Use of T.M.J. Disc as a Soft Tissue Interpositional Graft Material for Functional Rehabilitation of Ankylosed T.M. Joint

Introduction

Many surgical techniques have been described for the treatment of TMJ ankylosis, but no strategy has been uniformly agreed upon underscoring the difficulty of the problem. Despite new guidelines and updated methods, treating patients with TMJ Ankylosis remains a challenge as the incidence of recurrence after treatment is soaring. This study exemplifies our experience in using an unsullied method to treat TMJ Ankylosis to restore the structure of TMJ in conjunction with convalescing secondary maxillofacial deformity.

Materials and Methods

A total of 56 cases of unilateral bony TMJ ankylosis were included in the study, and postoperative results of T.M.J disc as a soft tissue interposition graft was evaluated. The operative protocol comprised of (1) resection of ankylotic mass, (2) intraoral ipsilateral coronoidectomy or contralateral coronoidectomy when needed, (4) interpositioning disc as soft tissue graft, (5) interposing and fixing sternoclavicular or costocondral graft with lag screws and (6) early mobilization, aggressive physiotherapy.

Results

The study assessed patients with regular follow‐up checks for a period of 3 years. The average preoperative mouth opening was found to be 5.46 mm (range 2–10 mm). Mean post-operative mouth opening was 33.05 mm (range 24–43 mm), while 3 years post operative mouth opening (mean) was 39.75 mm. No cases of reankylosis were reported during this period suggesting it as a viable and satisfactory approach.

Conclusion

The use of TMJ disc as a soft tissue interpositional graft material is an effectual method for functional rehabilitation of ankylosis cases and serves as an effective means of preventing recurrence.

     

Re-Assessment of Coronoid as a Graft for Condylar Reconstruction in TMJ Ankylosis Patients: A Prospective Study and Literature Review

Introduction

Treatment for TMJ ankylosis aims at restoring joint function, improving the patient’s aesthetic appearance and quality of life and preventing re-ankylosis. To rebuild a structurally and functionally satisfactory neocondyle is a challenging problem. Aim of this study is to re-assess the coronoid as a graft for condyle reconstruction.

Materials and Methods

Twenty patients of TMJ ankylosis without involvement of the coronoid process in ankylotic mass, coming in age group elder than 14 years were selected for the study over a period 3 years from 2011 to 2014. Clinical examination, radiographs, and photographs were used postoperatively to evaluate the grafts and TMJ function. After osteoarthrectomy coronoid process was detached and fixed with a 4 hole L-shaped titanium miniplate to form neo condyle.

Result

No donor site morbidity was observed as reported with other autogenous grafts. Satisfactory mouth opening was observed during follow up period with mean mouth opening 37.33 ± 4.20 mm except one case which required graft removal due to postoperative infection. Radiographically moderate amount of resorption of grafted coronoid process was observed in nearly all the cases however satisfactory mandibular function and occlusion was observed.

     

Outcome of amniotic membrane as an interpositional arthroplasty of TMJ ankylosis

Purpose

Temporomandibular joint ankylosis is a major disorder, mainly due to trauma and other reasons, which is responsible for the restriction of mandibular functional activities. The scope of the successful surgical correction of temporomandibular joint ankylosis with amniotic membrane is on the membrane’s being an interpositional material which we found not to elicit any host reaction, is capable of functional adaptation, and is very economical. Our purpose is to show the amniotic membrane as a suitable, biocompatible, and interpositional material alternative to the other materials, thereby reducing donor site morbidity.

Methods

A study was conducted in 13 patients with an age range of 10 to 35 years with unilateral and bilateral bony TMJ ankylosis confirmed by clinical and radiological evaluations. Preoperative and postoperative clinical assessments of TMJ functions were done. Amniotic membranes were collected from the tissue bank, sterilized by gamma radiation, and freeze-dried. Then, the prepared amniotic cap (10–15 layers of amniotic membrane) was placed over the condylar head and anchored loosely to the neck and the surrounding tissues with a 3/0 Vicryl suture.

