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Arthroscopic treatment of anterior disc displacement: A preliminary report
Abstract
A new suturing technique for stabilizing anteriorly displaced discs that have been reduced arthroscopically after removal of adhesions, lateral pterygoid release, and stretching the lateral capsule is presented. This procedure has provided successful results, although the evaluation is only short-term. No complications have occurred using this suturing technique.
... El tratamiento clínico todavía es prioritario al quirúrgico como modalidad de tratamiento para la disfunción de la ATM (6,9,10). Diferentes técnicas ten sido utilizadas para tratarla quirurgicamente, entre ellas, la artrocentesis, plicatura discal y discoplastias (10,(11)(12)(13). En el caso de desplazamiento anterior del disco la plicatura u otros procedimientos de reparo son adecuados si el disco estuviere desplazado antero-medialmente, irreducible y no estuviere deformado. ...
... Clinical treatment must be given before surgery in order to treat TMJ dysfunction (6,9,10). A variety of techniques have been used to correct it surgically such as arthrocenthesis, condylar disk plication and diskoplasties (10,(11)(12)(13). In cases of anterior disk displacement plication or another repair procedure is used if the disk is anterior-medially displaced, irreducible and not deformed. ...
... The normal position of the disk has been confirmed by MRI. Tarro (12) performed condylar disk plication using arthroscopy. Out of forty patients treated by this method, thirty-six felt less pain and improved their mandibular function during a 2-to-18 month follow-up. ...
To report six cases submitted to the TMJ condylar disk plication technique.
All patients presented a limitation of mandibular movements, severe pain and failure of previous clinical treatment. A definitive diagnosis of irreducible anterior disk displacement was made by MRI (Magnetic Resonance Imaging). Clinical evaluation consisted of the following: measurement of maximal mouth opening, movement to the left and right and protusion; presence of deviation during mouth opening; clicking during mouth opening or closing; presence of pain and personal satisfaction following surgery.
While all patients had preoperative pain, only one had severe pain; in the others, the pain was less intense at the end of the period of follow-up. Stomatognatic function was improved and has been maintained since the conclusion of this study.
On the basis of the follow-up of these patients, the proposed technique proved to be effective for disk stabilization, leading to a decrease in pain and an improvement in mandibular movements.
... Being a minimally invasive procedure, it has the advantage of smaller scars and lower risk of facial nerve injury as opposed to arthrotomy-based procedures, but requires a greater learning curve. Arthroscopic discopexy was initially reported by Israel (1988), Tarro (1989), and McCain (1992), but several other authors have reported variations in the technique with an aim to simplify it or improve the stability of the disc and hence the clinical outcome (24)(25)(26)(27)(28). ...
... Being a minimally invasive procedure, it has the advantage of smaller scars and lower risk of facial nerve injury as opposed to arthrotomy-based procedures, but requires a greater learning curve. Arthroscopic discopexy was initially reported by Israel (1988), Tarro (1989), and McCain (1992), but several other authors have reported variations in the technique with an aim to simplify it or improve the stability of the disc and hence the clinical outcome (24)(25)(26)(27)(28). ...
... Both techniques are done under arthroscopic vision with high success rates. Other fixation techniques includes pins [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31] All proposed discopexy techniques include disc reduction with or without anterior release followed by retrodiscal contracture and finally disc fixation. In specific cases disc maintains its normal position on top of condyle under function test during the procedure which brings us to think that in such cases retrodiscal contracture shall be enough to maintain disc position with no need for suture, or pin fixation. ...
... Recent studies suggested a combination of disc repositioning and treatment of the pathological changes such as condylar resorption or degenerative disease improved results and reduced or even prevented posterior condylar degeneration 38,39 . Despite their effectiveness, modern clinical practices continued to search for minimally invasive alternatives to open surgical procedures TMJ arthroscopic discopexy technique was first introduced by Israel and Tarro in 1989, 17,19,41 followed by McCain in 1992, The efficacy of the technique was evaluated by many authors yet the impact of ID severity on the success rates of arthroscopic discopxy is not well evaluated. Moreover the literature is still lacking enough successful reports on disc stability after repositioning. ...
... In 1989, Israel [7], Tarro [8], and Ohnishi [9] reported three types of arthroscopic suture for the treatment of anterior disc displacement or recurrent mandibular dislocation. In 1992, a new inventive technique for arthroscopic suture was reported by McCain et al. [10]. ...
... This observation triggered the development of different techniques of arthroscopic disc repositioning surgery. Although various arthroscopic disc repositioning/ suturing techniques have been reported since the late 1980s [7][8][9][10][11][12][13], the success rate has been considered comparable to arthroscopic lysis and lavage, and the necessary documentation of long-term disc reposition by postoperative IMR is clearly insufficient. ...
