Management

of Temporomandibular

Disorders

Myron ft. Tucker and Mark W. Ochs

C H A P T E R

CHAPTER OUTLINE

EVALUATION Interview Examination Radiographic Evaluation

Transcranial Radiographs Panoramic Radiography Tomograms Temporomandibular Joint Arthrography Computed Tomography Magnetic Resonance Imaging

Nuclear Imaging Psychologic Evaluation CLASSIFICATION OF TEMPOROMANDIBULAR

DISORDERS Myofascial Pain Disk Displacement Disorders

Anterior Disk Displacement with Reduction Anterior Disk Displacement without Reduction

Degenerative Joint Disease (Arthrosis, Osteoarthritis) Systemic Arthritic Conditions Chronic Recurrent Dislocation

Ankylosis Intracapsular Ankylosis Extracapsular Ankylosis

Neoplasia Infections REVERSIBLE TREATMENT

Patient Education Medication Physical Therapy Splints

Autorepositioning Splints Anterior Repositioning Splints

PERMANENT OCCLUSION MODIFICATION TEMPOROMANDIBULAR JOINT SURGERY Arthrocentesis Arthrocentesis Arthroscopy Disk-Repositioning Surgery Disk Repair or Removal

Condylotomy for Treatment of Temporomandibular Joint Disorders

Total Joint Replacement

atients frequently consult a dentist because of n or dysfunction in the temporomandibular ion. The most common causes of temporo-

mandibular disorders (TMDs) are muscular disorders, which are commonly referred to as myofascial pain and dysfunction. These muscular disorders are generally man-aged well with a variety of reversible nonsurgical treat-ment methods.

paireg

Other causes of temporomandibular pain or dysfunc-tion originate primarily within the temporomandibular joint (TMJ). These causes include internal derangement and osteoarthritis, rheumatoid arthritis, chronic recurrent dislocation, ankylosis, neoplasia, and infection. Although some of these disorders will respond to nonsurgical thera-py, some cases may eventually require surgical treatment. If a successful result is to be achieved, management of

672

these patients requires a coordinated plan between the general dentist, oral and maxillofacial surgeon, and other health care services.

EVALUATION The evaluation of the patient with temporomandibular pain, dysfunction, or both is like that in any other diag-nostic workup. This evaluation should include a thor-ough history, a physical examination of the masticatory system, and some type of routine TMJ radiography. Spe-cial diagnostic studies should be performed only as indi-cated and not as routine studies.

Interview The patient's history may be the most important part of the evaluation, because it furnishes clues for the diagno-sis. The history begins with the chief complaint, which is a statement of the patient's reasons for seeking con-sultation or treatment. The history of the present illness should be comprehensive, including an accurate descrip-tion of the patient's symptoms, chronology of the symp-toms, description of how the problem affects the patient, and information about any previous treatments (includ-ing the patient's response to those treatments).

Examination The physical examination consists of an evaluation of the entire masticatory system. The head and neck should be inspected for soft tissue asymmetry or evidence of mus-cular hypertrophy. The patient should be observed for signs of jaw clenching or other habits. The masticatory muscles should be systematically examined. The muscles should be palpated for the presence of tenderness, fascic-ulations, spasm, or trigger points (Fig. 30-1). The TMJs are examined for tenderness and noise (Fig.

30-2). The location of the joint tenderness (e.g., lateral, posterior) should be noted. If the joint is more painful during different areas of the opening cycle or with differ-ent types of functions, this should be recorded. The most common forms of joint noise are clicking (a distinct sound) and crepitus (i.e., multiple scraping or grating : sounds). Many joint sounds can be easily heard without special instrumentation or can be felt during palpation of the joint. However in some cases auscultation with a stethoscope may allow less obvious joint sounds, such as mild crepitus, to be appreciated.

The mandibular range of motion should be deter-mined. Normal range of movement of an adult's mandible is about 45 mm vertically (i.e., interincisally) and 10 mm protrusively and laterally (Fig. 30-3). The normal move-ment is straight and symmetric. In some cases tenderness in the joint or muscle areas may prevent opening. The cli-nician should attempt to ascertain not only the painless voluntary opening but also the maximum opening that can be achieved with gentle digital pressure. In some cases the patient may appear to have a mechanical obstruction in the joint causing limited opening but with gentle pressure may actually be able to achieve near nor-

mal opening. This may suggest muscular rather than intra-capsular problems.

