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.     

Osteochondroma of the mandibular condyle: Indications for different surgical methods: A case series of 7 patients

The aim of this study was to evaluate and discuss the long-term outcomes of patients with condylar osteochondroma managed through 3 different surgical techniques.Seven patients with condylar osteochondroma treated in the author's department from May 2012 to January 2019 were included in this retrospective study. Clinical evaluations (visual analogue scale for TMJ pain, jaw function, symmetry, and quality of life), maximum interincisal opening (MIO) and radiological findings were collected pre- and postoperatively. Other parameters assessed included tumour size and location; complications and follow-up. Radical condylectomy with immediate total joint alloplastic reconstruction was performed in 4 patients, local excision in 2 patients and low condylectomy with concomitant orthognathic surgery in 1 patient. During an average follow-up period of 40,8 months no clinical or radiographic signs of recurrence were found. Average MIO increased from 25,5mm to 39,5mm at the longest follow up, and all clinical evaluations were greatly improved.In conclusion, the described surgical techniques appear valuable in the treatment of condylar osteochondroma. Local excision is indicated in tumor involving less than half the surface of the condylar head; radical condylectomy with immediate alloplastic total joint reconstruction is indicated in gigantic lesion compromising the anatomical components and function of the joint. Orthognathic surgery procedures should be combined with tumor resection when correction of associated dentofacial deformities is indicated.     

The effect of arthroscopic disc repositioning on facial growth in juvenile patients with unilateral anterior disc displacement

ObjectiveTo investigate the effect of arthroscopic disc repositioning on condylar development and mandibular asymmetry in juvenile patients with unilateral temporomandibular joint (TMJ) anterior disc displacement (ADD).Patients and methodsA retrospective cohort study was conducted on unilateral juvenile anterior disc displacement (UJADD) patients of 10–20 years of age treated in Shanghai Ninth People's Hospital from 2010 to 2017. The primary predictor was TMJ arthroscopic disc repositioning surgery, according to which patients were divided into a surgery group and a control group. Initial and re-examined (with at least 6-month interval) magnetic resonance imaging (MRI) and posteroanterior cephalometric radiographs (PA) were collected. The condylar heights on both sides of the TMJ were measured by MRI and the difference between them was calculated. Menton (Me) deviation was measured based on PA. Changes in condylar height difference and Me deviation were compared between the two groups.ResultsA total of 108 UJADD patients were collected in this study, including 55 patients in the surgery group and 53 patients in the control group. There were no significant differences in age, sex and follow-up time between the two groups. The condylar height difference was (−0.61 ± 2.02) mm in surgery group and (1.68 ± 1.73) mm in control group (P < 0.0001); while the Me deviation was (−1.00 ± 1.15) mm in surgery group and (1.81 ± 1.96) mm in control group (P < 0.0001), indicating that TMJ arthroscopic disc repositioning surgery could significantly improve condylar height difference and Me deviation.ConclusionsUJADD should be treated as early as possible, especially in juvenile patients, in order to improve condylar development and avoid jaw deformities.     

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.     

Temporomandibular joint function and its effect on centric relation

An occlusal analysis in relation to the TMJ radiographs will reveal factors that should be added to the purely clinical definition of centric relation. It has been previously established that bilateral asymmetric TMJ spaces and condylar retrusion or protrusion are most often associated with disc derangement and/or palpable muscle spasm.⁴ Conversely, bilateral TMJ space symmetry and condylar concentricity (condyle centered in the superior portion of the glenoid fossa) are associated with joint and muscle health. All TMJ radiographs are obtained with the teeth in the acquired centric occlusion.Centric relation is considered functional when the magnitude and direction of the centric relation deflective slide to the acquired centric occlusion correlate with the condylar displacement observed on the TMJ radiographs. For example, if the patient has a 2 mm. deflective slide straight forward, the centric relation is considered functional when the TMJ radiographs reveal equal condylar protrusion proportional to the mandibular deflection. In the judgment of the dentist, the occlusal correction of the deflective contacts will result in bilateral condylar concentricity. Conversely, centric relation is dysfunctional when the magnitude and direction of the centric relation deflective slide to the acquired centric occlusiondo not correlate with condylar position in the TMJ radiographs. When no deflective slide is present, both condyles should be concentrically located in each fossa with bilateral symmetrical joint spaces in order for centric relation to be considered functional. Dysfunctional centric, relation is often associated with disc derangement and/or palpable muscle spasm. When the centric relation is functional, the most retruded jaw position should be used. If the centric relation is dysfunctional, a therapeutic or treatment centric occlusion must be established by the dentist, utilizing the TMJ radiographs as a guide. In this situation, the most retruded position would be harmful to the patient.     

