10.59987/ads/2016.3.73-78
Chronic disc displacement may lead to long-term pain. Temporomandibular joint surgery is reserved for those patients whose symptoms remain severe despite conservative treatment. We looked at the of effect of modified meniscopexy on patients with chronic disc displacement without reduction who did not respond to non-surgical pain management treatment. In this retrospective study a total of 59 joints was treated and all patients except one underwent splint assisted bilateral meniscopexy: this patient had splint assisted unilateral meniscopexy. At the time of presentation and following treatment all patients underwent clinical examination and were required to complete a pain and functional questionnaire. All patients reported improvement following treatment.
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Annali di stomatologia
meniscopexy
Splint-assisted disc plication surgery
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Original Article
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2022-08-10
2016-09-01
2023-12-04
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Ann Stomatol (Roma)
P. Ayliffe 
2016
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meniscopexy
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Splint-assisted disc plication surgery
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                                                                                                     Original article



    Splint-assisted disc plication surgery




                                                                                                                 i
                                                                                                               al
    Omar Sheikh1                                               Signs and symptoms commonly include TMJ pain,
    Greg Logan1                                                muscle pain, clicking, crepitus, restricted mouth




                                                                                                  n
    Deepak Komath2                                             opening, deviation on opening or closing and hea -
    Patrick Grossman3                                          daches. Tinnitus has also been reported as symp-




                                                                                               io
    Peter Ayliffe4                                             tom with studies reporting that when the most com-
                                                               mon causes of tinnitus are excluded, it is correct to
                                                               evaluate the functionality of the temporo-mandibular




                                                                   az
    1 London North West Hospitals, London, UK                  joint (2).
    2 Royal Free Hospital                                      Disruption of joint function by excessive/overloading
    3 Lister House Private Practice                            causes chronic irritation to the discs and synovium
    4 Great Ormond Street Hospital, University College         resulting in inflammation and disc displacement (3).




                                                                 rn
    Hospital, London, UK                                       Up to 75% of the population exhibits one recordable
                                                               sign of TMD with 5-33% of subjects reporting subjec-
                                                               tive symptoms. Symptoms peak between 20-40 years
    Corresponding author:                                      of age with a ratio of 3.3:1 females to males (4).




                                                               te
    Omar Sheikh                                                TMD is a multifactorial disease. Studies have quoted
    London North West Hospitals                                variable levels of trauma and dental treatment previ-
    Watford Road,                                              ous to the development of symptoms. Some patients
    London, HA13UJ, UK
                                                        In     also have an element of systemic disease such as
    E-mail: osheikh@nhs.net                                    joint hypermobility or arthritis with one study quoting
                                                               the figure at 13.1% (5).
                                                               Given a lack of consensus regarding best treatment
    Summary                                                    methods, the American Association of Oral and Max-
                                                ni

                                                               illofacial Surgeons (AAOMS) issued a statement re-
    Chronic disc displacement may lead to long-term            garding TMD syndrome. This categories TMD into 1.
    pain. Temporomandibular joint surgery is re-               extracapsular disorders, muscular in origin including
                                       io


    served for those patients whose symptoms re-               parafunction and pain referred from systemic muscle
    main severe despite conservative treatment. We             conditions and 2. intracapsular disorders involving disc
    looked at the of effect of modified meniscopexy            displacement. Degenerative changes including os-
                              iz



    on patients with chronic disc displacement with-           teoarthritis, rheumatoid arthritis, TMJ dislocation, anky-
    out reduction who did not respond to non-surgi-            losis and fractures are also responsible for TMD (6).
    cal pain management treatment. In this retrospec-          Initial management is non surgical and includes phys-
               Ed




    tive study a total of 59 joints was treated and all        ical therapy, occlusal appliance therapy, drug therapy
    patients except one underwent splint assisted bi-          (topical and systemic), intraarticular injection and
    lateral meniscopexy: this patient had splint as-           arthrocentesis, diet alteration and life style adapta-
    sisted unilateral meniscopexy.                             tion. Splint therapy has been reported with success
    At the time of presentation and following treat-           by Tsuga 1989, Gray 1991, Davies 1997 and shows
    ment all patients underwent clinical examination           to reduce muscle activity and providing neuromuscu-
 IC




    and were required to complete a pain and func-             lar balance to the TMJ (7-9).
    tional questionnaire. All patients reported im-            A Cochrane review of 12 randomised controlled trials
    provement following treatment.                             demonstrated no significant difference in the effec-
                                                               tiveness of stabilisation splint treatment compared to
C