Purpose: The aim of this report is to define a modification of the arthroscopic anterior myotomy that avoids disc suturing procedures for the treatment of advanced internal derangement (ID) of the temporomandibular joint (TMJ).
Surgical Technique: The minimally invasive arthroscopic anterior myotomy (MIAAM) is based on a partial resection of the superior belly of the lateral pterygoid muscle performed through a small incision of the articular capsule associated with a scarification of the posterior ligament of the TMJ. The high-frequency wave system, called Coblation, is extremely useful to be able to complete the MIAAM.
Conclusion: This technique is indicated for patients with ID and Wilkes stages III-IV without response to conservative treatments, and the presence of an integral disc with an appropriate consistency is transcendent for the success of the procedure. Because of the unique characteristics of the MIAAM, it can be considered as an alternative to arthroscopic discopexy procedures.
... One technique was initially described by McCain 22 and involved a single suture passing through the disc from the inferior joint space. In contrast, Tarro 23 used a suture passing through the external auditory canal. These procedures, which are performed under direct arthroscopic vision, alleviate TMJ pain and improve mouth opening. ...
... Although a TMJ arthroscopic discopexy technique was introduced by Israel et al, 34 Israel, 35 and Tarro 23 in 1989 and by McCain et al 20 in 1992, the published data lack studies evaluating the success rates of arthroscopic discopexy, in particular in relation to ID severity. Although some physicians have applied arthroscopic repositioning of the disc, a successful report on its stable effect has not been published. ...
Statement of the Problem: Disc repositioning for temporomandibular joint (TMJ) internal derangement (ID) is a well-established surgical technique with variable success. The purpose of this study is to assess the outcome of using arthroscopic disc repositioning (discopexy) for TMJ ID.
Study Design
This is a prospective, cohort, single institutional clinical study.
Study Sample
TMJ ID subjects who failed 1ry diagnostic arthroscopy were presented and treated through Miami Oral and Maxillofacial Surgery, Baptist Hospital, Miami FL.
Predictive variable
Wilkes diagnostic categories, presented in two groups: (II and III) group versus (IV and V) group.
Outcome variables
The primary outcome variable was the absence of joint pain at 12 months postoperatively. Secondary outcome variables included joint function, maximum inter-incisal opening (MIO), the need for medications, joint loading sign and muscle pain. Patients were followed for one year postoperatively. Statistical analyses included paired and independent sample Student t test, Chi square test and logistic regression
Results
32 subjects (42 joints), with a mean age of 31 years. 28 (87.5%) were females. 71.4% of studied joints were classified as Wilkes II and III group..
Successful outcome was seen in 69% of the studied subjects. Successful outcome was seen in 86.7% of Wilkes (II, III) group, versus 25% of patients with Wilkes (IV, V).P=0.001
Conclusion
This study showed that TMJ arthroscopic Discopexy is an effective and predictable treatment for TMJ ID patients who failed a primary TMJ arthroscopy. It further specifies that Wilkes II, III TMD patients had the most successful outcome.
... First reported in English byIsrael in 1989 [74], important variations soon followed[75][76][77][78][79]. The technique documented in 1992 by McCain et al.[80], involving 11 temporomandibular joints (8 patients), was subsequently modified by Yang et al. in 2012[81]. ...
Temporomandibular disorders (TMDs) affect a high percentage of children and adults worldwide. Surgery may be indicated in severe or recalcitrant cases. Several recent advancements in TMD and temporomandibular joint (TMJ) surgery have elevated understanding and the ability to treat affected patients. We discuss recent advances in TMD epidemiology, juvenile idiopathic arthritis (JIA) of the TMJ, and surgical techniques and technologies. Technical advancements have been identified in TMJ arthroscopy, the treatment of TMJ subluxation and dislocation, and extended prosthetic total TMJ reconstruction (eTMJR). Overall, this review provides valuable insights into significant recent advancements in TMJ disorders and their surgical management.
... One of the most notable developments in advanced TMJ arthroscopy in the last 10-15 years has been the development of discopexy for repositioning and fixation of an anteriorly displaced TMJ disc [72,73]. First reported by Israel in 1989 [74], important variations soon followed [75][76][77][78][79]. The technique documented in 1992 by McCain et al [80] involving 11 temporomandibular joints (8 patients was subsequently modified by Yang et al in 2012 [81]. ...
Temporomandibular disorders (TMD) affect a high percentage of children and adults worldwide. Surgery may be indicated in severe or recalcitrant case. Several recent advancements in the TMD and temporomanidbular joint (TMJ) surgery have elevated understanding and ability to treat affected patients. We discuss recent advances in TMD epidemiology, juvenile idiopathic arthritis (JIA) of the TMJ, and surgical techniques and technologies. Technical advancements have been identified in TMJ arthroscopy, treatment of TMJ subluxation and dislocation, and extended prosthetic total TMJ reconstruction (eTMJR). Overall, this review provides valuable insights into significant recent advancements of TMJ disorders and their surgical management.
