Temporomandibular Joints

Oral Abstract Session 7 TEMPOROMANDIBULAR JOINTS Friday, October 4, 2002, 8:00 am - 10:00 am

Oral and Maxillofacial Surgery in Patients With Chronic Oral, Facial, and Head Pain Howard A. Israel, DDS, 12 Bond St, Great Neck, NY 11021 (J. Desmond Ward, DDS; Brenda Horrell, DDS, MS; Steven J. Scrivani, DDS, DSc) (Oral Abstract accepted for presentation at 2001 Annual Meeting. Please refer to August 2001 Supplement No. 1 to the Journal of Oral and Maxillofacial Surgery for abstract.)

Relative Odds of TMJ Pain as a Function of MR Imaging Variables Rudiger Emshoff, MD, DMD, University of Innsbruck, Department of Oral and Maxillofacial Surgery, Maximilianstrasse 10, Innsbruck, A-6020 Austria (Iris Emshoff, MD; Stefan Bertram, MD, DMD; Ansgar Rudisch, MD) There are only few studies available concerned with the evaluation of the temporomandibular joint (TMJ) variable pain in relation to the magnetic resonance (MR) imaging findings of TMJ internal derangement and osteoarthrosis. The purpose of this study was to evaluate whether common MR imaging variables such as TMJ internal derangement, osteoarthrosis, effusion, and/or bone marrow edema may predict the presence of TMJ pain. The relationship between TMJ pain and TMJ internal derangement, osteoarthrosis, effusion, and bone marrow edema was analyzed in MR images of 338 TMJs in 169 patients with a clinical diagnosis of TMJ pain and dysfunction. Criteria for including a TMJ pain patient were report of orofacial pain referred to the TMJ, with the presence of unilateral or bilateral TMJ pain during palpation, function, and/or unassisted or assisted mandibular opening. Criteria for including a TMJ nonpain patient were absence of a TMJ with pain during palpation, function, and unassisted or assisted mandibular opening. A logistic regression analysis was used to compute the odds ratios for internal derangement, osteoarthrosis, effusion, and bone marrow edema for nonpain TMJs (n ⫽ 173) vs pain TMJs (n ⫽ 165). Using chi-square analysis for pair-wise comparison, the data showed a significant relationship between the MR imaging findings of TMJ pain and those of internal derangement (P ⫽ .000), osteoarthrosis (P ⫽ .015), effusion (P ⫽ .002), and bone marrow edema (P ⫽ AAOMS • 2002

.016). Of the MR imaging variables considered simultaneously in the multiple logistic regression analysis, osteoarthrosis (P ⫽ .405), effusion (P ⫽ .131), and bone marrow edema (P ⫽ .231) dropped out as nonsignificant in the diagnostic TMJ pain group when compared with the TMJ nonpain group. Significant increases in risk of TMJ pain occurred with “disc displacement without reduction in combination with osteoarthrosis and bone marrow edema” (3.7:1 odds ratio) (P ⫽ .000) and/or “disc displacement without reduction in combination with osteoarthrosis and effusion” (2.8:1 odds ratio) (P ⫽ .000). The results suggest that TMJ pain is related to internal derangement, osteoarthrosis, effusion, and bone marrow edema. However, the data reemphasize the aspect that these MR imaging variables may not be regarded as the unique and dominant factors in defining TMJ pain instances. References Emshoff R, Innerhofer K, Rudisch A, et al: Clinical versus magnetic resonance imaging findings with internal derangement of the temporomandibular joint: An evaluation of anterior disc displacement without reduction. J Oral Maxillofac Surg 60:36, 2002 Emshoff R, Innerhofer K, Rudisch A, et al: The biological concept of ‘internal derangement and osteoarthrosis’: A diagnostic approach in patients with temporomandibular joint pain? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 93:39, 2002

