Surgery for temporomandibular joint dysfunction

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Surgery for temporomandibular joint dysfunction
Specialty Oral and Maxillofacial Surgeon

Attempts in the last decade to develop surgical treatments based on MRI and CAT scans now receive less attention. These techniques are reserved for the most difficult cases where other therapeutic modalities have failed. The American Society of Maxillofacial Surgeons recommends a conservative/non-surgical approach first. Only 20% of patients need to proceed to surgery.[ citation needed ]

Contents

Examples of surgical procedures that are used in TMD, some more commonly than others, include arthrocentesis, arthroscopy, meniscectomy, disc repositioning, condylotomy or joint replacement. Invasive surgical procedures in TMD may cause symptoms to worsen. [1] Menisectomy, also termed discectomy refers to the surgical removal of the articular disc. This is rarely carried out in TMD, it may have some benefits for pain, but dysfunction may persist and overall there it leads to degeneration or remodeling of the TMJ. [2]

Arthrocentesis

TMJ arthrocentesis refers to lavage (flushing out) of the upper joint space (where most of the translation movement takes place) with saline via the introduction of cannulae. It is theorized that the hydraulic pressure generated within the joint combined with external manipulation is capable of releasing adhesions or the anchored disc phenomenon and leads to an improvement in the movement ("lysis and lavage"). [1] [3] It is also suggested that undesirable contents within the synovial fluid of the joint can be washed out, such as microscopic debris (from breakdown of the articular surfaces) and pain mediators (enzymes and prostaglandins), and there is also stimulation of the synovial membrane to restore its normal lubricating function. It was initially used to treat acute closed lock, however it has since come to be used chronic closed lock, chronic anterior displaced disc with reduction, and degenerative joint disease (e.g. arthritis). [1] In acute closed lock, it is theorized that the upper joint space is inflated from its normally collapsed state during this procedure, and this extra space frees up the articular disc which returns to its correct position. [4] This is the least invasive, and easiest to carry out of the surgical options. [1] It can be carried out under local anesthetic (and for this reason is cheaper than arthroscopy, although it may also carried out under general anesthetic) [4] and has minimal complications. Although it has been suggested that arthrocentesis decreases pain, increases maximal incisal opening and has prolonged effects, when the procedure was investigated by a systematic review, the impact on pain was comparable to arthroscopy and the results are unstable. The review concluded by suggesting that arthrocentesis only be used for TMD within well designed randomized controlled trial (i.e. for the purposes of further research and not for routine management). [1] Arthrocentesis may be combined with injection of sodium hyaluronate into the joint at the end of the lavage with the aim to improve lubrication within the joint. [4]

Arthroscopy

Arthroscopy involves the introduction of an arthroscope (a very thin, flexible camera) into the joint via single cannula (as opposed to arthrocentesis which usually involves 2 cannulae and no arthroscope), allowing the joint space to be visualized on a monitor and explored by the surgeon. Arthroscopy is also used in other joints and the technique is similar to laparoscopy. [5] The cannula is inserted via a small incision just in front of the ear. [5] The arthroscope has a built in capacity to pump in or suck out saline. [1] Arthroscopy may be intended as a purely diagnostic procedure, [4] or it may be employed in combination with surgical interventions within the joint, in which case a second "working" cannula is also inserted into the joint. [4] Examples include release of adhesions (e.g. by blunt dissection or with a laser) or release of the disc. [1] Biopsies or disc reduction can also be carried out during arthroscopy. [4] Arthroscopy is usually carried out under general anesthesia. Arthroscopy has advantages over arthrocentesis in that it allows for detection of problems inside the joint such as perforation or synovitis. [1] As with arthrocentesis, the procedure may be combined with sodium hyaluronate injection into the joint at the end of the procedure. [4]

Intra-articular injections

Both sodium hyaluronate and glucocorticoids have been injected into the joints in order to treat TMD. Sodium hyaluronate is a component of the normal synovial fluid that fills the joint spaces in health. Its function is to lubricate and maintain the internal environment of the joint. It has been used for arthritis in the knee and hip joints, and it was first used for TMD in 1985. A systematic review found that hyaluronate might be beneficial for clinical TMD signs in the long term, but that this may be unstable. The effects of hyaluronate may be similar to glucocorticoids. There may be added benefit in arthrocentesis or arthroscopy if intra-articular injections are combined with these procedures. Reported adverse events are minor and temporary. [6]

Joint replacement

Prosthetic TMJ placement surgery is used as a last resort to manage severe pain and restricted function due to TMJ disorders. At the onset of symptoms, primary prevention such as a soft diet, cessation of gum chewing, physiotherapy and the use of non-steroidal anti-inflammatory drugs are put into place. If primary prevention fails, TMJ joint replacement is one of the several surgical options. Recent studies have shown TMJ replacement surgery to be highly successful, improving mean pain scores, mean diet scores, mean maximum inter-incisal opening, and mean function and speech scores. [7]

