- Email: [email protected]
Disc-repositioning surgery of the temporomandibular joint using bioresorbable screws
Int. J. Oral Maxillofac. Surg. 2006; 35: 1149–1152 doi:10.1016/j.ijom.2006.06.010, available online at http://www.sciencedirect.com
Technical Note TMJ Disorders
Disc-repositioning surgery of the temporomandibular joint using bioresorbable screws
S. Sembronio, M. Robiony, M. Politi Department of Maxillofacial Surgery, Medical University of Udine, Udine, Italy
S. Sembronio, M. Robiony, M. Politi: Disc-repositioning surgery of the temporomandibular joint using bioresorbable screws. Int. J. Oral Maxillofac. Surg. 2006; 35: 1149–1152. # 2006 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. For successful disc-repositioning surgery, following arthrotomy and disc recovery by the release of attachments, the disc must be fixed and stabilized in the correct relationship with the condyle and fossa. This report describes a new surgical technique for fixing the disc to the condyle using two resorbable screws.
Internal derangement is a functional disorder of the temporomandibular joint (TMJ) caused most frequently by anterior and medial displacement of the articular disc. The two most common operations performed to solve the mechanical interference, improve the range of motion and reduce pain are disc repositioning and discectomy. The disc-repositioning procedure was first described in 1887 by ANNANDALE1 and then in 1979 by MCCARTY & FAR15 RAR . Disc repositioning has been performed alongside some other surgical procedures such as arthroplasty and eminectomy. Several authors5,6,8,12,14,17,28 have reported therapeutic success rates in conjunction with arthroplasty that range from 77 to 100%. In recent years, interest in disc-preservation surgery has decreased because of the spread of arthrocentesis21 and arthroscopic procedures24. Good results are 0901-5027/121149 + 04 $30.00/0
reported for these minimally invasive approaches to the functional disorders of TMJ9,10,19,20,24, but some patients may not respond to arthrocentesis and arthoscopy, and an open approach to the TMJ is then required. When the disc is fibrotic, deformed and unhealthy looking, discectomy is indicated11. If the disc can be recovered, disc preservation surgery is a valid option to eliminate mechanical interference with joint function, and to reposition the disc to achieve the correct relationship with the condyle7. Many methods have been proposed for disc repositioning, such as partial thickness or full-thickness plication8,12 of the disc and discopexy. This technique involves suturing the disc on to the top of the condylar stump23,28 and to the lateral capsule, or securing the disc with a Mitek anchor16,23. Recently, interest in resorbable devices has increased, espe-
Accepted for publication 20 June 2006 Available online 8 September 2006
cially in cranio-facial paediatric surgery, orthognathic surgery and preprosthetic surgery25. This report presents a new surgical procedure for TMJ disc-repositioning surgery using bioresorbable fixation for stabilisation of the disc. Technique
The joint is exposed through a preauricular incision extended to the temporal region and a deep subfacial approach22. Once the capsule itself is isolated, the superior and inferior joint spaces are opened by a ‘T’ incision. The top of the condyle, the articular fossa and the eminence are exposed. The whole joint is examined. The superior joint space (anterior and posterior recesses) and the disc surface are explored. The disc position and the mechanics of the condyle–disc complex are evaluated. Usually the disc is displaced anteriorly and medially.
# 2006 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
1150
Sembronio et al.
Fig. 1. Release of the disc using electrocautery to incise the anterior and medial attachments in the area of the anterior and medial capsule and pterygoid muscle.
Any adhesions in the superior joint space must be removed and any perforations of the posterior attachment are sutured. The bony surfaces of the condyle
and fossa are examined for the presence of degeneration and osteophytes, and evidence of osteoarthrosis. In cases of severe osteoarthrosis only, condylar reduction is
performed by removing 1–2 mm from the top of the condyle to improve visualisation and access into joint spaces, and to eliminate any mechanical interference. Recontouring the condyle and gross deformities is done with a diamond bur. Release of the disc anteriorly is achieved using electrocautery to incise the anterior and medial attachments in the area of the anterior and medial capsule and pterygoid muscle, freeing the displaced disc (Fig. 1). The disc is repositioned posteriorly and laterally in a satisfactory relationship with the condyle (Fig. 2). Two small holes are made in the lateral pole of the condyle (Fig. 3), and the disc is securely fixed onto the top of the condylar stump with two resorbable screws (Martin1) that are 7 or 9 mm in length with a diameter of 2 mm (Fig. 4). Joint function is tested after the procedure to verify the stability of the disc on top of the condyle, and to avoid any interference of the resorbable screws with other anatomical structures during mandibular movement. The excess bilaminar tissue is wedge resected, leaving a small portion of it attached to the posterior band of the disc and suturing the bilaminar tissue edges. The capsule, temporalis deep fascia, subcutaneous tissue and skin are then closed in a routine manner. Discussion
Fig. 2. The disc is freed and repositioned in a satisfactory relationship with the condyle.
