Internal derangement of the temporomandibular joint: an audit of clinical findings, arthrography and surgical treatment

Internal derangement of the temporomandibular joint: an audit of clinical findings, arthrography and surgical treatment W.

P. Smith,

Department

A. F. Markus of Oral & Maxillofacial Surgery,

Poole General

Hospital,

Poole

SUMMARY. Forty seven patients who underwent double contrast video-arthrography followed hy surgery for internal derangement of the temporomandibular joint were reviewed retrospectively. Of the 50 joints assessed, arthrography demonstrated 39 (78%) with irreducible meniscal’displacement and 11 (22%) with reducible displacement. Clinical findings were found to be unreliable in demonstrating the degree of internal derangement: 49% of irreducible meniscal displacements presented with clicking and only 20% with loss of click. The importance of video-arthrography is emphasised. Surgery for internal derangement proved successful. It is proposed that patients who have clinical evidence suggestive of irreducible meniscal displacement and have disabling symptoms should undergo early video-arthrography and be offered surgical correction.

is commonly cited. In the past, this conservative approach may have been so long term as to drive patients away from active treatment of organic disease. either to live with their symptoms (Moloney, 1986) or to seek treatment for the secondary effects of long term pain. Persistent pre-auricular pain, especially in association with limitation of jaw and arthrographically demonstrable movement internal derangement is considered by some to bc an indication for surgery (Gundlach, 1990; Ryan et al., 1990). The aims of the study wcrc to correlate clinical. arthrographic and surgical findings. thereby reassessing the need for arthrography, evaluate retrospectively the outcome of surgery for internal derangement of the temporomandibular joint and propose a surgical management protocol for internal derangement.

INTRODUCTION Internal derangement of the temporomandibular joint can be defined as a spectrum of progressive pathological alterations due to disruption of mcnisco-condylar function (Greenwood, 1989). It commonly results in meniscal displacement but also includes mcniscal tears, perforations and secondary degenerative changes of the condylar articular surface. The management of internal derangement is mainly’ conservative (Mcjersjo & Carlsson, 1983). success is dependent on obtaining a Ilowever. correct diagnosis. demonstrating organic disease within the joint and then performing the correct treatment (Nelson & Hutton, 1981). Accurate diagnosis requires soft tissue imaging. This is possible using double contrast video-arthrography (WcstessonI 1983) which remains a valuable invcstigation for internal derangement (Helms & Kaplan. 1990; Norman & Bramley, 1990). Although very accurate (Bronstein et af., 19Sl), it is an invasive, often uncomfortable procedure which requires specialist training and facilities. The clinical and pathological changes of internal derangement have been extensively documented (Farrar & McCarty, 1979; Eriksson & Wcstesson, 1983; Moloncy, 1985; Wilkes, 1989). There is an association between reciprocal clicking with reducible meniscal displacement and between loss of click and limited mouth opening with irreducible displacement. Furthermore, the latter disorder may. with the progress of time, exhibit signs of progressive secondary arthritic disease. The indications for surgery to correct internal derangement of the temporomandibular joint remains a contentious issue. Failed conservative treatment, sometimes drawn out over several years

MATERIALS

AND METHODS

Forty seven patients who had undergone vidcoarthrography for suspected internal derangement of the tcmporomandibular joint were reviewed rctrospectively following surgical treatment. Three patients undcrwcnt bilateral operations constituting a total of 50 joints. ‘The patients were assessed in terms of age. sex and the correlation of prcand surgical clinical, arthrographic operative findings. IndLations for video-arthrography arc well documented (Ogus & Toiler, 1986; Helms & Kaplan, 1990; Norman 8r Bramlcy, 1990), but in this study wcrc: 1. Failed conservative treatment 377

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2. Clinical evidence of irreducible mcniscal displacement 3. Symptoms and signs of internal derangement were inconsistent Indicdtions for surgical exploration have been documented above. In this study, the indications for surgery were based on arthrographic findings of: 1. Irreducible meniscal displacement with: (i) Limitation of mouth opening (ii) Disabling prc-auricular pain (iii) Painful crepitus and associated tenderness (iv) Failed conservative treatment 2. Kcducible meniscal displacement which failed to respond to conservative treatment Absolute contra-indications to surgery wcrc painless clicking. pain as an isolated finding and normal video-arthrography.

FEMALE

I4

cl-

12

?? -

16-24

2S-34

35-44 ALE

4!i-S4

RANGE

55-64

YALE

90v.r

65

I

(YEARS)

Fig. I - hgc and sex distrihution of patients undergoing surgery for internal dcrangcment of the tcmporomandihular joint.

