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Comparative Study of Inferior Versus Superior Joint Space Injection of Sodium Hyaluronate in Patients With Anterior Disc Displacement Without Reduction of the Temporomandibular Joint: A Randomized Controlled Trial
Oral Abstract Session 5 2.7 ⫾ 1.4 mm. All linear measurements showed significant surgical changes, but remained stable at long-term follow-up. All 15 patients had statistically significant reduction in the incidence and severity of facial pain and headaches (61.5%), and TMJ pain (100%). There was significant improvement of jaw function (63.3%), dietary restrictions (57.9%) and disability (60%). There was significant reduction post surgery of average MIO (9.2%) and lateral excursions (right side 37.5% and left side 30.8%). Conclusions: Conservative condylectomy with recontouring of the residual condylar neck to function as a condyle and repositioning of the articular disc is a viable option for treatment of osteochondromas of the mandibular condyle. The use of this method of treatment permits effective removal of the tumor (no recurrence of the tumor was encountered in any of the cases) and eliminates the need for autogenous grafts or total joint prostheses for temporomandibular joint reconstruction. The significant long-term stability of TMJ and orthognathic surgery movements and significant reduction of TMJ dysfunction and pain symptoms demonstrate the benefits and predictability of managing these complex patients with this treatment protocol. References Wolford LM, Mehra P, Franco P: Use of Conservative Condylectomy for Treatment of Osteochondroma of the Mandibular Condyle. J Oral Maxillofac Surg 60:262-268, 2002 Ribas MdeO, Martins WD, de Souza MH, Zanferrari FL, Lanzoni T: Osteochondroma of the mandibular condyle: literature review and report of a case. J Contemp Dent Pract 8:52-59, 2007
of lateral pterigoid muscle attachments, myotomy and electrocautery, motor debridement, injection of sodium hialuronate, and meniscal suture were performed within the whole series. Two-hundred and fifty-seven patients (344 joints) fulfilled the inclusion criteria for CCL of the TMJ: 1) clinical diagnosis of CCL of the TMJ (previous clicking of the TMJ replaced by pain in the TMJ and limitation of vertical and horizontal mandible movements); 2) unsuccessful nonsurgical treatment for at least 3 months; 3) MIO minor than 35 mm; and 4) unilateral or bilateral involvement. Results: Mean age of the series was 30.24 years. Two hundred and thirty seven patients (92.2%) were female and 20 (7.8 %) male. Mean pre-operative visual analogue scale (VAS) score for evaluation of TMJ pain was 53.21 ⫾ 23.02 for the whole series. Mean MIO was 24.75 ⫾ 4.89 mm for the whole series. Following arthroscopy, a significant decrease in TMJ pain was achieved (p⬍0.0001). In relation to MIO, mandibular protrusion and lateral excursion movements, a significant increase of mean values was observed following surgery (p⬍0.0001). No statistical differences were observed between arthroscopic lysis and lavage and operative arthroscopy in relation to post-operative pain or MIO at any time of the follow-up period. Conclusion: Arthroscopy is a useful method for the treatment of TMJ pain and limited mandibular function. It should be considered as a first-line method for the treatment of CCL of the TMJ. Arthroscopic lysis and lavage and operative arthroscopy seems to be equally effective for the treatment of CCL of the TMJ. References
Arthroscopy Surgery for the Treatment of Chronic Closed Lock of the Temporomandibular Joint: A Clinical Study in 344 Arthroscopic Procedures Raul Gonza´lez-Garcı´a, MD, Calle Los Ye´benes 35, 8C, Madrid, 28047 Spain (Monje F; Rodrı´guez-Campo FJ; Gil-Dı´ez Usandizaga JL) Background: Chronic closed lock (CCL) of the temporomandibular joint is the result of an internal derangement of the joint subsequent to disc displacement without reduction. Arthroscopic surgery has been reported to decrease pain in relation to the TMJ improving maximal interincisal opening (MIO). Although it has been reported as a reliable and minimally invasive method for the treatment of CCL, large series are still absent. Patients and methods: Five-hundred consecutive patients (670 joints) with TMJ derangement who underwent temporomandibular arthroscopy between 1995 and 2004 were retrospectively analyzed. All the patients were classified as II to V according to Wilkes. Lysis and lavage, electrocautery of the posterior ligament, injection of corticoids, injection of ethanolamine, myotomy AAOMS • 2008