... Arthroscopy-Diagnostic, Operative, Arthrotomy, Disc repositioning and stabilization procedures, Discectomy with or without reconstruction, Eminectomy and eminoplasty, Condylectomy and condylar shave, Condylotomy and vertical-ramus osteotomy, Coronoidectomy , Reconstructive procedures, orthognathic surgery, open joint TMJ surgery. Data suggests surgery is limited in most situations to cases of severe joint degeneration or destruction [52][53][54] following trauma or tumor resection. 55,56 FUTURISTIC APPROACH: Tissue regeneration recapitulates tissue formation-Bone morphogenetic proteins (BMPs'). ...
... long-term stability have not been satisfactory [9][10][11] . Since the original reports of arthroscopic disc suturing [12][13][14] , such technique has passed through different approaches with various rates of success and outcomes. Then, McCain et al. 9 reported an eminent technique of arthroscopic disc repositioning and suturing, with a success rate of 81.8%, however with smaller sample size (11 joints). ...
In order to optimize patient selection for temporomandibular joint (TMJ) arthroscopic discopexy to achieve favorable outcomes, prognostic indicators impacting the results are important to analyze. This longitudinal retrospective study aimed to analyze various prognostic factors impacting surgical outcomes following arthroscopic discopexy for management of TMJ closed lock using success criteria based on pain, maximal interincisal opening, diet, and quality of life. Furthermore, a quantitative MRI assessment was performed pre- and post-operatively. Multivariate analysis was used to evaluate various prognostic variables including gender, age, side, duration of illness, Wilkes staging, parafunctional habits, splint therapy and orthodontic treatment. A total of 147 patients (201 joints) were included. The outcome was categorized as excellent (n = 154/76.61%), good (n = 34/16.91%), or poor (n = 13/6.46%) with a success rate of 93.54%. Patients aged > 30 years old ( p = 0.048), longer duration of illness (12–24 months: p = 0.034) and (> 24 months: p = 0.022), and patients with Wilkes stage IV ( p = 0.002) were all significantly more likely to be in the poor outcome group. Finally, orthodontic treatment showed a significant association with excellent outcomes ( p = 0.015). Age, duration of illness, Wilkes staging, and orthodontic treatment are considered significant prognostic factors that can predict the outcomes following the arthroscopic discopexy for management of TMJ closed lock.
... Among various surgical interventions for management of ADD, the arthroscopic disc suturing and repositioning technique is now gaining more popularity due to development of new technologies and re nement of the provisional methods 6-8 . Since the original reports of arthroscopic disc suturing [9][10][11] , such technique has passed through different approaches with various rates of success and outcomes. ...
In order to optimize the patient selection for specific treatment modality and to achieve favorable treatment outcomes, prognostic indicators impacting the results are important to analyze. This longitudinal retrospective study aimed to analyze various prognostic factors impacting the surgical outcomes following Yang’s arthroscopic discopexy for management of temporomandibular joint anterior disc displacement using success criteria based on pain, maximal interincisal opening, diet, and quality of life. Furthermore, a quantitative MRI assessment of disc position and condylar height was performed pre- and postoperatively. Multinomial analysis was used to evaluate various prognostic variables including gender, age, duration of illness, Wilkes staging, parafunctional habits, and splint/orthodontic therapy. A total of 169 patients (234 joints) were included. The outcome was categorized as excellent (n = 67/39.6%), good (n = 72/42.6%), improved (n = 22/13.01%) or poor (n = 8/4.73%) with a success rate of 95.26%. Patients aged from 11–15 years old were significantly more likely to be in the good outcome group (odds ratio (OR), 0.20; P < 0.05). Also, patients with shorter duration of illness (OR, 0.29; P < 0.05) and with Wilkes stage III (OR, 0.11; P < 0.05) were more likely to be in the improved outcome group. Better outcomes can be achieved at younger patients with shorter disease history and earlier Wilkes staging.
... Методика артроскопического прошивания диска ВНЧС была внедрена H.A. Israel [12] и A.W. Tarro [13] в 1989 г. К настоящему времени техника артроскопического вмешательства по репозиции диска разработана достаточно хорошо [6], особенно с тех пор как в 2012 г. она была модифицирована Ch. Yang и соавт. ...
Disc displacement is one of the most common conditions affecting the temporomandibular joint (TMJ). In our previous publications we described the basic technical elements of the anterior disc repositioning surgery with arthroscopy and the success rates immediately after surgery. However, the surgical procedure is very complicated and difficult to study, and the technique has not been introduced in details in the previous papers. The present article presents the detailed introduction of the arthroscopic surgery to demonstrate the safe and successful performance of this procedure. It describes preparation for the surgery, the instruments and materials used, the puncture procedure with the choice of the puncture points, the technique of anterior release of the disc, stepwise disc suturing, and discusses some key points to avoid potential pitfalls and mistakes during the surgery. All steps of the technique are comprehensively illustrated by original photographs and diagrams and the intervention results are supported by magnetic resonance imaging scans. Since 2015, the arthroscopic procedure of this type has been performed by the study authors in 760 joints with a short-term success rate of up to 99.08%.
