Temporomandibular Joint Arthroscopy in the Pediatric Population

Poster Session oral and maxillofacial surgeons. While great advances have been made in understanding muscular and articular disorders, the diagnosis of inflammatory temporomandibular joint arthritis remains difficult and the literature to guide surgeons’ efforts in this field is scarce. Inflammatory arthritis is defined as a group of arthridites which cause inflammation rather than degenerative changes of the joint, such as rheumatoid arthritis, psoriatic arthritis or infective arthritis. Synovial biopsy has been used anecdotally to aid in diagnosis of the temporomandibular joint arthritis, although no literature exists that attempts to correlate a diagnosis of inflammatory arthritis of the temporomandibular joint with the biopsy specimen findings. The purpose of this study is to establish clear histologic features of the synovial biopsy for patients with inflammatory arthritis affecting their temporomandibular joints. The investigators hypothesize that discrete histopathologic findings will be correlated with the diagnosis of inflammatory arthritis. The aim of this study is provide evidence for an additional tool to aid in the difficult diagnosis of inflammatory temporomandibular joint arthritis. Patients were found through a medical record search using the CPT codes for arthroscopic procedures at the senior author’s practice from 1/1/2011 to 3/31/2016. The patients were selected using the following inclusion criteria: arthroscopy was performed on at least one temporomandibular joint and a synovial biopsy was performed. For the purposes of this study, inflammatory arthritis was defined as one of the following: rheumatoid arthritis, HLA-B27 associated arthritis, juvenile idiopathic arthritis, ankylosing spondylitis, Reiter’s syndrome, psoriatic arthritis, infective arthritis, crystal-induced arthritis or traumatic arthritis. The overall clinical impression was considered positive for inflammatory arthritis at the discretion of the senior author after consideration of the patient’s history, physical examination, laboratory values, intraoperative findings, biopsy results, and clinic course. Biopsy results were recorded and any of the following findings were considered ‘‘biopsy positive’’: lymphoplasmacytic infiltrate, hyperplastic synovium, chronic inflammation, and fibrinous exudate. Arthroscopic findings and laboratory values were also recorded. Descriptive statistics were reported and sensitivity, specificity, negative predictive value, and positive predictive value were calculated. Chi square tests were used to test the association between individual biopsy findings and the overall clinical impression of inflammatory arthritis. There were 289 patients that met the inclusion criteria during the study period; 91.5% of the study population was female. The mean age of the study cohort was 42.3 (standard deviation 18.9). There were 32 cases of inflammatory arthritis in this cohort (11.3%). The sensitivity of the synovial biopsy (any positive findings) for the identification of inflammatory arthritis in this study was 65.4%. The specificity was 83.3% and the positive and negative predictive values were 43.6% and 92.4%, respece-408

tively, in this study population. The findings lymphoplasmacytic infiltrate and hyperplastic synovium were associated with the overall clinical impression of inflammatory arthritis (p<0.0001 and p=0.0046, respectively). The findings in the present study suggest that synovial biopsy is an effective tool to rule out inflammatory arthritis. Two findings in particular were strongly associated with inflammatory arthritis of the temporomandibular joint – lymphoplasmacytic infiltrate and hyperplastic synovium. Arthroscopic biopsy is a useful tool to aid in the diagnosis of inflammatory temporomandibular joint arthritis. 1. Wechalekar MD, Smith MD: Arthroscopic guided synovial biopsy in rheumatology: current perspectives. Int J Rheu Dis Dec, 2016 2. Singhal O, Kaur V, Kalhan S, Singhal MK, Gupta A, Machave TV: Arthroscopic synovial biopsy in definitive diagnosis of joint diseases: an evaluation of efficacy and precision. Int J of App Basic Med Res 2:102, 2012

POSTER 57 Temporomandibular Joint Arthroscopy in the Pediatric Population D. Choi: Miami Oral & Maxillofacial Surgery / Baptist Hospital of Miami, C. Davis, K. Vandenberg, J. P. McCain Purpose: The temporomandibular joint has an essential role in the growth and development of the facial skeleton. In the pediatric patient, the temporomandibular joint may suffer mechanical or inflammatory disease that can propagate a cascade of joint degeneration. Significant derangements of the pediatric temporomandibular joint can lead to abnormalities in growth and facial morphology, necessitating extensive surgical intervention. Temporomandibular joint arthroscopy is a minimally invasive intervention that may help diagnose pathologic inflammatory conditions, halt a progressive osteoarthritic process and potentially preclude the need for open joint surgery. The purpose of this study is to evaluate preliminary outcomes of temporomandibular joint arthroscopy in the pediatric population. Materials and Methods: This was a retrospective analysis evaluating outcomes of pediatric temporomandibular joint arthroscopy from 2008-2016. All patients were treated at a single institution by the senior author (J.P.M.) at Miami Oral and Maxillofacial Surgery/Baptist Hospital. All patients received initial conservative medical management including soft diet, NSAIDs, muscle relaxants and a night guard appliance for 4-6 weeks. After failing conservative management, further evaluation was performed with diagnostic imaging including an MRI, CBCT and serology. Arthroscopic interventions varied from Level 1 (diagnostic), Level 2 (operative) to Level 3 (disc reconstruction) dependent on diagnostic findings and Wilkes classification. AAOMS  2017