Synthetic jaw implants already on the market prior to the 1976 Federal law requiring medical devices be proven safe and effective were exempt and continued to be sold after 1976 without proof of safety. Teflon implants made by Vitek, and silicone ones made by Dow Corning, raised the most concern. Vitek-Kent Proplast-Teflon partial & total prosthesis were manufactured from 1982 to 1990 in Houston TX. TMJ prostheses became popular with the introduction of Vitek, but evidence that the implants could cause debilitating reactions including pain, malocclusion, and foreign-body giant cell reaction (FBGCR) resulting in degeneration of the surrounding tissue led to a recall by the FDA on 1/7/91. Since Vitek declared bankruptcy in June 1990 and the owner fled the country, the FDA was left to handle the recall, which they did by sending out a safety alert and public health advisory. Otherwise, there was next to no follow-up on the recall. Silastic silicone TMJ Implants produced by Dow Corning became popular during the 1970s, but reports of widespread mechanical failure with wear, tearing, and fracture began to surface. Debris and fragments led to an inflammatory response, joint degeneration, bony ankylosis, and lymph node swelling. Marketing of Silastic for use in the TMJ was discontinued on 6/15/93 after warnings from the FDA and the American Association of Oral and Maxillofacial Surgeons (AAOMS). [8]

To date, the FDA has approved only 4 TMJ Implants by 3 manufacturers: the Anspach patient fitted Total TMJ Joint Replacement System by TMJ Concepts; the Walter Lorenz Total TMJ Replacement System by Biomet Microfixation; the TMJ Metal-on-Metal Total Joint Replacement System, and the Christensen TMJ Fossa-Eminence System (patient specific partial), both by TMJ Medical. [9]

The Hoffman-Pappas Total TMJ Replacement System produced by Endotech has been in use since 1995 while awaiting final FDA approval. Working with Dr. Mike Pappas, Dr. David Hoffman of Staten Island University Hospital received approval by the FDA to undertake a national study to investigate a clinical trial on the prosthetic joint system. [10]

Related Research Articles

<span class="mw-page-title-main">Temporomandibular joint dysfunction</span> Medical condition

Temporomandibular joint dysfunction is an umbrella term covering pain and dysfunction of the muscles of mastication and the temporomandibular joints. The most important feature is pain, followed by restricted mandibular movement, and noises from the temporomandibular joints (TMJ) during jaw movement. Although TMD is not life-threatening, it can be detrimental to quality of life; this is because the symptoms can become chronic and difficult to manage.

<span class="mw-page-title-main">Temporomandibular joint</span> Joints connecting the jawbone to the skull

In anatomy, the temporomandibular joints (TMJ) are the two joints connecting the jawbone to the skull. It is a bilateral synovial articulation between the temporal bone of the skull above and the mandible below; it is from these bones that its name is derived. The joints are unique in their bilateral function, being connected via the mandible.

<span class="mw-page-title-main">Arthroscopy</span> Medical procedure

Arthroscopy is a minimally invasive surgical procedure on a joint in which an examination and sometimes treatment of damage is performed using an arthroscope, an endoscope that is inserted into the joint through a small incision. Arthroscopic procedures can be performed during ACL reconstruction.

<span class="mw-page-title-main">Joint</span> Location at which two or more bones make contact

A joint or articulation is the connection made between bones, ossicles, or other hard structures in the body which link an animal's skeletal system into a functional whole. They are constructed to allow for different degrees and types of movement. Some joints, such as the knee, elbow, and shoulder, are self-lubricating, almost frictionless, and are able to withstand compression and maintain heavy loads while still executing smooth and precise movements. Other joints such as sutures between the bones of the skull permit very little movement in order to protect the brain and the sense organs. The connection between a tooth and the jawbone is also called a joint, and is described as a fibrous joint known as a gomphosis. Joints are classified both structurally and functionally.

<span class="mw-page-title-main">Trismus</span> Condition of limited jaw mobility

Trismus is a condition of restricted opening of the mouth. The term was initially used in the setting of tetanus. Trismus may be caused by spasm of the muscles of mastication or a variety of other causes. Temporary trismus occurs much more frequently than permanent trismus. It is known to interfere with eating, speaking, and maintaining proper oral hygiene. This interference, specifically with an inability to swallow properly, results in an increased risk of aspiration. In some instances, trismus presents with altered facial appearance. The condition may be distressing and painful. Examination and treatments requiring access to the oral cavity can be limited, or in some cases impossible, due to the nature of the condition itself.

<span class="mw-page-title-main">Orthopedic surgery</span> Branch of surgery concerned with the musculoskeletal system

Orthopedic surgery or orthopedics is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal trauma, spine diseases, sports injuries, degenerative diseases, infections, tumors, and congenital disorders.

An osteotomy is a surgical operation whereby a bone is cut to shorten or lengthen it or to change its alignment. It is sometimes performed to correct a hallux valgus, or to straighten a bone that has healed crookedly following a fracture. It is also used to correct a coxa vara, genu valgum, and genu varum. The operation is done under a general anaesthetic.