Results

Measurements of postoperative maximum interincisal opening was taken with scale among the 13 patients. Preoperative interincisal distances ranged from 0 to 15 mm, and preoperative and immediate postoperative were 33–45 and 25–32 mm, respectively. Postoperative follow-up of interincisal opening after 1-, 6-, and 12-month intervals was found from 32 to 35 mm. Lateral excursions (left and right), protrusive movements, and functional recovery were all satisfactory.

Conclusion

Amniotic membrane graft as an interpositional material in temporomandibular joint ankylosis can be a good alternative as to prevent reankylosis and recover functionality.

     

Diagnostic accuracy of magnetic resonance imaging and clinical signs of temporomandibular joint disorders: a 10-year research update review

Objectives

To review the past 10 years of research in the diagnostic accuracy of magnetic resonance imaging (MRI) and clinical signs of temporomandibular joint (TMJ) disorders with pain, sound, and function limitation in the existing literature.

Methods

A review of the literature was performed to search for all articles published between 2006 and 2016, and those that met the selection criteria were examined.

Results

The MRI results ranged from 25.3 to 69% for findings in TMJ with sound, 17–74.5% for findings in TMJ with function limitation, and 13.3–77% for findings in TMJ with pain. The reasons for the TMJ symptoms were variable and MRI findings for temporomandibular disorders were seen in asymptomatic patients as well as symptomatic patients. No singular outcome measure can be suggested as a predictor for TMJ symptoms on MRI images.

Conclusions

To increase study comparability with MRI, a standardized terminology and evidence-based guidelines are required for correlations of clinical symptoms and MRI findings.

     

Arthroscopy of the Inferior Compartment of the Temporomandibular Joint: A New Perspective

Objective

Arthroscopy of the temporomandibular joint (TMJ) has become a well-standardized non-invasive procedure for the treatment of TMJ internal derangement (ID). Since the last 1980s, no clinical application for arthroscopy of the inferior compartment has been established because of the intrinsic difficulty of the technique and the believing of the absence of clinical relevance for treatment of ID.

Methods

We report on a particular case in which arthroscopy of the inferior joint compartment together with the examination of the upper joint space was performed in a patient with ID of the TMJ. A 1.9 mm scope was used, while the technique for entering the inferior compartment is presented.

Results

The presence of intense synovitis, fibrous adhesion, and pseudowall were observed in the inferior joint compartment, thus leading to the hypothesis of the more than likely influence of the status of the synovial lining within this space in the persistence of symptoms in recalcitrant patients with ID.

Conclusion

We believe that this new insight could lead surgeons to a more complete use of this non-invasive procedure for the treatment of this entity.

Level of Evidence

4/5.

     

Abducens palsy after temporomandibular joint arthroscopy: a rare complication

Background

Arthroscopy of the temporomandibular joint (TMJ) is a minimally invasive and safe procedure; nevertheless, some accidents and complications have been described in the literature.

Case report

The purpose of this article is to describe a case report of a patient that progressed to paralysis of the abducens nerve after a TMJ arthroscopy procedure.

     

A novel treatment of temporomandibular joint arthritis as a complication in familial Mediterranean fever—literature review and a case report

Objectives

Articular involvement in familial Mediterranean fever (FMF) ranges between 40 and 70% of the patients. Involvement of temporomandibular joint (TMJ) in FMF is very rare, and only a few cases have been reported in the literature. There are no specific guidelines for treatment. We hereby present a new treatment for TMJ inflammation in FMF.

Materials and methods

A literature search was performed using PubMed according to the following criteria: key terms included in the search were FMF arthritis, TMJ involvement in FMF patients, and arthroscopy in FMF patients. All keywords were included both as medical subject headings (MeSH) terms and text words. Selections were limited to the English language.

Results

Literature search yielded four reported cases of TMJ involvement in FMF patients. The four cases were treated differently, with no clear guidelines for management of TMJ involvement. Our patient suffered from painful swelling and redness over the involved TMJ area and severe trismus. She was treated by arthroscopic lysis and lavage of her TMJ followed by aggressive physiotherapy resulting to improvement of her mouth opening.

