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The role of temporomandibular joint surgery in the treatment of patients with internal derangement
The role of temporomandibular joint surgery in the treatment of patients with internal derangement M. Franklin Dolwick, DMD, PhD, a Gainesville and Jacksonville, Fla. UNIVERSITY OF FLORIDA, COLLEGEOF DENTISTRY Surgery of the temporomandibular joint (TMJ) has made considerable progress, although significant failures have plagued this field in recent years. Despite the controversies, surgery of the TMJ continues to have a small but important role in the management of specific temporomandibular disorders. This article presents an overview of TMJ surgery. It is concluded that careful case selection is the most important aspect for a successful outcome. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:150-5)
The role of surgery in the management of TMJ pain and dysfunction gained renewed emphasis after the reintroduction of internal derangement during the 1970s. Interest was focused on the importance of disc displacement and deformity as the cause of TMJ pain and dysfunction. 1, 2 As a result, numerous open joint procedures were developed to reposition and reshape the displaced or deformed disc. 3-5 With the introduction of TMJ arthroscopy and, later, TMJ arthrocentesis, the success of simpler procedures such as lavage and lysis of adhesions has raised important questions about the pathosis of internal derangement. 6, 7 With the increased surgical options available to the surgeon, it seems prudent that selection of the surgical procedure with the highest probability of success and the least morbidity should be the objective. Surgical procedures currently used for the treatment of TMJ internal derangement range widely, from simple arthrocentesis and lavage to the more complex open joint operations. The purpose of this article is to review the currently used operations for the treatment of TMJ internal derangement. The operations to be reviewed are arthrocentesis, arthroscopy, arthrotomy (open TMJ surgery), and modified condylotomy. The undisputed application of surgery is found in the management of the less common TMJ disorders such as ankylosis, growth disturbances, trauma, and neoplasia. For the more common disorders, such as internal derangement and osteoarthritis, the indications are less clear and often are dependent on the patient' s ability to accurately report his or her symptoms as well as the surgeon's ability to interpret the often confusing clinical signs. 8-1° Ideally, one may adopt the policy of determining the need for surgery by the aProfessor and Director, Oral and Maxillofacial Surgery Residency Programs. Copyright © 1997 by Mosby-Yem"Book, Inc. 1079-2104/97/$5.00 + 0 7/0/78323 150
degree of the patient's disability in conjunction with the degree of improvement derived through nonsurgical treatment modalities, 11 as dictated by a clear understanding of the pathogenesis. In practice, however, the decision to operate seems to be a matter of the individual surgeon's training, experience, and attitudes toward the surgical management of temporomandibular disorders. TMJ arthrography and magnetic resonance imaging have proved to be of value in depicting disk position and shape, 12, 13 but the clinical symptoms have often failed to correlate with the findings of these imaging studies. 14, 15 Excessive reliance on the diagnostic value of imaging may lead to overdiagnosis of internal derangement and hence to overtreatment. Therefore it is essential for the clinician to place more emphasis on the history and clinical examination than on the results of imaging studies alone. Clinical indications for TMJ surgery for internal derangement are relative, rather than absolute, and the following general guidelines are recommended in the American Association of Oral and Maxillofaciai Surgeons Parameters of Care for Oral and Maxillofacial Surgery. 16 Surgical intervention is indicated only when nonsurgical therapy has been ineffective and when pain or dysfunction is moderate to severe. Surgery is not indicated for asymptomatic or minimally symptomatic patients. Surgery also is not indicated for preventive reasons in patients without pain and with satisfactory function. Therefore a patient with internal derangement who is incapacitated to the point at which work and relationships are severely disrupted and whose condition does not improve with nonsurgical treatment over a reasonable period of time may be an appropriate candidate for surgical treatment. It must be emphasized that the criteria for surgery is not simply refractory pain but pain that is localized specifically to the TMJ.
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The more localized the symptoms are to the TMJ, the better the surgical prognosis.