... In the same year, Murakami and Ono 7 described the arthroscopic removal of intra-articular adherences. In 1989, Israel, 8 Tarro,9 and Ohnishi 10 independently first described the use of arthroscopic suture for the treatment of anterior disk displacement or recurrent mandibular dislocation. Posteriorly, several techniques for arthroscopic suture were described by McCain and colleagues 11 in 1992, Tarro 12 in 1994, and Goizueta-Adame and Muñ oz-Guerra 13 and Yang and colleagues 14 in 2012. ...
Several open surgeries have been proposed for the treatment of internal derangement (ID) of the temporomandibular joint (TMJ), although minimally invasive temporomandibular joint surgery (MITMJS) plays a major role in the treatment of ID and has been widely used for the treatment of ID of the TMJ. Arthrocentesis, arthroscopic lysis and lavage, and operative or advanced arthroscopy are the 3 most relevant techniques for MITMJS; clear indications for their application and a detailed description of each technique are presented. Also, clinical outcomes for each technique from the most relevant studies in the literature are reported.
Copyright © 2015 Elsevier Inc. All rights reserved.
... 16 Tarro performed condylar disc plication using arthroscopy and achieved mandibular function. 17 Vázquez-Delgado et al 18 carried out a condylar disc plication and concluded an improvement in symptoms. Therefore, in our clinic, "disc plication technique" is the method of choice in patients with non-reduced disc dislocation. ...
Aim:
The objective of the present study was to examine whether joint sounds are objective criteria for evaluating the success of surgery for non-reduced anterior disc dislocation.
Method:
Twenty-seven patients (age, 35.6 ± 10.6 years; female/male, 22:5) with non-reduced disc dislocation, as confirmed by MRI, were included in the study. Temporomandibular joint (TMJ) sounds were assessed and digitized by custom-made device. As a surgical treatment, all patients underwent "disc plication technique". The success of surgery was evaluated with maximal interincisial opening (MIO), pain, patient satisfaction scores, MRI examination, and TMJ sound intensity. Recording of sounds of TMJ and pain and satisfaction scores were repeated again at postoperative 12 months and compared to preoperative results.
Results:
Mean preoperative sound intensities with jaw opening and closing and left-right movement were 79.37 ± 3.52 dB and 81.0 ± 4.99 dB, respectively. Mean postoperative sound intensity with jaw opening and closing was 64.81 ± 4.54 dB whereas that with left-right movement was 65.6 ± 5.38 dB. Examination of preoperative and postoperative sounds showed that decreased volume level related with clinical improvement and postoperative replaced disc image in MRI. MIO values increased from 25.89 ± 1.76 mm to 34.26 ± 1.403 mm. Postoperative pain scores were lower than preoperative period and patient satisfaction improved markedly.
Conclusion:
The results of this study showed that patients who underwent plication for non-reduced disc dislocation had clinical improvement, which was related with the decreasing volume level of the click sound, reducing the pain, improving satisfaction, and replacing the disc to normal position in MRI.
... Previously reported clinical results of surgical TMJ disc repositioning procedures have been variable, with failures related to a lack of long-term stability, indicating a need for improved methods of disc stabilization [2]. Since 1990s, the international community has been using arthroscope in the treatment of TMJ disc displacement, which was also tried in our department with an improved clinical efficacy [3][4][5][6]. Unfortunately, the technical requirement was relatively high, so it was very difficult for the patients in the late stages of ID, especially those with severe disc deformation or thickening bilaminar tissue. ...
Open joint procedures using bone anchors have shown clinical and radiograph good success, but post surgical disc position has not been documented with MRI imaging. We have designed a modified technique of using two bone anchors and 2 sutures to reposition the articular discs. This MRI study evaluates the post surgical success of this technique to reposition and stabilize the TMJ articular discs.
Consecutive 81 patients with unilateral TMJ internal derangement (ID) (81 TMJs) were treated between December 1, 2003, and December 1, 2006, at the Department of Oral and Maxillofacial Surgery, Ninth Peoples Hospital, Shanghai, Jiao Tong University School of Medicine. All patients were subjected to magnetic resonance imaging before and one to seven days post surgery to determine disc position using the modified bone anchor technique.
Postoperative MRIs (one to seven days) confirm that 77 of 81 joints were identified as excellent results and one joint was considered good for an overall effective rate of 96.3% (78 of 81 joints). Only 3.7% (3 of 81) of the joints were designated as poor results requiring a second open surgery.