Conclusions

The adverse effect of TMJ arthritis in FMF patients can be avascular necrosis and destruction of the mandibular condylar head. TMJ arthroscopy allows lysis and lavage of the joint with minimal operative and postoperative complication, resulting with satisfactory results. Thus, in case of TMJ arthritis in FMF, we recommend TMJ arthroscopy as soon as possible, following aggressive physiotherapy in order to gain normal mouth opening.

Clinical relevance

FMF rates have been described among the Mediterranean and Middle Eastern population ranging from 1:5 to 1:3; thus, TMJ involvement due to the disease is not so rare in this region, and a clear treatment protocol is needed.

     

Versatility of uniplanar prearthoplastic distraction osteogenesis in the correction of post-ankylosis facial deformities—a report of five different cases

Purpose

Unilateral or bilateral ankylosis can lead to severe micrognathia and facial deformity that requires multiple, often, staged surgical corrections. To date, there is no ideal treatment modality that satisfactorily corrects the complex anatomy, restores the ramal height, and corrects the micrognathia and microgenia. Distraction osteogenesis has been acclaimed as a successful modality for the treatment of such deformities. It is a cost-effective approach with low morbidity and less relapse thus providing better functional and esthetic outcomes. It allows the surgeon to correct the deformity in various planes by using various devices by changing osteotomy designs and vectors, with simultaneous hard tissue and soft tissue reconstruction.

Patients and methods

Here, we present a series of five cases where different types of distraction osteogenesis were combined with various other procedures to correct post-ankylotic facial asymmetry. In one case, simultaneous maxillo-mandibular distraction [Molina’s technique] was used.

Results

All patients showed significant improvement in function and esthetics. Outcome assessment was made using clinical photographs and radiographs.

Conclusion

Pre-arthroplastic distraction osteogenesis is a versatile cost effective approach that can be customized for every patient based on their needs.

     

Single Injection Technique Prolotherapy for Hypermobility Disorders of TMJ Using 25 % Dextrose: A Clinical Study

Introduction

Hypermobility disorders of the Temporomandibular joint (TMJ) can be treated by both conservative and surgical approaches. Conservative approaches should be considered as first line treatment for such disorders. Prolotherapy with 25 % dextrose being injected into the posterior pericapsular tissues is one such treatment modality with favorable outcomes.

Aim

To study the efficacy of single injection of 25 % dextrose in pericapsular tissues in the management of hypermobility joint disorders of TMJ as first line treatment.

Patients and Methods

We have studied a total of 23 patients suffering from either chronic recurrent dislocation or subluxation of the TMJ who were treated with the single injection technique prolotherapy with 25 % dextrose into the pericapsular tissues along with auriculotemporal nerve block and found encouraging results.

Results

Overall success rate in our study was 91.3 % (21/23) with a minimum follow up period of 13.9 months. Number of successfully treated patients requiring one injection was 7 (30.4 %), two injections was 8 (34.7 %) and requiring three injections was 6 (26.1 %). There were no permanent complications.

Conclusion

Hence the use of 25 % dextrose as a proliferant to treat hypermobilty disorders of the TMJ is recommended by us as a first line treatment option as it is safe, economical and an easy procedure associated with minimal morbidity.

     

Diagnostic efficiency of high-resolution ultrasonography in patients with chronic temporomandibular disorders

Purpose

Temporomandibular disorders (TMDs) affect 8–12 % of the adolescent and adult population, resulting in patient discomfort and affecting quality of life. Despite the growing incidence of these disorders, an effective screening modality to detect TMDs is still lacking. Although magnetic resonance imaging is the gold standard for imaging of the temporomandibular joint (TMJ), it has a few drawbacks such as cost and its time-consuming nature. High-resolution ultrasonography is a non-invasive and cost-effective imaging modality that enables simultaneous visualization of the hard and soft tissue components of the TMJ. This study aimed to evaluate the correlations between the clinical signs and symptoms of patients with chronic TMJ disorders and their ultrasonographic findings, thereby enabling the use of ultrasonography as an imaging modality for screening of TMDs.

