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Patho-anatomic position of nerves and vessels in the infratemporal fossa—a guide to surgical approach to the temporomandibular region
1068
TMJ
transverse scans. The findings of ultrasonography study were found to be consistent with magnetic resonance imaging study. Conclusion: Ultrasonography is a very affective, easy, economical and patient friendly diagnostic aid for patient with temporomandibular joint disorders with no adverse effects of radiation when compared to other diagnostic methods like computer tomography and magnetic resonance imaging.
considerable amounts of IL-1 beta were detected in the synovial fluid of the patients. Conclusion: Mandibular fractures can be a possible etiologic factor in cartilage destruction, biochemical and intra-articular pathology. Increased levels of IL-1 beta could be potential catabolic marker for cartilage degradation in the TMJ. Clinicians should recognize the aetiologic importance of TMJ macrotrauma and importance of long-term evaluation of TMJ.
doi:10.1016/j.ijom.2007.08.397 doi:10.1016/j.ijom.2007.08.398
O16.23 Mandibular fractures as a possible aetiology in temporomandibular joint disorders A. Kumar*, S. M. Kotrashetti, M. Umarani Kle’s Institute of Dental Sciences, Kle’s University Belgaum-10, Karnataka, India Background and objective: Mandibular fractures in specific is the main type of TMJ macrotrauma. Malocclusion, unilateral mastication as well as bad oral habits including bruxism and clenching are included in the category of TMJ microtrauma the articular disc in TMJ has a primary function of stress distribution. Trauma has been thought to alter the mechanical properties of the disc. TMJ macrotrauma may cause degeneration of articular cartilage and production of the inflammatory and pain mediators. A series of cytokines and chemical mediators are reported to play a major role in various arthropathies, for example, rheumatoid arthritis and osteoarthritis of TMJ. Among them, typically IL-1 beta appears to be of importance in pathogenesis of synovitis and in cartilage damage in these joint diseases. IL-1 beta acts to induce the production of metalloproteinases that induce matrix degradation. The inflammatory and degenerative changes of TMJ can develop after mandibular fractures. Method: Analysis of TMJ status of 15 mandibular fracture patients were done for histomorphic examination, blood cell examination. The procedure of arthrocentesis and synovial fluid biochemical analysis for IL-1 beta (IL-1 beta ELISA kit) was also performed on the selected patients. Exclusion criteria included high condylar and neck fractures and known cases of degenerative joint disorder. Results and observation: On histomorphic examination, bloody smear, degenerated cells, cartilage, inflammatory cells and crystals were observed. In biochemical analysis
O16.24 ‘Pterygoid dysjunction’—a new minimally invasive technique for treatment of painful TMJ dysfunction S. V. Kannan*, A. Thangavelu Depatment of Dentistry, Pondicherry Institute of Medical Sciences (A Unit of Madras Medical Mission), Kalapet, Puducherry 14, India Pain of the temporomandibular joint was a riddle for a long time and postulates, hypothesis and theories abound the literature and still remains a puzzle, yet to be solved conclusively. Conservative treatment methods were widely accepted as the first line of management, though medical treatment may help to alleviate the pain from inflammation and gives symptomatic relief to the patient, it does not reverse the dysfunction due to disc and muscle problems. Many surgical procedures have been advocated, dropped and still research is going on to find logical and least traumatic method for management of TMJ dysfunction with pain. Here we are proposing a new minimally invasive technique ‘pterygoid dysjunction’ as a surgical management of TMJ dysfunction which cannot be categorized under any pathological classification, especially in the patients who complain of pain confining to the lateral pterygoid muscle on palpation, were subjected in to this procedure and the outcome was evaluated using computed tomography. Postoperative follow-up was done for 1 year and all of our patients were free of pain. This is an intraoral and minimally invasive technique and can be done as a day care procedure. This does not involve invasion into the joint and is devoid of major complications. Moreover this technique aims not only at symptomatic management but also at the correction of TMJ dysfunction. doi:10.1016/j.ijom.2007.08.399
O16.25 Hemimandibular hyperplasia— management perspective in developing country J. I. Mahmud*, M. R. Molla, M. Ahmed, S. M. A. Sadat, M. M. Hasan, F. Hakim BSM Medical University, Dhaka Dental College and Hospital, Bangladesh Hemimandibular hyperplasia is a rare disease of unknown origin. Trauma, infection, intrauterine influences are thought to be responsible. Variety of clinical features like TMJ pain and clicking sound, facial asymmetry, trismus may present. We have managed five cases who were attended in the Department of Oral and Maxillofacial Surgery in BSM Medical University and Dhaka Dental College and Hospital from June 2003 to April 2007. They were treated by high condylectomy after cessation of growth with or without temporary IMF. Follow-up ranges from a period of 6 months to 4 years. doi:10.1016/j.ijom.2007.08.400