ARTHROCENTESIS TMJ arthrocentesis and lavage with manipulation is the simplest and least invasive of all surgical techniques. 17 The concept was based on the observations that simple lysis and lavage of the upper joint space using arthroscopy was highly successful in reestablishing normal range of mouth opening in patients with closed-lock of their TMJs. 18 The success of this technique has cast doubt on an abnormal disc shape or position as being the cause of closed-lock of the TMJ. Instead, it is speculated that restricted gliding movement of the mandibular condyle over the articular eminence may be due to reversible adhesion of the disk to the glenoid fossa caused by a vacuum effect or alteration in synovial fluid. 7 Preliminary results of this procedure have been promising in effectively establishing increased range of motion, improved function and decreased pain. 17, 19 A more recent study of 39 patients followed for an average of 40 months, reported that maximal mouth opening increased from 23.1 to 44.3 mm and contralateral movements increased from 4.8 to 8.2 mm. 2° In addition to these objective improvements there was a marked reduction in pain rate (85%) and dysfunction rate (72%) as measured on visual analog scales. All patients but 1 reported an improvement. Twentytwo (55%) patients reported 100% improvement, and 35 (90%) patients reported an improvement of more than 75% in both pain level and dysfunction rate. The advantages of TMJ arthrocentesis with lavage are that it is a simple, inexpensive, and minimally invasive procedure with little morbidity that can easily be performed in an outpatient setting. It is important, however, that the more acute the onset of closed-lock, the better the prognosis for a successful treatment outcome. 17 ARTHROSCOPY Arthroscopy of the TMJ was first described by Ohnishi, 21 in Japan, in 1975. A decade later the concept of TMJ arthroscopy spread to Europe and the United States, as intense interest developed in the idea that extended therapeutic application of arthroscopy could be added to this technique's diagnostic capabilities. 18, 22, 23 Arthroscopy is an equipment-dependent procedure that relies considerably on expensive and complex technology. Despite the minimally invasive nature of arthroscopy, which can be performed as an outpatient procedure, it is commonly performed during general anesthesia in an operating room. Skill is required to
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conceptualize a three-dimensional space on a two-dimensional screen image, and a high degree of manual dexterity is necessary, particularly for operative procedures. The advantages of arthroscopy compared with open joint surgery are that arthroscopy is less invasive, causes less surgical trauma to the joint, and is associated with lower morbidity. 24 In addition, healing time is shorter and recovery is more rapid than with open surgery. The results with TMJ arthroscopy have been uniformly satisfactory. 6' 18, 22-25 Success, as determined by decreased pain and improved range of motion, has varied from 79% to 93%. The most extensive data are from a 6-year multicenter retrospective study of 4831 joints. 26 After arthroscopic surgery, 91.6% of all patients had good or excellent motion; 91.3% had good or excellent pain reduction; 90.6% had good or excellent ability to maintain a normal diet; and 92% had a good or excellent reduction in disability. Also, the surgical technique was relatively free of complications (4.4%). The most successful results have been derived from arthroscopic lavage and lysis of adhesions in the upper joint space for the treatment of painful limited opening (closed-lock). 18The results of arthroscopic treatment of painful limited opening (closed-lock) compare favorably with results after open surgery. 6, 27 In light of these results, arthroscopy now plays an important role in clinical practice, particularly in the management of chronic closed-lock of the TMJ. The success of simple arthroscopic procedures, such as lavage and lysis, has raised important questions as to whether there is absolute necessity to reposition the disc to resolve TMJ pain and dysfunction. 6' 7 In addition, arthroscopic observation has revealed that the pathologic features associated with TMJ pain and dysfunction are more complex than simple disk displacement and disk deformity. 18, 22, 24 Steady growth in the popularity of TMJ arthroscopy has led to the development of numerous operative techniques, ranging from simple lavage and ablation of adhesions to electrocautery or laser treatment and suturing of the displaced disk. 2s, 29 Despite the complexity of the procedures that can be undertaken by the experienced arthroscopist, the outcomes of the more complex procedures are still to be fully evaluated, especially in comparison with simple lavage and lysis of adhesions.
ARTHROTOMY (OPEN JOINT SURGERY) Although numerous surgical approaches to the TMJ have been described, the most common approach is a preauricular incision made in the skin fold in front of the ear. Upon exposure of the joint capsule,
152
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January 1997 the superior joint space is entered first and is followed by exposure of the inferior joint space if necessary. Whereas other surgical procedures provide a limited range of options, arthrotomy provides the surgeon with an unlimited scope of procedures, ranging from simple lavage and debridement of the joint to complete removal of disk. The most commonly performed procedures are disk repositioning and diskectomy. Arthroplasty in the form of reconturing of articular eminence or condyle is sometimes necessary, particularly in cases of gross mechanical joint interference and advanced degenerative joint disease.
Disk repositioning First introduced by McCarty and Farrar 3 in 1979, disk repositioning to a more normal anatomic relation with the condyle and fossa is usually undertaken when the disk is displaced but otherwise free of disease or structural deformity. In a partial-thickness plication, described by Hall, 4 the disk is repositioned and stabilized with sutures without the need to enter the inferior joint space. Alternatively, in a full-thickness plication, described by Dolwick and Sanders, 5 the disk is repositioned by surgically exposing both joint spaces. Clinical studies have demonstrated a favorable outcome in terms of decreased pain and improved mandibular function in 80% to 94% of patients. 3-5, 3o Dolwick and Nitzan 31 evaluated 152 patients who underwent TMJ disk repositioning between 1984 and 1988 and found an 85% improvement in 90% of the patients. However, 5.3% reported no improvement after surgery, and 4.5% reported a worsening as a result of the surgery. Furthermore, it was found that the majority of those who did report an improvement after surgery continued to experience symptoms of pain, joint noise, and decreased range of motion, although to a lesser extent than before surgery.
Diskectomy Complete removal of the disk was one of the first intraarticular TMJ surgical procedures described. 32 Diskectomy is undertaken when the disk is found to be diseased or structurally compromised as a result of tears, perforations, or persistent symptoms of pain and dysfunction after previous disk surgery. Until recently, the removed disk was replaced with alloplastic implants. 33-35 However, because of the high incidence of foreign-body reactions found to result from the use of these alloplastic implants, their use has ceased. 36-39Various autogenous grafts such as auricular cartilage, dermis, and temporalis muscle and fascia have also been advocated for the replace-
merit of the disk. 4°-43 Because the advantages of using autogenous tissues for replacement of the disk are currently unclear, some authors advocate that the removed disk not be replaced with anything. 44 Diskectomy without disk replacement gained popularity between 1940 and 1960, 45, 46 and initially favorable results were reported in several series of patients who had been unsuccessfully treated with nonsurgical methods. 47' 48 Others have reported persistent pain, headache, and other signs and symptoms of dysfunction after diskectomy. 49 With time, the technique fell into disrepute and was abandoned. Improved diagnostic techniques and a better understanding of joint pathophysiology has resulted in discectomy's regaining popularity. In some recent studies on diskectomy used specifically for internal derangement success rates between 85% and 89% were reported.50, 51 Long-term follow-up data have also been published for diskectomy procedures. 52, 53 In one study, reporting long-term follow-up of almost 30 years after diskectomy, all 15 patients were reported to be free of pain and to have no subjective findings of mandibular dysfunction. 53 In another study, reporting long-term follow-up of 30 years after diskectomy, 96% of the patients experienced no pain after surgery, and all had mouth opening of 30 mm or more. 52 It is clear that discectomy without replacement can be performed safely and successfully on patients with certain well-defined criteria for treatment.
