Arthroscopic eminoplasty for habitual dislocation of the temporomandibular joint: preliminary study.

A unique surgical technique, arthroscopic eminoplasty was undertaken in 16 joints of 11 patients with habitual dislocation of the temporomandibular joint (TMJ). There were 10 joints with subluxation and 6 joints with complete dislocation in 4 male and 7 female patients with a mean age of 33 +/- 20 years. The procedure consisted of conventional diagnostic arthroscopy, followed by shaving of approximately 3 to 5 mm in height of the articular eminence with an electric motorized shaver with bone files, depending on the bone thickness as detected by preoperative imaging. The arthroscopic eminoplasty was accomplished without any peri- or postoperative complication. During the postoperative follow-up period of 19 months on average (6-36 months), all patients were free of dislocation of the TMJ, except for one joint. The patients could open their mouth 42 +/- 6 mm without arthralgia 2 weeks after surgery, and finally 47 +/- 7 mm without any subjective symptom but small joint noises (clicking or crepitus) in 10 joints. On postoperative radiographs only minor changes of the mandibular condyle were apparent in four joints. Arthroscopic eminoplasty might become a significant procedure for habitual dislocation of the TMJ and seems to produce results comparable to open arthrotomy. Further study will be required to assess this method as an acceptable modality in the future.     

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.     

The expression of vascular endothelial growth factor in synovial tissues in patients with internal derangement of the temporomandibular joint

OBJECTIVE: The aim of this study was to elucidate the expression and localization of vascular endothelial growth factor (VEGF) in synovial tissue taken from the temporomandibular joint (TMJ) with internal derangement (ID) and discuss the role of VEGF in the pathogenesis of ID. STUDY DESIGN: Through the use of an immunohistochemical technique, 39 TMJs in 37 patients were examined. As controls, synovial tissue specimens from 6 joints in 6 patients with habitual dislocation were also examined. RESULTS: In the synovial tissue from 35 of the patients with ID, expression of VEGF was observed in the synovial lining cells, in the endothelial cells of the blood vessels, and in the fibroblasts. In contrast, expression of VEGF was found in the TMJ tissue from only 2 of the controls. The percentage of VEGF-positive cells in the ID specimens was significantly higher than that in the habitual dislocation specimens (P < .02), and the expression of VEGF significantly correlated with the arthroscopic synovitis score (P = .004). CONCLUSION: These results suggest that the expression of VEGF is upregulated and involved in the development of inflammatory changes in synovial tissues in TMJs with ID.     

Eminectomy and discoplasty for correction of the displaced temporomandibular joint disc

Eminectomy with or without a subsequent discoplasty was performed on 30 patients (36 joints) with internal derangement of the temporomandibular joint (TMJ) confirmed either arthrographically or with magnetic resonance imaging. The importance of the inclination of the TMJ eminence and the therapeutic value of eminectomy are discussed. The TMJs were clinically evaluated before and at least 1 year after surgery in respect to opening function and symptoms. The results were promising (86.8% of the patients felt better). In five patients with a preoperative diagnosis of anterior disc displacement with reduction, only an eminectomy was performed. In these five cases eminectomy alone was sufficient to restore normal TMJ function.     

Specific expression of inducible nitric oxide synthase in the synovium of the diseased temporomandibular joint

OBJECTIVE: The expression of inducible nitric oxide synthase (iNOS) in temporomandibular joint (TMJ) specimens obtained arthroscopically from diseased TMJs was investigated by using immunohistochemistry and compared with clinical, arthroscopic, and histologic findings. STUDY DESIGN: Synovial biopsies were obtained arthroscopically from 18 TMJs in 15 patients with symptomatic internal derangement (ID) or osteoarthritis (OA). We also obtained arthroscopic biopsies from 8 control TMJs (3 with habitual luxation of the mandible, one with ID with clicking, and 4 with mandibular condyle fractures). The expression of iNOS was examined by immunohistochemistry and was compared with clinical, arthroscopic, and histologic findings. RESULTS: Definite or intense iNOS immunoreactivity was observed in both the synovial lining cells and the endothelial cells of TMJs with symptomatic ID or OA. Weaker immunoreactivity was present in synovial fibroblasts. In contrast, in TMJs without synovitis (eg, those with habitual luxation of the mandible) the expression of iNOS was weak or marginal. The expression of iNOS correlated significantly with arthroscopic evidence of synovitis (r = 0.406, P <.05) but not with cartilaginous degeneration (P >.05). The expression of iNOS also correlated with the histologic grade of the synovial lining cell layers (r = 0.530, P <.05). However, in patients with ID or OA of the TMJ, there was no statistically significant correlation between the intensity of iNOS immunoreactivity and clinical, arthroscopic, or histologic findings (P >.05). CONCLUSION: These data clearly suggest that nitric oxide is locally produced in the synovial lining of the TMJ in ID and OA.     