This procedure has provided successful repositioning of the articular discs in unilateral TMJ ID at one to seven days post surgery.
... In fact, this complication seems extremely uncommon, although joint infection, otitis media, and infratemporal joint infection have been reported. 20,21 Arthroscopy can be used to reduce pain and dysfunction almost immediately. The vast majority of complications appear during or immediately after the arthroscopy and most of them recover uneventfully. ...
Temporomandibular joint (TMJ) arthroscopy has been considered a safe surgical procedure in the treatment of TMJ derangement. However, it is not exempt from complications. This study evaluates the complications of arthroscopy in patients with internal derangement of TMJ.
Five hundred consecutive patients (670 joints) with TMJ derangement who underwent arthroscopy between 1995 and 2004 were retrospectively analyzed. All the patients were classified as II to V in the Wilkes classification. Lysis and lavage, electrocautery of the posterior ligament, injection of corticoids, injection of ethanolamine, myotomy of lateral pterygoid muscle attachments, myotomy and electrocautery, motor debridement, injection of sodium hyaluronate, and meniscal suture were performed in different patients.
Complications were recognized during or immediately after the surgery. They were observed in 5 of 341 (1.26%) arthroscopies of the right TMJ and 4 of 329 (1.21%) arthroscopies of the left TMJ. A 1.34% complication rate was found in the whole series. No blood clots within the external auditory canal were observed. Bleeding within the superior TMJ space was observed in 57 cases (8.5%), 36 of them in the right TMJ and 21 in the left TMJ, but they were not considered as true complications. Lacerations of the external auditory canal were found in 2 cases (0.3%), with no cases of perforation of the tympanic membrane. Lesion of the auriculotemporal nerve was observed in a case. Paresia of the facial nerve was found in 4 cases (0.6%). Alteration of visual accuracy of the ipsilateral eye was also observed in a patient immediately after the surgery.
Special care must be taken to reduce complications within the upper joint space by means of an adequate instrumentation and by paying attention to essential points of the arthroscopic technique.
Anterior disc displacement (ADD) is a common type of temporomandibular joint (TMJ) internal derangement. In adolescents, the relationship between ADD and dentofacial deformities are brought into focus. Whether treatment is needed, or by what kind of treatment are effective are still without a consensus. From the literature review, the consequences of ADD without treatment and the effect on disc repositioning were summarized. The results showed that after ADD, condylar height was prone to reduce that may lead to or aggravate dentofacial deformities in adolescents. Disc repositioning could promote the regeneration of condylar bone, thus improve the development of dentofacial deformities.
The aim of this systematic review was to evaluate the effectiveness of different temporomandibular joint arthroscopic discopexy techniques.
The systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement and an electronic search was performed using MEDLINE (PubMed), The Cochrane Library, ScienceDirect databases using a combination of the terms ‘‘discopexy,’’ ‘‘disc recapture,’’ ‘‘disc fixation,’’ and ‘‘temporomandibular joint’’ to identify clinical trials published from 2010.
In total, 493 records were screened, of which only 9 fulfilled the inclusion criteria and were included in qualitative data synthesis.
The results of clinical findings evaluation showed that arthroscopic discopexy statistically significantly improved levels of pain (VAS) and maximum interincisal opening whereas magnetic resonance imaging evaluation showed disc position improvement of up to 90% to 100%.
In conclusion, this review provides the evidence of the potential benefits of arthroscopic disc fixation in the treatment of patients with internal derangements : reduced pain, increased maximum interincisal opening, and improved disc position evaluated by magnetic resonance imaging, whereas disc fixation using suturing techniques seems to be the most appropriate method.
Aim
The aim of the present study is to assess the outcomes of monoportal arthroscopic disc repositioning (discopexy) for disc displacement of the temporomandibular joint.
Material and methods
A retrospective, single-institutional clinical study included patients with temporomandibular joint internal derangements diagnosed and treated by monoportal discopexy. Each patient was diagnosed as having anterior disk displacement with or without reduction. The arthroscopy treatment consists of one portal approach fixing the disc with a 3/0 nylon to the tragus cartilage without anterior liberation. Arthroscopy surgery was carried out with a 1.9-mm 0º arthroscope and only one simple cannula. We use a needle to pierce of the disc through the skin and retrieve the suture inside the joint using a blind method through the arthroscopic cannula. The evaluated variables included the maximum interincisal opening, the presence of clicking and pain score.