Surgical technique The temporomandibular joint was opened via the modified prc-auricular approach of Al-Kayat & Bramlcy (1979). Both joint spaces wcrc entered using a horizontal incision in the capsule and the meniscus located. Meniscus retrieval was achicvcd by blunt dissection and once mobiliscd to its normal position, interrupted 4/O silk sutures were placed through the lateral aspect of the meniscus and lateral capsular tissue to immobilise it (mcniscopcxy). In a few cases where meniscus repositioning was not possible due to dense, inaccessible adhesions, a high condylcctomy was performed. The articular surface of the condylc was inspected in every cast. A high condylcctomy (a limited excision of the diseased condylar head with contouring of the condylar stump) was also performed whenever marked dcgcncrative disease was visible. Hence, in some joints. a mcniscopexy and high condylectomy were required. Closure was performed in layers. after hacmostasis had been achieved using bipolar diathermy. No drains were inserted but an effective pressure dressing applied for 24 to 48 hours. ‘l‘hc follow-up period varied from 1 to 5 years. Patients were recalled for clinical examination and each joint assessed. The parameters examined were joint clicking, alleviation of prc-auricular pain (by WC of a pre- and postoperative visual analogue scale). locking and improvement of mouth opening. Locking implied a periodic inability to open the jaw fully until a manocuvrc allowed the patient to pass an apparent mechanical stop.

RESULTS

Age and sex The age and XX distribution are shown in Figure 1. .l‘hirty eight patients (81%) were female and nine (19%) wcrc male. The average age of the patient with osteoarthrosis was 52 years (range 29 to 77 years) in contrast to 36 years (range 17 to 45 years) for joints without ostcoarthrosis.

LATE CLICK

EARLY CLICK

Fig. 2- Principal prc-operative mcniscal displacement.

clinical findings in reducible

Clinical and wthrographic findings Fifty joints were examined. Eleven joints (22%) had reducible meniscal displacement and 39 (78%) irrcducible meniscal displaccmcnt. The pre-operative clinical findings in reducible and irreducible meniscal displacement are shown in Figures 2 and 3. In patients with radiographic evidence of osteoarthrosis, crepitus (53%) and a late click (47%) were the principal clinical findings. In addition, locking occurred in 25 (53%) patients. In this group, 20 patients had irreducible displacement and five patients had reducible displacement. In both types of meniscal displacement, a late click was the principal clinical finding associated with locking (16 patients). Inter-incisal distance was also assessed. In the reducible group. the mean distance was 30 mm (range 1.5 to 4.5 mm) whereas in the irreducible group, the mean distance was 23 mm (range 15 to 37 mm).

Internal

dcranoement

of the tcmnoromandihul;~r

medially. One meniscus thus removed.

41%

had extensive

ioint

379

tears and was

Osteoorthrosis. Fifteen (30%) condylar heads had macroscopic evidence of ostcoarthrosis. Thirteen (87%) of the joints with osteoarthrosis had concomitant irreducible meniscal displaccmcnt. The proccdurcs carried out and the results of surgery arc shown in Tables I and 2. Surgery also improved mouth opening to a mean of 36 mm (range 30 to 45 mm) in the reducible group and a mean 01 38 mm (range 28 to 50 mm) in the irreducible group. Success in increasing mouth opening was exprcsscd as a percentage which was calculated for each patient and a mean value obtained, as shown in Table 2.

LATE CLICK

LOSS OF CLICK

DISCUSSION

Fig. 3 - Principal pre-operative meniscal displacement.

Table 1 -Distribution internal derangcmcnt

clinical findings in irrcduciblc

of surgical procedures performed of the temporomandihular joint Reducible displacement

Operation

for

Irreducible displacement

_Mcniscopexy Iligh condylectomy Mcniscopexyhigh condylectomy Meniscectomy

I5 IO

x

I 2 0

I3

I

II

Total

30

Table 2 - Overall success rate of surgery for internal derangement of the tcmporomandibular joint

Clinical

findings .-..

Pain Locking Elimination of clicWcrepitus Mouth opening (“Aa incrcasc)

Reducible group (n-11)

Irreducible group (n-30) __-

% Success

‘%> Success

86 loo 82 20

92

100 83 65

Surgical findings Reducible meniscal displacement. The principal indications for surgery in this group (n=ll) wcrc failed conservative treatment of mechanical locking (n=.5) and increasingly painful clicking (n=6). In the 11 joints explored, every meniscus was hypermobilc when traction was applied. No adhesions wcrc noted with reducible displacement. Irreducible meniscal displacement. The principal indications for surgery in this group (n=39) were locking, painful clicking or crepitus and limitation of mouth opening. These findings occurred singly (49%) or in combination (51%). In the 39 joints every meniscus was displaced antcroexplored,

