Category Archives: Management of Temporomandibular Disorders

Total Joint Replacement

Total Joint Replacement

In some cases, joint” pathology results in destruction of  [oint structures so that reconstruction or replacement ofcomponents of the TMJ is necessary (Fig. 30-30, A). Examples of such situations include severe degenerative
or rheumatoid arthritic disorders, severe cases of ankylosis, neoplastic pathology, posttraumatic destruction of joint components, and multiple failed surgical procedures. Surgical techniques may involve rep lacement
of the co ndyle or fossa but most commonly include both elements.
One method of joint reconstruction involves grafting autogenous .tissue using a .•costochondral bone graft.v’ These grafts are most frequently used in growing individuals but also can be used effectively in the treatment of a
variety of adult disorders. figure 30-30, B shows the use of a costochondral graft for replacement of a severely degenerated mandibular condyle. In this situation the graft replaces only the condylar portion of the joint .and
does not address significant abnormalities of the fossa, Problems with costochondral grafting include recurrent ankylosis, degenerative changes of the graft, and (in some cases) excess and asymmetric growth of the graft.

 

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, In the past several types of prosthetic joint replacement  have been avallable.P Long-term results of prosthetic [oint replacements have been somewhat disappointing’ because of a variety of technical and biologic
‘problems. However, for many patients with significantdestruction of TMJ structures who have had poor results from other surgical treatment, no other viable surgical options ‘exist, In these cases thejoint destruction results in severe pain,. limited motion or complete ankylosis, and  severe malocclusions (see Fig. 30-30, A). Current technologicadvances include the use of three dimensional (3-D) reconstructed stereolithic models and custom fabrication of a total joint prosthesis, including the fossa and
condyle (Fig. 30-30, C and D). These recent advantages have provided significant improvement in outcome after total joint replacernent.

 

 

 

 

 

 

 

Condylotomy for Treatment of Temporomandibular Joint Disorders

Condylotomy for Treatment of Temporomandibular Joint Disorders

The condylotomy is an osteotomy completed in a manner identical to the vertical ramus osteotomy described in  Chapter 25. When used fot treatment of TMJ problemsthe osteotomyis completed, but 110 wireor screw fixation is placed, and the patient is placed into intermaxillary fixation for a period ranging from 2 to 6 weeks. The the ory behind this operation is that muscles attached to the proximal segment (i.e., segment attached to the condyle)
will passively reposition the condyle, resulting in a more favorable relationship between the condyle, disk, andfossa.33 This technique has been advocated primarily for treatment of disk displacement with or without reduction. DJD and subluxation or dislocation have also been suggested
as possible indications for use of this technique .Although this method of surgical treatment has been somewhat controversial, it appears to provide significant clinical improvement in a variety of TMJ disorders.

Disk Repair or Removal

Disk Repair or Removal

In some ~ses the disk is so severely. damaged that  remnants of disk tissue must be removed. Dlskectomy without replacement was one or the earliest surgical procedures described for treatment of severe TMJ internal erangernents. With current technology, the diskectomy procedure can be performed through arthro

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scopic techniques described earlier. Although this technique  has been widely used, there seems to be a wide variation in clinical results, with some joints showingminimal anatomic changes and significant clinical. improvement lo joints that demonstrate severe degenerative
changes with continued symptoms of pain and dysfunction. ” In advanced internal joint pathology, the disk-may be severely damaged and perforated but may’ have adequate remaining tissue so that a repair or patch procedure can beaccomplished (Fig. 30-28). A varietyof autogenous tissue
sources have been used for disk repair, including grafts of dermal or fascial tissue. In many cases the disk was previously replaced with alloplastic Implant material. However, significant failures have been seen with many of these implant materials, including implant fragmentation, foreign-body reaction, synovitis, and gross erosion of bony articular surfaces. These problems led to a renewed interest in autogenous tissue replacement after disk removal. Autogenous grafting techniques include the use of auricular cartilage, temporalis fascia, and the combination of muscle and fascial flaps “(Fig:30-29). 12 Although well-done long-term studies of the outcome of each of these techniques are limited, most patients realize some degree of improvement in pain and function after treatment with these’ procedures.

Disk-Repositioning Surgery

Disk-Repositioning Surgery

During the late 1970s and 1980s one of the most commonly  performed TMJ surgical procedures was disk repositioningand p)ication. The indication for this procedure is anterior disk displacement that has not responded to nonsurgical treatment and that most frequently results in
persistent painful clicking joints or closed locking (i.e., anterior disk displacement with or without reduction). Although these disorders are more frequently managed surgically with arthrocentesis or arthroscopy, many surgeons still prefer this type of surgical correction. In this operation the displaced disk is identified and repositioned into a more normal position by.removing a wedge of tissue from the posterior attachment of the disk and suturing the disk back to the correct anatomic position (Fig..30·Z7). In some cases this procedure is combined with recontouring
of the disk, articular eminence, and mandibular condyle. After surgery, patients generally begin a nonchew diet for several weeks, progressing to a relatively normal diet in 3 to 6 months. A progressive regimen of jaw exercises is also instituted in an attempt to obtain normal’ jaw motion within 6 to 8 weeks after surgery. In general the results of open arthroplasty have been good, with 8091)to 9S’){,of the patients experiencing less pain and improved jaw function.i” Unfortunately this’  surgery does not produce improvement in all paients, with 10% to lS(M,of patients describing no improvement or a worsening of the condition.