Fig. 3. Two small holes are made in the lateral pole of the condyle.
The aetiology and pathogenesis of TMJ dysfunction remain unclear. Many different surgical open procedures have been proposed to eliminate pain and improve mandibular function in patients afflicted by internal derangement. The literature5,6,8,12,14,15,17,28 supports disc-repositioning surgery as a successful procedure associated with fewer complications than discectomy27. As seen in short-term and long-term follow-up studies26,29, discectomy almost always results in bony changes such as flattening of the condyle and tubercle, osteophytes on the condyle, and erosion of the condyle. After plication surgery, relapse of disc displacement occurs early in the postsurgical period. Some studies showed no change in disc displacement2,18, although this is not necessary for the clinical success of the surgery. All the methods of disc repositioning by suturing (plication) involve the posterior, medial and lateral discal ligaments that are often inflamed and degenerated, with significant loss of integrity to the supportive ligaments of the disc, such as the bilaminar zone. These anatomic structures are unsuitable for disc stabilisation16. The result is
Disc-repositioning surgery of the temporomandibular joint
10.
11.
12.
13.
Fig. 4. The disc is fixed onto the top of the condylar stump with two resorbable screws. 14.
failure of the disc-repositioning surgery, and degenerative changes in the joint continue to occur. It has been demonstrated that the disc does not need to be in a normal position for the patient to be asymptomatic. One goal of disc-repositioning surgery is therefore the elimination of mechanical interference with smooth movement, but not necessarily the return of the disc to a normal position3,4. A very important step in the procedure is the release of the anterior, medial and lateral attachments to free the disc and allow passive repositioning (without any tension) of the disc over the condylar head. The joint cannot then return to its normal physiological state because the disc is no longer a dynamic structure, but mechanical interference is eliminated and the joint can have a normal range of motion. Another goal is to stop further progression of osteoarthritis and disc degeneration16. The presence and morphological preservation of the disc are important factors in preventing excess remodelling or arthritic hard-tissue changes of the TMJ13; between the condyle and fossa the disc acts to ameliorate the overloading that can develop in TMJ disease. Arthroplasty, such as eminectomy or condylar reduction, should not be performed unless absolutely necessary to preserve the fibrocartilage of the articular surface of the joint, and to prevent the formation of any adhesions and the progression of degenerative joint disease. The clinical results of surgical disc repositioning show failure correlated to a lack of long-term stability, indicating the need for improved methods of disc stabilisation16. The method reported here
was developed because, by rigid fixation of the disc to the condyle, stability in the disc after repositioning is guaranteed. The efficacy of the method described here should be confirmed by future long-term and radiological studies.
15.
16.
References 1. Annandale T. On displacement of the interarticular cartilage of the lower jaw and its treatment by operation. Lancet 1887: 1: 411–412. 2. Bronstein SL. Postsurgical TMJ athrography. J Craniomandib Pract 1984: 2: 165–171. 3. Dimitroulis G. The role of surgery in the management of disorders of the temporomandibular joint: a critical review of the literature Part 2. Int J Oral Maxillofac Surg 2005: 34: 231–237. 4. Dolwick MF. Disc preservation surgery for the treatment of internal derangements of temporomandibular joint. J Oral Maxillofac Surg 2001: 59: 1047–1050. 5. Dolwick MF, Katzberg RW, Helms CA. Internal derangements of the temporomandibular joint: fact or fiction? J Prosthet Dent 1983: 49: 415–418. 6. Dolwick MF, Nitzan DW. TMJ disk surgery: 8 year follow-up evaluation. Fortschr Kiefer Gesichtschir 1990: 35: 162–163. 7. Dolwick MF, Nitzan DW. The role of disc repositioning surgery for internal derangements of the temporomandibular joint. Oral Maxillofac Surg Clin North Am 1994: 6: 271. 8. Dolwick MF, Sanders B. TMJ Internal Derangement And Arthrosis—Surgical Atlas. St. Louis: CV Mosby Co. 1985. 9. Emshoff R, Rudisch A, Bo¨sch R, Gaßner R. Effect of arthrocentesis and hydraulic distension on the temporomandibular joint disk position. Oral Surg Oral
17.