Modified condylotomy The modified condylotomy is a modification of the intraoral vertical ramus osteotomy used in orthognathic surgery to correct mandibular prognathism. The idea of performing osteotomy of the condylar process for treatment of temporomandibular disorders was derived from observations that patients who had sustained condylar fractures rarely complained of TMJ pain. 54 In the 1980s Nickerson and Veaco 55 developed the modified condylotomy as a means of treating TMJ pain when there is evidence of a reducing disk. A study by Hall et al., 56 conducted on 400 patients over a 9-year period, found good pain relief in about 90% of the patients treated. Although the surgery itself is simple, there is a prolonged period of postoperative rehabilitation involving 3 to 6 weeks of maxillomandibular fixation. The advantages of this procedure compared with other procedures are that the joint is not entered, and postoperative imaging indicated that a normal disc relation to the condyle is frequently achieved.
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DISCUSSION Over the years numerous techniques have been advocated for the treatment of internal derangement, but few techniques have gained universal acceptance. This situation reflects the continued poor understanding of the etiology, pathology, and natural history of this disorder as well as a poor understanding of the complex behavioral influences on the patient's pain and dysfunction. Surgical treatment of TMJ internal derangement has proven effective for reducing pain and increasing range of motion in about 80% of patients, regardless of operative technique, on the basis of published short-term retrospective studies. These studies are limited by the shortcomings often associated with retrospective clinical studies: poorly defined patient populations, observer bias in data collection, loss of m a n y treated patients to follow-up, and lack of control subjects. Long-term randomized controlled prospective studies are clearly lacking. The success of simple surgical procedures, such as arthroscopic lavage and lysis of the upper joint space, has raised serious doubts about the pathologic significance of disk position as the sole cause of pain and joint dysfunction. 6, 7 Clearly, an alternative explanation must be sought to corroborate the effectiveness of lysis and lavage in the management of some stages of internal derangement. It has been speculated that inflammation of the synovium (synovitis), capsule (capsulitis), or retrodiskal tissues (retrodiscitis) that is often observed during arthroscopy may be responsible for joint p a i n s Conversely, degenerative changes within the articular surfaces or disk may release chemical substances into the synovial fluid that may alter its consistency, hence compromising lubrication of the joint resulting in restricted mandibular movements seen in joint dysfunction. 5s, 59 Further research in this area is needed to elucidate the precise pathologic processes involved in TMJ pain and dysfunction. Surgery of the T M J has made considerable progress, although significant failures have plagued this field in recent years. The extensive experience in TMJ surgery reflects the vast numbers of surgeons who undertake this kind of surgery as a matter of routine within their scope of practice. The danger, however, is the creation of an environment where there may well be a tendency to overtreat, which may be further compounded by the lack of clearly defined and widely accepted criteria for surgery. Currently, the greatest problems faced by surgeons in the management of temporomandibular disorders involve failed alloplastic implants and patients undergoing multiple operations. It has become evident
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that the potential for success for any further surgery rapidly decreases as the number of operations increases. 6° The problems facing the surgeon may not be solely the structural abnormality of the multiply operated joint but also may include long-term muscle dysfunction resulting from chronic pain and limited jaw motion and abnormal illness behavior created by chronic pain and multiply failed treatments. Currently, the literature is virtually devoid of long-term solutions to the treatment of these patients, a deficiency that reinforces the need for careful planning and case selection.
Research recommendations Clearly, the lessons learned with regard to TMJ surgery should provide adequate warning to clinicians less experienced in this complex field of oral and maxillofacial surgery. The most important points are the mandatory need for long-term randomized prospective controlled studies of currently used techniques, especially new techniques, and the essential requirement for clearly defined criteria and objectives for TMJ surgery that would avoid the problems of failed treatment. Conclusions Surgery of the TMJ continues to have a small but nonetheless important role in the management of specific TMJ disorders. Appropriate case selection is the mandatory requirement for successful surgical intervention to achieve the desired outcomes of relief of pain and improvement in function. Surgery of the TMJ is best undertaken by surgeons who maintain the philosophy that surgery should aim to avoid further harm to the joint and who consider more conservative surgical procedures whenever possible. The benefits and limitations of each of the surgical procedures are readily determined on an individual case basis. The goal is to determine the most appropriate technique that will yield the highest probability of success with the lowest morbidity. REFERENCES 1. FarrarWB. Diagnosis and treatment of anterior dislocation of articular disc. NY J Dent 1971;41:348-51. 2. Wilkes CH. Arthrography of the temporomandibularjoint in patients with tmj pain dysfunction syndrome. Minn Med 1978;61:645-52. 3. McCarty WL, Farrar WB. Surgery for internal derangement of the temporomandibular joint. J Prosthet Dent 1979;42: 191-6. 4. Hall MB. Meniscoplastyof the displaced temporomandibular meniscus without violating the inferior joint space. J Oral Maxillofac Surg 1984;42:788-92. 5. DolwickMF, Sanders B. TMI internal derangementand artJarosis: surgical atlas 1985. St. Louis: CV Mosby, 1985:158-72.