The dental evaluation is also important. Odontogenic sources of pain should be eliminated. The teeth should be examined for wear facets, soreness, and mobility, which may be evidence of bruxism. Although the significance of occlusal abnormalities is controversial, the occlusal rela-tionship should be evaluated and documented. Missing teeth should be noted, and dental and skeletal classifica-tion should be determined. The clinician should note any centric relation and centric occlusion discrepancy or sig-nificant posturing by the patient. The examination find-ings can be summarized on a TMD evaluation form and included in the patient's chart. In many cases a more detailed chart note may be necessary to adequately docu-ment all of the history and examination findings described previously.

Radiographic Evaluation Radiographs of the TMJ are extremely helpful in the diag-nosis of intraarticular, osseous, and soft tissue pathology. The use of radiographs in the evaluation of the patient with TMD should be based on the patient's signs and symptoms instead of routinely ordering a "standard" set of radiographs. In many cases the panoramic radiograph pro-vides adequate information as a screening radiograph in evaluation of TMD. A variety of other radiographic tech-niques are available that may provide useful information in certain cases.

Transcranial radiographs. A standard dental radio-graphic unit combined with a head-holding device can be used to produce a transcranial image of the TMJ. Although this view will not allow detailed examination of all aspects of the TMJ, excellent evaluation of the lat-eral pole of the condyle can be accomplished when the proper radiographic technique is used. Because bony pathology of the TMJ frequently extends to the lateral pole, this technique can be helpful in diagnosing bony internal joint pathology (Fig. 30-4).'

Panoramic radiography. One of the best overall radio-graphs for screening evaluation of the TMJs is the panoramic radiograph. This technique allows visualiza-tion of both TMJs on the same film. Because a panoramic technique provides a tomographic type of view of the TMJ, this can frequently provide a good assessment of the bony anatomy of the articulating surfaces of the mandibu-lar condyle and glenoid fossa (Fig. 30-5), and other areas, such as the coronoid process, can also be visualized. Many machines are equipped to provide special views of the mandible, focusing primarily on the area of the TMJs. These radiographs can often be completed in both the open and closed position.

Tomograms. The tomographic technique allows a more detailed view of the TMJ.2 This technique allows radiographic sectioning of the joint at different levels of the condyle and fossa complex, which provides individual views visualizing the joint in "slices" from the medial to the lateral pole (Fig. 30-6). These views eliminate bony superimposition and overlap and provide a relatively clear picture of the bony anatomy of the joint (see Fig. 30-6).

FIG. 30-1 Systematic evaluation of muscles of mastica-tion. A, Palpation of masseter muscle. B, Palpation of temporalis muscle. C, Palpation of medial pterygoid intra-orally. D, Palpation of origin of lateral pterygoid. E, Palpa-tion of stemodeidomastoid muscle.

FIG. 30-2 Evaluation of temporomandibular joint (TMJ) for tenderness and noise, joint is palpated laterally in closed position (A), open position (B), and through the external auditory canal in the closed position (C) and open position (D).

FIG. 30-3 Measurement of range of jaw motion. A, Maximum voluntary vertical opening (should be 45 mm or greater). B, Protrusion (should be approximately 10 mm). C and D, Left and right lateral excursions (should be approximately 10 mm). FIG. 30-4 Examples of transcranial radiographs. A, Radiograph of right side shows normal anatomy of fossa and condyle. B, Left-side view demonstrates degenerative changes of condyle.

Temporomandibuimaging method was allowed visualization (

Arthrography involvrial into the inferior owhich the joint is radifiguration of the dye inof the position and mo30-7). This technique perforations and adhesWith the availability techniques arthrograph

Computed tomograprovides a combinatijoint, combined with and soft tissue images.of a variety of hard andCT images provide thement of the bony compscan reconstruction caone plane of space to bcan be evaluated fromof the joint from a vafrom a single radiation

Magnetic resonancdiagnostic imaging tecis magnetic resonancetechnique allows excetissue, making MRI a disk morphology andobtained showing dynfashion, providing vanatomical componenfact that this techniquea significant advantage

Nuclear imaging. of Tc", a gamma-emitareas of active bone mafter injection of the isgamma camera. Singltomography (SPECT) mine active areas of