    Key words: temporomandibular joint, splint,                other active treatments. This review also stated that
    meniscopexy.                                               occlusal adjustments make no difference to outcome.
                                                               TMJ surgery is reserved for those patients whose
                                                               symptoms remain severe despite conservative treat-
@




    Introduction                                               ment. Surgical options include:
                                                               - disc repair and disc repositioning procedures
    Temporomandibular disorders (TMD) are a heteroge-               (meniscopexy)
    neous group of pathologies and the most common             - menisectomy with/without autogenous implants
    orofacial pain conditions of non-dental origin affecting   - condylectomy
    the temporomandibular joint (TMJ), the masticatory         - condylotomy
    muscles or both (1).                                       - eminectomy.

    Annali di Stomatologia 2016;VII (3):73-78                                                                         73
    O. Sheikh et al.


    No one procedure is a panacea for all TMJ patholo-          -   clinical examination of the head and neck includ-
    gies (10).                                                      ing palpation of 90 osseous and muscular
    In contrast to open joint procedures, arthrocentesis            anatomical landmarks; a record was also made of
    and arthroscopy are less invasive, comparatively eas-           maximum mouth opening, left and right lateral ex-
    ier and less expensive (11).                                    cursions, spontaneous pain, pain on movement,
    A review of arthrocentesis and arthroscopy found no             presence of clicking/crepitus and/or locking.
    statistically significant difference between these inter-   In total 59 joints were treated and all patients except




                                                                                                                    i
                                                                                                                  al
    ventions in terms of pain. However the complication         one underwent bilateral meniscopexy, this patient
    rate for TMJ arthrocentesis is considered to be less        had unilateral meniscopexy.
    than that for TMJ arthroscopy (12).                         Following surgery all patients underwent clinical ex-
    Guo et al. (2009) state there is insufficient evidence      amination and were required to complete a pain and




                                                                                                    n
    (should conservative management fail) to support or         functional questionnaire. The categories in the pain
    refute other strategies (13).                               questionnaire were None, Rare, Slight, Occasional,




                                                                                                 io
    Our retrospective study focused on disc displacement        Moderate and Constant.
    without reduction (DDWoR) which can happen when             The meantime interval from surgery to completing the
    the ligaments are stretched beyond their elastic po-        questionnaire was 8.5 years, with a range of 22 months




                                                                    az
    tential. It can be described as a ‘door jam’ preventing     to 16 years.
    normal joint movement.

                                                                Presurgical technique




                                                                  rn
    Materials and methods
                                                                Prior to surgery all patients underwent splint therapy
    Inclusion criteria:                                         for 3 months. The mandibular flat plane pivot-type




                                                                te
    Patients that had disc displacement without reduction       splint was worn 24 hours a day, 7 days a week and
    confirmed on an MRI scan. Patients that did not re-         only removed for cleaning. The purpose of the splint,
    spond to splint therapy.                                    the height of which is determined by the swallow
    Patients that did not respond to conservative mea-          technique, is to decompress the TMJ, thereby creat-
                                                         In
    sures such as physiotherapy for a minimum of 6              ing superior joint space, obviating the need for condy-
    months, the average having such measures up to 18           lar surgery.
    months.                                                     Only the upper mesiopalatal cusps of the terminal
    Various options for surgery including arthrocentesis        molars contact the splint creating a bilateral occlusal
                                             ni
    and arthroscopy were discussed with the patients.           interference that limits postero-superior movement of
    Due to the prolonged nature of symptoms it was felt         the condyle and reducing loading forces on the
    that modified meniscopexy to restore normal anatomy         condylar head (Fig. 1). Any osteoarthritic process in
                                    io


    of the joint would provide the best result for these pa-    the inferior compartment is therefore reduced or even
    tients.                                                     arrested. One week before surgery the splint is resur-
    Prior to surgery, all patients underwent an MRI scan        faced to a highly indexed version locating the
                           iz



    followed by 3 months of fulltime splint treatment. The      mandible into an idealised relationship to the maxilla
    scans of all but 7 patients were classified according       and this so-called anterior repositioning splint is worn
    to Wilkes below:                                            during surgery.
              Ed