O16.26 Therapy of the osteoarthritis of the TMJ V. Machon12*, J. Paska12, D. Hirjak12 1Department of Head and Neck Surgery, Homolka Hospital, Prague, Czech Republic2Department of Maxillofacial Surgery, Bratislava-Ruzinov, Slovakia Authors present four therapeutic methods for therapy of the arthrocentesis of the TMJ (analgotherapy and soft diet, occlusal splint, arthrocentesis only, arthrocentesis and occlusal splint together). This study undertakes 100 patients. Authors valued pain (O–5) and mouth opening before and after therapy in long-term study (1, 2, 3 and 6 months after). Good result was identified as pain O–11 and mouth opening minimally 30 mm interincisively. The best method for the therapy of the osteoarthritis of the TMJ is arthrocentesis and occlusal splint (86% patients with good results 6 month after therapy). doi:10.1016/j.ijom.2007.08.401
O16.27 Patho-anatomic position of nerves and vessels in the infratemporal fossa—a guide to surgical approach to the temporomandibular region
TMJ K. Ramneet*, S. Sandhu, T. Kaur, P. Salwan, A. Kapur Department of Oral and Maxillofacial Surgery, Sri Guru Ram Das Institute of Dental Sciences & Research, Amritsar, Punjab, India Understanding the anatomic relationship of the major vessels and nerves to the temporomandibular joint can prevent intraoperative or postoperative complications. However, most reports have focussed on the surgical approach to this region, with little anatomic consideration of the medial aspect of the joint. The medial capsule of the temporomandibular joint is the most lateral aspect of the infratemporal fossa. The middle meningeal artery, which is in close proximity to the medial capsule, carries the risk of haemorrhage during TMJ surgery. The carotid artery and internal jugular vein are also close to the joint and therefore at risk for injury. Several cases of sinus bradycardia have also been reported. The close anatomic relationship of mandibular nerve as it emerges from foramen ovale and that of the auriculotemporal nerve, as it courses from medial to posterior aspect of condyle warrants an analytic evaluation. This study attempts to describe the anatomic position of nerves and vessels in the infratemporal fossa by means of cadaveric dissection. The valuable information gained by this means, is then correlated with a radiographic analysis of CT scans of patients presenting with TMJ ankylosis, thereby serving as an important guide for the surgeon.
collected for histopathological examination. Results: S. aureus isolated from the joint fluid of a patient with septic arthritis of the TMJ was recovered from the liver, kidneys, knees, interphalangeal joints and TMJs of several animals. Acute septic arthritis of the TMJs was confirmed in several animals 4 days after inoculation. Histopathology showed severe damage to chondrocytes and collagen fibres in the condyles and discs. All cultures were negative in animals inoculated with bacteria from the other sources. Conclusions: A murine model for haematogenous septic arthritis of the TMJ was successfully developed with S. aureus isolated from a patient with a TMJ infection. The bacteria induced multiple organ and joint infections. Onset was rapid. It produced extensive degenerative changes. The study confirms the need for prompt diagnosis and treatment of patients with septic arthritis. doi:10.1016/j.ijom.2007.08.403
O16.29 Function of the temporomandibular joint following open reduction and internal fixation of diacapitular condylar fractures: a follow-up study L. Gerzanic*, M. Rasse, Ch. Kermer, R. Ewers, G. Undt University Hospital for Craniofacial and Oral Surgery, University of Vienna Waehringer, Guertel 18-20 1090, Vienna, Austria
doi:10.1016/j.ijom.2007.08.402
O16.28 A murine model for septic arthritis of the temporomandibular joint X.-Y. Cai*, C. Yang, Z.-Y. Zhang, W.L. Qiu, Q. Ha, X.-D. Wang Department of Oral & Maxillofacial Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiaotong University, China Objective: This study was designed to establish a murine model of haematogenously acquired arthritis of the temporomandibular joint (TMJ) in order to investigate the pathogenesis of this infection. Methods: One hundred and forty mice were inoculated intravenously with three different staphylococcal suspensions. They were sacrificed at intervals between 1 day and 2 months. Bacterial cultures were obtained from peripheral blood, liver, kidney, TMJs, knees and interphalangeal joints. The TMJs were