Temporomandibular joint "open lock" versus condylar dislocation: signs and symptoms, imaging, treatment, and pathogenesis.

PURPOSE: In the temporomandibular joint (TMJ) "open-lock" condition the condyle is entrapped in front of the lagging disc and cannot slide back under the fossa. The aim of this retrospective study was to describe the signs and symptoms and imaging of TMJ "open lock" versus condylar dislocation and clarify its pathogenesis. The study stresses the efficacy of arthrocentesis in restoring the functional capacity of the joint, while obviating the need for surgical intervention. PATIENTS AND METHODS: The study included 5 patients (3 females and 2 males; ages ranging from 11 to 26 years) presenting 6 open-lock joints that did not respond to conservative treatment. The TMJs postarthrocentesis status in 5 joints (follow-up period, 6 to 32 months) was determined by patient self-assessment and clinical examination. RESULTS: Five TMJs had recurrent open lock and were treated by arthrocentesis. They reacted favorably to the treatment and the open-lock events were eliminated. The first case was apparently misdiagnosed as condylar dislocation, and unnecessary surgical intervention was performed. CONCLUSIONS: Arthrocentesis is a safe and rapid procedure that prevents recurrence of open-lock conditions. This disorder should be distinguished from recurrent condylar dislocation, which requires surgical intervention.     

Outcomes of 152 temporomandibular joints following arthroscopic anterolateral capsular release by holmium: YAG laser or electrocautery

OBJECTIVE: The aim of this study was to investigate the clinical results and efficacy of arthroscopic anterolateral capsular release achieved through the use of a holmium:YAG laser or electrocautery for the management of patients with internal derangements of the temporomandibular joint (TMJ). STUDY DESIGN: We studied internal derangement (106 joints) and osteoarthritis (46 joints) of the TMJ in 129 patients. Preoperatively, the mean mouth-opening degree was 31 mm and 129 TMJs exhibited moderate to severe arthralgia. All patients underwent arthroscopic anterolateral capsular release achieved with a holmium:YAG laser (84 TMJs) or through electrocautery (68 TMJs). RESULTS: At the end of each patient's respective follow-up period, which ranged from 2 to 72 months (mean, 19 months), the mean mouth-opening degree was 43 mm (P<.0001). Also during that time, 105 joints were discovered to exhibit no arthralgia and 36 had mild arthralgia. The total success rates with 2 sets of criteria were 92.8% and 95.6%. CONCLUSIONS: Arthroscopic anterolateral capsular release is a minimally invasive and effective surgical method for the treatment of patients with TMJ intracapsular disorders.     

The Effect of Chronic Temporomandibular Joint Dislocation: Frequency on the Success of Autologous Blood Injection

Autologous blood injection (ABI) is a conservative, non-surgical method of treating chronic temporomandibular joint (TMJ) dislocation. Although many clinicians have reported positive results, procedural success has not been evaluated according to dislocation type. This study investigated the success of ABI on chronic TMJ dislocation with respect to dislocation frequency. ABI was used to treat 27 joints in 17 patients. The patients were divided into two groups based on dislocation frequency: (A) at least twice a week on different days and (B) at least twice a day. The procedure was successful in 13 of the 15 injected joints (86.6 %) in group A and six of the 12 injected joints (50 %) in group B. This difference was statistically significant (p = 0.03814). Autologous blood injection had limited success in patients with very frequent dislocation, while it was useful for treating less frequently dislocated TMJs.     

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.     