Results
A total of 19 patients, 21 joints, were included in the present study. Of the 21 joints, 16 were classified as disc displacement with reduction and 5 without. Visual analogue scale (VAS) values (0-10) decreased from 5.5 to 1.26 (p < 0.0001) 1 year after surgery. At the first review, all patients had a VAS of at least 4 points less than before the surgery, four patients showed a VAS of 0, and nine patients near to 1. Mouth opening increased from 36.6 (±8.09) mm to 39.37 (±4.35) mm, and no significant limitations in the mouth opening range were seen (p < 0.12) 1 year after surgery. Clicking disappeared in all patients and remained stable after 12 months of follow-up. Postoperative magnetic resonance imaging demonstrated a correct or improved position of the disc in all but one patient.
Conclusions
A minimally invasive single portal arthroscopic discopexy is an effective technique to improve function and pain reduction in patients with anterior disk displacement with or without reduction.
68 joints associated with disk displacement with reduction were examinated whether they were candidate for anterior repositioning splint (AR-splint) therapy. 53 joints were evaluated as to be candidate and treated with AR-splint. Another 15 joints were evaluated to be not candidate and had charactaristic configulation of disk (biplanar), style and timming of sound (crepitus, early at closing). Differences of the configulation of disk and the style and timming of clicking were found between the group of candidate and not to be candidate. We analysed the effectivenes of AR-splint in 53 joints according to whether click recurred or not when the splint was removed after 8 weeks and mandible was returned to original position. 43 joint (81.1%) were again experienced clicking and in only 9 joints (17.0%) the disks were kept recaptured and clicking was not experienced at any time. The clicking period of non-recurrence group was shorter than that of recurrence group (p<0.05).
No statistically significant differences were found between two groups about a configulation of disk and a style and timming of clicking.
As previous rports showed, temporomandibular joints with clicking can be succesfully treated by anterior repositioning splint. This study showed recurrence of clicking in majority of patients when the splint was removed after 8 week.
It suggested that more permanent devices are needed to stabilize the mandible in an anterior position and maintain the recaptured disk in a normal relationship to the condyle.
Purpose
To describe the use of resorbable pins for disc fixation in a series of patients and their medium-term outcomes.
Materials and methods
A study was conducted in 26 patients who underwent operative arthroscopic surgery and discopexy using resorbable pins. All patients were refractory to conservative treatment and presented, in at least one joint, anterior disc displacement without reduction on magnetic resonance imaging (MRI). Pre- and postoperative evaluation parameters were disc position on MRI, maximal interincisal opening, lateral movements, joint pain, and articular locking and clicking.
Results
The technique was performed in 34 joints, and 47 pins were inserted. Mouth opening increased significantly, from a mean of 31.24 mm preoperatively to 39.57 mm 1 year postoperatively (p < 0.05). Patients reported a decrease in pain, obtaining values on a visual analogue scale (1–100) of less than 20 after 1 year postsurgery (mean improvement 47.9 points, p < 0.05). Analyzing 1-year MRI findings, in 65% of joints the discs were repositioned and in 20% of joints discs were in a more posterior position.
Conclusions
The use of resorbable pins is a useful technique for disc fixation and shows medium-term improvement in clinical parameters and mandibular function. However, further studies are needed to evaluate a longer follow-up, joint morphologic changes, and disc stability on imaging.
Arthroscopic surgery has been widely used for treatment of temporomandibular joint (TMJ) internal derangements and diseases for the last 40 years. Although 626 articles have been hit by Pubmed search in terms of “TMJ arthroscopic surgery”, this review article is described based on distinguished publishing works and on my experiences with TMJ arthroscopic surgery and related research with an aim to analyse the rationale of arthroscopic surgeries of the temporomandibular joint.
With arthrocentesis emerging as an alternative, less invasive, treatment for internal derangement with closed lock, the primary indication of arthroscopic surgery seems to be somewhat limited. However, the value of endoscopic inspection and surgery has its position for both patient and physician with its long-term reliable results.
To assess whether arthroscopic lysis and lavage (ALL) or operative arthroscopy (OA) is more effective for the treatment of temporomandibular joint (TMJ) internal derangement at any stage of involvement.
In 458 patients (611 joints) with internal derangement of the TMJ classified as Wilkes stages II through V, arthroscopy was performed. Pain (visual analog scale score, 0-100) and maximal interincisal opening were assessed at 1, 3, 6, 9, 12, and 24 months after surgery.
ALL was performed in 308 of 611 arthroscopies (50.4%), and OA was performed in 303 arthroscopies (49.59%). A significant decrease in pain (P < .001) was observed for all patients at any time during the follow-up period from the first month postoperatively to the end of the 2-year follow-up period. A highly significant increase in mouth opening greater than 13 mm was observed in the group of patients classified as Wilkes stage IV from the first month postoperatively. When we compared ALL versus OA among Wilkes stages, no significant differences in terms of pain were observed during the entire follow-up period.
Both ALL and OA are equally effective at decreasing pain in patients with TMJ internal derangement of any Wilkes stage. Patients classified as Wilkes stage IV presenting with chronic closed lock of the TMJ had the highest decrease in pain and the highest increase in mouth opening among the stages, thus confirming these patients as the best candidates for arthroscopy.