    Patients were considered for surgery if demonstrat-
    ing:
    - decreased inter-incisal opening                           Surgical technique
    - severe pain during function
    - audible crepitus                                          A modified preauricular approach is used and then
    - consistent muscle hyperactivity with unstable tem-        dissection proceeds to the superficial temporal fascia,
 IC




         poromandibular joints                                  then blunt dissection anteriorly in this plane. After
    - no medical contraindications to surgery                   identifying the lateral capsular ligament, a horizontal
    - no mental/emotional contraindications to surgery.         incision is required at its superior aspect to enter the
                                                                superior joint space. The disc is then located (Fig. 2).
C




                                                                Further dissection to the lateral aspect of the articular
    Patients                                                    eminence and anterior to this may be required for
                                                                this. The disc is then relocated and sutured laterally
    The study included 26 females and 4 males of which,         and posteriorly to the capsular ligament. No wedge
@




    9 were self referred, 16 referred by their general den-     resection of the retrodiscal tissues is needed unless
    tal practitioner, 5 from maxillofacial surgeons and 1       they prevent relocation of the disc into its normal po-
    from a chiropractor. All patients completed:                sition.
    - a TMJ medical, social and family history                  Prior to closure the joint is flushed with 2% lignocaine
    - a diagnostic pain questionnaire                           and 1:100,000 adrenaline. The mandible manipulated
    - a pictographic representation by the patient indi-        up and down making sure that the occlusal surfaces
        cating pain sites (head, neck, face and shoulders)      of the maxillary teeth correspond to the index in the

    74                                                                              Annali di Stomatologia 2016;VII (3):73-78
    Splint-assisted disc plication surgery


                                                                                         Figure 1. Splint in situ demonstrat-
                                                                                         ing occlusal interference thereby de-
                                                                                         creasing load on condylar head.




                                                                                                                     i
                                                                                                      n            al
                                                                                                   io
                                                                        az
                                                                      rn
    mandibular repositioning splint. This allows open in-           minutes per hour for the following 10 weeks. Patients
    spection for movement of the meniscus and determi-              are expected to have an active mouth opening of 48-




                                                                    te
    nation of the stability of sutures and surgical reposi-         52 mm after 90 days. Most patients prefer a soft diet
    tioning.                                                        for the first few weeks although no restrictions are
                                                                    placed.
                                                            In      The repositioning splint is worn 24 hours a day in-
                                                                    cluding eating, for up to 12 months postoperatively.
                                                                    As postsurgical oedema reduces and the masticatory
                                                                    musculature relaxes, adjustments to the splint need
                                                ni
                                                                    to be undertaken initially every 3-4 weeks for the first
                                                                    few months. At 12 months when full healing has been
                                                                    attained, splint therapy is concluded and any restora-
                                       io


                                                                    tive or orthodontic treatment can then be undertaken.
                                                                    Analyses of the results were conducted retrospective-
                                                                    ly by independent researchers. Information was ob-
                                                                    tained from the patients’ clinical notes, pre-treatment
                              iz



                                                                    and post-treatment pain questionnaires, MRI and
                                                                    hospital reports. The determination for success of
               Ed




                                                                    treatment was two fold, firstly the patients’ subjective
                                                                    evaluation and secondly the objective change in
                                                                    physical signs.


                                                                    Results
 IC




                                                                    The overall subjective improvement reported by the
                                                                    patients was measured on a visual analogue scale
                                                                    (VAS) as part of the post surgical questionnaire: in
                                                                    this study the mean improvement was 86% on a VAS
C




                                                                    of 1-10, with 1 being nil improvement and 10 maxi-
    Figure 2. Location of disc: relocation and suturing laterally   mum improvement. The minimum improvement was
    and posteriorly to the capsular ligament.                       40% and the maximum was 100%. The majority of
                                                                    patients felt that they had benefited from the proce-
@




    Postsurgical treatment                                          dure (Tab. 1).
                                                                    Shows overall improvement of the patients’ quality of
    Aggressive physical therapy is initiated within 24              life in response to 5 questions: the majority of pa-
    hours of surgery with a Therabite Exerciser. Patients           tients exhibited improved opening except for one pa-
    are instructed to use it for 5 minutes every half hour          tient whose opening decreased by 10 mm, this pa-
    (during waking hours) for the first 2 weeks and for 5           tient had a pre-operative mouth opening of 60 mm


    Annali di Stomatologia 2016;VII (3):73-78                                                                              75
    O. Sheikh et al.