Management of condylar resorption before or after orthognathic surgery: A systematic review

BackgroundOrthognathic surgery is a surgical procedure for the correction of maxillofacial deformities. The existence of condylar resorption before orthognathic surgery affects the selection of surgery time and plan. Besides, condylar resorption after orthognathic surgery often leads to the recurrence of deformities and affects the long-term effect of surgery. The purpose of this study was to perform a systematic review of the management of condylar resorption before or after orthognathic surgery.MethodsA systematic review of the scientific literature listed on PubMed, Embase, and Cochrane Controlled Trials Register was performed, up to October 2018. The outcome of the search was reviewed with a chart.ResultsTen articles with 180 patients were included in this study based on inclusion and exclusion criteria. We compared these studies to examine the effectiveness of the management of condylar resorption.ConclusionThe occurrence of condylar resorption can be influenced by complex factors. The management of condylar resorption before or after orthognathic surgery should base on the severity of condylar resorption. As the eligible studies with small sample sizes, heterogeneity in management method and outcome, high-quality clinical study concerning condylar resorption treatment is needed.     

Total Temporomandibular Joint Replacement and Simultaneous Orthognathic Surgery Using Computer-Assisted Surgery

BackgroundDisorders of the temporomandibular joint (TMJ) are frequent and are usually associated with other disorders of the facial skeleton. Surgery might be needed to correct TMJ anatomy and function and, in cases where pathologies coexist, a two-stage corrective surgery might be needed. However, the current fashion of single-stage procedures is feasible with the aid of new technologies such as computer-assisted surgery (CAS). This is a step forward toward performing complex procedures such as a TMJ replacement with simultaneous orthognathic surgery. CAS allows designing patient-fitted prosthesis and more predictable and accurate surgeries. Moreover, intraoperative development can be controlled in real time with intraoperative navigation, and postoperative results can be measured and compared afterwards.AimsThe primary purpose of this article is to present the protocol used in our institution for orthognathic surgery associated with unilateral and bilateral TMJ replacement with patient-fitted prostheses guided with CAS.Materials and methodsWe present two cases to illustrate our protocol and its results.ResultsIn the first case, the difference in millimeters between planning and surgical outcomes was 1.72 mm for the glenoid component and 2.16 mm for the condylar prosthesis; for the second case, differences in the right side were 2.59 mm for the glenoid component and 2.06 mm for the ramus, and in the left side, due to the anatomy the difference was a little greater, without clinical significanceConclusionCombined surgery of the midface and mandible with total TMJ replacement is feasible and beneficial for the patient. CAS facilitates the planning and design of custom-fit prosthesis and execution of these procedures.     

Conservative management of unilateral condylar hyperplasia

Objective

The purpose of this study was to eliminate orthodontic treatment in mild to moderate cases of condylar hyperplasia in its early stages by condylectomy.

Patients and methods

A total of five patients (two females and three males) aged between 17 and 40 years were treated with unilateral condylectomy of the involved side without orthodontic treatment. All patients underwent standardized clinical and radiological examination at initial consultation, before surgery, immediately after surgery, and follow-up. Objective and subjective evaluation of temporomandibular joint (TMJ) included maximal incisal opening, lateral excursions, correction of facial asymmetry, occlusal harmony, TMJ pain, and jaw function. Results were recorded at 5-year follow-up.

Results

In all our cases, we achieved good mouth opening and near to normal occlusion. Good facial aesthetics was obtained after 3 months postoperative follow-up without secondary orthodontic treatment.

Conclusion

Thus, we conclude that treatment of mild to moderate cases of unilateral condylar hyperplasia during the inactive phase can be treated with condylectomy without orthodontic treatment, and it significantly improves long-term surgical outcomes.     