Several procedures have been described to reposition and secure the disc during arthroscopic surgery of the temporomandibular joint. The usefulness of these procedures remains controversial since simple lysis and lavage shows a high percentage of clinical success and it is difficult to obtain radiological imaging of the surgically acquired new disc position. This report describes a new arthroscopic discopexy method, and the clinical as well as radiological results obtained with this new technique.
Sixteen patients with a clinical and radiological diagnosis of Temporomandibular Joint (TMJ) dysfunction (TMD) were treated using our discopexy method. Each patient was evaluated with a visual analogue scale (VAS) for pain, radiological and functional parameters. The evaluation also included a clinical examination. Each patient was recorded at baseline before surgery and at a one-year follow-up. Statistical analysis was performed to evaluate the differences in VAS, maximum opening and lateral movements before and after treatment and were considered statistically significant when p < 0.05.
Patient evaluation showed an improvement in the clinical parameters. There were statistically significant reductions in the amount of pain according to the VAS (p < 0.01). Maximal interincisal opening (MIO) and contralateral translation movement (CTM) (p < 0.05) were substantially improved one-year after operation. In the post-surgical MRI study at the one-year follow-up, a significant improvement in the disc position was observed in 13 out of the 16 joints operated on.
This method of arthroscopic disc repositioning is an effective surgical method for treating symptomatic patients with a diagnosis of TMJ disc displacement. Because of the minimally invasive character of the procedure, it should be considered in the surgical treatment of TMJ dysfunction.
To evaluate the incidence, clinical manifestation, and prognosis of malocclusion after arthroscopic disc repositioning and suturing of the temporomandibular joint (TMJ).
The study included 211 patients (270 joints) with internal derangement of the TMJ who underwent arthroscopic disc repositioning and suturing from November 2005 to August 2006. The occlusion was checked and recorded preoperatively and at different intervals (0, 3, 7, 14, 21, 28, 35, 42, and 49 days after surgery) for all patients. The incidence of malocclusion after surgery was determined for every follow-up period. The χ(2) test was applied to assess the statistical significance of the changes of the incidence of malocclusion.
The incidences of malocclusion were 100%, 80.1%, 67.8%, 46.9%, 28.9%, 18.0%, 15.7%, 14.6%, and 14.2% at 0, 3, 7, 14, 21, 28, 35, 42, and 49 days after surgery, respectively. There was a significant difference between neighboring follow-up periods within 28 days after surgery, whereas there was no significant difference from 28 to 49 days after surgery (P > .05). The main clinical manifestations of malocclusion were posterior open bite on the surgery side, incisal prematurities, and mandible midline deviated or nondeviated.
Malocclusion commonly occurs after TMJ arthroscopic disc repositioning and suturing. However, it will improve within 28 days after surgery in most patients. If malocclusion lasts over 28 days, appropriate treatments should be considered.
To evaluate the efficiency of an arthroscopic suturing technique for stabilizing anteriorly displaced discs in patients with internal derangement of the temporomandibular joint (TMJ) by magnetic resonance (MR) imaging.
Six hundred thirty-nine patients (764 joints) diagnosed as having stages II to V of internal derangement were treated with arthroscopic disc repositioning and suturing from August 2004 to March 2007. Consecutive MR images were used to evaluate internal derangement before and approximately 1 to 7 days after the operation for all 639 patients. The disc position of the TMJ was judged according to the success criteria, which included 3 different sagittal planes (lateral, central, and medial). Operative efficiency in those patients, whose discs of the TMJ were affirmed to be in a normal position in all 3 planes, was evaluated to be excellent. Those patients whose discs were in a normal position in 2 planes were evaluated to be good. The others were evaluated to be poor. Cases evaluated as excellent and good were considered success cases (if the disc is displaced only in 1 or 2 planes before operation, the efficiency of the operation would be evaluated as a success only if the whole disc was in normal position).
Postoperative consecutive MR images for all 764 joints confirmed that 95.42% (729/764) of the joints were excellent, 3.14% (24/764) were good, and only 1.44% (11/764) were poor. Repeated arthroscopic surgery or open surgery was carried out for the joints that were evaluated as poor.
This study indicates that the TMJ arthroscopic suturing technique is effective in repositioning the TMJ disc as confirmed by an MR imaging examination, but long-term follow-up is necessary.
The purpose of this study was to evaluate the treatment outcome of temporomandibular joint (TMJ) lysis and lavage using ultrathin TMJ arthroscopy.
Closed lock patients who had not shown response to the conservative treatment for more than 3 months were included in this study. The clinical data were collected using standard protocol including questionnaire. Under the informed consent, TMJ lysis and lavage were performed using ultrathin arthroscopy. For the evaluation of the treatment outcome, maximum mouth opening (MMO) and visual analog scale (VAS) were used.
