A Retrospective Study of Patient Outcomes Following Temporomandibular Joint Replacement with Total Joint Prosthesis at Massachusetts General Hospital

Poster Session early detection of joint pathology. In the child population, such frequent imaging often mandates sedation in addition to increased cost and time when compared to other imaging modalities. Methods/ Data Analysis: In this review of the literature, the authors attempted to determine the current state of TMJ imaging in JIA patients, specifically with regard to the use of ultrasound (US) versus MRI for evaluation of acute and chronic joint changes. PubMed was searched for prospective studies using the terms ‘‘temporomandibular’’ or ‘‘TMJ’’ and ‘‘juvenile idiopathic arthritis’’ or ‘‘JIA’’ with 273 results. Of these, the authors excluded studies that were not prospective or did not involve US imaging of the TMJ. Twelve papers were identified that involved the use of US in the TMJ with some reference to patients with JIA. Results / Outcomes Data: Out of the 12 studies, five were specific to JIA. Of these five articles only two had an MRI comparison, and no pediatric study utilized dynamic US images. Additionally, many of the studies included patients with TMD and disc displacement rather than a strict rheumatologic condition (only 7/12 studies included patients with rheumatic diseases). In general, there were two types of studies using US. The first group studied low-resolution US (LR-US; defined as an US probe <12 MHz) and the second group studied high-resolution US (HR-US; defined as an US probe >12 MHz). Within the high-resolution group, some studies did not compare US in JIA patients to MRI or to a control group, and although other studies did compare US to MRI they did not compare JIA patients to a control group. There were no prospective studies comparing US and MRI in patients with JIA and healthy controls. For diagnosis of disc displacement, the overall sensitivity of HR-US compared to MRI ranged from 81%85.1%, specificity ranged from 66.7%-100%, and accuracy ranged from 79.4%-95%. For diagnosis of some degree of bony condylar destruction, the overall sensitivity of HRUS compared to MRI ranged from 67.3%-94%, specificity ranged from 26.3%-100%, and accuracy ranged from 55.9%-94%. Lastly, for joint effusion, the overall sensitivity of HR-US compared to MRI ranged from 81%-85.1%, specificity ranged from 66.7%-100%, and accuracy ranged from 79.4%-95%. Conclusions: Despite the variability between the studies leading to challenging comparisons, the authors feel that some conclusions can be made regarding US. First, it appears that dynamic imaging and HR-US improve sensitivity/specificity compared to static imaging and LRUS. Furthermore, with most reported US sensitivities and specificities in the range of 60-70%, it is clear that MRI currently remains the superior imaging modality. Nevertheless, we feel that the results were promising enough that it raises the question of whether US can supplement MRI, especially in cases like JIA where frequent imaging is required. Specifically, one study by Jank et al. illustrated the benefit of having a baseline MRI for improving US ace-406

curacy, as seen by the increase in sensitivity and specificity when comparing prospective and retrospective data. Additionally all studies reviewed were able to detect both acute and chronic TMJ changes with US. References: 1. Emshoff R, et al. The diagnostic value of ultrasonography to determine the temporomandibular joint disk position. OOOO. 1997;84(6):688-96 2. Jank S, et al.. High-resolution ultrasonography of the TMJ: helpful diagnostic approach for patients with TMJ disorders? J Craniomaxillofac Surg. 2001;29(6):366-71

POSTER 54 A Retrospective Study of Patient Outcomes Following Temporomandibular Joint Replacement with Total Joint Prosthesis at Massachusetts General Hospital R. Sahdev: Harvard School of Dental Medicine, Massachusetts General Hospital, N. Anderson, K. S. Nasir, S. Kim, D. A. Keith Background: Disorders of the temporomandibular joint (TMJ) occur frequently with a prevalence of between 15% and 18%. Total joint replacement (TJR) surgery is reserved for patients with end-stage TMJ disease with an original diagnosis of congenital abnormality, growth disorder, infection, fracture, tumor, arthritis, ankylosis, dislocation, internal derangement, and other conditions that have not responded to prior non-surgical or surgical treatments. Purpose: The aim of this study was to assess changes in pain and range of motion, as well as postoperative complications and comorbid factors in subjects undergoing alloplastic TMJ reconstruction at Massachusetts General Hospital (MGH). Methods: This study is a retrospective review that describes the clinical variables in 95 patients (85 females, 10 males; mean age 44, range 18-75) with a total of 177 reconstructed TMJs (41 unilateral, 68 bilateral surgeries) following total alloplastic TMJ reconstruction performed at MGH from 2000 to 2015. Clinical variables included primary and secondary diagnoses, duration of symptoms, previous surgeries, comorbidities, pre- and post-operative pain, pre-, intra- and post-operative range of motion and complications. Descriptive statistics and parametric paired t-tests were used to compare intra-patient range of motion and change in pain score. Independent t-tests were used to compare patients with and without exposure to Proplast-Teflon. One-way ANOVA were used for comparisons among patients with different primary diagnoses, pain, and range of motion categories. AAOMS  2017

