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Objective. The purpose of this study was to assess the outcomes of temporomandibular joint (TMJ) “functional arthroplasty” on the inferior compartment and disc reposition as a surgical treatment for internal derangement (ID). Patients and methods. By retrospective chart review, all patients who had TMJ surgery on the inferior compartment for TMJ ID from 1985 to 2010 were identified. Their charts were reviewed and subjective data as well as objective data was collected.
Results. The chart review yielded 352 patients treated through this approach for a total of 696 joints involved. Analysis of the data showed that there was a good health improvement. The mid VAS about pre surgical TMJ pain was 58.3, after surgery 7.7. About headache and cervical pain the pre surgery mid VAS was 47.7, after surgery 16.7.
Conclusions. Outcome data presented show that TMJ surgery on the inferior compartment and disc reposition could be an effective and successful surgical treatment of TMJ ID. This success has been seen and maintained also in long term follow up in this specific patient population. For this reason, we propose to call this procedure “functional arthroplasty”.
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Annali di stomatologia
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TMJ inferior compartment arthroplasty procedure through a 25-year follow-up (functional arthroplasty)
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TMJ inferior compartment arthroplasty procedure through a 25-year follow-up (functional arthroplasty)
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                                                                                                    Original article



    TMJ inferior compartment arthroplasty procedure
    through a 25-year follow-up
    (functional arthroplasty)




                                                                                                                 i
                                                                                                               al
    Piero Cascone1                                           Key words: TMJ, internal derangement, TMJ
    Valerio Ramieri1                                         surgery, functional arthroplasty.




                                                                                                 n
    Paolo Arangio1
    Valentino Vellone1




                                                                                              io
    Achille Tarsitano2                                       Introduction
    Claudio Marchetti2
                                                             TMD (temporo-mandibular joint disorder) is a collec-




                                                                 az
                                                             tive term used to describe a number of related disor-
    1Unit of Maxillofacial Surgery, Policlinico Umberto I,   ders affecting the temporo-mandibular joint (TMJ),
    Sapienza University of Rome, Italy                       masticatory muscles and associated structures, with
    2Department of Biomedical and Neuromotor Sciences,       a variety of common symptoms such as pain and lim-




                                                               rn
    Section of Maxillofacial Surgery, University of          ited mouth opening (1). TMDs are a common cause
    Bologna, Policlino S. Orsola, Bologna, Italy             of persistent facial pain, headaches, jaw clicking, and
                                                             jaw locking. Internal Derangement (ID) is one of the
                                                             most common type of disorder affecting the TMJ (2).




                                                             te
    Corresponding author:                                    Internal derangement can be classified by 5 stages of
    Valentino Vellone                                        dysfunction according to Wilkes (3). The reciprocal
    Unit of Maxillofacial Surgery, Policlinico Umberto I,    clicking of the joint, considered as the early stage of
    Sapienza University of Rome
                                                        In   ID, is common, affecting about 40% of the general
    Via del Policlinico                                      population (4-7). Whereas, later stages such as disc
    04100 Latina, Italy                                      displacement without reduction and TMJ degenera-
    E-mail: valentino.vellone@gmail.com                      tive changes are less frequent (8-10). Procedures in-
                                                             volving the temporo-mandibular joint, including open
                                            ni

                                                             surgery and arthroscopy have been used to correct
    Summary                                                  either position or structural problems of the disc, ar-
                                                             ticular eminence and the condyle. Open surgery is
                                   io


    Objective. The purpose of this study was to as-          still considered to be the “last chance” for patients af-
    sess the outcomes of temporomandibular joint             fected by chronic recurrent TMD for which other ther-
    (TMJ) “functional arthroplasty” on the inferior          apies have failed to improve signs and symptom, pre-
                           iz



    compartment and disc reposition as a surgical            ferring minimally invasive surgical techniques. Some
    treatment for internal derangement (ID).                 studies (11) have indicated that nonsurgical treatment
    Patients and methods. By retrospective chart re-         can eliminate ID signs and symptoms in patients with
             Ed




    view, all patients who had TMJ surgery on the in-        TMD, considering it as a self-limiting pathology. Al-
    ferior compartment for TMJ ID from 1985 to 2010          though these studies might demonstrate the thera-
    were identified. Their charts were reviewed and          peutic prevalence of nonsurgical treatments com-
    subjective data as well as objective data was col-       pared with surgery ones, they seem to have not sta-
    lected.                                                  tistical significance and sufficient follow-up period
    Results. The chart review yielded 352 patients           (12). Main role of IDs surgical correction has been
 IC