Analysis of temporomandibular joint function after orthognathic surgery using condylar path tracings

Condylar path tracings provide quantitative and qualitative data regarding the functional status of the temporomandibular joint. This study was designed to identify the functional status of the TMJ by means of condylar path tracings before treatment and to monitor the response of the TMJ to orthognathic surgery. Baseline data for condylar tracings using a sagittal recording device were established in relation to normal limits for opening, protrusive, and medial excursions of the mandible. In 54 patients 108 joints were studied before and up to 1 year after orthognathic surgery. Internal derangements were identified with condylar tracings before treatment in 72% of all joints studied. Also, condylar tracings identified internal derangements that were not found on clinical examination in 11 of 39 patients. Functional adaptation of the TMJ was found to be more favorable for mandibular reduction and maxillary impaction than for mandibular advancement or combined upper and lower jaw procedures. Condylar path tracings were shown to represent a noninvasive technique to identify and monitor the functional status of the TMJ in response to surgical orthodontics.     

Correlation between computer-assisted measurements of mandibular opening and closing movements and clinical symptoms of temporomandibular dysfunction

197 subjects (74 male, 123 female) were evaluated in this Study of Health in Pomerania associated project (SHIP 0). Both a clinical functional status and an instrumental analysis of functional movement patterns of the mandible were performed in each subject, in the latter case using an ultrasonic jaw motion analysis system. Correlations between instrumental movement pattern features and clinical signs and symptoms of temporomandibular joint dysfunction (TMD), such as joint sounds, palpable impairment of jaw movement, and the termination of opening movement at the incisal point, were particularly significant (p <0.005). Correlations for TMJ crepitation sounds and joint pain on palpitation from the lateral or posterior aspect tended to be less significant (p < 0.1). No association was found for pain on jaw movement or muscle tenderness in response to pressure. A multivariate logistic regression model showed a significant correlation between Helkimo Clinical Dysfunction grades 2 and 3 and the following independent variables: frequent headaches (odds ratio [OR] 4.12; p = 0.032), frequent popping sounds in the jaw joints (OR 5.79; p = 0.012), incisal paths showing conspicuous signs of dysfunction such as deviation or deflection (OR 4.35; p = 0.05), and condylar path anomalies such as jumpy, straight/inverse or irregular tracings (OR 28.59; p = 0.006). Instrumental functional analysis of condylar path tracings allows one to draw statistically valid conclusions about the occurrence of TMD symptoms. It can be helpful to perform condylar path analysis when performing risk assessments for temporomandibular dysfunction in certain situations, particularly before prosthetic rehabilitation.     

Protocol for fully digital and customized management of concomitant temporomandibular joint replacement and orthognathic surgery

End-stage temporomandibular joint (TMJ) disease is caused by a multitude of pathological processes that impair TMJ anatomy and function. In many cases, end-stage TMJ disease and dentofacial skeletal deformities coexist. The optimal treatment for such conditions is total alloplastic joint replacement and orthognathic surgery. Such procedures have historically been conducted in two separate stages. Furthermore, while technological improvements resulting from the widespread adoption of virtual reality initially led to significant improvements in the field of orthognathic planning, the adoption of virtual design techniques to optimize TMJ reconstruction was a later achievement. Therefore, planning for TMJ replacement and orthognathic surgery did not develop in parallel, leading to various combinations of planning for orthognathic surgery and TMJ replacement with the aim of performing both procedures simultaneously in one stage. Nowadays, improvements in virtual planning and three-dimensional printing have allowed these procedures to be conducted in the same surgical step based on fully digital planning and entirely customized surgery. This paper introduces a fully digital protocol for the treatment of end-stage TMJ disease and associated acquired dentofacial deformities, in which all surgical steps are customized and the whole surgery is performed in succession using automated procedures, thanks to the combined use of virtual surgical planning, surgical guides, custom-designed TMJ prostheses, and patient-fitted osteosynthesis devices.     

Functional changes in the temporomandibular joint mechanoreceptors associated with experimentally induced condylar resorption in rats

ObjectivesTo evaluate the influence of experimentally induced progressive condylar resorption (PCR) on temporomandibular joint (TMJ) mechanoreception.Materials and MethodsTwenty 13-week-old male albino Wistar rats were divided equally into control and PCR groups. A compressive force was loaded on the left TMJ of PCR group rats to induce condylar resorption. Single-unit activities of TMJ mechanoreceptors were also induced through passive jaw movement. Recording was performed for the left Gasserian ganglion at 3 days and 1 week after the establishment of PCR group. The effects of PCR on TMJ units were assessed by measuring the firing threshold, maximum instantaneous firing frequency, and average firing frequency.ResultsCompared with the control group, there were no significant differences in the firing threshold of the PCR group after 3 days. The thresholds were significantly higher 1 week after compressive force loading on the condyle. The maximum instantaneous firing frequencies and the average firing frequencies showed no significant differences after 3 days. However, these were significantly lower 1 week after compressive force loading.ConclusionsThe findings suggest that compressive force loading on the condyle may influence the function of TMJ mechanoreceptors.     