18.
19.
20.
21.
22.
23.
1151
Med Oral Pathol Oral Radiol Endod 2000: 89: 271–277. Gabler MJ, Greene CH, Palacios E, Perry HT. Effect of arthroscopic temporomandibular joint surgery on articular disc position. J Craniomandib Disord 1989: 3: 191–202. Hall HD. The role of discectomy for treating internal derangement of temporomandibular joint. Oral Maxillofac Surg Clin North Am 1994: 6: 287– 294. Hall MB. Meniscoplasty of the displaced temporomandibular joint meniscus without violating the inferior joint space. J Oral Maxillofac Surg 1984: 42: 788–792. Kondoh T, Hamada Y, Kazutoshi K, Seto K. Simple disc reshaping surgery for internal derangement of the temporomandibular joint: 5-years follow up results. J Oral Maxillofac Surg 2003: 61: 41–48. Marciani RD, Ziegler RC. Temporomandibular joint surgery: a review of fifty-one operations. Oral Surg Oral Med Oral Pathol 1983: 56: 472–476. McCarty WL, Farrar WB. Surgery for internal derangements of the temporomandibular joint. J Prosthet Dent 1979: 42: 191–196. Mehra P, Wolford LM. The Mitek mini anchor for TMJ disc repositioning: surgical technique and results. Int J Oral Maxillofac Surg 2001: 30: 497–503. Mercuri LG, Campbell RL, Shamaskin RG. Intra-articular meniscus dysfunction surgery. Oral Surg Oral Med Oral Pathol 1982: 54: 613–621. Montgomery MT, Gordon SM, Van Sickels JE, Harms SE. Changes in sign and symptoms following temporomandibular joint disc repositioning surgery. J Oral Maxillofac Surg 1992: 50: 320– 328. Montgomery MT, Van Sickels JE, Harms S, Thrash WJ. Arthroscopic TMJ surgery: effects on signs, symptoms, and disc position. J Oral Maxillofac Surg 1989: 47: 1263–1271. Moses JJ, Sartoris D, Glass R, Tanaka T, Poker I. The effect of arthroscopic surgical lysis and lavage of the superior joint space on TMJ disc position and mobility. J Oral Maxillofac Surg 1989: 47: 674–678. Nitzan DW, Dolwick MF, Martinez GA. Temporomandibular joint arthrocentesis: a simplified treatment for severe limited mouth opening. J Oral Maxillofac Surg 1991: 48: 1163–1167. Politi M, Toro C, Cian R, Costa F, Robiony M. The deep subfascial approach to the temporomandibular joint. J Oral Maxillofac Surg 2004: 62: 1097– 1102. Quinn PD. Surgery for internal derangement. Color Atlas Of Temporomandibular Joint Surgery. St. Louis: Mosby Co. 1998: 55–99.
1152
Sembronio et al.
24. Sanders B. Arthroscopic surgery of the temporomandibular joint: treatment of internal derangement with persistent closed lock. Oral Surg Oral Med Oral Pathol 1986: 62: 361–372. 25. Suuronen R, Hears PE, Lindqvist C, Sailer HF. Update on bioresorbable plates in maxillofacial surgery. Facial Plast Surg 1999: 15: 61–72. 26. Takaku S, Toyoda T. Long-term evaluation of discectomy of the temporomandibular joint. J Oral Maxillofac Surg 1994: 52: 722–726.