    treated through this approach for a total of 696         described as relief of symptoms and pain (13). In
    joints involved. Analysis of the data showed that        1994, Dolwick and Dimitroulis (14) stated that the in-
    there was a good health improvement. The mid             dications for performing surgery could be divided into
    VAS about pre surgical TMJ pain was 58.3, after          relative and absolute. Absolute indications were TMJ
C




    surgery 7.7.                                             tumors, ankylosis and condyle growth abnormalities.
    About headache and cervical pain the pre surgery         Relative indications were usually ascribed to those
    mid VAS was 47.7, after surgery 16.7.                    pathologies in which surgery appears to have a less
    Conclusions. Outcome data presented show that            defined role, such as internal derangement with ab-
@




    TMJ surgery on the inferior compartment and disc         normal disc position and arthritic changes. Inauspi-
    reposition could be an effective and successful          ciously, the failure of non-surgical therapy appears to
    surgical treatment of TMJ ID. This success has           suffer from misdiagnosis or incomplete diagnosis of
    been seen and maintained also in long term fol-          TMDs, which could account for about 20% of failed
    low up in this specific patient population. For this     cases (15, 16). Some studies (17, 18) have demon-
    reason, we propose to call this procedure “func-         strated that more the patient can define and localize
    tional arthroplasty”.                                    their symptoms, more effective the surgery and out-

    60                                                                           Annali di Stomatologia 2016;VII (3):60-64
    TMJ inferior compartment arthroplasty procedure through a 25-year follow-up (functional arthroplasty)


    comes can be. The Authors propose a logical approach          ringer lactate lavage was performed. The inferior
    to internal derangement with an early minimally inva-         compartment was then access by using a 15 blade
    sive technique, that could result in an immediate effec-      cutting through the lateral ligaments of the disc. After
    tive and long-lasting reduction in patient’s symptoms         entering the inferior compartment care was taken to
    such as atypical orofacial pain, neck pain and                protect the disc, retrodiscal tissues and medial aspect
    headaches. The Authors present a 25-year- retrospec-          of the capsule by placing three retractors on the head
    tive study and a different technique in treating ID with      of the condyle. A high condylectomy (about 1-2 mm)




                                                                                                                  i
                                                                                                                al
    an open surgery called “functional arthroplasty”.             was then accomplished by using a straight fizzure bur
                                                                  or piezo surgery. After removal of this piece and
                                                                  smoothing off the edges, the joint and retrodiscal tis-
    Patients and methods                                          sues were evaluated from the inferior compartment




                                                                                                     n
                                                                  for perforations, adhesions, or anomalies. After cor-
    In this study the Authors performed a retrospective           recting any perforations with suture or freeing any ad-




                                                                                                  io
    analysis of all patients with a diagnosis of internal de-     hesions, the lateral ligaments of the disc were su-
    rangement who underwent to “functional arthroplasty”          tured in a posterior lateral fashion. The last step was
    with the same surgeon (P.C), from 1985 to 2010 for a          a washing of the inferior compartment using lactated




                                                                      az
    total number of 565 patients. Inclusion criteria were         ringer solution (200 cc) and the surgical site closed
    as follows: the patients must have had internal de-           using two layers. Patients are closely followed up
    rangement according to Wilkes criteria II or higher           during the first weeks to restore the correct function.
    (3); no other TMJ operations performed in the past; a




                                                                    rn
    minimum follow-up period of 5 years whether by
    phone or in person.                                           Results
    Every patient included in the study had been evaluat-




                                                                  te
    ed in the following issues:                                   Out of the inner sample of 565 patients only 352
    a) internal derangement and laterality                        (62.3%) satisfied inclusion criteria. 337 patients had
    b) chief complaint as pertaining to the TMJ                   diagnosis of bilateral internal derangement (in this
    c) localization and laterality of pain associated with        case diagnosis was given in relation to the worse
                                                         In
        each joint                                                TMJ pathology) and 22 had monolateral involvement
    d) headache and cervical pain.                                for a total number of 696 treated joints. The sample
    The Authors adopted a Visual Analogue Scale (VAS)             was composed by 299 females (85%) and 53 males
    ranging from 0 to 100 to evaluate pain. All values had        (15%). In relation to age, the lowest value observed
                                                ni
    been approximated to the closest whole number. In             was of 16 years to the highest of 68 with a mean val-
    relation to symptom the Authors have divided the              ue of 32. Long-term follow up was accomplished in
    sample before and post surgery in condyle luxation,           every patient from the smallest value of 5 years to the
                                       io