Temporomandibular Joint Meniscus Perforation: Diagnostic Accuracy of Arthroscopy and Arthrogram Marc R. Smith, DDS, 1930 Alcoa Highway, Medical Building A, Suite 335, Knoxville, TN 37920 (J.W. Huson, DDS) Purpose: The purpose of this study is to calculate the diagnostic accuracy of arthroscopy and arthrogram in regard to diagnosis of TMJ meniscus perforations. The diagnostic importance of fibrillation or “crabmeat” as it relates to perforations was also examined. Patients and Methods: A retrospective study of 93 open TMJ surgeries was used to compare arthrographic results, arthroscopic findings, and direct clinical findings seen during arthrotomy. Open joint surgery was performed while treating internal derangements that were refractory to conservative therapy sustained over 3 to 6 months, consisting of soft diet, physical therapy, occlusal splint therapy and medications. Arthrograms at this institution were performed by a board-certified oral and maxillofacial surgeon, oral radiologist, and oral pathologist. The arthroscopic pro51

Oral Abstract Session 7: Temporomandibular Joints cedures and the open joint dissection were performed by the same operator, who is also board certified in oral and maxillofacial surgery. Arthrogram and arthroscopic results were reviewed with regard to perforations and the diagnosis was compared to what was seen during surgical removal of a meniscus. None of the patients had a prior arthrotomy. Arthroscopic results were objective findings from the arthroscopic images obtained at the arthroscopic surgery, and from the subsequent descriptions in the operative reports. Results: Of the 93 joints that were examined, 31 were found to have perforations. Of the 31 perforated discs, 27 had undergone arthrographic studies, and 9 (33%) were diagnosed from the arthrogram as having a perforation. The positive and negative predictive value of the arthrogram for a diagnosis of perforation was 0.9 and 0.76, respectively. There was 1 false positive and 18 false-negatives for perforation diagnosis of the meniscus. Of the 31 perforated discs, 24 had undergone arthroscopy, and 15 of those joints, or 63%, showed fibrillation. Conclusions: It has already been established that the arthrogram is the most accurate method for diagnosing perforations, but it is not without error, even in the best hands. Although most of the perforated discs demonstrated fibrillation or a “crabmeat” appearance, it is not reliable for diagnosing perforations. References Graham GS, Ferraro NF, Simms DA: Perforations of the temporomandibular joint meniscus: Arthrographic, surgical, and clinical findings. J Oral Maxillofac Surg 42:35, 1984 Westesson P: Diagnostic imaging of internal derangements of the temporomandibular joint. Oral Maxillofac Clin North Am 6:227, 1994

Condylar Regeneration in Adolescent Minipigs Kenneth J. Zouhary, DDS, Department of OMS, Attn: Stephen Feinberg, 1011 N University Ave, Ann Arbor, MI 48109 (Stephen E. Feinberg, DDS, MS, PhD; Ryan P. Frank, MD) Introduction: Reconstruction of the temporomandibular joint (TMJ) can involve replacement of the mandibular condyle, articular disc, and/or glenoid fossa. Traditionally, bone grafts and prosthetic devices have allowed clinicians to restore form and function to the temporomandibular joint with varying degrees of success. Recently, distraction osteogenesis (DO) has been applied to the reconstruction of the temporomandibular joint in the clinical setting with promising results. It is thought that DO may be successful in regeneration of the TMJ because of the formation of fibrous connective tissue on the leading edge of the transport segment. This leading edge may, in turn, either act as a “pseudodisc” between the regenerated condyle and the 52