27. Vallerand WP, Dolwick MF. Complications of temporomandibular joint surgery. Oral Maxillofac Surg Clin North Am 1990: 2: 481–488. 28. Walker RV, Kalamchi S. A surgical technique for management of internal derangement of the temporomandibular joint. J Oral Maxillofac Surg 1987: 45: 299–305. 29. Widmark G, Dahlstrom L, Kahnberg KE. Diskectomy in temporomandibular joints with internal derangement: a follow-up study. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 1997: 83: 314– 320. Address: Salvatore Sembronio Cattedra di Chirurgia Maxillo-Facciale Policlinico Universitario P.le S. Maria della Misericordia 33100 Udine Italy Tel: +39 0432 559455 Fax: +39 0432 559868. E-mail: [email protected]
Technical Note TMJ Disorders
Disc-repositioning surgery of the temporomandibular joint using bioresorbable screws
S. Sembronio, M. Robiony, M. Politi Department of Maxillofacial Surgery, Medical University of Udine, Udine, Italy
S. Sembronio, M. Robiony, M. Politi: Disc-repositioning surgery of the temporomandibular joint using bioresorbable screws. Int. J. Oral Maxillofac. Surg. 2006; 35: 1149–1152. # 2006 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. For successful disc-repositioning surgery, following arthrotomy and disc recovery by the release of attachments, the disc must be fixed and stabilized in the correct relationship with the condyle and fossa. This report describes a new surgical technique for fixing the disc to the condyle using two resorbable screws.
Internal derangement is a functional disorder of the temporomandibular joint (TMJ) caused most frequently by anterior and medial displacement of the articular disc. The two most common operations performed to solve the mechanical interference, improve the range of motion and reduce pain are disc repositioning and discectomy. The disc-repositioning procedure was first described in 1887 by ANNANDALE1 and then in 1979 by MCCARTY & FAR15 RAR . Disc repositioning has been performed alongside some other surgical procedures such as arthroplasty and eminectomy. Several authors5,6,8,12,14,17,28 have reported therapeutic success rates in conjunction with arthroplasty that range from 77 to 100%. In recent years, interest in disc-preservation surgery has decreased because of the spread of arthrocentesis21 and arthroscopic procedures24. Good results are 0901-5027/121149 + 04 $30.00/0
reported for these minimally invasive approaches to the functional disorders of TMJ9,10,19,20,24, but some patients may not respond to arthrocentesis and arthoscopy, and an open approach to the TMJ is then required. When the disc is fibrotic, deformed and unhealthy looking, discectomy is indicated11. If the disc can be recovered, disc preservation surgery is a valid option to eliminate mechanical interference with joint function, and to reposition the disc to achieve the correct relationship with the condyle7. Many methods have been proposed for disc repositioning, such as partial thickness or full-thickness plication8,12 of the disc and discopexy. This technique involves suturing the disc on to the top of the condylar stump23,28 and to the lateral capsule, or securing the disc with a Mitek anchor16,23. Recently, interest in resorbable devices has increased, espe-
Accepted for publication 20 June 2006 Available online 8 September 2006
cially in cranio-facial paediatric surgery, orthognathic surgery and preprosthetic surgery25. This report presents a new surgical procedure for TMJ disc-repositioning surgery using bioresorbable fixation for stabilisation of the disc. Technique
The joint is exposed through a preauricular incision extended to the temporal region and a deep subfacial approach22. Once the capsule itself is isolated, the superior and inferior joint spaces are opened by a ‘T’ incision. The top of the condyle, the articular fossa and the eminence are exposed. The whole joint is examined. The superior joint space (anterior and posterior recesses) and the disc surface are explored. The disc position and the mechanics of the condyle–disc complex are evaluated. Usually the disc is displaced anteriorly and medially.
# 2006 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
1150
Sembronio et al.
Fig. 1. Release of the disc using electrocautery to incise the anterior and medial attachments in the area of the anterior and medial capsule and pterygoid muscle.
Any adhesions in the superior joint space must be removed and any perforations of the posterior attachment are sutured. The bony surfaces of the condyle
and fossa are examined for the presence of degeneration and osteophytes, and evidence of osteoarthrosis. In cases of severe osteoarthrosis only, condylar reduction is
performed by removing 1–2 mm from the top of the condyle to improve visualisation and access into joint spaces, and to eliminate any mechanical interference. Recontouring the condyle and gross deformities is done with a diamond bur. Release of the disc anteriorly is achieved using electrocautery to incise the anterior and medial attachments in the area of the anterior and medial capsule and pterygoid muscle, freeing the displaced disc (Fig. 1). The disc is repositioned posteriorly and laterally in a satisfactory relationship with the condyle (Fig. 2). Two small holes are made in the lateral pole of the condyle (Fig. 3), and the disc is securely fixed onto the top of the condylar stump with two resorbable screws (Martin1) that are 7 or 9 mm in length with a diameter of 2 mm (Fig. 4). Joint function is tested after the procedure to verify the stability of the disc on top of the condyle, and to avoid any interference of the resorbable screws with other anatomical structures during mandibular movement. The excess bilaminar tissue is wedge resected, leaving a small portion of it attached to the posterior band of the disc and suturing the bilaminar tissue edges. The capsule, temporalis deep fascia, subcutaneous tissue and skin are then closed in a routine manner. Discussion
Fig. 2. The disc is freed and repositioned in a satisfactory relationship with the condyle.