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January 1997 6. Nitzan DW, Dolwick MF. Arthroscopic lavage and lysis of the temporomandibular joint: a change in perspective. J Oral Maxillofac Surg 1990;48:798-801. 7. Nitzan DW, Dolwick MF. An alternative explanation for the genesis of closed-lock symptoms in the internal derangement process. J Oral Maxillofac Surg 1991;49:810-5. 8. Dolwick MF. Clinical diagnosis of temporomandibular joint internal derangement and myofascial pain and dysfunction. Oral Maxillofac Surg Clin North Am 1989;1:1-6. 9. Clark GT, Seligman DA, Solberg WK, Pullinger AG. Guidelines for the examination and diagnosis of temporomandibular disorders. J Craniomand Disord Facial Oral Pain 1989;3:714. 10. Dworkin SF, LeResch LR, DeRouen T, Van Korff M. Assessing clinical signs of temporomandibular disorders: reliability of clinical examiners. J Prosthet Dent 1990;63: 574-9. 1 l. Okeson, JP. Management of temporomandibular disorders and occlusion. 3rd ed. St. Louis: CV Mosby, 1993:403-48. 12. Tasaki M, Westesson P-L. Temporomandibular joint: diagnostic accuracy with sagittal and coronal MR images. Radiology 1993;186:723-9. 13. Westesson P-L, Katzberg RW, Tallents RH, Woodworth RE, Svensson SA. CT and MRI of the temporomandibular joint: comparison with autopsy specimens. Am J Roentgenol 1987; 148:1165-1171. 14. Hansson LG, Hansson T, Petersson A. A comparison between clinical and radiological findings in 259 temporomandibular joint patients. J Prosthet Dent 1983;50:89-94. 15. Kircos LT, Ortendahl DA, Mark AS, Arakawa MS. Magnetic resonance imaging of the TMJ disc in asymptomatic volunteers. J Oral Maxillofac Surg 1987;45:852-4. 16. Helfrick JF, Kelly JF, Carberry A. Parameters of care for oral and maxillofacial surgery: a guide for practice, monitoring, and evaluation. J Oral Maxillofac Surg 1995;53:201-38. 17. Nitzan DW, Dolwick MF, Martinez GA. Temporomandibular joint arthrocentesis: a simplified treatment for severe, limited mouth opening. J Oral Maxillofac Surg 1991;49: 1163-7. 18. Sanders B. Arthroscopic surgery of the temporomandibular joint: treatment of internal derangement with persistent closed-lock. Oral Surg Oral Med Oral Pathol 1986;62:361-4. 19. Dimitroulis G, Dolwick MF, Martinez A, Temporomandibular joint arthrocentesis and layage for the treatment of closedlock: a follow-up study. Br J Oral Maxillofac Surg 1995; 33:23-7. 20. Nitzan DW. Temporomandibular joint arthrocentesis: biologic basis and treatment outcome. In: Stegenga B, de Bont LGM, editors. Management of temporomandibular joint degenerative diseases: biologic basis and treatment outcome. Basel: Birkhuser Verlag, 1996:113-23. 21. Ohnishi M. Arthroscopy of the temp0romandibular joint [in Japanese]. J Jpn Stomat 1975;42:207-12. 22. McCain JP. Arthroscopy of the human temporomandibular joint. J Oral Maxillofac Surg 1988;46:648-52. 23. Holmlund A, Hellsing G. Arthroscopy of the temporomandibular joint: occurrence and location of osteoarthritis and synovitis in a patient material. Int J Oral Maxillofac Surg 1988;17:36-40. 24. Bronstein SL. Diagnostic and operative arthroscopy: historical perspectives and indications. Oral Maxillofac Surg Clin North Am 1989;1:59-68. 25. Moses JJ, Poker I. TMJ arthroscopic surgery: an analysis of 237 patients. J Oral Maxillofac Surg 1989;47:790-4. 26. McCain JP, Sanders B, Koslin MG, Quinn JD, Peters PB, Indresano T. Temporomandibular joint arthroscopy: a 6-year multicenter retrospective study of 4,831 joints. J Oral Maxillofac Surg 1992;50:926-930. 27. Zeitler D, Porter BA. A retrospective study comparing arthroscopic surgery with arthrotomy and disc repositioning.