FIG. 30-5 Modified panoramic view demonstrates normal anatomy of right condyleand degenerative changes of left condyle. This modified panoramic radiographic tech-nique shows increased detail of posterior ramus and condyle area while eliminating theanterior mandible from radiographic image.

lar joint arthrography. Thisthe first technique available thatindirect) of the intraarticular disk.es the injection of contrast mate-r superior spaces of a joint, afterographed.-3 Evaluation of the con- the joint spaces allows evaluationrphology of the articular disk (Fig.also demonstrates the presence ofions of the disk or its attachments.of more advanced, less invasivey is rarely used.

phy. Computed tomography (CT)on of tomographic views of the

computer enhancement of hard4 This technique allows evaluation soft tissue pathology in the joint.

most accurate radiographic assess-onents of the joint (Fig. 30-8). CT

pabilities allow images obtained ine reconstructed so that the images

a different view. Thus evaluationriety of perspectives can be made exposure.e imaging. The most effectivehnique to evaluate TMJ soft tissues imaging (MRI) (Fig. 30-9).5 Thisllent images of intraarticular softvaluable technique for evaluating position. MRI images can be

amic joint function in a cinematicaluable information about the

ts of the joint during function. The does not use ionizing radiation is.

This technique involves injectionting isotope that is concentrated inetabolism. Approximately 3 hoursotope, images are obtained using ae photon emission computerizedimages can then be used to deter- bone metabolism (Fig. 30-10).6

FIG. 30- lar jointdemonstra ll-definedjoint spac anteriorcondylar l

Althoughmation oBecause identicalevaluatefindings.

Psychol

Many pfunctiontions of may incldepressiassociateinclude results flimitatiothe paticlinicallybe warra

6 Tomographic projection of temporomandibutes typical degenerative changes with loss of wee, absence of cortical outline of condyle, andipping.

this technique is extremely sensitive, the infor-btained may be somewhat difficult to interpret.

bone changes, such as degeneration, may appear to repair or regeneration, this technique must bed cautiously and in combination with clinical

ogic Evaluation

atients with temporomandibular pain and dys- of long-standing duration develop manifesta-chronic pain syndrome behavior. This complexude gross exaggeration of symptoms and clinicalon.7 To evaluate possible behavioral changesd with pain and dysfunction, the history shouldquestions regarding functional limitation thatrom the patient's symptoms. If the functionaln appears to be excessive when compared withent's clinical signs or the patient appears to be depressed, further psychologic evaluation maynted.8

FIG. 30-7 Arthrogram shows dye in inferior and superior joint spaces. Anatomy and locationof disk is indirectly interpreted from dye pattern observed after injection of joint spaces aboveand below disk. This arthrogram demonstrates anterior disk displacement without reduction.A, Closed position. B, Open position.

FIG. 30-8 Computerized tomographyshows disk displacement with reduction.A, Condyle in closed position with diskanteriorly displaced. B, Maximum openingposition (after click) with disk in reducedposition. C, Coronal reconstruction of axiallyproduced computerized tomogram, whichillustrates degenerative joint disease, result-ing from alloplastic implant replacement ofdisk tissue.

Myofamon cwhichThe somasticresult This aalwaysbruxis

FIG. 30-9 Magnetic resonance image. A, This view shows normal disk and condyle relationship inopen position. B, Image demonstrates anterior disk displacement and slight bone changes on articu-lating surface of condyle.

generally considered to be multifactorial.9 One of themost commonly accepted causes of MPD is bruxism sec-ondary to stress and anxiety, with occlusion being a mod-ifying or aggravating factor. MPD may also occur second-ary to internal joint problems, such as disk displacementdisorders or degenerative joint disease (DJD).

Patients with MPD generally complain of diffuse,poorly localized, preauricular pain that may also involveother muscles of mastication, such as the temporalis andmedial pterygoid muscles. In patients with nocturnalbruxism, the pain is frequently more severe in the morn-ing. Patients generally describe decreased jaw openingwith pain during functions such as chewing. Headaches,usually hitemporal in location, may also be associatedwith these symptoms. Because of the role of stress, thepain is often more severe during periods of tension andanxiety.