    that decreased to 50 mm. She had constant pain on                      TMJ locking prior to treatment was a constant prob-
    opening and a dull ache at rest, this was reduced to                   lem for 20% of the patient group with 33.3% stating
    rarely. The mean increase in mouth opening was 8.6                     this was of moderate or occasional concern.
    mm and the maximum increase was 20 mm (Tab. 2).                        Following surgery, TMJ locking and crepitus was re-
    The AAOMS states that the average inter-incisal dis-                   solved for the entire group.
    tance is 50-60 mm and this measurement is an objec-                    Both locking and crepitus are objective observations
    tive assessment of joint function. In this study the aver-             and less open to bias or interpretation unlike psycho-




                                                                                                                               i
    age pre-op distance=37.5 mm (range of 25-60 mm).                       logical factors which may depend on the patients’ sta-




                                                                                                                             al
    This method improves mouth opening and function                        tus at the time of questioning.
    but not every patient achieved the 50-60 mm range                      Neck pain is frequently associated with TMJ pain.
    reported by AAOMS.                                                     TMJD whilst not causative can exacerbate an existing




                                                                                                               n
    Clicking of the TMJ was as reviewed and is present-                    neck pain. 60% of patients reported constant neck
    ed in Table 3: 53.3% of patients reported constant                     pain pre-treatment, with only 3.3% of patients report-




                                                                                                            io
    clicking preoperatively whilst none reported constant                  ing constant pain post-treatment. However, after
    clicking postoperatively, confirming a marked im-                      treatment 70% still experienced occasional/rare pain.
    provement in symptoms.                                                 Pain is the most reported symptom of TMJD (6).




                                                                               az
    Table 4, shows that constant spontaneous jaw pain                      The improvement in reported pain pre and post treat-
    reduced in all but 3.3% of patients: 36.7% of patients                 ment.
    presented with crepitus preoperatively with complete                   14 of the 30 patients reported constant joint pain pre-
    resolution for all patients after surgery.                             operatively while 4 never reported pain. Post-opera-




                                                                             rn
    Table 1. Pre-treatment Wilkes classification.




                                                                           te
    Stage 1                  Stage 2                    Stage 3                 Stage 4                  Stage 5
    0                        0                          14                      22                      9
                                                                  In
    Table 2. Global post-operative subjective impressions.

                                                                                        Overall improvement
                                                   ni

    Question:                                                     Better               Same               Worse
    Overall my physical well-being is?                            74%                  19.3%              6%
                                              io


    Overall my mental/emotional state is?                         64.5%                29%                6%
    Overall my ability to deal with stress is?                    48.3%                48.3%              4.4%
                                 iz



    Overall my enjoyment of life is?                              70.9%                22.5%              6.6%
    Overall my quality of life is?                                77%                  19%                4%
                Ed




    Table 3. Overall improvement in TMJ Clicking.

    Frequency of clicking            Constant                Rare                    Occasionally         Never
    Pre op Clicking                  53.3%                   13.3%                   3.3%                 30%
 IC




    Post-op Clicking                 0%                      0%                      6.7%                 93.3%



    Table 4. Spontaneous jaw pain Pre and Post treatment.
C




                                          Pre-treatment pain                           Post-treatment pain
    None                                  2                                            7
@




    Rare                                  3                                            9
    Slight                                0                                            1
    Occasional                            1                                            10
    Moderate                              2                                            2
    Constant                              22                                           1



    76                                                                                         Annali di Stomatologia 2016;VII (3):73-78
    Splint-assisted disc plication surgery


    Table 5. It shows the improvement in reported pain pre vs post operatively.

    Frequency of Pain        Constant           Moderate           Occasionally           Rare                   Never
    Pre operatively          66.67%             10%                6.67%                  10%                    6.67%
    Post operatively         3.33%              6.67%              33.33%                 33.33%                 23.33%




                                                                                                                              i
                                                                                                                            al
    tively 7 patients never experienced joint pain and only          -   access is confined to the superior joint space;
    1 patient reported constant pain (Tab. 5).                       -   the relocated disc is sutured posterolaterally to the cap-
    Chronic pain sufferers did not report complete resolu-               sule and not posteriorly to the retrodiscal tissues;




                                                                                                              n
    tion of symptoms which may suggest that the most                 - the splint is worn during surgery;
    significant improvement is conferred on those pa-                - aggressive physical therapy commences 24 hours




                                                                                                           io
    tients with a lower pre-operative level of pain.                     post surgery (16, 17);
    One patient suffered temporary right facial nerve palsy          - the splint is worn full-time post surgery for 12
    post-surgery with loss of ability to raise the right eye-            months prior to any orthodontic/restorative proce-




                                                                         az
    brow. There were no post-treatment orthodontic compli-               dures;
    cations. At the time of surgery two tears were seen in           - As postsurgical oedema reduces and the mastica-
    the disc itself and two tears in retro-discal tissue.                tory musculature relaxes, the splint is adjusted
                                                                         every 3-4 weeks for the first few months.