Arthroscopy

Arthroscopy

Arthroscopic surgery has become one of the most popular and effective methods of diagnosing and treating TMJ disorders.I” This technique involves placement of a small cannula into the superior [oint space. An arthroscope
with light source is then inserted through the cannula into the superior joint space (Fig, 30-26). The arthroscope is then connected to a video camera and monitor, which allow excellent visualization of all aspects of the glenoid

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Arthrocentesis

Arthrocentesis

Arthrocentesis involves placing needles into the TMJ  and therefore is not actually a surgical procedure. How. ever, because it is somewhat invasive and generally performedby oral and maxillofacfal surgeons, it is discussed
here,Most patients undergoing arthrocentesis do so with local anesthesia and intravenous (IV) sedation. Several techniques have been described for TMJ arthrocente- ·24The most common method Involves initially placing
one needle into the superior joint space. A small  mount of lactated Ringer’s solution is injected to distend  the joint space and can then be withdrawn and evaluated for diagnostic purposes, if desired. The joint is red istended, and a second needle is placed into the superior [oint space. This allows larger amounts of fluid (approximately 20:) ml) to lavage the joint. During the arthrocentesis the jn” can be gently “llanipulated. At the conclusion of the procedure, -terotds, local anesthesia, or a combination of both can

TMPOROMANDJBULAR JOINT SUREGRY

TMPOROMANDJBULAR  JOINT SURGERY

Despite the fact that many patients with internal joint pathology'”will improve with reversible nonsurgical treatment, some patients will eventually require surgical intervention to improve masticatory function and decrease pain. Several techniques are currently available for   of a variety of TMJ derangements.

 

 

 

Splints

Splints

Occlusal splints are generally considered it part of ‘the  reversible or conservative treatment phase in the management of ‘lMl) patients. Splint designs vary; however.most splints can be classified into two distinct groups: (1) autorepositioning splints and (2) anterior repositioning
splints. splints. The autorepositioning splints, also called anterior guidance splints, superior rcpositioning splints, or muscle splints, are most frequently used to treat muscle problems or eliminate TM] pain when no
specific internal derangement or other obvious pathology can be identified. However, these splints may be used  insome cases, such as anterior disk displacement or DJD,in an attempt to unload or reduce the force placed directly on the TM] area. Nitzan has shown that properly designed splints can be effective in reducing intraarticular pressure.V The splint is usually designed to provide full-arch contact without working or balancing interfereflces and without ramps or deep interdigitation, which
would force the mandible to function in one specific cclusal position (Fig. 30-24). This splint allows the patient to seek a comfortable muscle and joint position without excessive influence of the occlusion. An example
of this type of splint would be in a patient with a class II malocclusion and significant overjet who continually postures forward to obtain incisor contact during mastication. Many of these patients complain of muscular
symptoms and describe a feeling that they do’ not have a consistent, repeatable bite relationship. Wearing

Physical Therapy’

Physical Therapy

Physical therapy can be extremely useful in the management of patients with temporomandibular pain and dysfunction. The most common modalities used include EMG biofeedback and relaxation training, ultrasound, spray and stretch, and pressure massage. Relaxation training, although perhaps not physical therapy in the strictest sense, can be extremely effective in reducing symptoms caused by muscular pain and
hyperactivity. During the educational phase, patients are made aware of the contribution of stress and muscular hyperactivity to pain. Relaxation techniques can be used to.reduce the effects of stress on mucle and joint pain.EMG monitoring of the patient’s ‘muscular activity can be
used as an effective teaching tool by providing instant feedback demonstrating relaxation therapy, reduction of muscular hyperactivity, and the resultant improvement in symptoms of pain. Ultrasound is an effective way to- produce tissue heating with the use of ultrasonic waves, which alter bloodflow and metabolic activity at a deeper level.than that
provided by simple surface moist-heat applications.F The effect of ultrasonic tissue heating is theeretically related to increase in tissue temperature, increase in Circulation, increase in uptake of painful metabolic by-products, and . disruption of collagen cross-linking, which may affect adhesion formation: All of these effects may result in a
more comfortable manipulation of muscles and a wider range of motion. In additi9n, intraarticular inflammation may also be .reduced with ultrasonic applications. Ultrasonic treatments are usually provided by a physical” therapist in combination ‘with other treatment modahties. The typic l routine for application of ultrasound is the U’l’ 01 n.7 to 1.0 watts per earn applied for approximately

Medication

Medication

Four types of medication haw been widely used in the treatment of temporomandibular disorders: O./NSAIDs, (2) occasional. use of stronger analgesics, (3) muscular relaxants, and (-l) tricyclic antidepressants.
NSAIDs not only reduce inflammation but also serve as an excellent analgesic. Some examples of TSAIDsare naproxen (Naprosyn), ibuprofen (Morrin), diflunisal (Dolobid), and piroxicarn (Feldene). These medications
can be effective in reducing inflammation in both muscles and joints and in most cases provide satisfactory pain relief. These drugs are not associated with severe addiction problems, and their use (IS an anagesic is strongly
preferred over narcotic medications. It is important to  remember that these medications work best when administered on a timetable rather than on a pain-dependent schedule. Patients should be instructed to take the medicine on a regular basis, obtaining an adequate.blood level that should then be maintained for a minimum of 7 to 10  days. Discontinuation or tapering of the medii: e can then be attempted. . The COX-2 inhibitors such as  and  have gained popularity in the treatment of inflammation and pain. Prostaglandins produced by COX-l activity appear to be required for normal physiologic function, whereas those produced by COX-2 activation mediate pain and Inflammation. The COX-2 inhihitors are intended to reduce pain and inflammation “lthout  affecting prostaglandin-dependent functions. These drugs have been associated with significant side
effects, inc uding gastric and cardiac complications. ,\nalgesic medicines for T~!] patients may range from acetaminophen to potent narcotics. One important principle of treatment for all pain and dysfunction patients is