Examination of the patient reveals diffuse tendernessof the masticatory muscles. The TMJs are frequently non-tender to palpation. In isolated MPD, joint noises are usu-ally not present. However, as mentioned previously, MPDmay be associated with a variety of other joint problemsthat may produce other TMJ signs and symptoms. Therange of mandibular movement in MPD patients may bedecreased and is associated with deviation of themandible toward the affected side. The teeth frequentlyhave wear facets. However, the absence of such facetsdoes not eliminate bruxism as a cause of the problem.

Radiographs of the TMJs are usually normal. Somepatients have evidence of degenerative changes, such as

FIG. 30-10 Single photon emission computed tomography {bonescan). Area of increased activity is apparent in both temporoman-dibular joints.

CLASSIFICATION OF TEMPOROMANDIBULARDISORDERS

Myofascial Pain

sdal pain and dysfunction (MPD) is the most com-ause of masticatory pain and limited function for

patients seek dental consultation and treatment.urce of the pain and dysfunction is muscular, withatory muscles developing tenderness and pain as aof abnormal muscular function or hyperactivity.bnormal muscular function is frequently but not associated with daytime clenching or nocturnalm. The cause of MPD is controversial, although it is

altered surface contours, erosion, or osteophytes. Thesechanges, however, may be secondary to or unassociatedwith the MPD problem.

Disk Displacement Disorders

In a normally functioning TMJ the condyle functions inboth a hinge and a sliding fashion. During full openingthe condyle not only rotates on a hinge axis but alsotranslates forward to a position near the most inferior

portion of the articular eminence (Fig. 30-11). Duringfunction the biconcave disk remains interpositionedbetween the condyle and fossa, with the condyle remain-ing against the thin intermediate zone during all phasesof opening and closing.

Anterior disk displacement with reduction. In ante-rior disk displacement the disk is positioned anterior andmedial to the condyle in the closed position. Duringopening the condyle moves over the posterior band ofthe disk and eventually returns to the normal condyleand disk relationship, resting on the thin intermediatezone. During closing the condyle then slips posteriorlyand rests on the retrodiscal tissue, with the disk returningto the anterior, medially displaced position (Fig. 30-12).

Examination of the patient usually reveals joint ten-derness, and muscle tenderness may also exist. Jointnoise (i.e., clicking) is commonly heard with opening,when the condyle moves from the area posterior to thedisk into the thin concave area in the middle of the disk.In some cases clicking can be heard or palpated during

the closing cycle. Maximal opening can be normal orslightly limited, with the click occurring during the open-ing movement. Anatomically the opening click corre-sponds to the disk reducing to a more normal position.The closing click (i.e., reciprocal click) corresponds to thedisk failing to maintain its normal position between thecondylar head and the articular eminence and slippingforward to the anteriorly displaced position. Crepitusmay be present and is usually a result of articular move-ment across irregular surfaces.

The images obtained from plain TMJ radiography inpatients with anterior disk displacement may be normal ormay demonstrate slight bone abnormalities. MRI imagesusually demonstrate anterior displacement of the disk.

Anterior disk displacement without reduction. Inthis type of internal derangement the disk displacementcannot be reduced, and thus the condyle is unable totranslate to its full anterior extent, which prevents maxi-mal opening and causes deviation of the mandible to theaffected side (Fig. 30-13).

FIG. 30-11 Normal disk and condyle relationship. A, Biconcave disk is interpositioned between fossaand condyle in closed position. B, When condyle translates forward, thin intermediate zone stays inconsistent relationship with condyle. C, Maximum open position.

FIG. 30-12 Anterior disk displacement with reduction. A, Biconcave disk is situated anterior to artic-ulating surface of condyle. When condyle translates forward, it eventually passes over thickened pos-terior band of disk, creating clicking noise. B, After click occurs, disk remains in appropriate relation-ship with condyle through remainder of opening cycle. C, Maximum opening position. When

mandible closes, condyle and disk relationship will return to position as shown in A.

FIG. 30-13 Anterior disk displacement without reduction. A, Disk that has been chronically anteri-orly displaced now has amorphous shape rather than distinct biconcave structure. B, When condylebegins to translate forward, disk remains anterior to condyle. C, In maximum open position, disk tis-sue continues to remain anterior to condyle, with posterior attachment tissue interposed betweencondyle and fossa.