glenoid fossa or remodel into an articular surface on the condylar stump as it advances in a cephalic direction. The aim of this pilot study was to evaluate the efficacy of DO in generation of a neocondyle and functional TMJ in condylectomized Yucatan minipigs. Materials and Methods: The University Committee on the Use and Care of Animals (UCUCA) approved this study. Nine 6-month-old Yucatan minipigs, approximately 30 kg in weight, were placed into 2 groups. Group I consisted of 6 minipigs that had unilateral mandibular condylectomy with placement of a distraction device on the vertical ramus of the mandible. Osteotomy cuts were made to create a transport segment that was distracted superiorly, in a cephalic direction, into the region that was previously occupied by the resected condylar head. Distraction occurred at 1 mm/d after a latency period of 5 days until resistance was experienced. Group II consisted of 3 minipigs that had condylectomy without placement of a distraction device. At 30, 60, and 90 days postsurgery 2 minipigs from group I and 1 minipig from group II were killed. Preserved specimens were imaged using an x-ray mCT (model #MS8-MAIN) and reconstructed using 3-dimensional image analysis software (EVS). The specimens were decalcified and processed for histologic examination. Specimens were cut at 7-␮m thick and alternate sections were stained with H&E, Masson trichome, Saffronin-O and Fast Green, and Alcian Blue-hematoxyalin and acid fuschion-eosin. Results: Preliminary observation showed an exuberant osteogenic growth in both the distracted and nondistracted minipigs by observation on trimming of the specimens and confirmation with micro-CT. Histologic preparation of the specimens is presently in progress. Conclusions: Preliminary conclusions, from clinical and micro-CT, indicate that 6-month-old minipigs, which are similar in age to adolescent humans, have the capability to regenerate pseudocondyles after condylar resection, without the use of distraction osteogenesis, if periosteum, capsule, and interpositional disc are preserved and not violated. Histologic evaluation is expected to give a further comparison of the leading edge of the condylectomized segment with and without the use of DO. References Perrott DH, Vargervik K, Kaban LB: Costochondral reconstruction of mandibular condyles in nongrowing primates. J Craniofac Surg 6:227, 1995 Dodson TB, Bays RA, Pfeffle RC, Barrow et al: Cranial bone graft to reconstruct the mandibular condyle in Macaca mulatta. J Oral Maxillofac Surg 55:260, 1997 Stucki-McCormick SU, Mizrahi RD, Fox RM, et al: Distraction osteogenesis of the mandible using a submerged intraoral device: A report of three cases. J Oral Maxillofac Surg 57:192, 1999

Funding Source: Funded in part by KLS-Martin L.P.

AAOMS • 2002

Oral Abstract Session 7: Temporomandibular Joints

Idiopathic Condylar Resorption: Outcome Assessment of TMJ Disc Repositioning and Orthognathic Surgery Carlos A. Morales-Ryan, DDS, MSD, 3409 Worth St, Suite 400, Dallas, TX 75246 (Patricia Garcia-Morales, DDS, MSD; Larry M. Wolford, DMD) Purpose: Evaluate the long-term efficacy of concomitant TMJ disc repositioning (using the Mitek Mini Anchor) and orthognathic surgery in the treatment of active idiopathic condylar resorption (ICR). Methods: Records of 44 patients diagnosed with active ICR (86 joints) were retrospectively evaluated. Patients were divided in 2 groups. Group 1 (7 females, 3 males) underwent orthognathic surgery only, and group 2 (31 females, 2 males) was treated with orthognathic surgery concomitantly with TMJ disc repositioning using the Mitek Mini Anchor technique. Lateral cephalograms were evaluated; initial evaluation (T1), presurgery (T2), immediate postsurgery (T3), and longest follow-up (T4). Measurements included 1) condylion to superior screw (Co-SS), 2) condylion to gonion (Co-Go), 3) condylion to B point (Co-B), 4) distance from perpendicular line to FH through sella, to B point (SP-B), 5) mandibular plane (MP), and 6) occlusal plane (OP). Also for the patients in group 2, objective and VAS scores for subjective parameters were included: maximal incisal opening (MIO) and lateral excursions (LE), TMJ pain, jaw function, and diet. For statistical analysis, Pearson correlation and t test were used. Results: Total sample average age was 19.3 years (R 11-43). Sixty-six percent of the cases were between the ages of 11 and 19 years. Group 1 average age was 19.4 years and group 2 average age was 19.3 years. Average follow-up for group 1 was 37 months (R 14-60) and for group 2 was 25.5 months (R 12-86). There was no significant difference presurgery (T1-T2) and for surgical changes (T2-T3) for any of the parameters between the 2 groups. ICR continued after orthognathic surgery in group 1; there was a statistically significant decrease (P ⬍ .01) in Co-SS, Co-Go, Co-B, and SP-B and a statistically significant increase (P ⬍ .05) in MP and OP from T3 to T4. In group 2 patients, ICR was arrested and orthognathic surgery results remained stable at longterm follow-up; with no statistically significant changes for any of the cephalometric measurements from T3 to T4. Group 2 subjective evaluation showed a statistically significant decrease in TMJ pain and improvement in jaw function and diet. There were no changes in MIO but there was a statistically significant decrease in lateral excursions between T2 and T4. Conclusions: The results of this study show that treatment of ICR with TMJ disc repositioning using the Mitek Mini Anchor concomitantly with orthognathic surgery has a highly predictable outcome. Correcting the TMJ AAOMS • 2002