Fig. 3. Two small holes are made in the lateral pole of the condyle.
The aetiology and pathogenesis of TMJ dysfunction remain unclear. Many different surgical open procedures have been proposed to eliminate pain and improve mandibular function in patients afflicted by internal derangement. The literature5,6,8,12,14,15,17,28 supports disc-repositioning surgery as a successful procedure associated with fewer complications than discectomy27. As seen in short-term and long-term follow-up studies26,29, discectomy almost always results in bony changes such as flattening of the condyle and tubercle, osteophytes on the condyle, and erosion of the condyle. After plication surgery, relapse of disc displacement occurs early in the postsurgical period. Some studies showed no change in disc displacement2,18, although this is not necessary for the clinical success of the surgery. All the methods of disc repositioning by suturing (plication) involve the posterior, medial and lateral discal ligaments that are often inflamed and degenerated, with significant loss of integrity to the supportive ligaments of the disc, such as the bilaminar zone. These anatomic structures are unsuitable for disc stabilisation16. The result is
Disc-repositioning surgery of the temporomandibular joint
10.
11.
12.
13.
Fig. 4. The disc is fixed onto the top of the condylar stump with two resorbable screws. 14.
failure of the disc-repositioning surgery, and degenerative changes in the joint continue to occur. It has been demonstrated that the disc does not need to be in a normal position for the patient to be asymptomatic. One goal of disc-repositioning surgery is therefore the elimination of mechanical interference with smooth movement, but not necessarily the return of the disc to a normal position3,4. A very important step in the procedure is the release of the anterior, medial and lateral attachments to free the disc and allow passive repositioning (without any tension) of the disc over the condylar head. The joint cannot then return to its normal physiological state because the disc is no longer a dynamic structure, but mechanical interference is eliminated and the joint can have a normal range of motion. Another goal is to stop further progression of osteoarthritis and disc degeneration16. The presence and morphological preservation of the disc are important factors in preventing excess remodelling or arthritic hard-tissue changes of the TMJ13; between the condyle and fossa the disc acts to ameliorate the overloading that can develop in TMJ disease. Arthroplasty, such as eminectomy or condylar reduction, should not be performed unless absolutely necessary to preserve the fibrocartilage of the articular surface of the joint, and to prevent the formation of any adhesions and the progression of degenerative joint disease. The clinical results of surgical disc repositioning show failure correlated to a lack of long-term stability, indicating the need for improved methods of disc stabilisation16. The method reported here
was developed because, by rigid fixation of the disc to the condyle, stability in the disc after repositioning is guaranteed. The efficacy of the method described here should be confirmed by future long-term and radiological studies.
15.
16.
References 1. Annandale T. On displacement of the interarticular cartilage of the lower jaw and its treatment by operation. Lancet 1887: 1: 411–412. 2. Bronstein SL. Postsurgical TMJ athrography. J Craniomandib Pract 1984: 2: 165–171. 3. Dimitroulis G. The role of surgery in the management of disorders of the temporomandibular joint: a critical review of the literature Part 2. Int J Oral Maxillofac Surg 2005: 34: 231–237. 4. Dolwick MF. Disc preservation surgery for the treatment of internal derangements of temporomandibular joint. J Oral Maxillofac Surg 2001: 59: 1047–1050. 5. Dolwick MF, Katzberg RW, Helms CA. Internal derangements of the temporomandibular joint: fact or fiction? J Prosthet Dent 1983: 49: 415–418. 6. Dolwick MF, Nitzan DW. TMJ disk surgery: 8 year follow-up evaluation. Fortschr Kiefer Gesichtschir 1990: 35: 162–163. 7. Dolwick MF, Nitzan DW. The role of disc repositioning surgery for internal derangements of the temporomandibular joint. Oral Maxillofac Surg Clin North Am 1994: 6: 271. 8. Dolwick MF, Sanders B. TMJ Internal Derangement And Arthrosis—Surgical Atlas. St. Louis: CV Mosby Co. 1985. 9. Emshoff R, Rudisch A, Bo¨sch R, Gaßner R. Effect of arthrocentesis and hydraulic distension on the temporomandibular joint disk position. Oral Surg Oral
17.