A total of 15 patients were included in this study. Concerning arthroscopic findings, fibrillation and adhesion were detected in 9 patients. Synovial hyperemia and ecchymosis was detected in 6 patients. There were no complications related with arthroscopic procedure in this study. Improvement of mouth opening more than 5 mm was detected in 14 patients. VAS score was reduced more than 60%, and VAS was recorded no more than 2 postoperatively in 12 patients. Good outcome was obtained in 12 patients (80%) from the total 15 patients.
From the clinical outcomes, TMJ lysis and lavage using ultrathin TMJ arthroscopy could be considered as an alternative treatment for the closed lock patients.
A new surgical technique has been developed to combine arthroscopic laser surgery with suturing to be used clinically in the treatment of temporomandibular joint disorders. This new technique involves the use of a recently invented double-channel cannula needle scope to visualize the lesion. Subsequently, we combined Nd-YAG laser with suturing in the cavity in order to treat the area around the intraarticular wall. The primary use of arthroscopic laser surgery is for treatment of lesions in the inner wall of the joint cavity. In this article, we give an outline of both the arthroscopic laser surgery and the arthroscopic suturing as well as the clinical, postoperative results of these cases.
A case is reported in which instrument breakage occurred in the temporomandibular joint during arthroscopic surgery. The technique used for removal of the broken metal fragment is described.
A case report of an extradural haematoma (EDH) after temporomandibular joint arthroscopy is presented. The possible cause of this unusual occurrence is discussed.
Advanced arthroscopic procedures, including disc suturing, are advantageous in managing temporomandibular joint disorders. These techniques are indicated in cases of long-standing closed lock, displaced discs with reduction, and hypermobility with chronic dislocation. Disc suturing procedures can be done blindly, partially blindly, or fully visualized. Fully visualized suturing techniques have obvious advantages, but can be time-consuming, difficult to perform, and traumatic. This article presents a new suturing technique that is fully visualized and is less time-consuming and relatively easy to perform.
This study evaluated the complications of temporomandibular joint (TMJ) arthroscopic lysis and lavage performed using the triangulation technique.
The 202 consecutive patients (301 joints) who underwent arthroscopic lysis and lavage between 1992 and 1995 were retrospectively surveyed. The preoperative diagnosis of all patients was anterior disc displacement without reduction.
Complications were observed in 31 (10.3%) of 301 cases of arthroscopic lysis and lavage. Of these, otologic complications were found in 26 cases (8.6%): blood clots in the external auditory canal in 9; laceration of external auditory canal in 7; partial hearing loss in 5; ear fullness in 2; vertigo in 1; and perforation of tympanic membrane with laceration of external auditory canal in 1. Neurologic injuries were found in 5 cases (1.7%): fifth cranial nerve injuries in 3; and seventh cranial nerve injuries in 2. No other complications were observed.
A high level of understanding of the regional anatomy helps reduce the complications associated with arthroscopic lysis and lavage in the TMJ.
Recent advances in ultrasound imaging suggested endoarticular ultrasound imaging of the temporomandibular joint (TMJ) in combination with TMJ-arthroscopy as a new diagnostic method. Our investigations were performed on human cadavers, in combination with traditional TMJ-arthroscopy. During our investigations, the main articular structures were identified: the glenoid fossa of the temporal bone, articular disc, condyle of the mandible, and retrodiscal tissue. The combination of arthroscopy and ultrasound imaging provides more information on position, movement, and pathological changes in joint structures. Although all of the advantages, disadvantages, indications, and complications of this new diagnostic procedure are not yet clear, the authors consider this new method a useful diagnostic procedure for TMJ imaging.
Arthroscopy of the temporomandibular joint (TMJ) has advanced to the point that excellent diagnostic examination and a number of surgical procedures can be performed. A refined technique is presented and instrumentation for surgical arthroscopy is discussed. Short-term results are also presented.
Arthroscopic surgery to correct symptoms of persistent closed locking of the temporomandibular joint appears, in the short term, to be an alternative to arthrotomy. Obviously, long-term follow-up will be necessary.
Diagnostic arthroscopy of the tem-poromandibular joint, part II: Arthroscopic findings of ar-thrographically diagnosed disc displacements. Oral Surg 65:135, 1988 4. Sanders B: Arthroscopic surgery of the temporomandibular joint: Treatment of internal derangement with persistent closed lock
- L Heffez
- Blaustein
Heffez L, Blaustein D: Diagnostic arthroscopy of the tem-poromandibular joint, part II: Arthroscopic findings of ar-thrographically diagnosed disc displacements. Oral Surg 65:135, 1988 4. Sanders B: Arthroscopic surgery of the temporomandibular joint: Treatment of internal derangement with persistent closed lock. Oral Surg 62:361, 1986