disc displacement before or concomitantly with orthognathic surgery is recommended to aid in the stability of the surgical outcome in treating ICR. References Wolford LM, Cardenas L: Idiopathic condylar resorption: Diagnosis, treatment protocol, and outcomes. Am J Orthod Dentofacial Orthop 116:667, 1999 Arnett GW, Milam SB, Gottesman L: Progressive mandibular retrusion—idiopathic condylar resorption. Part I. Am J Orthod Dentofacial Orthop 110:8, 1996

The Relationship Between Arthroscopically Diagnosed Temporomandibular Joint Synovitis and Adhesions Michael D. Singer, DMD, 1320 York Ave, #25M, New York, NY 10021 (Howard Israel, DDS) Problem: Patients with severe limitation of mandibular opening and temporomandibular joint pain, whose symptoms are resistant to conservative therapy, commonly undergo temporomandibular joint arthroscopy. In the past, internal derangement was a common diagnosis and thought to be a major cause of these symptoms. However, recent studies have demonstrated that internal derangement is common in asymptomatic individuals and may not be a major cause of symptoms in patients with severe temporomandibular disorders. Synovial fluid analysis studies have shown elevated levels of inflammatory mediators in painful temporomandibular joints that have undergone arthroscopy. This suggests that synovitis is a major pathologic entity in patients with severe symptoms. Furthermore, it has been our clinical arthroscopic experience that significant synovial inflammation is often accompanied by adhesions, particularly in the posterior recess of the superior joint space. Orthopedic studies on other synovial joints have shown that joint immobilization is accompanied by the formation of intra-articular adhesions. The purpose of this investigation was to determine if there was a relationship between arthroscopically diagnosed synovitis and adhesions in a population of patients with significant limitation of mandibular opening and temporomandibular joint pain. Materials and Methods: The study population included 80 patients with severe temporomandibular joint disease, recalcitrant to conservative therapy, who underwent arthroscopic surgery at New York Presbyterian Hospital over a 4-year period. Arthroscopic TMJ surgery was performed on 126 joints, and each joint was assessed diagnostically for the presence of synovitis and adhesions, immediately before operative treatment. Numerous dilated tortuous blood vessels, erythema, and edema of the synovial membrane characterized the presence of synovitis. Adhesions were characterized as fi53