18.
19.
20.
21.
22.
23.
1151
Med Oral Pathol Oral Radiol Endod 2000: 89: 271–277. Gabler MJ, Greene CH, Palacios E, Perry HT. Effect of arthroscopic temporomandibular joint surgery on articular disc position. J Craniomandib Disord 1989: 3: 191–202. Hall HD. The role of discectomy for treating internal derangement of temporomandibular joint. Oral Maxillofac Surg Clin North Am 1994: 6: 287– 294. Hall MB. Meniscoplasty of the displaced temporomandibular joint meniscus without violating the inferior joint space. J Oral Maxillofac Surg 1984: 42: 788–792. Kondoh T, Hamada Y, Kazutoshi K, Seto K. Simple disc reshaping surgery for internal derangement of the temporomandibular joint: 5-years follow up results. J Oral Maxillofac Surg 2003: 61: 41–48. Marciani RD, Ziegler RC. Temporomandibular joint surgery: a review of fifty-one operations. Oral Surg Oral Med Oral Pathol 1983: 56: 472–476. McCarty WL, Farrar WB. Surgery for internal derangements of the temporomandibular joint. J Prosthet Dent 1979: 42: 191–196. Mehra P, Wolford LM. The Mitek mini anchor for TMJ disc repositioning: surgical technique and results. Int J Oral Maxillofac Surg 2001: 30: 497–503. Mercuri LG, Campbell RL, Shamaskin RG. Intra-articular meniscus dysfunction surgery. Oral Surg Oral Med Oral Pathol 1982: 54: 613–621. Montgomery MT, Gordon SM, Van Sickels JE, Harms SE. Changes in sign and symptoms following temporomandibular joint disc repositioning surgery. J Oral Maxillofac Surg 1992: 50: 320– 328. Montgomery MT, Van Sickels JE, Harms S, Thrash WJ. Arthroscopic TMJ surgery: effects on signs, symptoms, and disc position. J Oral Maxillofac Surg 1989: 47: 1263–1271. Moses JJ, Sartoris D, Glass R, Tanaka T, Poker I. The effect of arthroscopic surgical lysis and lavage of the superior joint space on TMJ disc position and mobility. J Oral Maxillofac Surg 1989: 47: 674–678. Nitzan DW, Dolwick MF, Martinez GA. Temporomandibular joint arthrocentesis: a simplified treatment for severe limited mouth opening. J Oral Maxillofac Surg 1991: 48: 1163–1167. Politi M, Toro C, Cian R, Costa F, Robiony M. The deep subfascial approach to the temporomandibular joint. J Oral Maxillofac Surg 2004: 62: 1097– 1102. Quinn PD. Surgery for internal derangement. Color Atlas Of Temporomandibular Joint Surgery. St. Louis: Mosby Co. 1998: 55–99.
1152
Sembronio et al.
24. Sanders B. Arthroscopic surgery of the temporomandibular joint: treatment of internal derangement with persistent closed lock. Oral Surg Oral Med Oral Pathol 1986: 62: 361–372. 25. Suuronen R, Hears PE, Lindqvist C, Sailer HF. Update on bioresorbable plates in maxillofacial surgery. Facial Plast Surg 1999: 15: 61–72. 26. Takaku S, Toyoda T. Long-term evaluation of discectomy of the temporomandibular joint. J Oral Maxillofac Surg 1994: 52: 722–726.
27. Vallerand WP, Dolwick MF. Complications of temporomandibular joint surgery. Oral Maxillofac Surg Clin North Am 1990: 2: 481–488. 28. Walker RV, Kalamchi S. A surgical technique for management of internal derangement of the temporomandibular joint. J Oral Maxillofac Surg 1987: 45: 299–305. 29. Widmark G, Dahlstrom L, Kahnberg KE. Diskectomy in temporomandibular joints with internal derangement: a follow-up study. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 1997: 83: 314– 320. Address: Salvatore Sembronio Cattedra di Chirurgia Maxillo-Facciale Policlinico Universitario P.le S. Maria della Misericordia 33100 Udine Italy Tel: +39 0432 559455 Fax: +39 0432 559868. E-mail: [email protected]