    only pain, crepitus, disc displacement with reduction         highest of 27 with a mean value of 12.5 years.
    and disc displacement without reduction. These con-           In relation to symptom 5% suffered from condyle lux-
    ditions were very often associated with temporo-              ation, 6% only pain, 24% crepitus, 30% click, 35%
                              iz



    mandibular pain according to Wilkes stages.                   lock) (Fig. 1) while after surgery 77% of patients re-
    VAS was used to evaluate pain. The patient were               ported no symptoms, 9% presented with click, 2%
    grouped values into 5 main classes before and post            lock and 12% crepitus (Fig. 2).
               Ed




    surgery: Class I absence of pain, Class II pain rang-         These conditions were very often associated with
    ing from 1 to 25, Class III pain ranging from 25 to 50,       temporomandibular pain according to Wilkes stages
    Class IV pain ranging from 50 to 75 and Class V pain          (Stages I and II 82.3%; III and IV 97.1%; V 100%).
    ranging from 75 to 100. The issue “Headache and               VAS was used to evaluate pain. The patients were
    cervical pain” has been investigated before and post          grouped values into 5 main classes: Class I absence
    surgery with the VAS considering the same classes             of pain, Class II pain ranging from 1 to 25, Class III
 IC




    of values.                                                    pain ranging from 25 to 50, Class IV pain ranging
                                                                  from 50 to 75 and Class V pain ranging from 75 to
                                                                  100.
    Surgical technique                                            Before surgery 6% of patients was classified in VAS
C




                                                                  group ranged from 1-25, 11% in 25-50 VAS, 13% no
    Open surgery. A pre-auricolar post-tragal incision            pain, 31% 50-75 VAS, 39% 75-100 VAS) (Fig. 3).
    was performed with a bevelled 45° inclination, ap-            After surgery 78% of patient reported no pain, 10%
    proximately 1.5 cm long. The temporal vessels are             were classified in VAS group ranged from 1-25, 6% in
@




    then isolated and ligated with 3-0 silk suture. Dissec-       VAS group 25-50, 4% in VAS group 50-75 while only
    tion was then carried down to the TMJ capsule, with           2% in VAS group 75 to 100 (Fig. 4).
    special care given not to damage the facial nerve.            The issue “Headache and cervical pain” has been in-
    The aim is to preserve as much as possible the TMJ            vestigated before surgery with the VAS considering
    biomechanics. A diagnostic arthroscopy was then               the same classes of values as shown in Chart 3 (13%
    carried out in the superior compartment to check for          1-25 VAS, 17% 25-50 VAS, 18% no pain, 23% 50-75
    perforations in the disc and adhesions and 200 cc             VAS, 29% 75-100 VAS) (Fig. 5).

    Annali di Stomatologia 2016;VII (3):60-64                                                                          61
    P. Cascone et al.


                              Figure 1. Evaluation of presurgical main
                              symptom.




                                                                   i
                                                   n             al
                                                io
                              Figure 2. Evaluation of postsurgical main
                              symptom.




                                 az
                               rn
                             te
                             In
                              Figure 3. Evaluation of presurgical pain.
                         ni
                        io
                        iz
              Ed
 IC




                              Figure 4. Evaluation of postsurgical pain.
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@




    62                             Annali di Stomatologia 2016;VII (3):60-64
    TMJ inferior compartment arthroplasty procedure through a 25-year follow-up (functional arthroplasty)


                                                                                 Figure 5. Evaluation of presurgical
                                                                                 headache.




                                                                                                                     i
                                                                                                      n            al
                                                                                                   io
                                                                      az
    After surgery 54% of patient reported no headache and         the lateral ligament most of the time bilateral surgical
    cervical pain, 22% was classified in VAS group ranged         treatment. As pertaining to the high condylectomy it is
    from 1-25, 11% in VAS group 25-50, 6% in VAS group            Authors’ opinion that, essentially, it brings the following




                                                                    rn
    50-75, while 7% in VAS group 75 to 100 (Fig. 6).              results: a) eliminates condylar disparities which are al-
                                                                  ways observed in case of long lasting disc displace-
                                                                  ment; b) it widens the articular space which has been
    Discussion                                                    reduced by the vertical height loss; c) creates scar ad-