Methods

Twenty patients with chronic TMDs were selected according to the Research Diagnostic Criteria for TMDs. Ultrasonographic imaging of individual TMJs was performed to assess the destructive changes, effusion, and disc dislocation. Fisher’s exact test was used to examine the correlations between the findings obtained from the ultrasonographic investigation and the clinical signs and symptoms.

Results

There was a significant correlation between pain and joint effusion as well as between clicking and surface erosion.

Conclusions

The present findings suggest that ultrasonography can be used as a screening modality to assess the hard and soft tissue changes in patients presenting with signs and symptoms of TMDs.

     

Pre-arthroplastic mandibular distraction osteogenesis for the correction of OSA in TMJ ankylosis: a prospective observational study of 25 cases

Introduction

In severe TMJ ankylosis cases, the lack of growth of the mandible creates an anatomically narrow airway with a reduced pharyngeal airway space [PAS] which predisposes these patients towards obstructive apnoea [OSA]. There is evidence in the literature that such patients experience severe discomfort during physiotherapy if such airway abnormalities are not corrected prior to ankylosis release. This eventually leads to non-compliance towards physiotherapy and increases the risk of re-ankylosis.

Objective

In our study, pre-arthroplastic mandibular distraction osteogenesis [DO] was used to increase the PAS and resolve the underlying OSA prior to releasing the ankylosis.

Materials and methods

Twenty-five cases of TMJ ankylosis with micrognathia and OSA were included in this prospective observational sleep study. They were further divided into a paediatric group [14 subjects] and an adult group [11 subjects]. All cases presented with a history of onset of ankylosis during childhood [before the completion of craniofacial growth] as result of which there was a lack of forward growth of the mandible. Subjects included in our study underwent initial DO of the mandible followed by a second procedure for distractor removal and ankylosis release. Questionnaires, lateral cephalograms and sleep studies were taken pre-operatively (T0), immediate post-distraction to the desired length (T1) and 12 months post the distractor removal and ankylosis release (T2). The parameters studied were PAS width, apnoea hypopnea index [AHI], O₂ saturation, mouth opening and mandibular advancement.

Results

The paediatric group variables were as follows: mean PAS width which increased from 3.5 mm [T0] to 9 mm [T2], mean AHI which decreased from 48.04 [T0] to 3.60 [T2], mouth opening which increased from 4.5 mm [T0] to 34 mm [T2] and mean O₂ saturation which increased from 89.86% [T1] to 96.88% [T2]. The adult group variables were as follows: mean PAS width which increased from 5 mm [T0] to 11 mm [T2], mean AHI which decreased from 31.45 [T0] to 1.43 [T2], mouth opening which increased from 5 mm [T0] to 34 mm [T2] and mean O₂ saturation which increased from 92.01% [T0] to 96.84% [T2]. Statistical analysis revealed that DO of the mandible significantly improved OSA by increasing the PAS which was evident by the lower AHI score. Mouth opening was also significantly improved post ankylosis release and maintained at the T2 interval. Ten subjects followed up beyond the T2 interval [mean 28 months post ankylosis release] and their data also revealed positive compliance towards physiotherapy, adequate mouth opening and maintenance of normal AHI.

Conclusion

Pre-arthroplastic mandibular DO has proved to be a successful modality for treatment of OSA in TMJ ankylosis patients with stable results at 12 months. By resolving the narrow airway and OSA, compliance towards physiotherapy was improved thus reducing the risk of re-ankylosis in the long term.

     

Value of additional axial imaging in magnetic resonance imaging of the temporomandibular joint to identify extra-articular diseases

Objectives

The conventional magnetic resonance (MR) imaging protocol for the temporomandibular joint (TMJ) is typically performed with focused oblique, sagittal, and coronal imaging of each joint and can miss extra-articular diseases and conditions that may present with similar symptoms. The purpose of this study was to investigate the value of an additional axial short tau inversion recovery (STIR) sequence to identify conditions other than ordinal TMJ disorders.