                                                                       rn
                                                                     The multiple adjustments of the splint gradually re-
    Discussion                                                       duce superior joint space allowing the disc to retain
                                                                     its correct anatomical position and prevent the disc
    This study reviewed a group of patients (n=30) treat-            relapsing anteriorly, preventing a relatively common




                                                                     te
    ed by the senior Authors who presented with disc dis-            complication. The suture posterolaterally also aids
    placement without reduction, either unilateral or bilat-         this. Other studies have discussed the use of Mitek
    eral. Anterior repositioning splints can be used to cre-         screws and double pass sutures to stabilise the artic-
    ate superior joint space as well as an idealised maxil-
                                                           In        ular disc in its correct anatomical position. However
    lo-mandibular relationship which is subsequently sta-            very rarely did these methods result in a ‘click free’
    bilized by disc relocation. The need to wear the splint          joint for every patient post surgery in their respective
    prior to surgery is mandatory as it is during surgery to         study groups (18-20).
                                                                     The weakness of the study is that the pre- and post-
                                                ni
    prevent relapse of the disc into the painful pre-surgi-
                                                                     surgical questionnaire was not aligned with OHIP and
    cal position.
                                                                     therefore limited in scope.
    Patients with disc displacement without reduction
                                                                     Furthermore, outcomes were reliant on subjective
                                       io


    show condyles that are superiorly positioned in the
                                                                     and functional improvements which could not be di-
    fossa reducing superior joint space. Occlusion, al-
                                                                     rectly associated to disc repositioning, since no post-
    though not a causative factor, maintains the patholog-
                                                                     operative MRI scans were taken.
                              iz



    ical condyle/fossa relationship by virtue of intercuspa-
    tion. Creation of superior joint space is key to provid-
    ing disc space and stability thereafter. Previous at-
                                                                     Conclusion
               Ed




    tempts at creating space have involved condylar
    surgery but this does not address muscle spasm.
                                                                     To ensure long-term stability and relief of symptoms,
    Furthermore, such surgery carries complications in-              all aspects of disc derangement aetiology must be
    cluding adhesion formation, bone degeneration and                addressed. Patients in this study presented with disc
    ankyloses (14).                                                  displacement without reduction, occlusal dishar-
    Splint therapy allows non-invasive creation of superi-           monies, degenerative change, muscle spasm and ab-
 IC




    or joint space, elongation of the masticatory muscles            normal condylar position.
    together with a functional maxillomandibular relation-           By restoring normal joint anatomy with subsequent
    ship. The surgeon and orthodontist opted for the mini-           orthodontic stabilisation treatment which provided oc-
    mally invasive soft tissue procedure of disc plication           clusal support, predictable long-term results can be
C




    as it poses fewer post-surgical complications as com-            achieved for this group of challenging patients.
    pared with more invasive techniques. Invasive tech-              Whilst not a cure-all procedure, splint assisted disc pli-
    niques can damage the connective tissue covering of              cation surgery can be recommended for refractory pa-
    osseous tissues thereby reducing the possibility for             tients with chronic disc displacement without reduction.
@




    remodeling and healing (15).
    The surgical protocol differs from other published
    studies in the following ways:                                   References
    - all surgery was preceded by 3 months of full-time
         splint therapy;                                             1.    Leresche L. Epidemiology of temporomandibular disorders:
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    7. Gray RJ, Davies SJ, Quayle AA, Wastell DG. A comparison             17. Austin BD, Shupe SM. The role of physical therapy in recovery
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    8. Davies SJ, Gray RJ. The pattern of splint usage inthe man-              poromandibular joint disc-repositioning surgery with Mitek mini
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               Ed
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    78                                                                                             Annali di Stomatologia 2016;VII (3):73-78