In a retrospective study, functional, radiological and axiographic results of open reduction and osteosynthesis of diacapitular condylar fractures of the mandible were evaluated. From April 1989 till December 1998, a total number of 59 patients with 67 diacapitular fractures received an operative treatment. After a mean follow-up time of 4 years and 2 months ranging from 5 to 10 years the patients were examined. Clinical examination involved an occlusal status and measurements of the mandible. Articular and muscular pain was evaluated and recorded. Further more self-rating scales including VAS (Visual Analogue Scale) was completed by the patient. Computeraided axiography was recorded in each of the 20 patients with unilateral diacapitular fractures using a SAM double facebow system and the CADIAX software programme for a three-dimensional analysis of movements. The lengths of condylar paths were measured for the
1069
maximum interincisial opening, protrusion and laterotrusion. Compared to the unaffected joint the fractured condyle showed decreased but good excursion in all functional movements – demonstrated one by one. doi:10.1016/j.ijom.2007.08.404
O16.30 Five-year study of patients with rheumatoid arthritis and temporomandibular joint changes M. Helenius*, P. Laine, C. Lindqvist, M. Leirisalo-Repo Department of Oral and Maxillofacial Surgery, HUCH, Kasarmikatu 11-13, PL 263, 00290 HUS, Finland We investigated correlations between subjective, clinical and radiographic changes in patients with rheumatoid arthritis (RA) during a 5-year follow-up study (1997– 2002). Approximately 80% of the patients with RA have subjective symptoms in temporomandibular joint (TMJ) and 40% have erosion changes in condyles in panoramic radiographs. A total of 25 patients with RA participated and answered a written questionnaire for craniomandibular disorders. They were clinically examined and panoramic tomogram (OPTG) and lateral panoramic radiographs were obtained. There were no differences noted between subjective symptoms with RA patients during the study. Distinct erosion was observed in 16% of RA patients in 1997 and 36% in 2002 (P < 0.001). Restricted TMJ movement was found in lateral panoramic radiographs relating to 28% of RA patients in 1997 and 44% patients in 2002 (P < 0.001). Evidence of distinct erosion in panoramic tomogram was significantly associated with evidence of restricted condylar movement in a lateral OPTG (P < 0.001). The clinical marker of maximal mouth opening was significantly lower with RA patients studied in 2002 than 1997 (P < 0.001). The reduction of maximal mouth opening and erosion deterioration of condyles in panoramic radiographs is related to the duration of the disease with RA patients TMJ is not related to duration of the disease. doi:10.1016/j.ijom.2007.08.405
O16.31 Surgical key to lock the jaw (an innovative application)
TMJ
transverse scans. The findings of ultrasonography study were found to be consistent with magnetic resonance imaging study. Conclusion: Ultrasonography is a very affective, easy, economical and patient friendly diagnostic aid for patient with temporomandibular joint disorders with no adverse effects of radiation when compared to other diagnostic methods like computer tomography and magnetic resonance imaging.
considerable amounts of IL-1 beta were detected in the synovial fluid of the patients. Conclusion: Mandibular fractures can be a possible etiologic factor in cartilage destruction, biochemical and intra-articular pathology. Increased levels of IL-1 beta could be potential catabolic marker for cartilage degradation in the TMJ. Clinicians should recognize the aetiologic importance of TMJ macrotrauma and importance of long-term evaluation of TMJ.
doi:10.1016/j.ijom.2007.08.397 doi:10.1016/j.ijom.2007.08.398
O16.23 Mandibular fractures as a possible aetiology in temporomandibular joint disorders A. Kumar*, S. M. Kotrashetti, M. Umarani Kle’s Institute of Dental Sciences, Kle’s University Belgaum-10, Karnataka, India Background and objective: Mandibular fractures in specific is the main type of TMJ macrotrauma. Malocclusion, unilateral mastication as well as bad oral habits including bruxism and clenching are included in the category of TMJ microtrauma the articular disc in TMJ has a primary function of stress distribution. Trauma has been thought to alter the mechanical properties of the disc. TMJ macrotrauma may cause degeneration of articular cartilage and production of the inflammatory and pain mediators. A series of cytokines and chemical mediators are reported to play a major role in various arthropathies, for example, rheumatoid arthritis and osteoarthritis of TMJ. Among them, typically IL-1 beta appears to be of importance in pathogenesis of synovitis and in cartilage damage in these joint diseases. IL-1 beta acts to induce the production of metalloproteinases that induce matrix degradation. The inflammatory and degenerative changes of TMJ can develop after mandibular fractures. Method: Analysis of TMJ status of 15 mandibular fracture patients were done for histomorphic examination, blood cell examination. The procedure of arthrocentesis and synovial fluid biochemical analysis for IL-1 beta (IL-1 beta ELISA kit) was also performed on the selected patients. Exclusion criteria included high condylar and neck fractures and known cases of degenerative joint disorder. Results and observation: On histomorphic examination, bloody smear, degenerated cells, cartilage, inflammatory cells and crystals were observed. In biochemical analysis