The results of this study demonstrated that clinical findings alone were unreliable indicators of the precise nature and extent of internal derangement of the tcmporomandibular joint. In particular, 49% of casts with arthrographically demonstrable irreduciblc displaccmcnt presented with tither an early or late click and only 20% with a history of loss of click. The unreliability of clinical findings as a consistent indicator of the type and degree of internal dcrangemcnt has important implications in both the diagnosis and management of this disorder. It highlights the value of video-arthrography in obtaining an accurate pre-operative diagnosis and contradicts those studies (Schwartz & Kendrick, 1984; Moloney. 1985; Lessin & Goss, 19X9) where clinical signs alone were considered adequate for an accurate diagnosis. Furthermore, Leopard (1984). without using prc-operative arthrography, reported 36% of temporomandibular joints with clinical evidence of internal derangement had a normal meniscal position. Anderson et al. (1989) reported the difficulty in distinguishing on clinical findings. normal joints from those of chronic irreducible mcniscal displacement. We found video-arthography to bc csscntial in demonstrating the degree of pathological change within the temporomandibular joint. Various techniques of TMJ arthrography have been described. Kyan ef al. (1990) advocated simple lower joint space arthrography but admitted to finding most adhesions in the upper joint space at operation. The prcscnt study used double contrast video-arthrography as advocated by Wcstcsson (19X3). This technique proved highly successful and reproducible with a 100% correlation with surgical findings. I-Iowcver. despite its clarity. it was not able to demonstrate adhesions in cithcr joint Presumably, injected contrast medium is space. supcrimposcd upon the images produced by these adhesions. The management of internal dcrangcment is often conscrvativc, there being a wide variety of different methods (Ogus 8r ‘l‘ollcr, 1986). Majcrsjo and Carlsson (1983) rcportcd a longtcrm success rate of XC)‘%,I lowcvcr. Green and Laskin (198X) proposed

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that no anatomical mechanism cxistcd for the retraction of the irreducibly anteriorly displaced meniscus to its normal position. It could. therefore, be argued that conservative therapy will not be successful for such derangement. Kirk and Calabresc (1989) demonstrated, with the use of arthrography. that a 86% success rate for conservative treatment was achieved in those patients with early or reducible internal derangement of the meniscus, but that there was only a 7% success rate with an irreducible displacement. The indications for surgery have been described above. Surgery was performed predominantly on joints where there was arthrographic evidence of irreducible displacement. The results obtained demonstrated a high success rate comparable to other studies (Moloncy, 1985; Gundlach. 1990). The technique of meniscal retrieval and suture (meniscopexy) as advocated by Leopard (1984) appears successful. It would seem that in these patients who underwent surgery: the high success rate could be attributed to the correct prc-opcrativc diagnosis having been established at an early stage from both clinical and arthrographic data. Although conservative methods remain the mainstay of treatment for internal derangement, the results of this study indicate that patients who present with clinical evidence suggestive of irreducible displacement should not undergo protracted conservative treatment. Video-arthrography requested at the time of initial consultation will confirm, or refute, the clinical diagnosis. Thcsc patients can be offered surgery in the knowledge that this will result in a rapid resolution of their disabling temporomandibular joint symptoms. rather than undergo protracted and often unsucccssful courses of conservative therapy. Such is the inconsistency of clinical symptoms alone as an accurate guide to the most effective management of internal derangement that there is a good case to be made for routine arthrography to be carried out, except in those patients with the mildest of symptoms relating to internal derangement. Acknowledgements The authors wish to thank Dr D Shepherd. Consultant Radiologist. Royal Victoria Hospital. Boscombe, for performing the \,idco-arthrogr;lplly. They would also like to thank The Dcpartmcnt of Medical Photography at Poole General Hospital for the illustrations and Mrs Vc.lda J. Jackson for typing the manuscript.

References Al-Kayat. A. & Bramlcy. P. (1979). A modified prc-auricular approach to the temporomandibular joint and malar arch. Rrirish Journal of&al Surgery. 17. 91. Anderson. G. C.. Schiffman. E. I.... Schcllas. K. P. & Friction, J. R. (1989). Clinical v’s arthrographic diagnosis of T.M.J. internal derangement. Journal of Den/al Re.seurch. 68. X26. Bronstcin. S. L.. Tomasctti. H. J. Xr Ryan. I>. E. (19X1). Internal derangements of the tcmporomandibul~Ir joint: correlation of arthrography with surgical findings. Jortrncr/ofOrcr(Surg~r~. 39.572. Erikkson. 1.. c(: Westcsson. P-L. (1Y83). Clinical and radiological study of patients with anterior disc displacement of the temporomandibul;lr joint. Swcdi.sh Den/a/Journal. 7, 55. Farrar. W. B. K: McCarty. W’. I_. (lY7Y). Inferior joint space arthro?raphy and characteristics ofcondylar path\ in internal

derangements of the ‘f.M.J. Journal of Prosthetic Denriqy. 41. SIX.
The Authors W. P. Smith FDSRCS,

FRCS Registrar A. F. Markus FDSRCPS Consultant Department of Oral and Maxillofacial Poole Gcncral I lospilal I .ongflcct Road Poole BHlS 2JR Corrcspondcncc

Surecry

and rcqucsts for ottprints lo Mr A. i-. Markus

Paper rcceivcd 28 March Accepted 4 July 1991

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