Homlund A, Gynther G, Axelsson S. Efficacy of arthroscopic lysis and lavage in patients with chronic locking of the temporomandibular joint. Int Oral Maxillofac Surg 1994;23:262 Murakami K, Hosaka H, Moriya Y, Segami N, Iizuka T. Short-term treatment outcome study for the management of temporomandibular joint closed lock. A comparison of arthrocentesis to nonsurgical therapy and arthroscopic lysis and lavage. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;80:253-7 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;34:231-7
Comparative Study of Inferior Versus Superior Joint Space Injection of Sodium Hyaluronate in Patients With Anterior Disc Displacement Without Reduction of the Temporomandibular Joint: A Randomized Controlled Trial Xing Long, DDS, PhD, No237 Luo Yu Road, Wuhan, Hubei, 430079, China (Deng M; Cheng Y; Cai HX; Mong QG) Aims: To compare the outcome of inferior versus superior joint space injection of sodium hyaluronate in 65
Oral Abstract Session 5 patients with disc displacement without reduction of the temporomandibular joint (TMJ). Methods: 120 patients with a symptomatic disc displacement without reduction that did not respond to a conservative therapy were recruited. They were randomly assigned into two groups. One group of patients received three injections of sodium hyaluronate in the superior joint space and the other one in the inferior joint space. Patient’s TMJ status and clinical symptoms were evaluated at 3 and 6 months follow-up. The clinical parameters recorded were maximal mouth opening (MMO), pain intensity on a visual analogue scale (VAS), and a modified Helkimo’s clinical dysfunction index. The results were analyzed with ANCOVA. Results: 50 patients of the superior and 54 of the joint space injection group attended the follow up appointments. MMO, VAS and Helkimo’s index improved at the 3 months and 6 months follow-up appointments in both groups. At the 3 months follow-up the improvement in TMJ pain was significantly larger in the inferior than in the superior injection group (p⬍0.001), while the improvements in MMO and TMJ function were similar. At the 6 months follow-up the improvements in MMO (p⬍0.005), VAS (p⬍0.001) and Helkimo’s index (p⬍0.001) were significantly larger in the inferior than the superior joint injection group. Conclusion: This study demonstrated that the inferior joint space injection with sodium hyaluronate is a valid method for the treatment of disc displacement without reduction and should therefore be considered as a treatment modality as it appears to give patients a better long term clinical outcome than the superior joint space injection.
Zoledronic Acid Disrupts VEGFR2 Intracellular Trafficking in Endothelial Cells David L. Basi, DMD, PhD, University of Minnesota, 515 Delaware Street SE, 7-174 Moos Tower, Minneapolis, MN 55455 (Mariash A) Statement of the Problem: Long-term use of nitrogencontaining bisphosphonates (n-BISs) are associated with jaw necrosis. Tooth extraction is the most frequent precipitating factor. Proper healing after tooth extraction requires angiogenesis, which is inhibited by n-BIS in vitro and in vivo. Vascular endothelial growth factor (VEGF) is a potent pro-angiogenic signal for endothelial cells. N-BIS inhibit VEGF responses in endothelial cells (2). The molecular mechanism(s) that account for these attenuated responses to VEGF are not known. VEGF receptor-2 (VEGFR2) is the main signaling receptor for VEGF in endothelial cells. Control of VEGF signaling involves VEGFR2 internalization and intracellular trafficking. Caveolae-mediated endocytosis is a recognized 66