                                                                  te
                                                                  hesions between disc and condyle thus leading to a
    To date there is no agreement about when to do an             greater after surgical stability. Performing the surgery
    open surgery of the TMJ. Several approaches in the            bilaterally bring a better result because ID affects most
    past have shown a variety of results with poor long
                                                        In        of the time both joints in a variety of pathology. It was
    term outcome.                                                 interesting to observe some patients had crepitus after
    Moreover, there are not adequate comparative studies          surgery especially if they were affected by chronic lock.
    (19) and an unique classification is not widely recog-        A complete crepitus resolution was observed in pa-
                                                ni
    nized. Many surgical strategies, such as discectomy or        tients with a previous diagnosis of crepitus. This partic-
    articular prosthesis, mainly deal with patient referred       ular phenomenon has to be referred to the physiologi-
    pain and don’t take into account the anatomical and           cal sliding of the malformed disc. It was felt that this
                                       io


    morphological issues (20-22). Other strategies aimed to       treatment worked because it restored balance to the
    restore the anatomy, however they have not seen long          TMJs bilaterally, created space for the disc and condyle
    lasting results such as those that have used proplast-        to function once again in harmony, and made it possi-
                              iz



    teflon substitution of the disc (23, 24). From the 1985,      ble for the patient to once again have normal range of
    when was first approached this surgery, impressive out-       motion of their mandible. This procedure respects
    comes were seen and since then the surgical technique         anatomy and biomechanical function and restriction
               Ed




    has never been changed in its basic principles: high          that guides TMJ movements. For this reason, we would
    condylectomy, disc repositioning and reconstruction of        like to call this surgery “functional arthroplasty”.




                                                                                 Figure 6. Evaluation of postsurgical
 IC




                                                                                 headache.
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@




    Annali di Stomatologia 2016;VII (3):60-64                                                                             63
    P. Cascone et al.


    Conclusions                                                                 cause of craniomandibular pain and dysfunction: A unifying
                                                                                concept. J Oral Maxillofac Surg. 1989;47:249.
                                                                          10.   Stegenga B, de Bont LG, Boering G, van Willigen JD. Tis-
    This study adds to previously reported successful re-
                                                                                sue responses to degenerative changes in the temporo-
    sults (25) and encourages surgeons to pursue open
                                                                                mandibular joint: a review. J Oral Maxillofac Surg.
    technique respecting TMJ anatomy and biomechani-                            1991;49:1079.
    cal functional restriction.                                           11.   Dimitroulis, G. The role of surgery in the management of
    The outcome data showed that “functional arthroplas-




                                                                                                                                      i
                                                                                disorders of the temporomandibular joint: a critical review




                                                                                                                                    al
    ty” on the inferior compartment with disc repositioning                     of the literature. Part 1. Int J Oral Maxillofac Surg. 2005;
    could be an effective and successful surgical treat-                        34:107-113.
    ment option for patients with TMJ ID especially those                 12.   Murakami K, Kaneshita S, Kanoh C, Yamamura I. Ten-year
    who have problems bilaterally. In conclusion, “func-                        outcome of nonsurgical treatment for the internal derange-




                                                                                                                    n
    tional arthroplasty” on the inferior compartment is an                      ment of the temporomandibular joint with closed lock. Oral
                                                                                Surg Oral Med Oral Pathol Oral Radiol Endod.
    effective and successful surgical treatment for TMJ ID




                                                                                                                 io
                                                                                2002;94(5):572-5.
    in our specific patient population. This success has                  13.   Pedullà E, Meli GA, Garufi A, Mandalà ML, Blandino A, Ca-
    been continued for over 25 years.                                           scone P. Neuropathic pain in temporomandibular joint dis-
                                                                                orders: case-control analysis by MR imaging. AJNR Am J




                                                                              az
                                                                                Neuroradiol. 2009;30(7):1414-8.
    Conflict of interest                                                  14.   Dolwick MF, Dimitroulis G. Is there a role for temporo-
                                                                                mandibular joint surgery? Br J Oral Maxillofac Surg. 1994;
    The Authors declare that there is no conflict of inter-                     32:307-313.




                                                                            rn
    est in publishing this paper.                                         15.   Dimitroulis G. The role of surgery in the management of dis-
                                                                                orders of the temporomandibular joint: a critical review of the
                                                                                literature. Part 2. Int J Oral Maxillofac Surg. 2005;34:231-237.
    Funding
                                                                          16.   Nitzan DW, Dolwick MF, Martinez GA. Temporomandibular
    This research did not receive any specific grant from




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    64                                                                                             Annali di Stomatologia 2016;VII (3):60-64