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In: Clark G, Sanders B, Bertolami C, editors. Advances in diagnostic and surgical arthroscopy of the temporomandibular joint. Philadelphia: WB Saunders, 1993:47-60. McCain JP, Humberto, R. Principles and practice of operative arthroscopy of the human temporomandibular joint. Oral Maxillofac Surg Clin North Am 1989;1:135-52. McCain JP, Podrasky AlE, Zabiegalski A. Arthroscopic disc repositioning and suturing: a preliminary report. J Oral Maxillofac Surg 1992;50:568-73. Piper MA. Microscopic disc preservation surgery of the temporomandibular joint. Oral Maxillofac Surg Clin North Am 1989; 1:279-302. Dolwick MF, Nitzan DW. The role of disc repositioning surgery for internal derangements of the temporomandibular joint. Oral Maxillofac Surg Clin North Am 1994;6: 271-5. Lanz AB. Dictis mandibularis. Zentralbl Chir 1909;36:28991. Hansen WC, Deshazo BW. Silastic reconstruction of temporomandibular meniscus. Plast Reconstr Surg 1969;43:38891. Gallagher DM, Wolford LM. Comparison of Silastic and Proplast implants in the temporomandibular joint after condylectomy for osteoarthritis. J Oral Maxillofac Surg 1982;40:627-30. Estabrooks LN, Fairbanks CE, Collett RJ, et al. A retrospective evaluation of 301 Proplast-Teflon implants. Oral Surg Oral Med Oral Pathol 1990;70:381-6. Dolwick MF, Aufdemorte TB. Silicone induced foreign body reaction and lymphadenopathy after temporomandibular joint arthroplasty. Oral Surg Oral Med Oral Pathol 1985;59:44952. Timmis DP, Aragon SB, Van Sickels JE, Aufdemorte TB. Compressive study of alloplastic materials for temporomandibular joint disk displacement in rabbits. J Oral Maxillofac Surg 1986;44:541-54. Westesson P-L, Ericksson L, Linstrom G. Destructive lesions of the mandibular condyle following discectomy with temporary silastic implants. Oral Surg Oral Med Oral Pathol 1987;63:143-50. Ryan DE. Alloplastic implants in the temporomandibular joint. Oral Maxillofac Surg Clin North Am 1989;1:427-41. Witsenberg B, Freihofer HPM. Replacement of the pathological temporomandibular disc using autogenous cartilage of the external ear. Int J Oral Surg 1984;13:401-4, Hall HD, Link J. Discectomy alone and with ear cartilage in joint reconstruction. Oral Maxillofac Surg Clin North Am 1989;1:329-40. Meyer RA. The autogenous dermal graft in temporomandibular joint disc surgery. J Oral Maxillofac Surg 1988;46:94854. Feinberg S, Larson P. The use of pedicled tempnralis muscle-pericranial flap for replacement of the TMJ disc: preliminary report. J Oral Maxillofac Surg 1989;47:142-6. Eriksson L, Westesson P-L. The need for disc replacement after discectomY. Oral Maxillofac Surg Clin North Am 1994;6:295-305. Burman M, Sinberg SE. Condylar movement in the study of internal derangement of the temporomandibular joint. J Bone Joint Surg Am 1946;28:351-73. Silver CM, Simon SD, Savastano AA. Meniscus injuries of the temporomandibular joint. J Bone Joint Surg Am 1956; 38:541-52. Dingman RO, Moorman WC. Meniscectomy in the treatment of lesions of the temporomandibular joint. J Oral Surg 1951;9:214-24. Kiehn CL, DesPrez JD. Meniscectomy for internal derangement of the temporomandibular joint. Br J Plast Surg 1962;15:199-207. Poswillo D. The treatment of mandibular dysfunction. In:
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Zarb GA, Carlsson GE, editors. Temporomandibular joint function and dysfunction. Copenhagen: Munksgaard, 1979: 395-431. Ericksson L, Westesson P-L. Discectomy in the treatment of anterior disc displacement of the temporomandibular joint: a clinical and radiographic one-year follow-up study. J Prosthet Dent 1986;55:106-15. Wilkes CH. Surgical treatment of internal derangement of the temporomandibular joint. Arch Otolaryngol Head Neck Surg 1991;117:64-72. Silver CM. Long-term results of meniscectomy of the temporomandibular joint. J Craniomand Pract 1984;3:46-57. Ericksson L, Westesson P-L. Long-term evaluation of meniscectomy of the temporomandibular joint. J Oral Maxillofac Surg 1985;43:263-9. Ward TG, Smith DG, Sommar M. Condylotomy for mandibular joints. Br Dent J 1957;103:147-8. Nickerson JW, Veaco NS. Condylotomy in surgery of the temporomandibular joint. Oral Maxillofac Surg Clin North Am 1989;1:303-27. Hall HD, Nickerson JW, McKenna SJ. Modified condylo-
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tomy for treatment of the painful temporomandibular joint with a reducing disc. J Oral Maxillofac Surg 1993 ;51:133-42. Yih WY. Pathology of arthroscopic tissue of the temporomandibular joint. Oral Maxillofac Surg Clin North Am 1989;1:93-102. Israel HA. Synovial fluid analysis. Oral Maxillofac Surg Clin North Am 1989;1:85-92. Quinn JH, Bazan NG. Identification of prostaglandin E2 and leukotrine B4 in synovial fluid of painful, dysfunctional temporomandibular joints. J Oral Maxillofac Surg 1990;48:96871. Henry CH, Wolford LM. Treatment outcomes for temporomandibulai: joint reconstruction after proplast-tefion implant failure. J Oral Maxillofac Surg 1993;51:352-8.