Methods

From September 2000 to April 2006, 601 patients with clinically diagnosed TMJ disorders underwent MR imaging at 0.5 T with a dedicated TMJ coil. In addition to the standard TMJ MR imaging protocol with oblique, sagittal, and coronal proton-density and T2-weighted images of each TMJ in the closed- and open-mouth positions, axial STIR images from the superior orbit to the thoracic inlet level were obtained.

Results

Of 601 patients, 580 (96.5 %) had TMJ disorders without other imaging abnormalities. Extra-articular diseases outside the TMJ were found in 21 patients (3.5 %), with all abnormalities seen only on axial STIR images. These conditions comprised 13 infectious/inflammatory processes and 8 neoplasms including 7 malignancies. Six of these patients had coexistent TMJ disorders, and 15 had no TMJ abnormality.

Conclusions

The addition of axial STIR images to the standard TMJ MR imaging protocol detected unexpected pathology in 3.5 % of patients, including malignancies (1.0 %). The addition of these images could potentially be used as an adjunct to the typical TMJ MR imaging protocol to improve detection of unexpected extra-articular disease.

     

The use of intra-articular analgesics to improve outcomes after temporomandibular joint arthrocentesis: a review

Purpose

The aim of this review was to assess the efficacy of intra-articular analgesics in improving outcomes after temporomandibular joint (TMJ) arthrocentesis.

Material and methods

An electronic search of PubMed, Scopus, and Google scholar databases was performed for papers in English published up to December 2017 reporting the use of intra-articular analgesics after TMJ arthrocentesis. Randomized controlled trials (RCTs), controlled clinical trials (CCTs), comparative studies, retrospective studies, and case series were included while case reports, technical reports, animal studies, cadaveric studies, and review papers were excluded.

Results

Of the six studies included in the review, three were RCTs, two were randomized comparative studies, and one was a retrospective study. Both opioids and non-steroidal anti-inflammatory drugs have been used after TMJ arthrocentesis. Morphine, tramadol, fentanyl, buprenorphine, tenoxicam, and COX-2 inhibitors are the drugs used till date. Placebo-controlled studies reported improved outcomes after TMJ arthrocentesis with morphine and fentanyl but no such results with buprenorphine and tenoxicam. Tramadol was found to be better than COX-2 inhibitor. The quality of literature was not high.

Conclusions

There is inconclusive evidence in literature on the benefits of using intra-articular analgesics after TMJ arthrocentesis. Well-designed high-quality RCTs with standard protocol studying the effects of intra-articular opioids and NSAIDS after TMJ arthrocentesis would provide stronger evidence on its use.

     

The Efficacy of Platelets Rich Plasma Injection in the Superior Joint Space of the Tempromandibular Joint Guided by Ultra Sound in Patients with Non-reducing Disk Displacement

Objective

The objective of this study was to determine average improvement during the rest and active mouth opening after ultrasound guided platelets rich plasma injection in the tempromandibular superior joint space for the patients complaining from non-reducing disk displacement.

Patients and Methods

Thirty-four patients with non-reducing disk displacement underwent guided ultrasound injection of platelet rich plasma to the upper joint space. The extent of maximal mouth opening, chewing efficiency, sound intensity of the TMJ, and tenderness of the TMJ and the masticatory muscles at rest, motion and mastication were thoroughly assessed at the beginning of the study and scheduled for next follow-up at 1st, 3rd, and 6th months.

Results

Injection with platelets rich plasma was significantly more effective in improvements of the extent of maximal mouth opening, statistics result demonstrated a significant reduction in the VAS values of pain at rest, motion and mastication compared to the baseline VAS values.

Conclusion

PRP injection to the upper temporomandibular joint space provided improvement in signs and symptoms of patient with non-reducing disk displacement of the temporomandibular joint.