无牙牙合患者修复前后双侧颞下颌关节盘-髁关系的初步分析

目的:观察无颞下颌关节症状和体征的无牙颌患者修复前后双侧颞下颌关节(TMJ)盘-髁关系、关节腔积液及髁突骨质异常的变化。方法:通过8例无牙颌患者全口义齿修复前后双侧颞下颌关节的磁共振成像(MRI)检查,比较其修复前后双侧颞下颌关节MRI影像表现的差异。结果:修复前,8例无牙颌患者的16个关节中,10个关节盘移位(62.5%),包括7个关节盘内侧移位(43.8%),2个关节盘外侧移位(12.5%),1个关节盘前移位(6.25%);关节腔积液7个关节(43.8%);髁突骨质异常4个关节(25.0%)。修复后,8例无牙颌患者的16个关节中,10个关节盘移位(62.5%),包括7个关节盘内侧移位(43.8%)、2个关节盘外侧移位(其中1个关节盘外侧移位好转)和1个关节盘前移位(6.25%);关节腔积液7个关节(43.8%);髁突骨质异常4个关节(25.0%)。除1个关节的积液增加外,其余关节积液无变化。结论:长期缺牙可能引起无牙颌患者颞下颌关节的结构紊乱。无牙颌患者全口义齿修复后近期,关节盘移位、关节腔积液及髁突骨质异常无明显改变。     

Inappropriate treatments in temporomandibular joint chronic recurrent dislocation: a literature review presenting three particular cases

Chronic recurrent dislocation (CRD) is characterized by a condyle that slides over the articular eminence, catches briefly beyond the eminence, and than returns to the fossa. A variety of techniques have been proposed for the treatment of CRD involving tightening of the capsule with sclerosing agents, capsular plication, open condylotomy, eminectomy, and eminoplasty. In eminoplasty, to produce a barrier and eventually to incarcerate the condyle, zygomatic down-fracture, and autografts were used. Studies incorporating the use of screws and wires in the treatment of CRD have never been published. In this article, complications in three patients with CRD who were previously treated by screw eminoplasty and their treatment are presented. Three of the patients were referred to the author's clinic with reports of spontaneous and severe pain around the TMJ area. All of the patients reported in the article were treated previously by other surgeons by fixing screws on articular eminences in an attempt to limit the excursion of the condyle. Placement of materials such as screws with the purpose of creating a barrier, erosion of the articular eminence, and the anterior wall of the condyle are the major problems for this type of surgical option. The other option, as it is applied in treatment of the three cases presented, is to remove the barrier to enable spontaneous reduction, a process that is accomplished best by eminectomy.     

Disc mobility and arthroscopic condition of the temporomandibular joint associated with long-term mandibular discontinuity.

PURPOSE: The present study aimed to explore disc mobility and arthroscopically diagnosed morphologic changes in the temporomandibular joint (TMJ) associated with long-term mandibular discontinuity. PATIENTS AND METHODS: Twelve patients (24 TMJs) who had undergone mandibulectomy including the unilateral condyle or segmental mandibulectomy without mandibular reconstruction, more than 8 months before this study were examined. The 24 TMJs were classified into 3 groups as follows: group 1, TMJs with a major mandibular fragment including the mandibular body (n = 11); group 2, TMJs with a mandibular ramus including the coronoid process (n = 5); and group 3, TMJs with only a condylar process, a mandibular ramus not including the coronoid process, or without a condyle (n = 8). Disc mobility was evaluated by magnetic resonance imaging, and arthroscopic observation of the superior joint compartment (SJC) was performed in all TMJs. The relationship between disc mobility and the arthroscopic findings was also studied. RESULTS: The frequency of immobile discs differed significantly among groups 1 (0%), 2 (40.0%), and 3 (100%). Arthroscopic findings were normal in all SJCs of group 1. Various types of fibrous adhesions were observed in 40.0% of group 2 and in 75.0% of group 3. The development of fibrous adhesions in the SJC was significantly related to the presence of an immobile disc. CONCLUSIONS: Long-term immobilization of the TMJ in a nonfunctional state seems to promote the development of fibrous adhesions in the SJC. Preservation of the mandibular fragment including the coronoid process, during mandibulectomy appears to contribute to postoperative TMJ mobility. To ensure recovery of a physiologic TMJ after mandibulectomy, it seems important to re-establish TMJ mobility by establishing mandibular continuity as soon as possible.     

Releasing severe adhesions around the eminence and the synovial portion of the TMJ: a clinical study of combined treatment using hydraulic lavage, arthroscopic surgery and rehabilitative therapy.