Reprint requests: M. Franklin Dolwick, DMD Oral and Maxillofacial Surgery Residence Programs JHMHC Box 416 University of Florida, College of Dentistry Gainesville, FL 32610
The role of surgery in the management of TMJ pain and dysfunction gained renewed emphasis after the reintroduction of internal derangement during the 1970s. Interest was focused on the importance of disc displacement and deformity as the cause of TMJ pain and dysfunction. 1, 2 As a result, numerous open joint procedures were developed to reposition and reshape the displaced or deformed disc. 3-5 With the introduction of TMJ arthroscopy and, later, TMJ arthrocentesis, the success of simpler procedures such as lavage and lysis of adhesions has raised important questions about the pathosis of internal derangement. 6, 7 With the increased surgical options available to the surgeon, it seems prudent that selection of the surgical procedure with the highest probability of success and the least morbidity should be the objective. Surgical procedures currently used for the treatment of TMJ internal derangement range widely, from simple arthrocentesis and lavage to the more complex open joint operations. The purpose of this article is to review the currently used operations for the treatment of TMJ internal derangement. The operations to be reviewed are arthrocentesis, arthroscopy, arthrotomy (open TMJ surgery), and modified condylotomy. The undisputed application of surgery is found in the management of the less common TMJ disorders such as ankylosis, growth disturbances, trauma, and neoplasia. For the more common disorders, such as internal derangement and osteoarthritis, the indications are less clear and often are dependent on the patient' s ability to accurately report his or her symptoms as well as the surgeon's ability to interpret the often confusing clinical signs. 8-1° Ideally, one may adopt the policy of determining the need for surgery by the aProfessor and Director, Oral and Maxillofacial Surgery Residency Programs. Copyright © 1997 by Mosby-Yem"Book, Inc. 1079-2104/97/$5.00 + 0 7/0/78323 150
degree of the patient's disability in conjunction with the degree of improvement derived through nonsurgical treatment modalities, 11 as dictated by a clear understanding of the pathogenesis. In practice, however, the decision to operate seems to be a matter of the individual surgeon's training, experience, and attitudes toward the surgical management of temporomandibular disorders. TMJ arthrography and magnetic resonance imaging have proved to be of value in depicting disk position and shape, 12, 13 but the clinical symptoms have often failed to correlate with the findings of these imaging studies. 14, 15 Excessive reliance on the diagnostic value of imaging may lead to overdiagnosis of internal derangement and hence to overtreatment. Therefore it is essential for the clinician to place more emphasis on the history and clinical examination than on the results of imaging studies alone. Clinical indications for TMJ surgery for internal derangement are relative, rather than absolute, and the following general guidelines are recommended in the American Association of Oral and Maxillofaciai Surgeons Parameters of Care for Oral and Maxillofacial Surgery. 16 Surgical intervention is indicated only when nonsurgical therapy has been ineffective and when pain or dysfunction is moderate to severe. Surgery is not indicated for asymptomatic or minimally symptomatic patients. Surgery also is not indicated for preventive reasons in patients without pain and with satisfactory function. Therefore a patient with internal derangement who is incapacitated to the point at which work and relationships are severely disrupted and whose condition does not improve with nonsurgical treatment over a reasonable period of time may be an appropriate candidate for surgical treatment. It must be emphasized that the criteria for surgery is not simply refractory pain but pain that is localized specifically to the TMJ.
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The more localized the symptoms are to the TMJ, the better the surgical prognosis.
ARTHROCENTESIS TMJ arthrocentesis and lavage with manipulation is the simplest and least invasive of all surgical techniques. 17 The concept was based on the observations that simple lysis and lavage of the upper joint space using arthroscopy was highly successful in reestablishing normal range of mouth opening in patients with closed-lock of their TMJs. 18 The success of this technique has cast doubt on an abnormal disc shape or position as being the cause of closed-lock of the TMJ. Instead, it is speculated that restricted gliding movement of the mandibular condyle over the articular eminence may be due to reversible adhesion of the disk to the glenoid fossa caused by a vacuum effect or alteration in synovial fluid. 7 Preliminary results of this procedure have been promising in effectively establishing increased range of motion, improved function and decreased pain. 17, 19 A more recent study of 39 patients followed for an average of 40 months, reported that maximal mouth opening increased from 23.1 to 44.3 mm and contralateral movements increased from 4.8 to 8.2 mm. 2° In addition to these objective improvements there was a marked reduction in pain rate (85%) and dysfunction rate (72%) as measured on visual analog scales. All patients but 1 reported an improvement. Twentytwo (55%) patients reported 100% improvement, and 35 (90%) patients reported an improvement of more than 75% in both pain level and dysfunction rate. The advantages of TMJ arthrocentesis with lavage are that it is a simple, inexpensive, and minimally invasive procedure with little morbidity that can easily be performed in an outpatient setting. It is important, however, that the more acute the onset of closed-lock, the better the prognosis for a successful treatment outcome. 17 ARTHROSCOPY Arthroscopy of the TMJ was first described by Ohnishi, 21 in Japan, in 1975. A decade later the concept of TMJ arthroscopy spread to Europe and the United States, as intense interest developed in the idea that extended therapeutic application of arthroscopy could be added to this technique's diagnostic capabilities. 18, 22, 23 Arthroscopy is an equipment-dependent procedure that relies considerably on expensive and complex technology. Despite the minimally invasive nature of arthroscopy, which can be performed as an outpatient procedure, it is commonly performed during general anesthesia in an operating room. Skill is required to