O16.24 ‘Pterygoid dysjunction’—a new minimally invasive technique for treatment of painful TMJ dysfunction S. V. Kannan*, A. Thangavelu Depatment of Dentistry, Pondicherry Institute of Medical Sciences (A Unit of Madras Medical Mission), Kalapet, Puducherry 14, India Pain of the temporomandibular joint was a riddle for a long time and postulates, hypothesis and theories abound the literature and still remains a puzzle, yet to be solved conclusively. Conservative treatment methods were widely accepted as the first line of management, though medical treatment may help to alleviate the pain from inflammation and gives symptomatic relief to the patient, it does not reverse the dysfunction due to disc and muscle problems. Many surgical procedures have been advocated, dropped and still research is going on to find logical and least traumatic method for management of TMJ dysfunction with pain. Here we are proposing a new minimally invasive technique ‘pterygoid dysjunction’ as a surgical management of TMJ dysfunction which cannot be categorized under any pathological classification, especially in the patients who complain of pain confining to the lateral pterygoid muscle on palpation, were subjected in to this procedure and the outcome was evaluated using computed tomography. Postoperative follow-up was done for 1 year and all of our patients were free of pain. This is an intraoral and minimally invasive technique and can be done as a day care procedure. This does not involve invasion into the joint and is devoid of major complications. Moreover this technique aims not only at symptomatic management but also at the correction of TMJ dysfunction. doi:10.1016/j.ijom.2007.08.399
O16.25 Hemimandibular hyperplasia— management perspective in developing country J. I. Mahmud*, M. R. Molla, M. Ahmed, S. M. A. Sadat, M. M. Hasan, F. Hakim BSM Medical University, Dhaka Dental College and Hospital, Bangladesh Hemimandibular hyperplasia is a rare disease of unknown origin. Trauma, infection, intrauterine influences are thought to be responsible. Variety of clinical features like TMJ pain and clicking sound, facial asymmetry, trismus may present. We have managed five cases who were attended in the Department of Oral and Maxillofacial Surgery in BSM Medical University and Dhaka Dental College and Hospital from June 2003 to April 2007. They were treated by high condylectomy after cessation of growth with or without temporary IMF. Follow-up ranges from a period of 6 months to 4 years. doi:10.1016/j.ijom.2007.08.400
O16.26 Therapy of the osteoarthritis of the TMJ V. Machon12*, J. Paska12, D. Hirjak12 1Department of Head and Neck Surgery, Homolka Hospital, Prague, Czech Republic2Department of Maxillofacial Surgery, Bratislava-Ruzinov, Slovakia Authors present four therapeutic methods for therapy of the arthrocentesis of the TMJ (analgotherapy and soft diet, occlusal splint, arthrocentesis only, arthrocentesis and occlusal splint together). This study undertakes 100 patients. Authors valued pain (O–5) and mouth opening before and after therapy in long-term study (1, 2, 3 and 6 months after). Good result was identified as pain O–11 and mouth opening minimally 30 mm interincisively. The best method for the therapy of the osteoarthritis of the TMJ is arthrocentesis and occlusal splint (86% patients with good results 6 month after therapy). doi:10.1016/j.ijom.2007.08.401
O16.27 Patho-anatomic position of nerves and vessels in the infratemporal fossa—a guide to surgical approach to the temporomandibular region
TMJ K. Ramneet*, S. Sandhu, T. Kaur, P. Salwan, A. Kapur Department of Oral and Maxillofacial Surgery, Sri Guru Ram Das Institute of Dental Sciences & Research, Amritsar, Punjab, India Understanding the anatomic relationship of the major vessels and nerves to the temporomandibular joint can prevent intraoperative or postoperative complications. However, most reports have focussed on the surgical approach to this region, with little anatomic consideration of the medial aspect of the joint. The medial capsule of the temporomandibular joint is the most lateral aspect of the infratemporal fossa. The middle meningeal artery, which is in close proximity to the medial capsule, carries the risk of haemorrhage during TMJ surgery. The carotid artery and internal jugular vein are also close to the joint and therefore at risk for injury. Several cases of sinus bradycardia have also been reported. The close anatomic relationship of mandibular nerve as it emerges from foramen ovale and that of the auriculotemporal nerve, as it courses from medial to posterior aspect of condyle warrants an analytic evaluation. This study attempts to describe the anatomic position of nerves and vessels in the infratemporal fossa by means of cadaveric dissection. The valuable information gained by this means, is then correlated with a radiographic analysis of CT scans of patients presenting with TMJ ankylosis, thereby serving as an important guide for the surgeon.