Dislocated pediatric condyle fractures — should conservative treatment always be the rule?

AimThe results of conservative treatment of pediatric dislocated (luxative) condyle fractures are usually unsatisfactory. We therefore decided to present and analyze the results of surgical treatment of these fractures.Patients and methodsChildren with dislocated condyle fractures were treated surgically, with the approach always including opening the temporomandibular joint (TMJ).Postoperatively, patients had regular controls at 1 week, 1 month, 3 months, and 6 months, and then yearly thereafter. At each control visit, facial symmetry, maximal mouth opening, lateral chin deflection upon mouth opening, TMJ pain, condylar motion, palpable pathological phenomena, and occlusion were all checked clinically. Healing of the fracture site, condylar height, shape and growth were assessed on panoramic radiographs. Possible surgical complications were noted: temporary facial nerve palsy, development of a parotid salivary fistula, disturbance of auricle sensibility due to injury of the greater auricular nerve, miniplate fracture, intraoperative bleeding, postoperative hematoma formation, infection, and reoperation due to fragment malposition. The postoperative scars were assessed.ResultsOver the 6-year period from 2013 until the end of 2018, seven children with dislocated condyle fractures were treated surgically. Six of the seven patients were treated with open reduction and internal fixation, and the plates and screws were deliberately not removed. The age range of the patients was 1.5–14 years (average 6.1 years). Follow-up time was 15 months to 6 years. No growth disturbances or facial asymmetries were seen over this follow-up period, with all patients maintaining proper occlusion, joint movement, and mouth opening. Fracture healing and condylar growth were clearly demonstrated with serial control panoramic radiographs. Condylar height asymmetry was observed only in one case, in which only reduction of the fracture with no fixation was performed. In all other cases, condylar height was symmetric. None of the children presented with chewing difficulties or joint pain. No intra- or postoperative surgical complications were noted. The preauricular scars were all very discreet, and none of the patients or parents complained about them.ConclusionSurgical treatment in cases of dislocated (luxative) condylar fractures in children and small infants restores anatomy and thus securely enables further symmetric growth of the condyles, mandible, and the entire facial skeleton.     

The relationship between clinical and MRI findings in patients with unilateral temporomandibular joint pain

BACKGROUND: With the advent of magnetic resonance imaging, or MRI, clinicians and researchers have sophisticated techniques by which to assess the anatomy of the temporomandibular joint, or TMJ. Imaging is indicated when the results will affect the patient's care beyond that which can be gained from a complete clinical assessment. One of the primary indications for treatment of patients with temporomandibular disorders, or TMDs, is jaw pain, including TMJ pain. Therefore, it is necessary to assess whether MRI-depicted TMJ findings are associated with TMJ pain. This study assessed the relationship between TMJ pain and clinical and MRI findings. METHODS: Subjects consisted of 85 patients with unilateral jaw pain in the area of the TMJ. The contralateral, nonpainful TMJ served as the matched control. All patients underwent a complete stomatognathic examination that included palpation of both TMJs. No care was given and no anti-inflammatory medications were prescribed until bilateral MRIs were obtained within one week. RESULTS: The authors found significant relationships between the side of reported jaw pain and the patient's report that palpation of the TMJ was painful and between the side of reported pain and the presence of MRI-detected effusions. The authors found no relationship between the side of reported pain and the presence of a disk displacement, or DD, or between the presence of effusions and DD on either side of the jaw. CONCLUSION: Although MRI-depicted effusions of the TMJ were associated with reports of TMJ pain, there was a high level of false-positive and false-negative findings. The results indicate that palpation of the TMJ is more accurate than MRI-depicted effusions in identifying the TMJ as the source of pain for patients with unilateral jaw pain. CLINICAL IMPLICATIONS: The results of this study suggest that palpation of the TMJ is superior to MRI in identifying the joint as the source of pain. Therefore, the most cost-effective and valid test to determine if the TMJ is a source of jaw pain is a complete clinical assessment.     