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conceptualize a three-dimensional space on a two-dimensional screen image, and a high degree of manual dexterity is necessary, particularly for operative procedures. The advantages of arthroscopy compared with open joint surgery are that arthroscopy is less invasive, causes less surgical trauma to the joint, and is associated with lower morbidity. 24 In addition, healing time is shorter and recovery is more rapid than with open surgery. The results with TMJ arthroscopy have been uniformly satisfactory. 6' 18, 22-25 Success, as determined by decreased pain and improved range of motion, has varied from 79% to 93%. The most extensive data are from a 6-year multicenter retrospective study of 4831 joints. 26 After arthroscopic surgery, 91.6% of all patients had good or excellent motion; 91.3% had good or excellent pain reduction; 90.6% had good or excellent ability to maintain a normal diet; and 92% had a good or excellent reduction in disability. Also, the surgical technique was relatively free of complications (4.4%). The most successful results have been derived from arthroscopic lavage and lysis of adhesions in the upper joint space for the treatment of painful limited opening (closed-lock). 18The results of arthroscopic treatment of painful limited opening (closed-lock) compare favorably with results after open surgery. 6, 27 In light of these results, arthroscopy now plays an important role in clinical practice, particularly in the management of chronic closed-lock of the TMJ. The success of simple arthroscopic procedures, such as lavage and lysis, has raised important questions as to whether there is absolute necessity to reposition the disc to resolve TMJ pain and dysfunction. 6' 7 In addition, arthroscopic observation has revealed that the pathologic features associated with TMJ pain and dysfunction are more complex than simple disk displacement and disk deformity. 18, 22, 24 Steady growth in the popularity of TMJ arthroscopy has led to the development of numerous operative techniques, ranging from simple lavage and ablation of adhesions to electrocautery or laser treatment and suturing of the displaced disk. 2s, 29 Despite the complexity of the procedures that can be undertaken by the experienced arthroscopist, the outcomes of the more complex procedures are still to be fully evaluated, especially in comparison with simple lavage and lysis of adhesions.
ARTHROTOMY (OPEN JOINT SURGERY) Although numerous surgical approaches to the TMJ have been described, the most common approach is a preauricular incision made in the skin fold in front of the ear. Upon exposure of the joint capsule,
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January 1997 the superior joint space is entered first and is followed by exposure of the inferior joint space if necessary. Whereas other surgical procedures provide a limited range of options, arthrotomy provides the surgeon with an unlimited scope of procedures, ranging from simple lavage and debridement of the joint to complete removal of disk. The most commonly performed procedures are disk repositioning and diskectomy. Arthroplasty in the form of reconturing of articular eminence or condyle is sometimes necessary, particularly in cases of gross mechanical joint interference and advanced degenerative joint disease.
Disk repositioning First introduced by McCarty and Farrar 3 in 1979, disk repositioning to a more normal anatomic relation with the condyle and fossa is usually undertaken when the disk is displaced but otherwise free of disease or structural deformity. In a partial-thickness plication, described by Hall, 4 the disk is repositioned and stabilized with sutures without the need to enter the inferior joint space. Alternatively, in a full-thickness plication, described by Dolwick and Sanders, 5 the disk is repositioned by surgically exposing both joint spaces. Clinical studies have demonstrated a favorable outcome in terms of decreased pain and improved mandibular function in 80% to 94% of patients. 3-5, 3o Dolwick and Nitzan 31 evaluated 152 patients who underwent TMJ disk repositioning between 1984 and 1988 and found an 85% improvement in 90% of the patients. However, 5.3% reported no improvement after surgery, and 4.5% reported a worsening as a result of the surgery. Furthermore, it was found that the majority of those who did report an improvement after surgery continued to experience symptoms of pain, joint noise, and decreased range of motion, although to a lesser extent than before surgery.
Diskectomy Complete removal of the disk was one of the first intraarticular TMJ surgical procedures described. 32 Diskectomy is undertaken when the disk is found to be diseased or structurally compromised as a result of tears, perforations, or persistent symptoms of pain and dysfunction after previous disk surgery. Until recently, the removed disk was replaced with alloplastic implants. 33-35 However, because of the high incidence of foreign-body reactions found to result from the use of these alloplastic implants, their use has ceased. 36-39Various autogenous grafts such as auricular cartilage, dermis, and temporalis muscle and fascia have also been advocated for the replace-
merit of the disk. 4°-43 Because the advantages of using autogenous tissues for replacement of the disk are currently unclear, some authors advocate that the removed disk not be replaced with anything. 44 Diskectomy without disk replacement gained popularity between 1940 and 1960, 45, 46 and initially favorable results were reported in several series of patients who had been unsuccessfully treated with nonsurgical methods. 47' 48 Others have reported persistent pain, headache, and other signs and symptoms of dysfunction after diskectomy. 49 With time, the technique fell into disrepute and was abandoned. Improved diagnostic techniques and a better understanding of joint pathophysiology has resulted in discectomy's regaining popularity. In some recent studies on diskectomy used specifically for internal derangement success rates between 85% and 89% were reported.50, 51 Long-term follow-up data have also been published for diskectomy procedures. 52, 53 In one study, reporting long-term follow-up of almost 30 years after diskectomy, all 15 patients were reported to be free of pain and to have no subjective findings of mandibular dysfunction. 53 In another study, reporting long-term follow-up of 30 years after diskectomy, 96% of the patients experienced no pain after surgery, and all had mouth opening of 30 mm or more. 52 It is clear that discectomy without replacement can be performed safely and successfully on patients with certain well-defined criteria for treatment.