In these patients no clicking occurs, because they areunable to translate the condyle over the posterior aspectof the disk. This lack of translation may result in restrict-ed opening, deviation to the affected side, and decreasedlateral excursions to the contralateral side. Some evidencesuggests that the limitation of motion may not be direct-ly related to the actual displacement of the disk but ratherto the adherence of the disk to the fossa, causing a restric-tion of the sliding function of the joint.10

Radiographic evaluation of disk displacement withoutreduction is similar to findings in anterior disk displace-ment with reduction. Plain TMJ radiography may appearnormal, whereas CT scans and MRIs generally demonstrateanteromedial disk displacement. However, in this disorder,images taken in the maximal open position continue toshow anterior disk displacement within the open position.

Degenerative Joint Disease (Arthrosis,Osteoarthritis)

DJD includes a variety of anatomic findings, includingirregular, perforated, or severely damaged disks in associa-tion with articular surface abnormalities, such as articularsurface flattening, erosions, or osteophyte formation (Fig.30-14). The mechanisms of TMJ degenerative diseases arenot clearly understood but are thought to be multifactorial.Current concepts of DJD incorporate three possible mecha-nisms of injury: (1) direct mechanical trauma, (2) hypoxiareperfusion injury, and (3) neurogenic inflammation.11

Mechanical trauma may be a result of significant andobvious trauma to the joint or much less obvious micro-trauma, such as excessive mechanical loading. The exces-sive stress produced in the joint can lead to molecular dis-ruption and the generation of free radicals, with resultingoxidative stress and intracellular damage. Excess loadingcan also affect local cell populations and reduce thereparative capacity of the joint.

The hypoxia-reperfusion theory suggests that exces-sive intracapsular hydrostatic pressure within the TMJmay exceed the blood vessel perfusion pressure, resultingin hypoxia.

This type of increased intracapsular pressure has beenclearly demonstrated in patients during clenching andbruxing.12 When the pressure in the joint is decreased andperfusion is reestablished, free radicals are formed. Thesefree radicals may interact with other substances in thejoint (e.g., hemoglobin) to produce even more damage.

Neurogenic inflammation results when a variety ofsubstances are released from peripheral neurons. It ishypothesized that in cases of disk displacement the com-pression or stretching of the nerve-rich retrodiscal tissuemay result in release of proinflammatory neuropep-tides.11'13 The release of cytokines results in the releaseand activation of a variety of substances including pros-taglandins, leukotrienes, and matrix-degrading enzymes.These compounds not only have a role in the diseaseprocess but also may serve as biologic markers that mayhelp to diagnose and eventually treat joint pathology.14'15

It must be emphasized that it is impossible to predict theprogression of joint pathology.

Patients with DJD frequently experience pain associat-ed with clicking or crepitus, located directly over the TMJ.Usually, an obvious limitation of opening is present, andsymptoms usually increase with function. Radiographicfindings are variable but generally exhibit decreased jointspace, surface erosions, osteophytes, and flattening of thecondylar head. Irregularities in the fossa and articulareminence may also be present.

Systemic Arthritic Conditions

A variety of systemic arthritic conditions are known toaffect the TMJ. The most common of these is rheumatoidarthritis. Other processes, such as systemic lupus, can also

FIG. 30-14 Degenerative joint disease demonstrates large perforation of disk tissue anderosion and flattening of articulating surfaces of both condyle and fossa.

affect the TMJ. In these caseed to the TMJs, and several arthritis are usually present

In the case of rheumatoprocess results in abnormalsue in a so-called pannus fo

TMJ symptoms that resumay occur at an earlier agDJD. As opposed to DJD, rheumatoid arthritis (and otally affects the TMJs bilatera

Radiographic findings ofsive changes in the anteriocondylar heads. These cha

FIG. 30-15 Changes seen in rheumatoid arthritis of temporomandibularjoint. These changes include proliferation of synovial tissue, creating resorp-tion in anterior and posterior areas of condyle. Irregularities of disk tissueand articulating surface of condyle eventually occur.

FIG. 30-16 Anatomic specimen demonstrating dislocation of condyle in front of eminence.EAC, External auditory canal.

s symptoms are rarely isolat-other signs and symptoms ofin other areas of the body.id arthritis, an inflammatory proliferation of synovial tis-rmation (Fig. 30-15).lt from rheumatoid arthritis

e than those associated withwhich is usually unilateral,

her systemic conditions) usu-lly. the TMJ initially show ero-r and posterior aspects of thenges may progress to large

eroded areas that leave the appearance of a small, point-ed condyle in a large fossa. Eventually the entire condyleand condylar neck may be destroyed. Laboratory tests,such as rheumatoid factor and erythrocyte sedimentationrate, may be helpful in confirming the diagnosis ofrheumatoid arthritis.