     

Efficacy of Temporomandibular Joint Arthrocentesis with Sodium Hyaluronate in the Management of Temporomandibular Joint Disorders: A Prospective Randomized Control Trial

Purpose

This study was designed to investigate the efficacy of the temporomandibular joint arthrocentesis with and without injection of sodium hyaluronate (SH) in the treatment of temporomandibular joint disorders.

Patients and Methods

A total of sixty two TMJs in 34 males and 28 females aged 20–65 years comprised the study material. The patients’ complaints were limited mouth opening, TMJ pain, and joint noises during function. Patients were randomly divided into 2 groups in which arthrocentesis plus intra-articular injection of sodium hyaluronate was performed in 1 group and only arthrocentesis was performed in the other group. Both groups contained patients with disc displacement with reduction and without reduction. Clinical evaluation of the patients was done before the procedure, immediately after the procedure, at 1 week and 1, 3 and 6 months postoperatively. Intensity of TMJ pain was assessed using visual analog scales. Maximal mouth opening and lateral jaw movements also were recorded at each follow-up visit.

Results

Both techniques increased maximal mouth opening, lateral movements, and function, while reducing TMJ pain and noise.

Conclusions

Although patients benefitted from both techniques, arthrocentesis with injection of SH seemed to be superior to arthrocentesis alone.

     

Early postoperative healing following buccal <Emphasis Type="Italic">single flap approach</Emphasis> to access intraosseous periodontal defects

Aim

This study aims to evaluate the early postoperative healing of papillary incision wounds and its association with (1) patient/site-related factors and technical (surgical) aspects as well as with (2) 6-month clinical outcomes following buccal single flap approach (SFA) in the treatment of intraosseous periodontal defects.

Methods

Forty-three intraosseous defects in 35 patients were accessed with a buccal SFA alone or in combination with a reconstructive technology (graft, enamel matrix derivative (EMD), graft + EMD, or graft + membrane). Postoperative healing was evaluated at 2 weeks using the Early Wound-Healing Index (EHI).

Results

EHI ranged from score 1 (i.e., complete flap closure and optimal healing) to score 4 (i.e., loss of primary closure and partial tissue necrosis). SFA resulted in a complete wound closure at 2 weeks in the great majority of sites. A significantly more frequent presence of interdental contact point and interdental soft tissue crater, and narrower base of the interdental papilla were observed at sites with either EHI?>?1 or EHI?=?4 compared to sites with EHI = 1. No association between EHI and the 6-month clinical outcomes was observed.

Conclusions

At 2 weeks, buccal SFA may result in highly predictable complete flap closure.

Clinical relevance

Site-specific characteristics may influence the early postoperative healing of the papillary incision following SFA procedure. Two-week soft tissue healing, however, was not associated with the 6-month clinical outcomes.

     

Sodium hyaluronate: an effective adjunct in temporomandibular joint arthrocentesis

Background

Internal derangement of the temporomandibular joint (TMJ) is one of the most common forms of temporomandibular disorders. The minimally invasive treatments such as arthrocentesis as well as arthroscopic lysis and lavage are often used as a first-line surgical treatment or in conjunction with nonsurgical modalities with low morbidity and high efficacy. Sodium hyaluronate (SH) has been proposed as an alternative therapeutic agent with similar therapeutic effects.

Objective

A prospective study was carried out for evaluation of efficacy of TMJ arthrocentesis with and without injection of SH in management of internal derangements.

Material and methods

A total of 30 patients suffering from internal derangement of TMJ were selected for this study. Patients were randomly divided into the following two groups: group 1—arthrocentesis-only group and group 2—arthrocentesis + SH group. Each group constituted 15 patients.

Results

Six-month postoperative mean mouth opening (MMO) increase was 13.61?±?1.64 and 15.53?±?3.01 mm in group 1 and group 2, respectively. At 6 months, there was marked improvement in masticatory efficiency with mean increase of 5.07?±?0.13 in group 1 and 6.40?±?0.04 in group 2. Mean pain reduction was 5.27?±?0.67 and 6.48?±?0.44 in group 1 and group 2, respectively.