Poster Session Primary outcome variable assessed pain analogs (0 = no pain, 100 = worst pain) at one-year postoperatively. Secondary outcome variables evaluated jaw function (0 = normal jaw function, 100 = complete jaw dysfunction), mouth opening, medication use, joint loading (contralateral joint pain when biting on the canine), joint noise and muscle pain. Methods of Data analysis: Patients were identified by searching medical records through CPT codes and date of birth at the time of surgery. Data was collected in Excel and a t-test was performed to determine statistical significance. Results: A total of 23 patients (37 joints) with a mean age of 14.1 years underwent TMJ arthroscopic surgery with one-year postoperative follow-up. 22/23 (96%) of the patients were female. Of the 37 joints, 14 (38%) were Wilkes II, 17 (46%) were Wilkes III and 6 (16%) were classified as Wilkes IV. Average pain analogs improved by 25%(42 to 17), average perceived jaw function improved by 22% (43 to 21), and average mouth opening improved by 21% (33 mm to 42 mm). Improvements in pain analog, jaw function and mouth opening were all statistically significant (P<0.05). 10/16 (62%) joints with preoperative muscle pain resolved after 1 year. 10/13 (77%) joints with preoperative joint loading pain resolved after 1 year. 14/25 (56%) joints with joint noise had resolution of joint noise. 8/10 (80%) patients requiring preoperative medication no longer required medications after one year. Only 2/23 (9%) patients required any medications after 1 year. No complications were encountered. Conclusions: Temporomandibular joint arthroscopy is an effective and minimally invasive form of surgical intervention in treating Wilkes II,III, IV in the pediatric population. Further longer-term evaluation is needed to assess continual resolution of symptoms and subsequent facial growth. References: 1. Schellhas, Kurt P, Steven R. Pollei, and Clyde H. Wilkes. ‘ Pediatric internal derangements of the temporomandibular joint: effect on facial development.’’ American Journal of Orthodontics and Dentofacial Orthopedics 104.1 (1993): 51-59 2. Siparsky, Patrick N, and Mininder S. Kocher. ‘ Current concepts in pediatric and adolescent arthroscopy.’’ Arthroscopy: The Journal of Arthroscopic & Related Surgery 25.12 (2009): 1453-1469

TRAUMA MANAGEMENT POSTER 58 Maxillofacial Gunshot Wound & Delayed Psuedoaneurysm: Recognition & Endovascular Intervention R. A. McKinney: Naval Medical Center San Diego AAOMS  2017

Introduction: Pseudoaneurysms of the extracranial head and neck vasculature are rarely encountered. However, they bring significant risks when present. There is an adequate buffer of soft tissue in the maxillofacial region reducing the incidence. Most trauma to the external carotid artery and its branches will predominately cause complete transection rather than partial laceration. The process of a pseudoaneurysm formation is a partial vessel wall breach resulting in leakage of arterial blood into surrounding tissues. Tamponade with partial clot formation will follow. Some pseudoaneurysms self-resolve, however others require treatment to prevent uncontrolled hemorrhage. The most vulnerable of the External Carotid Artery branches are the superficial temporal, internal maxillary, and facial arteries. Case Description: This case reviews the initial treatment and perioperative management of a young healthy male who sustained a .40 caliber handgun round to the left midface. Consistent with most low velocity gunshot injuries, there was no exit wound. His injuries included: avulsion of left midface epidermis and lateral nasal ala, comminution of left maxillary sinus and pterygoid plate, obliteration of left posterior dentition with dentoalveolar fractures, left mandibular coronoid process fracture, and C1 fracture of foramen transversarium. Carotid space involvement was noted through the tract of the projectile. Vascular lacerations or psuedoaneurysms of cervical circulation could not be ruled out until angiogram on post injury day 4. He was then taken to the operating room for facial debridement and archbar placement for DA fractures. His clinical progression improved daily until PID 10 when delayed clinical signs lead to an additional angiogram order. Likely due to late cavitation injury, an 8.5mm traumatic pseudoaneurysm of the distal segment of left IMAX artery was discovered. The psuedoaneurysm was embolized and the distal IMAX artery was occluded with a combination of detachable coils and Onyx liquid embolic agent. Discussion: This case exemplifies the importance of vigilant perioperative patient management. It also displays the strengths of angiography and catheter based embolization, which can be both diagnostic and therapeutic. This alternative allows rapid access to surgically inaccessible vessels, as well as superior cosmesis by preventing facial scars and wound-related complications. Parent vessel sacrifice (IMAX) in this case proved to be a safe and effective treatment alternative. 1. Deepak G. Krishnan, Amir Marashi, Anil Malik: Pseudoaneurysm of Internal Maxillary Artery Secondary to Gunshot Wound Managed by Endovascular Technique. J Oral Maxillofac Surg 62:500-502, 2004 2. Deming Wang, Lixin Su, et al: Embolization Treatment of Pseudoaneurysms Originating From the External Carotid Artery. J Vasc Surg 2015;61:920-6

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