means of VEGFR2 internalization. Caveolin-1 is the main protein component found within caveolae and mediates VEGFR2 endocytosis and VEGFR2 signal transduction. Caveolin-1-mediated VEGFR2 endocytosis within endothelial cells is not completely understood but involves guanosine triphosphate (GTPase). These GTPases are inhibited by n-BIS. We, therefore, hypothesize that n-BIS disrupts VEGFR2 trafficking in endothelial cells. Materials and Methods: We investigated the effect of zoledronic acid (ZOL), a n-BIS, on caveolin-1-mediated VEGFR2 trafficking in treated human umbilical vein endothelial cells (HUVECs) using confocal microscopy, western blotting and real-time PCR (RT-PCR). Results: HUVECs treated with 12.5M ZOL for 48 hrs demonstrated a statistically significant increase in the percent of Caveolin-1 colocalized with VEGFR2 (p⫽0.0001) compared to non-treated cells. In addition, the quantity of VEGFR2/cell increased with ZOL treatment (p⫽0.015). Western blotting confirmed that 48hrs of ZOL treatment significantly increased the total amount of VEGFR2 (p⫽0.004) and caveolin-1 (p⫽0.004) protein in HUVECs compared to non-treated cells. To determine if ZOL increased the quantity of VEGFR2 or caveolin-1 protein by induction of VEGFR2- or Caveolin1-specific mRNA, we incubated endothelial cells with or without 12.5M ZOL for 2, 4, 24 and 48hrs and then analyzed the isolated RNA for VEGFR2- and caveolin-1specific mRNA by RT-PCR. We found that the relative amount of VEGFR2- or Caveolin-1-specific mRNA was not significantly increased by 12.5M ZOL at the time points tested. N-BIS prevents the formation of geranylgeranyl pyrophosphate by inhibiting farnesyl pyrophosphate synthase within the mevalonate pathway (1). Geranylgeranyl pyrophosphate is required for the prenylation and subsequent membrane targeting of small GTPases. Because GTPases are involved in endocytosis and we theorize that VEGFR2 trafficking is altered by ZOL, we hypothesized that ZOL inhibition of the mevalonate pathway is involved with increased caveolin-1 and VEGFR2 colocalization. Therefore, we treated HUVEC cultures with 12.5 M ZOL and/or 2 M geranylgeranyl pyrophosphate for 48hrs, then assessed for VEGFR2 and caveolin-1 colocalization by confocal microscopy. The addition of geranylgeranyl pyrophosphate to ZOL treated HUVECs reduced (p⫽0.0001) the percent of caveolin-1 colocalized with VEGFR2 and the accumulation of VEGFR2 within HUVECs during ZOL treatment. Statistical Method: 2- and 1-way ANOVAs with Tukey multiple comparison adjustments. Differences were considered significant at the 0.05 level. Conclusions: The data suggests that the increased Caveolin-1/VEGFR2 interactions are due to an accumulation of VEGFR2 and Caveolin-1 within the ZOL-treated endothelial cells. Furthermore, this ZOL-induced aberrant VEGFR2 accumulation and interaction with caveoAAOMS • 2008
of lateral pterigoid muscle attachments, myotomy and electrocautery, motor debridement, injection of sodium hialuronate, and meniscal suture were performed within the whole series. Two-hundred and fifty-seven patients (344 joints) fulfilled the inclusion criteria for CCL of the TMJ: 1) clinical diagnosis of CCL of the TMJ (previous clicking of the TMJ replaced by pain in the TMJ and limitation of vertical and horizontal mandible movements); 2) unsuccessful nonsurgical treatment for at least 3 months; 3) MIO minor than 35 mm; and 4) unilateral or bilateral involvement. Results: Mean age of the series was 30.24 years. Two hundred and thirty seven patients (92.2%) were female and 20 (7.8 %) male. Mean pre-operative visual analogue scale (VAS) score for evaluation of TMJ pain was 53.21 ⫾ 23.02 for the whole series. Mean MIO was 24.75 ⫾ 4.89 mm for the whole series. Following arthroscopy, a significant decrease in TMJ pain was achieved (p⬍0.0001). In relation to MIO, mandibular protrusion and lateral excursion movements, a significant increase of mean values was observed following surgery (p⬍0.0001). No statistical differences were observed between arthroscopic lysis and lavage and operative arthroscopy in relation to post-operative pain or MIO at any time of the follow-up period. Conclusion: Arthroscopy is a useful method for the treatment of TMJ pain and limited mandibular function. It should be considered as a first-line method for the treatment of CCL of the TMJ. Arthroscopic lysis and lavage and operative arthroscopy seems to be equally effective for the treatment of CCL of the TMJ. References