正颌外科患者术前的颞下颌关节功能评价

目的　了解正颌患者颞下颌关节 (TMJ)的功能状况 ,探讨牙颌面畸形与颞下颌关节之间的关系。方法正颌外科发育性牙颌面畸形 12 3例患者 ,平均年龄 2 3.8岁 ,男性 45例 ,女性 78例。颞下颌关节功能的检查方法采取问诊与检查相结合 ,颞下颌关节功能记分采取 Helkim o指数记分方法。结果　 (1)牙颌面畸形患者颞下颌关节紊乱病 (TMD)各种症状发生率明显高于对照组人群。(2 )男性患者弹响症状发生率高于女性 ,而女性患者关节触诊疼发生率高。(3) 16～ 2 5岁患者张口受限发生率较高 ,但大多数为轻度张口受限。(4 )不对称畸形 (下颌前突偏斜 )者弹响症状发生率较高 ,而且相应偏斜侧最大侧向移动度小。而下颌后缩组开口度明显小于其他各组 ,提示其关节功能受损较严重。结论　牙颌面畸形患者的颞下颌关节功能不同于正常人 ,部分下颌偏斜与后缩患者关节功能受损     

Tumor necrosis factor mediates temporomandibular joint bone tissue resorption in rheumatoid arthritis

Abstract

Objective. To investigate if TNF, IL-1 or their endogenous controls, in relation to ACPA, are associated with radiological signs of ongoing temporomandibular joint (TMJ) bone tissue resorption and disc displacement in RA patients. Methods. Twenty-two consecutive outpatients with TMJ of RA were included. Systemic inflammatory activity was assessed by DAS28. The number of painful regions in the body and ESR, CRP, RF and ACPA were analyzed. TMJ synovial fluid and blood samples were obtained and analyzed for TNF, TNFsRII, IL-1ra, IL-1sRII and ACPA. The ratios between the mediators and their endogenous control receptors were used in the statistical analysis. Magnetic resonance imaging was performed in closed- and open-mouth positions and evaluated regarding disc position and presence of condylar and temporal erosions of the TMJ. Results. A high TNF level in relation to TNFsRII in TMJ synovial fluid correlated to the degree of TMJ condylar erosion. A high IL-1ra level in relation to TNF in TMJ synovial fluid was also correlated to the degree of TMJ condylar erosion. The total degree of TMJ condylar erosion was correlated with the number of painful regions. Conclusion. This study indicates that TNF in TMJ synovial fluid mediates TMJ cartilage and bone tissue resorption in RA. The study also suggests that the degree of endogenous cytokine control is of importance for development of bone tissue destruction.     

Efficacy of high condylectomy for management of condylar hyperplasia.

The purpose of this study was to compare the treatment outcome and long-term stability of 2 groups of young adult patients diagnosed with active condylar hyperplasia and treated with 2 different surgical methods. Thirty-seven patients (19 females and 18 males) met the criteria for inclusion in the study. Group 1 (n = 12; average age at surgery, 17.5 years) was treated with orthognathic surgery only, while group 2 (n = 25; average age at surgery, 16.7 years) had high condylectomy, articular disc repositioning, and orthognathic surgery. All patients underwent standardized clinical and radiographic examination at initial consultation, immediately before surgery, immediately after surgery, and at longest follow-up. Objective evaluation of temporomandibular joint (TMJ) function included maximum incisal opening and lateral excursions. Subjective evaluations were performed in group 2 for TMJ pain, jaw function, and diet. Lateral cephalometric radiographs were evaluated for presurgical and postsurgical mandibular growth. There were no statistically significant differences (P >.05) between the 2 groups for maximal incisal opening, lateral excursions, or subjective jaw function before surgery. Presurgical growth differed significantly (P <.05), with group 2 showing more active growth. At the long-term follow-up, no differences were found in lateral excursions or subjective jaw function. There was a statistically significant difference in maximum incisal opening (P <.01), with a greater increase in group 2, as well as a statistically significant difference (P <.05) in cephalometric stability, with group 2 being much more stable at long-term follow-up. All patients in group 1 grew back into skeletal and occlusal Class III relationships and required secondary intervention. Only 1 patient in group 2 required secondary surgery, involving maxillary surgery to correct postsurgical transverse maxillary relapse; the mandible was stable at long-term follow-up. The results of this study showed that patients with active condylar hyperplasia treated with high condylectomy, articular disc repositioning, and orthognathic surgery have stable, predictable outcomes compared with those treated with orthognathic surgery alone.     