Oral Abstract Session 7: Temporomandibular Joints brous bands of tissue attached to the synovial membrane and were either present or absent in the superior joint space. Chi square analysis was used to determine if there was a significant relationship between the arthroscopic presence of synovitis and adhesions. Results: Arthroscopic examination of 126 temporomandibular joints in patients with severe pain and limitation of mandibular function demonstrated the following: no synovitis and no adhesions in 18 of 126 joints (14%), no synovitis with adhesions in 33 joints (26%), synovitis with no adhesions in 13 joints (10%), and synovitis with adhesions in 62 joints (49%). The chi-square analysis showed a significant relationship between arthroscopically diagnosed synovitis and adhesions (P ⬍ .05). Conclusions: Synovitis and adhesions are commonly present in temporomandibular joints of patients who undergo arthroscopy. There is a significant relationship between the presence of synovial inflammation and adhesions in this patient population. The results of this investigation suggest that the severe symptoms of temporomandibular joint pain with limitation of joint motion are likely to be exacerbated by the combination of synovitis and adhesions. References Quinn JH, Bazan MD: Identification of prostaglandin E2 and leukotriene B4 in the synovial fluid of painful, dysfunctional temporomandibular joints. J Oral Maxillofac Surg 48:968, 1990 Akeson WH, Amiel D, Abel MF, et al: Effects of immobilization on joints. Clin Orthop 219:28, 1987

Outcome Assessment Following Simultaneous Orthognathic and TMJ Surgery Eber Stevao, DDS, PhD, 3409 Worth St, Suite 400, Dallas, TX 75246 (Carlos A. Morales-Ryan, DDS, MSD; Larry M. Wolford, DMD; Michael J. Downie, DDS, MD) (Oral Abstract accepted for presentation at 2001 Annual Meeting. Please refer to August 2001 Supplement No. 1 to the Journal of Oral and Maxillofacial Surgery for abstract.)

Purpose: The purpose of this study was the assessment of the long-term safety and effectiveness of the Techmedica (Camarillo, CA) CAD/CAM Total Temporomandibular Joint Reconstruction System (now called the TMJ Concepts Patient Fitted Total Temporomandibular Joint Reconstruction System; Ventura, CA). Patients and Methods: A survey was mailed to the available addresses of 170 (79%) of the 215 patients who had been implanted with the Techmedica System devices between 1990 and 1994. Seventy-nine (46%) surveys were returned by the US Postal Service as undeliverable. Three (3) patients (1.4%) were reported as deceased in returns from relatives. Therefore, of the remaining 91 possible responses, 60 (65.9%) were returned. Fifty-eight surveys, considered complete and valid (96.7%), representing 97 (39 bilateral, 19 unilateral) devices with a mean follow-up of 107.4 (⫾15.5) (range, 60 to 120) months, were analyzed. Subjective data related to pain, mandibular function, diet consistency, and present quality of life were collected using visual analog scales. Objective measures of mandibular interincisal opening and lateral excursions were obtained from direct measurements using the Therabite (Philadelphia, PA) measuring scale provided in the survey with instructions as to its use. Results: Analysis of the subjective data at 10 years revealed a 76% reduction in mean pain scores and a 68% increase in mean mandibular function and diet consistency scores (P ⬍ .0001). Analysis of objective data revealed a 30% improvement in mandibular range of motion after 10 years (P ⫽ .0009). Long-term quality of life improvement scores were statistically related to the number of prior temporomandibular joint operations the patients had undergone. Conclusion: These data indicate that the CAD/CAM Patient Fitted Total Temporomandibular Joint Reconstruction System has proven to be a safe and effective long-term management modality in the patient population surveyed for this study. References

Long-Term Follow-Up Study of a PatientFitted Allolastic TMJ Reconstruction System Andres Herrera, DDS, Loyola University Medical Center, 2160 S First Ave, 105-1814, Maywood, IL 60153 (Louis G. Mercuri, DDS, MS; Anita GiobbeHurder, MS)

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Mercuri LG, Wolford LM, Sanders B, et al: Custom CAD/CAM total temporomandibular joint reconstruction system: Preliminary multicenter report. J Oral Maxillofac Surg 53:106, 1995 Mercuri LG: The TMJ concepts patient fitted total temporomandibular joint reconstruction prosthesis. Oral Maxillofac Surg Clin North Am 12:73, 2000

Funding Source: TMJ Concepts.

AAOMS • 2002