Arthroscopy Surgery for the Treatment of Chronic Closed Lock of the Temporomandibular Joint: A Clinical Study in 344 Arthroscopic Procedures Raul Gonza´lez-Garcı´a, MD, Calle Los Ye´benes 35, 8C, Madrid, 28047 Spain (Monje F; Rodrı´guez-Campo FJ; Gil-Dı´ez Usandizaga JL) Background: Chronic closed lock (CCL) of the temporomandibular joint is the result of an internal derangement of the joint subsequent to disc displacement without reduction. Arthroscopic surgery has been reported to decrease pain in relation to the TMJ improving maximal interincisal opening (MIO). Although it has been reported as a reliable and minimally invasive method for the treatment of CCL, large series are still absent. Patients and methods: Five-hundred consecutive patients (670 joints) with TMJ derangement who underwent temporomandibular arthroscopy between 1995 and 2004 were retrospectively analyzed. All the patients were classified as II to V according to Wilkes. Lysis and lavage, electrocautery of the posterior ligament, injection of corticoids, injection of ethanolamine, myotomy AAOMS • 2008
Homlund A, Gynther G, Axelsson S. Efficacy of arthroscopic lysis and lavage in patients with chronic locking of the temporomandibular joint. Int Oral Maxillofac Surg 1994;23:262 Murakami K, Hosaka H, Moriya Y, Segami N, Iizuka T. Short-term treatment outcome study for the management of temporomandibular joint closed lock. A comparison of arthrocentesis to nonsurgical therapy and arthroscopic lysis and lavage. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;80:253-7 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;34:231-7
Comparative Study of Inferior Versus Superior Joint Space Injection of Sodium Hyaluronate in Patients With Anterior Disc Displacement Without Reduction of the Temporomandibular Joint: A Randomized Controlled Trial Xing Long, DDS, PhD, No237 Luo Yu Road, Wuhan, Hubei, 430079, China (Deng M; Cheng Y; Cai HX; Mong QG) Aims: To compare the outcome of inferior versus superior joint space injection of sodium hyaluronate in 65
Oral Abstract Session 5 patients with disc displacement without reduction of the temporomandibular joint (TMJ). Methods: 120 patients with a symptomatic disc displacement without reduction that did not respond to a conservative therapy were recruited. They were randomly assigned into two groups. One group of patients received three injections of sodium hyaluronate in the superior joint space and the other one in the inferior joint space. Patient’s TMJ status and clinical symptoms were evaluated at 3 and 6 months follow-up. The clinical parameters recorded were maximal mouth opening (MMO), pain intensity on a visual analogue scale (VAS), and a modified Helkimo’s clinical dysfunction index. The results were analyzed with ANCOVA. Results: 50 patients of the superior and 54 of the joint space injection group attended the follow up appointments. MMO, VAS and Helkimo’s index improved at the 3 months and 6 months follow-up appointments in both groups. At the 3 months follow-up the improvement in TMJ pain was significantly larger in the inferior than in the superior injection group (p⬍0.001), while the improvements in MMO and TMJ function were similar. At the 6 months follow-up the improvements in MMO (p⬍0.005), VAS (p⬍0.001) and Helkimo’s index (p⬍0.001) were significantly larger in the inferior than the superior joint injection group. Conclusion: This study demonstrated that the inferior joint space injection with sodium hyaluronate is a valid method for the treatment of disc displacement without reduction and should therefore be considered as a treatment modality as it appears to give patients a better long term clinical outcome than the superior joint space injection.