Oral and maxillofacial surgery is a surgical specialty focusing on reconstructive surgery of the face, facial trauma surgery, the oral cavity (mouth), head and neck, and jaws, as well as facial cosmetic surgery/facial plastic surgery including cleft lip and cleft palate surgery.

Articular cartilage, most notably that which is found in the knee joint, is generally characterized by very low friction, high wear resistance, and poor regenerative qualities. It is responsible for much of the compressive resistance and load bearing qualities of the knee joint and, without it, walking is painful to impossible. Osteoarthritis is a common condition of cartilage failure that can lead to limited range of motion, bone damage and invariably, pain. Due to a combination of acute stress and chronic fatigue, osteoarthritis directly manifests itself in a wearing away of the articular surface and, in extreme cases, bone can be exposed in the joint. Some additional examples of cartilage failure mechanisms include cellular matrix linkage rupture, chondrocyte protein synthesis inhibition, and chondrocyte apoptosis. There are several different repair options available for cartilage damage or failure.

<span class="mw-page-title-main">Microfracture surgery</span> Cartilage repair technique

Microfracture surgery is an articular cartilage repair surgical technique that works by creating tiny fractures in the underlying bone. This causes new cartilage to develop from a so-called super-clot.

Articular cartilage repair treatment involves the repair of the surface of the articular joint's hyaline cartilage, though these solutions do not perfectly restore the articular cartilage. These treatments have been shown to have positive results for patients who have articular cartilage damage. They can provide some measure of pain relief, while slowing down the accumulation of damage, or delaying the need for joint replacement surgery.

Autologous chondrocyte implantation is a biomedical treatment that repairs damages in articular cartilage. ACI provides pain relief while at the same time slowing down the progression or considerably delaying partial or total joint replacement surgery.

Kevin Robert Stone is an American physician, orthopedic surgeon, clinician, researcher, and company founder of The Stone Clinic and the Stone Research Foundation in San Francisco.

<span class="mw-page-title-main">Sodium hyaluronate</span> Chemical compound

Sodium hyaluronate is the sodium salt of hyaluronic acid, a glycosaminoglycan found in various connective tissue of humans.

<span class="mw-page-title-main">Dislocation of jaw</span> Medical condition

Dislocations occur when two bones that originally met at the joint detach. Dislocations should not be confused with subluxation. Subluxation is when the joint is still partially attached to the bone.

<span class="mw-page-title-main">Hip arthroscopy</span>

Hip arthroscopy refers to the viewing of the interior of the acetabulofemoral (hip) joint through an arthroscope and the treatment of hip pathology through a minimally invasive approach. This technique is sometimes used to help in the treatment of various joint disorders and has gained popularity because of the small incisions used and shorter recovery times when compared with conventional surgical techniques. Hip arthroscopy was not feasible until recently, new technology in both the tools used and the ability to distract the hip joint has led to a recent surge in the ability to do hip arthroscopy and the popularity of it.

<span class="mw-page-title-main">Condylar resorption</span> Medical condition

Condylar resorption, also called idiopathic condylar resorption, ICR, and condylysis, is a temporomandibular joint disorder in which one or both of the mandibular condyles are broken down in a bone resorption process. This disorder is nine times more likely to be present in females than males, and is more common among teenagers.

<span class="mw-page-title-main">Index of trauma and orthopaedics articles</span>

Orthopedic surgery is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal injuries, sports injuries, degenerative diseases, infections, bone tumours, and congenital limb deformities. Trauma surgery and traumatology is a sub-specialty dealing with the operative management of fractures, major trauma and the multiply-injured patient.

The treatment of equine lameness is a complex subject. Lameness in horses has a variety of causes, and treatment must be tailored to the type and degree of injury, as well as the financial capabilities of the owner. Treatment may be applied locally, systemically, or intralesionally, and the strategy for treatment may change as healing progresses. The end goal is to reduce the pain and inflammation associated with injury, to encourage the injured tissue to heal with normal structure and function, and to ultimately return the horse to the highest level of performance possible following recovery.

<span class="mw-page-title-main">Rüdiger Emshoff</span> German oral and maxillofacial surgeon and associate professor

Rüdiger Emshoff is a German oral and maxillofacial surgeon and associate professor at the Medical University of Innsbruck, where he is head of the Orofacial Pain and Temporomandibular Disorder Unit. Emshoff is known for his work in the field of chronic orofacial pain management with a focus on the development of non-invasive and minimally-invasive methods in the diagnosis and treatment of temporomandibular joint dysfunction.

References

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  7. NICE (2014) 'Total prosthetic replacement of the temporomandibular joint', NICE interventional procedure guidance, ([IPG500]), pp. Section 2 [Online]. Available at:http://www.nice.org.uk/guidance/ipg500/chapter/2-Indications-and-current-treatments(Accessed: September 1, 2015).
  8. Hilts, Philip J. (June 5, 1992). "F.D.A. Issues Warning on Jaw Implants That May Disintegrate in the Body". The New York Times.
  9. "TMJ Implants- A Consumer Informational Update". www.fda.gov. Archived from the original on 2009-07-09.
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