% pain relief at the follow‐up. At 3 years, improvement in pain relief, physical functioning, emotional functioning and global improvement differed non‐significantly between local anaesthetics and anaesthetics and lavage. Compared with baseline, significant improvements (P < 0·05) in pain intensity, physical functioning, emotional functioning and global changes had occurred in both groups after 3 years. Because outcome measurements in the local anaesthetics and lavage and the local anaesthetics groups differed non‐significantly 3 years after treatment of painful TMJ disc displacement without reduction, use of lavage (50 mL saline) has an equivalent effect as local anaesthetics.     

颞下颌关节区疼痛患者全身伴随症状的初步研究

目的调查与颞下颌关节(TMJ)区疼痛伴随出现的全身症状的发生情况。方法选取TMJ区疼痛患者51例及TMJ区无疼痛的对照者31人,调查其TMJ症状及全身伴随症状。治疗半年后对TMJ区疼痛患者进行复查。应用一元线性回归和卡方检验对TMJ区疼痛与全身症状的相关性及伴随性进行统计学分析。结果与TMJ疼痛有相关性的症状包括头痛、背痛、手麻抖、肩颈痛、失眠、目眩、听力下降、眼痛和易疲劳(P<0.05)。患者组部分症状(头痛、肩颈痛、眼痛、耳鸣、目眩、眼下抽搐、易疲劳、手脚发凉、易烦躁、注意力不集中和消化不良)发生的比例显著高于对照组(P<0.01)。半年后与TMJ区疼痛伴随改善的症状有头痛、肩颈痛和易疲劳(P<0.05)。结论头部、肩颈等口腔颌面邻近器官的症状是TMJ区疼痛的主要伴随症状,与TMJ症状的改善有伴随关系。     

Delayed temporomandibular joint pain and dysfunction induced by whiplash trauma: a controlled prospective study

BACKGROUND: The Quebec Task Force on Whiplash-Associated Disorders urged for controlled, prognostic studies of symptoms after whiplash trauma. The authors conducted a study that met the design requirements to enhance knowledge about short-term and long-term temporomandibular joint (TMJ) pain, dysfunction or both induced by whiplash trauma. METHODS: The authors studied 60 consecutive patients who had neck symptoms after whiplash trauma and were seen at a hospital emergency department. They followed up 59 subjects one full year later. At the inceptive examination and at follow-up, each subject completed a self-administered questionnaire, followed by a comprehensive interview. Fifty-three frequency-matched control subjects followed the same protocol concurrently. RESULTS: The incidence of new symptoms of TMJ pain, dysfunction or both between the inceptive examination and follow-up was five times higher in subjects (34 percent) than in control subjects (7 percent). The frequency of TMJ pain increased significantly in female subjects, as did the frequency of TMJ symptoms that were reported to be the main complaint. At the follow-up, 20 percent of all subjects reported that TMJ symptoms were their main complaint. CONCLUSIONS: Our results suggest that one in three people who are exposed to whiplash trauma is at risk of developing delayed TMJ symptoms that may require clinical management. CLINICAL IMPLICATIONS: Awareness of a significant risk for delayed onset of TMJ symptoms after whiplash trauma is crucial for making adequate diagnoses, prognoses and medicolegal decisions.     

Review article: oral surgery and TMJ-related papers published in BJOMS in 2008 and 2009

This review summarises the 81 papers relating to oral surgery and to the temporomandibular joint (TMJ) published in the British Journal of Oral and Maxillofacial Surgery (BJOMS) January 2008–December 2009. They include full length articles on distraction osteogenesis, imaging, extraction techniques, implants, and the management of facial pain and disorders of the TMJ including joint replacement. Many short communications were also published, but an editorial decision was taken in August 2009 to publish most of these in future in the online journal only. As BJOMS encompasses the whole remit of the specialty, and other specialist journals on oral surgery are available, it was encouraging to see that authors still choose submit their work to our journal.     