The Mitek mini anchor for TMJ disc repositioning: surgical technique and results

This study evaluated our treatment outcomes in 105 patients (188 discs) using the Mitek mini anchor for temporomandibular joint (TMJ) articular disc repositioning surgery, with 88 patients having simultaneous orthognathic surgery. Criteria for inclusion into the study were: (1) Presurgical TMJ disc displacement with salvageable disc; (2) No prior TMJ surgery; (3) TMJ disc repositioning with the Mitek mini anchor; (4) Absence of connective tissue/autoimmune disease; (5) Absence of postsurgical trauma; and (6) Minimum of 12 months postsurgery follow up. Presurgery (T1), immediately postsurgery (T2), and longest follow up (LFU) clinical and radiographic evaluations were performed. The mean age of the patients was 32.6 years (range 14-57 years), and mean follow-up time was 46.2 months (range 14-84 months). Radiographic evaluation at LFU demonstrated no significant condylar resorption or positional changes of the anchors. At LFU, there was a statistically significant reduction in: TMJ pain, facial pain, headaches, TMJ noises and disability, and improvement in jaw function and diet. Maximum incisal opening improved slightly and lateral excursive movements decreased slightly. The Mitek mini anchor provides a predictable method for stabilizing the TMJ articular disc to the condyle and a high success rate in decreasing TMJ dysfunction and pain in patients with no previous TMJ surgery.     

Treatment guidelines for temporomandibular joint ankylosis with secondary dentofacial deformities in adults

Temporomandibular joint (TMJ) ankylosis with secondary dentofacial deformities in adult patients is a severely disfiguring condition and surgical treatment of this disease remains a great clinical challenge. Treatment goals are to restore the joint function, to improve facial appearances and to correct malocclusion, as well as to re-establishing harmony among them. Currently, various surgical techniques, such as arthroplasty with or without interpositional material, orthognathic surgery, distraction osteogenesis, autologous bone or bone replacement materials graft and plastic surgery, have been described in the literature. In most cases these techniques should be used in combination to achieve satisfactory outcomes. The biggest difficulty for most clinicians is to determine the proper sequence of these procedures because no uniform treatment protocol has been established. Based on the published literature and our own clinical experiences, we have prepared this review article to provide some guidelines for the surgical management of TMJ ankylosis with dentofacial deformities in adults, which will be modified and updated periodically to provide the best treatment options to benefit our patients.     

Effect of bimaxillary orthognathic surgery on dysfunction of the temporomandibular joint: a retrospective study of 500 consecutive cases

We investigated the effect of bimaxillary orthognathic surgery on symptoms in the temporomandibular joint (TMJ) and predictive factors for postoperative dysfunction. A total of 500 patients with different craniofacial deformities who were having bimaxillary orthognathic surgery were assessed for overjet, overbite, maximal mouth opening, maximal protrusion, maximal lateral movement to both sides, and symptoms of TMJ dysfunction (pain on palpation, clicking, or crepitus) before operation and one year postoperatively. The panoramic radiographs taken on the same dates were assessed for reduction in the height of the ramus. Other variables were age, sex, segmentation of the maxilla, and additional genioplasty. Changes in the symptoms of dysfunction were investigated with the McNemar test. Measurements of the maximum mandibular movements taken preoperatively and postoperatively were compared using the paired t test. Multivariate logistic regression was used to assess the influence of the variables on symptoms preoperatively and postoperatively. The effect of occlusal stability (overjet and overbite) on postoperative symptoms in the TMJ was investigated with the unpaired t test. Women and class II patients had significantly more pain on palpation preoperatively, and a significant reduction in pain on palpation and clicking after operation. Predictive factors were preoperative crepitus for postoperative pain, and preoperative clicking for postoperative clicking. Patients with and without symptoms showed no significant differences in overjet and overbite postoperatively. Condylar resorption was found in 29 patients (5.8 %), and only 14 of them had symptoms in the TMJ. In patients with no preoperative symptoms or radiological abnormalities of the condyle, condylar resorption was rare (0.8 %). Orthognathic surgery has a beneficial effect on dysfunction of the TMJ as it reduces pain and clicking considerably. Patients should be informed, however, that TMJ disorders could still develop even if they had no symptoms preoperatively.