This paper evaluates the effects of treatment with a pumping technique and arthroscopic lysis and lavage, followed by rehabilitative training, on condylar head mobility of the temporomandibular joint (TMJ). We studied 32 TMJs in 19 patients suffering from chronic closed lock with severe adhesion. The results were compared between cases with adhesions concentrated in two areas: mostly in the posterior and/or the anterior synovial portion of the upper TMJ compartment (11 joints) and mostly around the eminence (21 joints). The results showed a statistically significant improvement in condylar head movement for both groups between the initial and final stages of treatment. However, the results also suggested that patients with adhesion concentrated around the eminence are less likely to recover condylar head mobility to the same extent as those in the other group.     

Levels of fibroblast growth factor 2 in synovial fluids in human patients with internal derangement of the temporomandibular joint

OBJECTIVE: We sought to elucidate the levels of fibroblast growth factor 2 (FGF-2) in synovial fluid taken from internally deranged human temporomandibular joints (TMJs) and to discuss the role of FGF-2 in the pathogenesis of internal derangement. STUDY DESIGN: Through the use of a pumping procedure, diluted synovial fluid was collected from the upper joint compartment of 22 TMJs with evidence of internal derangement (21 patients) and 8 TMJs with no such evidence (5 control subjects). Two of the control subjects were patients who had habitual dislocation, and three were healthy volunteers. The level of FGF-2 in the synovial fluid was assessed by means of an enzyme-linked immunosorbent assay. RESULTS: FGF-2 levels were at detectable levels in 15 of the 22 TMJs (68%) with internal derangement. The mean concentration of FGF-2 was 24 pg/mL. In the control group, FGF-2 levels were detectable in only 1 of 8 joints (13%), for a concentration of 3 pg/mL. The mean concentration of FGF-2 in the synovial fluid was significantly higher in the internal derangement group than in the control group (P =.02). CONCLUSIONS: FGF-2 levels are elevated in the human synovial fluid of TMJs with internal derangement.     

Magnetic resonance evidence of joint effusion of the temporomandibular joint after fractures of the mandibular condyle: a preliminary report

To investigate the clinical significance of magnetic resonance (MR) evidence of joint effusion of the temporomandibular joint after mandibular condylar fractures, magnetic resonance imaging (MRI) was performed on 18 joints in 15 patients with either unilateral or bilateral mandibular condylar fractures using a 1.5 Tesla MRI scanner (Signa, General Electric, Milwaukee, WI). MR evidence of joint effusion was evaluated and compared with the types and the positions of the fractures. MR evidence of joint effusion was observed in 11 of 18 TMJs, which was 61% of the condylar fractures. It appeared more frequently after fractures with dislocation than those without dislocation (p < 0.05). In addition, MR evidence of effusion appeared more frequently in TMJs after high condylar fractures (head to upper neck) than low condylar fractures (lower neck to subcondylar) (p < 0.05). These findings indicate that MR evidence of joint effusion may serve as a marker for the detection of severe intra-articular damage to the TMJ after mandibular condyle fractures.     

Visually guided temporomandibular joint irrigation in patients with chronic closed lock: clinical outcome and its relationship to intra-articular morphologic changes

OBJECTIVE: The aim of this study was to evaluate the clinical outcome after visually guided irrigation (VGIR) of the temporomandibular joint (TMJ) and its relationship with postoperative arthroscopic changes. STUDY DESIGN: Of the original 69 patients, thirty patients (30 TMJs) underwent VGIR of the TMJ a second time. After the first VGIR, the clinical outcome was assessed, and 18 patients were assigned to the good outcome group. The remaining 12 patients were assigned to the poor outcome group. The arthroscopic findings related to the articular surface, synovial lining, and fibrous adhesion scores were recorded. Then, the arthroscopic findings in the first and second VGIR were compared. RESULTS: The intra-articular tissue status between the first and second VGIR was unchanged in approximately 40% of all joints. No significant differences with respect to an improvement in tissue status were found when the good outcome and poor outcome groups were compared. CONCLUSIONS: In patients with chronic closed lock of the TMJ, a clinical improvement after VGIR does not seem to be accompanied by improved intra-articular tissue status.     