Chronic Recurrent Dislocation

Dislocation of the TMJ occurs frequently and is caused bymandibular hypermobility. Subluxation is a displacementof the condyle, which is self-reducing and generallyrequires no medical management. A more serious condi-tion occurs when the mandibular condyle translates ante-

riorly in front of the articular eminence and becomeslocked in that position (Fig. 30-16). Dislocation may beunilateral or bilateral and may occur spontaneously afteropening the mouth widely, such as when yawning, eat-ing, or during a dental procedure. Dislocation of themandibular condyle that persists for more than a fewseconds generally becomes painful and is often associat-ed with severe muscular spasms.

Dislocations should be reduced as soon as possible.This reduction is accomplished by applying downwardpressure on the posterior teeth and upward pressure onthe chin, accompanied by posterior displacement of themandible. Usually reduction is not difficult. However,muscular spasms may prevent simple reduction, particu-larly when the dislocation cannot be reduced immediate-ly. In these cases, anesthesia of the auricular temporalnerve and the muscles of mastication may be necessary.Sedation to reduce patient anxiety and provide muscularrelaxation may also be required. After reduction thepatient should be instructed to restrict mandibular open-ing for 2 to 4 weeks. Moist heat and nonsteriodal anti-inflammatory drugs (NSAIDs) are also helpful in control-ling pain and inflammation.

Ankylosis

Intracapsular ankylosis. Intracapsular ankylosis, orfusion of the joint, leads to reduced mandibular openingthat ranges from partial reduction in function to com-plete immobility of the jaw. Intracapsular ankylosisresults from a fusion of the condyle, disk, and fossa com-plex, as a result of the formation of fibrous tissue, bonefusion, or a combination of the two (Fig. 30-17). Themost common cause of ankylosis involves macrotrauma,most frequently associated with condylar fractures.Other causes of ankylosis include previous surgical treat-ment that resulted in scarring and, in very rare cases,infections.

Evaluation of the patient reveals severe restriction ofmaximal opening, deviation to the affected side, anddecreased lateral excursions to the contralateral side. Ifthe ankylosis is the result primarily of fibrous tissue, jawmobility will be greater than if the ankylosis is a result ofbone fusion.

Radiographic evaluation reveals irregular articularsurfaces of the condyle and fossa, with varying degreesof calcified connection between these articulatingsurfaces.

Extracapsular ankylosis. This type of ankylosis usu-ally involves the coronoid process and temporalis muscle.Frequent causes of extracapsular ankylosis are coronoidprocess enlargement, or hyperplasia, and trauma to thezygomatic arch area. Infection around the temporalismuscle may also produce extracapsular ankylosis.

Patients initially have limitation of opening anddeviation to the affected side. In these cases, completerestriction of opening is extremely rare, and limited later-al and protrusive movements can usually be performedindicating no intracapsular ankylosis. Panoramic radiog-raphy generally demonstrates the elongation of a coro-noid process. A submental vertex radiograph may be use-

FIG. 30-17 Bony ankylosis. Diagram represents complete bonefusion of condyle process and glenoid fossa area.

ful in demonstrating impingement caused by a fracturedzygomatic arch or zygomaticomaxillary complex.

Neoplasia

Neoplasms in the TMJ are extremely rare. They can occa-sionally result in restriction of opening and joint pain.Tumors within the TMJ may result in an abnormalcondyle and fossa relationship or an intracapsular anky-losis. A complete discussion of the neoplastic processesknown to occur in the TMJ area is beyond the scope ofthis chapter.

InfectionsInfections in the TMJ area are extremely rare, even in thecase of trauma or surgical intervention in this area. Inthird world countries where antibiotic therapy of middleear infections is not available, extension of infectiousprocesses may occasionally involve the TMJ and result inintracapsular ankylosis.