Poster Session Results: Data was obtained from 95 patients (85 females, 10 males) with a total of 177 TJR (41 unilateral, 68 bilateral). The most common primary indication for TJR was recurrent fibrous or bony ankylosis (n=42) and inflammatory disease (n=39). Maximum inter-incisal opening improved by a mean of 7.1  11.13 mm and pain decreased by a mean of 1.5  3.32 points on the visual analogue scale. Transient facial nerve palsy (n=27) was the most common postoperative complication, however, long-term postoperative complications were rare. Twenty eight percent of the patients (n=23) had prior failed TMJ implant materials, specifically Proplast-Teflon (Vitek, Houston, TX), resulting in significant bony destruction. These patients were significantly older, and had smaller pre- and post-operative range of motion, compared to non Proplast-Teflon patients. Conclusion: Overall, patients gained a significant increase in range of motion and reduction in pain. TJR is an effective treatment option in patients with a broad range of end stage TMJ disorders and should be considered when other non-surgical and surgical treatments have failed or when non-surgical treatment is not indicated. References: 1. Mercuri LG, Giobbie-Hurder A. Long-term outcomes after total alloplastic temporomandibular joint reconstruction following exposure to failed materials. J Oral Maxillofac Surg. 2004. doi:10.1016/j.joms.2003.10.012 2. Johnson NR, Roberts MJ, Doi SA, Batstone MD. Total temporomandibular joint replacement prostheses: a systematic review and bias-adjusted meta-analysis. Int J Oral Maxillofac Surg. 2016;(1):1-7. doi:10.1016/j.ijom.2016.08.022

POSTER 55 Can a Senior Oral and Maxillofacial Surgery Resident Perform Temporomandibular Joint Surgery during and Following Training? M. R. Momin: University of Illinois at Chicago, M. Miloro, L. G. Mercuri, M. R. Markiewicz The purpose of this study was to sample senior level oral and maxillofacial surgery (OMS) residents’ opinions as to their preparation during residency for the diagnosis and management of temporomandibular joint (TMJ) disorders (TMD), exposure to various TMJ procedures, and confidence level to perform TMJ procedures upon completion of their program. Between December 2016 and January 2017, an email containing a survey questionnaire link (Qualtrics, Seattle, WA) was sent to all Program Directors of Commission on Dental Accreditation recognized OMS programs in the United States. They were asked to forward the survey link to their senior residents for completion. The survey AAOMS  2017

consisted of 20 multiple-choice questions, which included the demographics of the program, TMJ surgical procedure experience, confidence in performing TMJrelated surgical procedures, comfort level in managing TMD patients, and whether the resident perceived they received sufficient education and training in management of TMJ-related disorders. The data was collected and summarized using standard spreadsheet analysis, and appropriate descriptive and analytical tests, including principal component analysis, multiple correspondence analysis, regression model summary, decision tree analysis, and cluster analysis. Of the 56 total respondents, out of approximately 200 senior residents currently enrolled in CODA accredited OMS training programs (a 28.0% response rate), 52 (92.9%) stated they had received instruction in non-surgical management of TMD. Further, all respondents confirmed that TMJ surgical procedures were performed in their program. The most common surgical procedure performed with the highest mean rating (m = 3.11) was TMJ arthrocentesis followed by open joint surgery (m = 2.82). The least performed surgical procedure was autogenous total joint replacement surgery (m = 1.39). With regards to competency level, 80.4% of residents were comfortable managing TMJ-related cases, but the only surgical procedure that the residents were highly confident performing, both during and following training, was TMJ arthrocentesis (m = 3.89). This study provides information regarding the inadequacies of the education and training of OMS residents that may influence their confidence and willingness to evaluate and manage the patient with TMJ-related disorders following residency, leading to an access to such care issues nationwide. Based on this sample, it appears that confidence and competence levels may be correlated to TMJ management opportunities and experiences during residency. References: 1. Lotesto A, Miloro M, Mercuri LG, & Sukotjo C. (2016). Are Oral and Maxillofacial Surgery Residents Trained Adequately in Alloplastic Total Temporomandibular Joint Replacement? J Oral Maxillofac Surg, 74(4), 712-718. doi:10.1016/j.joms.2015.10.020 2. Elledge R, Speculand B, Green J, & Attard A. (2016). Training in surgery of the temporomandibular joint: perceptions of trainees in oral and maxillofacial surgery in the United Kingdom. Br J Oral Maxillofac Surg, 54(8), 941-945. doi:10.1016/j.bjoms.2016.06.020

POSTER 56 Utility of Synovial Biopsy for the Diagnosis of Inflammatory Temporomandibular Joint Arthritis B. Christensen: Louisiana State University Health Science Center, D. Choi, J. P. McCain The diagnosis of temporomandibular joint disorders has long been a challenge commonly encountered by e-407