collected for histopathological examination. Results: S. aureus isolated from the joint fluid of a patient with septic arthritis of the TMJ was recovered from the liver, kidneys, knees, interphalangeal joints and TMJs of several animals. Acute septic arthritis of the TMJs was confirmed in several animals 4 days after inoculation. Histopathology showed severe damage to chondrocytes and collagen fibres in the condyles and discs. All cultures were negative in animals inoculated with bacteria from the other sources. Conclusions: A murine model for haematogenous septic arthritis of the TMJ was successfully developed with S. aureus isolated from a patient with a TMJ infection. The bacteria induced multiple organ and joint infections. Onset was rapid. It produced extensive degenerative changes. The study confirms the need for prompt diagnosis and treatment of patients with septic arthritis. doi:10.1016/j.ijom.2007.08.403
O16.29 Function of the temporomandibular joint following open reduction and internal fixation of diacapitular condylar fractures: a follow-up study L. Gerzanic*, M. Rasse, Ch. Kermer, R. Ewers, G. Undt University Hospital for Craniofacial and Oral Surgery, University of Vienna Waehringer, Guertel 18-20 1090, Vienna, Austria
doi:10.1016/j.ijom.2007.08.402
O16.28 A murine model for septic arthritis of the temporomandibular joint X.-Y. Cai*, C. Yang, Z.-Y. Zhang, W.L. Qiu, Q. Ha, X.-D. Wang Department of Oral & Maxillofacial Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiaotong University, China Objective: This study was designed to establish a murine model of haematogenously acquired arthritis of the temporomandibular joint (TMJ) in order to investigate the pathogenesis of this infection. Methods: One hundred and forty mice were inoculated intravenously with three different staphylococcal suspensions. They were sacrificed at intervals between 1 day and 2 months. Bacterial cultures were obtained from peripheral blood, liver, kidney, TMJs, knees and interphalangeal joints. The TMJs were
In a retrospective study, functional, radiological and axiographic results of open reduction and osteosynthesis of diacapitular condylar fractures of the mandible were evaluated. From April 1989 till December 1998, a total number of 59 patients with 67 diacapitular fractures received an operative treatment. After a mean follow-up time of 4 years and 2 months ranging from 5 to 10 years the patients were examined. Clinical examination involved an occlusal status and measurements of the mandible. Articular and muscular pain was evaluated and recorded. Further more self-rating scales including VAS (Visual Analogue Scale) was completed by the patient. Computeraided axiography was recorded in each of the 20 patients with unilateral diacapitular fractures using a SAM double facebow system and the CADIAX software programme for a three-dimensional analysis of movements. The lengths of condylar paths were measured for the
1069
maximum interincisial opening, protrusion and laterotrusion. Compared to the unaffected joint the fractured condyle showed decreased but good excursion in all functional movements – demonstrated one by one. doi:10.1016/j.ijom.2007.08.404
O16.30 Five-year study of patients with rheumatoid arthritis and temporomandibular joint changes M. Helenius*, P. Laine, C. Lindqvist, M. Leirisalo-Repo Department of Oral and Maxillofacial Surgery, HUCH, Kasarmikatu 11-13, PL 263, 00290 HUS, Finland We investigated correlations between subjective, clinical and radiographic changes in patients with rheumatoid arthritis (RA) during a 5-year follow-up study (1997– 2002). Approximately 80% of the patients with RA have subjective symptoms in temporomandibular joint (TMJ) and 40% have erosion changes in condyles in panoramic radiographs. A total of 25 patients with RA participated and answered a written questionnaire for craniomandibular disorders. They were clinically examined and panoramic tomogram (OPTG) and lateral panoramic radiographs were obtained. There were no differences noted between subjective symptoms with RA patients during the study. Distinct erosion was observed in 16% of RA patients in 1997 and 36% in 2002 (P < 0.001). Restricted TMJ movement was found in lateral panoramic radiographs relating to 28% of RA patients in 1997 and 44% patients in 2002 (P < 0.001). Evidence of distinct erosion in panoramic tomogram was significantly associated with evidence of restricted condylar movement in a lateral OPTG (P < 0.001). The clinical marker of maximal mouth opening was significantly lower with RA patients studied in 2002 than 1997 (P < 0.001). The reduction of maximal mouth opening and erosion deterioration of condyles in panoramic radiographs is related to the duration of the disease with RA patients TMJ is not related to duration of the disease. doi:10.1016/j.ijom.2007.08.405
O16.31 Surgical key to lock the jaw (an innovative application)