Conclusion

Although our series comprised a limited number of cases and a short follow-up period, initial results suggested that arthrocentesis with SH injection seemed to be superior to art.

     

Sub-Periosteal Dissection with Denture-Guided Epithelial Regeneration: A Novel Method for Peri-Implant Soft Tissue Management in Reconstructed Mandibles

Background

In patients with reconstructed mandibles using free fibula flaps, management of soft tissues around implants supporting dental rehabilitation, is often a clinical problem.

Aim

The aim of this paper is to describe a new technique, namely "Sub-periosteal dissection and denture-guided epithelial regeneration (SD-DGER)", as a method of peri-implant soft tissue management in these patients.

Materials and methods

The technique consists of performing a subperiosteal dissection with creation of buccal and lingual flaps. These flaps form the buccal and lingual vestibule. Implants are placed and an interim denture is immediately loaded onto the implants to guide the regenerated epithelium. A keratinized mucosal layer is formed on the bare fibula bone in six months time.

Results

This technique was successful in producing fixed keratinized epithelial tissue around implants in patients with mandibles reconstructed using the free fibula flap in patients who did not undergo radiotherapy.

Conclusion

The sub-periosteal dissection with denture guided epithelial regeneration is a predictable form of peri-implant soft tissue management in selected patients with reconstructed jaws.

     

Custom-made mouth prop for TMJ arthrocentesis: a technical note

Introduction

TMJ arthrocentesis involves lavage of the upper joint space which forces the disc apart from the fossa and washes away the inflammatory components of the joint. To increase the joint space during arthrocentesis, the patient is usually asked to open the mouth and deviate it to the opposite side so as to distract the condyle from the glenoid fossa thereby increasing joint space.

Method

The authors describe a simple and rapid technique of preparing a custom-made mouth prop to hold the mandible in eccentric position during arthrocentesis.

Findings

The custom-made mouth prop is an effective tool to help relax the patient in an eccentric position during the duration of arthrocentesis procedure.

     

Soft tissue augmentation procedures at second-stage surgery: a systematic review

Objectives

The aim of this systematic review was to evaluate the efficacy of different soft tissue augmentation/correction methods in terms of increasing the peri-implant width of keratinized mucosa (KM) and/or gain of soft tissue volume during second-stage surgery.

Materials and methods

Screening of two databases, MEDLINE (PubMed) and EMBASE (OVID), and hand search of related articles, were performed. Human studies reporting on soft tissue augmentation/correction methods around submucosally osseointegrated implants during second-stage surgery up to July 31, 2015 were considered. Quality assessment of the selected full-text articles was performed according to the Cochrane collaboration’s tool to assess the risk of bias.

Results

Overall, eight prospective studies (risk of bias: high) and two case series (risk of bias: high) were included. Depending on the surgical technique and graft material used, the enlargement of keratinized tissue (KT) ranged between ?0.20 and 9.35 mm. An apically positioned partial-thickness flap/vestibuloplasty (APPTF/VP) in combination with a free gingival graft (FGG) or a xenogeneic graft material (XCM) was most effective. Applying a roll envelope flap (REF) or an APPTF in combination with a subepithelial connective tissue graft (SCTG), mean increases in soft tissue volumes of 2.41 and 3.10 mm, respectively, were achieved. Due to the heterogeneity of study designs, no meta-analysis could be performed.

Conclusions

Within the limitations of this review, regarding the enlargement of peri-implant KT, the APPTF in the maxilla and the APPTF/VP in combination with FGG or XCM in the lower and upper jaw seem to provide acceptable outcomes. To augment peri-implant soft tissue volume REF in the maxilla or APPTF + SCTG in the lower and upper jaw appear to be reliable treatment options.

Clinical relevance

The localization in the jaw and the clinical situation are crucial for the decision which second-stage procedure should be applied.