Zoledronic Acid Disrupts VEGFR2 Intracellular Trafficking in Endothelial Cells David L. Basi, DMD, PhD, University of Minnesota, 515 Delaware Street SE, 7-174 Moos Tower, Minneapolis, MN 55455 (Mariash A) Statement of the Problem: Long-term use of nitrogencontaining bisphosphonates (n-BISs) are associated with jaw necrosis. Tooth extraction is the most frequent precipitating factor. Proper healing after tooth extraction requires angiogenesis, which is inhibited by n-BIS in vitro and in vivo. Vascular endothelial growth factor (VEGF) is a potent pro-angiogenic signal for endothelial cells. N-BIS inhibit VEGF responses in endothelial cells (2). The molecular mechanism(s) that account for these attenuated responses to VEGF are not known. VEGF receptor-2 (VEGFR2) is the main signaling receptor for VEGF in endothelial cells. Control of VEGF signaling involves VEGFR2 internalization and intracellular trafficking. Caveolae-mediated endocytosis is a recognized 66
means of VEGFR2 internalization. Caveolin-1 is the main protein component found within caveolae and mediates VEGFR2 endocytosis and VEGFR2 signal transduction. Caveolin-1-mediated VEGFR2 endocytosis within endothelial cells is not completely understood but involves guanosine triphosphate (GTPase). These GTPases are inhibited by n-BIS. We, therefore, hypothesize that n-BIS disrupts VEGFR2 trafficking in endothelial cells. Materials and Methods: We investigated the effect of zoledronic acid (ZOL), a n-BIS, on caveolin-1-mediated VEGFR2 trafficking in treated human umbilical vein endothelial cells (HUVECs) using confocal microscopy, western blotting and real-time PCR (RT-PCR). Results: HUVECs treated with 12.5M ZOL for 48 hrs demonstrated a statistically significant increase in the percent of Caveolin-1 colocalized with VEGFR2 (p⫽0.0001) compared to non-treated cells. In addition, the quantity of VEGFR2/cell increased with ZOL treatment (p⫽0.015). Western blotting confirmed that 48hrs of ZOL treatment significantly increased the total amount of VEGFR2 (p⫽0.004) and caveolin-1 (p⫽0.004) protein in HUVECs compared to non-treated cells. To determine if ZOL increased the quantity of VEGFR2 or caveolin-1 protein by induction of VEGFR2- or Caveolin1-specific mRNA, we incubated endothelial cells with or without 12.5M ZOL for 2, 4, 24 and 48hrs and then analyzed the isolated RNA for VEGFR2- and caveolin-1specific mRNA by RT-PCR. We found that the relative amount of VEGFR2- or Caveolin-1-specific mRNA was not significantly increased by 12.5M ZOL at the time points tested. N-BIS prevents the formation of geranylgeranyl pyrophosphate by inhibiting farnesyl pyrophosphate synthase within the mevalonate pathway (1). Geranylgeranyl pyrophosphate is required for the prenylation and subsequent membrane targeting of small GTPases. Because GTPases are involved in endocytosis and we theorize that VEGFR2 trafficking is altered by ZOL, we hypothesized that ZOL inhibition of the mevalonate pathway is involved with increased caveolin-1 and VEGFR2 colocalization. Therefore, we treated HUVEC cultures with 12.5 M ZOL and/or 2 M geranylgeranyl pyrophosphate for 48hrs, then assessed for VEGFR2 and caveolin-1 colocalization by confocal microscopy. The addition of geranylgeranyl pyrophosphate to ZOL treated HUVECs reduced (p⫽0.0001) the percent of caveolin-1 colocalized with VEGFR2 and the accumulation of VEGFR2 within HUVECs during ZOL treatment. Statistical Method: 2- and 1-way ANOVAs with Tukey multiple comparison adjustments. Differences were considered significant at the 0.05 level. Conclusions: The data suggests that the increased Caveolin-1/VEGFR2 interactions are due to an accumulation of VEGFR2 and Caveolin-1 within the ZOL-treated endothelial cells. Furthermore, this ZOL-induced aberrant VEGFR2 accumulation and interaction with caveoAAOMS • 2008