Modified condylotomy The modified condylotomy is a modification of the intraoral vertical ramus osteotomy used in orthognathic surgery to correct mandibular prognathism. The idea of performing osteotomy of the condylar process for treatment of temporomandibular disorders was derived from observations that patients who had sustained condylar fractures rarely complained of TMJ pain. 54 In the 1980s Nickerson and Veaco 55 developed the modified condylotomy as a means of treating TMJ pain when there is evidence of a reducing disk. A study by Hall et al., 56 conducted on 400 patients over a 9-year period, found good pain relief in about 90% of the patients treated. Although the surgery itself is simple, there is a prolonged period of postoperative rehabilitation involving 3 to 6 weeks of maxillomandibular fixation. The advantages of this procedure compared with other procedures are that the joint is not entered, and postoperative imaging indicated that a normal disc relation to the condyle is frequently achieved.
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DISCUSSION Over the years numerous techniques have been advocated for the treatment of internal derangement, but few techniques have gained universal acceptance. This situation reflects the continued poor understanding of the etiology, pathology, and natural history of this disorder as well as a poor understanding of the complex behavioral influences on the patient's pain and dysfunction. Surgical treatment of TMJ internal derangement has proven effective for reducing pain and increasing range of motion in about 80% of patients, regardless of operative technique, on the basis of published short-term retrospective studies. These studies are limited by the shortcomings often associated with retrospective clinical studies: poorly defined patient populations, observer bias in data collection, loss of m a n y treated patients to follow-up, and lack of control subjects. Long-term randomized controlled prospective studies are clearly lacking. The success of simple surgical procedures, such as arthroscopic lavage and lysis of the upper joint space, has raised serious doubts about the pathologic significance of disk position as the sole cause of pain and joint dysfunction. 6, 7 Clearly, an alternative explanation must be sought to corroborate the effectiveness of lysis and lavage in the management of some stages of internal derangement. It has been speculated that inflammation of the synovium (synovitis), capsule (capsulitis), or retrodiskal tissues (retrodiscitis) that is often observed during arthroscopy may be responsible for joint p a i n s Conversely, degenerative changes within the articular surfaces or disk may release chemical substances into the synovial fluid that may alter its consistency, hence compromising lubrication of the joint resulting in restricted mandibular movements seen in joint dysfunction. 5s, 59 Further research in this area is needed to elucidate the precise pathologic processes involved in TMJ pain and dysfunction. Surgery of the T M J has made considerable progress, although significant failures have plagued this field in recent years. The extensive experience in TMJ surgery reflects the vast numbers of surgeons who undertake this kind of surgery as a matter of routine within their scope of practice. The danger, however, is the creation of an environment where there may well be a tendency to overtreat, which may be further compounded by the lack of clearly defined and widely accepted criteria for surgery. Currently, the greatest problems faced by surgeons in the management of temporomandibular disorders involve failed alloplastic implants and patients undergoing multiple operations. It has become evident
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that the potential for success for any further surgery rapidly decreases as the number of operations increases. 6° The problems facing the surgeon may not be solely the structural abnormality of the multiply operated joint but also may include long-term muscle dysfunction resulting from chronic pain and limited jaw motion and abnormal illness behavior created by chronic pain and multiply failed treatments. Currently, the literature is virtually devoid of long-term solutions to the treatment of these patients, a deficiency that reinforces the need for careful planning and case selection.
Research recommendations Clearly, the lessons learned with regard to TMJ surgery should provide adequate warning to clinicians less experienced in this complex field of oral and maxillofacial surgery. The most important points are the mandatory need for long-term randomized prospective controlled studies of currently used techniques, especially new techniques, and the essential requirement for clearly defined criteria and objectives for TMJ surgery that would avoid the problems of failed treatment. Conclusions Surgery of the TMJ continues to have a small but nonetheless important role in the management of specific TMJ disorders. Appropriate case selection is the mandatory requirement for successful surgical intervention to achieve the desired outcomes of relief of pain and improvement in function. Surgery of the TMJ is best undertaken by surgeons who maintain the philosophy that surgery should aim to avoid further harm to the joint and who consider more conservative surgical procedures whenever possible. The benefits and limitations of each of the surgical procedures are readily determined on an individual case basis. The goal is to determine the most appropriate technique that will yield the highest probability of success with the lowest morbidity. REFERENCES 1. FarrarWB. Diagnosis and treatment of anterior dislocation of articular disc. NY J Dent 1971;41:348-51. 2. Wilkes CH. Arthrography of the temporomandibularjoint in patients with tmj pain dysfunction syndrome. Minn Med 1978;61:645-52. 3. McCarty WL, Farrar WB. Surgery for internal derangement of the temporomandibular joint. J Prosthet Dent 1979;42: 191-6. 4. Hall MB. Meniscoplastyof the displaced temporomandibular meniscus without violating the inferior joint space. J Oral Maxillofac Surg 1984;42:788-92. 5. DolwickMF, Sanders B. TMI internal derangementand artJarosis: surgical atlas 1985. St. Louis: CV Mosby, 1985:158-72.
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Reprint requests: M. Franklin Dolwick, DMD Oral and Maxillofacial Surgery Residence Programs JHMHC Box 416 University of Florida, College of Dentistry Gainesville, FL 32610