Clinical diagnosis of temporomandibular joint arthritis

Evidence‐based clinical diagnostic criteria for temporomandibular joint (TMJ) arthritis are not available. To establish (i) criteria for clinical diagnosis of TMJ arthritis and (ii) clinical variables useful to determine inflammatory activity in TMJ arthritis using synovial fluid levels of inflammatory mediators as the reference standard. A calibrated examiner assessed TMJ pain, function, noise and occlusal changes in 219 TMJs (141 patients, 15 healthy individuals). TMJ synovial fluid samples were obtained with a push–pull technique using the hydroxycobalamin method and analysed for TNF, TNFsRII, IL‐1β, IL‐1ra, IL‐1sRII, IL‐6 and serotonin. If any inflammatory mediator concentration exceeded normal, the TMJ was considered as arthritic. In the patient group, 71% of the joints were arthritic. Of those, 93% were painful. About 66% of the non‐arthritic TMJs were painful to some degree. Intensity of TMJ resting pain and TMJ maximum opening pain, number of jaw movements causing TMJ pain and laterotrusive movement to the contralateral side significantly explained presence of arthritis (AUC 0.72, P < .001). Based on these findings, criteria for possible, probable and definite TMJ arthritis were determined. Arthritic TMJs with high inflammatory activity showed higher pain intensity on maximum mouth opening (P < .001) and higher number of painful mandibular movements (P = .004) than TMJs with low inflammatory activity. The combination TMJ pain on maximum mouth opening and Contralateral laterotrusion <8 mm appears to have diagnostic value for TMJ arthritis. Among arthritic TMJs, higher TMJ pain intensity on maximum mouth opening and number of mandibular movements causing TMJ pain indicates higher inflammatory activity.     

Deficient cytokine control modulates temporomandibular joint pain in rheumatoid arthritis

The aim was to investigate how endogenous cytokine control of tumor necrosis factor (TNF) influences temporomandibular joint (TMJ) pain in relation to the role of anti‐citrullinated peptide antibodies (ACPA) in patients with rheumatoid arthritis (RA). Twenty‐six consecutive patients with TMJ RA were included. Temporomandibular joint pain intensity was assessed at rest, on maximum mouth opening, on chewing, and on palpation. Mandibular movement capacity and degree of anterior open bite (a clinical sign of structural destruction of TMJ tissues) were also assessed. Systemic inflammatory activity was assessed using the Disease Activity Score in 28 joints (DAS28) for rheumatoid arthritis. Samples of TMJ synovial fluid and blood were obtained and analyzed for TNF, its soluble receptor, soluble TNF receptor II (TNFsRII), and ACPA. A high concentration of TNF in relation to the concentration of TNFsRII in TMJ synovial fluid was associated with TMJ pain on posterior palpation on maximum mouth opening. The ACPA concentration correlated significantly to the TNF concentration, but not to the TNFsRII concentration, indicating that increased inflammatory activity is mainly caused by an insufficient increase in anti‐inflammatory mediators. This study indicates that TMJ pain on palpation in patients with RA is related to a deficiency in local cytokine control that contributes to increased inflammatory activity, including sensitization to mechanical stimuli over the TMJ.     

Single stage treatment of ankylosis of the temporomandibular joint using patient-specific total joint replacement and virtual surgical planning

Ankylosis of the temporomandibular joint (TMJ) is a debilitating condition that can result in pain, trismus, and a poor quality of life. It can be caused by injury, infection, and rheumatoid disease. Current management includes gap arthroplasty, interpositional arthroplasty, and reconstruction. Traditionally, joints are reconstructed using stock implants, or the procedure is done in two stages with an additional computed tomography (CT) scan between the resective and reconstructive procedures and use of stereolithographic models to aid the design of the definitive prostheses. We describe a technique for the resection of ankylosis and reconstruction of the joint in a single operation using virtually designed custom-made implants. Five patients with ankylosis of the TMJ had a single stage operation with reconstruction between 2010 and 2012. All had preoperative high-resolution CT with contrast angiography. During an international web-based teleconference between the surgeon and the engineer a virtual resection of the ankylosis was done using the reconstructed CT images. The bespoke cutting guides and implants were designed virtually at the same time and were then manufactured precisely using computer-aided design and manufacture (CAD-CAM) over 6 weeks. After release of the ankylosis and reconstruction, the patients underwent an exercise regimen to improve mouth opening. Follow-up was for a minimum of 6 months. Four patients had one operation, and one patient had two. Median/Mean maximum incisal opening increased from 0.6 mm before operation to 25 mm afterwards (range 23–27), and there was minimal surgical morbidity. This new method effectively treats ankylosis of the TMJ in a single stage procedure. Fewer operations and hospital stays, and the maintenance of overall clinical outcome are obvious advantages.