Arthroscopic surgery for treatment of anterior displacement of the disc without reduction of the temporomandibular joint

The aim of this study was to investigate the clinical results and efficacy of an arthroscopic approach to correct anterior displacement of the disc without reduction of the temporomandibular joint (TMJ) with limitation of mouth opening. We studied 28 joints with internal derangement in 23 patients, all of whom had had arthroscopic surgery (lavage, lysis of adhesions in the superior compartment, incision parallel to the disc-synovial crease of the upper joint compartment, and pull back of the anteriorly located disc). Objective and subjective data (increase in maximal interincisal opening, magnetic resonance imaging, and visual analogue pain score, VAS) were collected preoperatively and at 7, 30, 60 days, and 6 months or more postoperatively. Maximal interincisal opening improved from a mean (SD) of 20.4 (±4.5) mm preoperative measurement to 38.9 (±3.2) mm by 6 months postoperatively where indicated in previous line. The VAS showed a significant improvement in pain score (p=0.0023). Sixty days postoperatively the positions of the discs in 14 of the TMJs had improved considerably. In 13 of the TMJs the positions had improved slightly. Only 1 of the TMJs had not improved at all. There were no complications in any patient. Our arthroscopic procedure is safe, minimally invasive, and effective for the treatment of patients with displacement of the disc anteriorly without reduction of the TMJ.     

Early diagnosis of osteoarthrosis of the temporomandibular joint: correlation between arthroscopic diagnosis and keratan sulfate levels in the synovial fluid

The role of osteoarthrosis (OA) and proteoglycan degradation in the pathogenesis of temporomandibular joint (TMJ) disorders has not been well established. The orthopaedic literature has demonstrated that proteoglycan degradation plays a significant role in the pathology of many joints. The purpose of this investigation was to determine if levels of immunoreactive keratan sulfate (an important component of cartilage proteoglycans) present in synovial fluid aspirates from TMJs correlated with arthroscopically demonstrated OA. Temporomandibular joint arthroscopy was performed on 25 joints in 20 patients and synovial fluid aspirates were obtained just prior to the insertion of arthroscopic cannulas. The results showed that synovial fluid aspirates from joints that arthroscopically demonstrated OA had significantly higher levels of keratan sulfate than synovial fluid aspirates from those joints that showed no evidence of OA (NON-OA). This study gives support to the theory that the pathogenesis of OA of the TMJ is similar to that of chondromalacia of other synovial joints. The combination of TMJ arthroscopy and synovial fluid analysis is an important model that can be used for investigation of the pathogenesis of TMJ disorders.     

硬化疗法及牵引缝合治疗复发性颞下颌关节脱位的远期疗效

目的 评判关节镜手术治疗复发性脱位患者远期疗效的稳定性。方法 ３０例患者的３４例复发性脱位关节进行了３８例次关节镜手术（关节盘后区硬化疗法和关节盘缝合牵引固定术）,其中４例次为重复关节镜手术,４例次为双侧同期手术,随访期２年以上的有２１例患者的２２侧受累关节,平均随访期４年（８年）。远期疗效：有效率９５％（２１／２２）,治愈率８２％（１２／２２）。结论 关节盘后区硬化疗法及关节盘牵引固定术对复发性     

A modified approach for eminectomy for temporomandibular joint dislocation under local anaesthesia: report on a series of 50 patients

Conventional eminectomy for habitual dislocation of the temporomandibular joint is usually performed under general anaesthesia. This technique was modified for use under local anaesthesia to treat medically compromised patients. Fifty elderly patients (90 joints) were treated, for whom general anaesthesia was considered a serious risk due to systemic diseases; the dislocation was habitual in 39 and long-standing in 11. Following intravenous sedation and local anaesthesia, a 2-cm superficial vertical skin incision was made directly above the articular eminence. Careful and gentle dissection of the subcutaneous tissue was performed until the lateral joint capsule was exposed. The superior compartment was entered, followed by shaving of the articular eminence in a conventional manner. The surgery was successful in all patients, with a mean operative time of 47 ± 12 minutes. Intraoperative events occurred in 10 patients (20%). Postoperative complications affected 25 patients (50%), varying from severe (two deaths, due to cardiopulmonary arrest and accidental fall) to mild (local infection, etc.). Eleven patients (22%) had facial nerve palsy limited to the temporal branch; all recovered after 6 months. This approach is useful when general anaesthesia is contraindicated due to existing medical conditions. However, prudent consideration may be required to avoid serious complications when local anaesthesia is used.