Although the cause of temporomandibular pain and dys-function can arise from several different sources, initialtreatment is frequently aimed at nonsurgical methods ofreducing pain and discomfort, decreasing inflammationin muscles and joints, and improving jaw function. Insome cases, such as ankylosis or severe joint degenera-tion, surgical treatment may be the preferred initialcourse of therapy. However, in most cases, includingMPD, disk displacement disorders, and degenerative andsystemic arthritic disorders, a nonsurgical, reversibletreatment phase may provide significant reduction in

pain and improvement in function. In fact, most patientswith MPD and internal derangements do extremely wellwithout any type of long-term or invasive treatment. Inthe case of anterior disk displacement without reduction(i.e., closed lock), most patients experience a gradual pro-gression of increased opening and decreased discomfortwithout extensive treatment. This is apparently the resultof physiologic and anatomic adaptation of tissue withinthe joint. It appears that in many patients the posteriorattachment tissue undergoes fibrous adaptation and ade-quately serves as interpositioning tissue between thecondyle and fossa.16 This is often termed pseudodisk adap-tation (Fig. 30-18). This pseudodisk formation, combinedwith other normal healing capabilities of joints, is mostlikely responsible for clinical improvement in manypatients.

Patient EducationThe first step in involving patients in their own treatmentis to make them aware of the pathology producing theirpain and dysfunction and to describe the prognosis orpossible progression of their pain and dysfunction. Manyproblems of masticatory pain and dysfunction stabilize orimprove with conservative therapy, despite patients' con-cerns that they may be on a continually deterioratingcourse. In the case of a patient with MPD, a precise, con-fident explanation should attempt to assure the patientthat muscular pain usually improves with minimal treat-ment. The clinician should also explain that althoughsymptoms may recur on occasion, they generally can becontrolled with the treatment (described later in thischapter).

In some cases, such as DJD, the patient should be madeaware of the long-term spectrum of outcomes of this prob-lem. Warning signs of further deterioration, includingincreased pain, limitation of motion, and increased jointnoise, should be emphasized to the patient.

Patients who have an awareness of the factors associ-ated with their pain and dysfunction can actively partic-ipate in their own improvement. Myofascial pain oftenresults from parafunctional habits or muscular hyperac-tivity secondary to stress and anxiety. Patients who areaware of these factors are often able to control their activ-ity and thereby reduce discomfort and improve function.Biofeedback devices provide information to patients tohelp them control their muscular activity. For example,the output from surface electrodes over the masseter ortemporalis muscle can be used to indicate clenching orgrinding during daytime activity (Fig. 30-19).I7 Elec-tromyographic (EMG) recordings can also be useful inevaluating nocturnal bruxism and associated pain andcan be used to monitor the effectiveness of splint therapyand medication to control muscular hyperactivity. Otherforms of stress control, such as physical exercise, reducing

FIG. 30-18 Pseudodisk adaptation. When disk becomes anteriorlydisplaced, retrodiscal tissue undergoes fibrous adaptation, producingfunctional, although anatomically different, interpositional disk.

FIG. 30-19 Electromyographic biofeedbackmonitor. A, This instrument provides audio andvisual (meter) output (B), allowing patient tohear and see increased muscle activity. Varioustreatments, such as physical therapy, splinttherapy, and medication, can then be used toreduce muscle activity.

exposure to stressful situations, and psychologic counsel-ing, can also be explored.

When the patient becomes aware of the relationshipbetween personal actions and the symptoms of pain anddysfunction, behavior modification can follow.

Modification of diet and home exercise routines are alsoan important part of the patient's educational process.Patients who experience temporomandibular pain or dys-function frequently find that it is most apparent whenchewing hard food. Temporary alteration of the diet withnonchew, blenderized food may result in a significantreduction in symptoms. A gradual progression to a morenormal diet over a period of 6 weeks may be sufficient toreduce joint or muscle symptoms.

Although the patient is generally encouraged toreduce the functional load placed on the joint and mus-cles, it is important to remember that maximizing rangeof motion is also an important aspect of treatment of alltemporomandibular disorders. Home exercises may behelpful in maintaining normal function. These exercisesinclude gentle stretching exercises done to pain tolerancethrough passive opening or active exercise routines. Insome cases patients can obtain simple appliances thatprovide easy and efficient methods for improving jawmobility (Fig. 30-20).

Medication

Four types of medication have been widely used in thetreatment of temporomandibular disorders: (1) NSAlDs,(2) occasional use of stronger analgesics, (3) muscularrelaxants, and (4) tricyclic antidepressants.

NSAIDs not only reduce inflammation but also serveas an excellent analgesic. Some examples of NSAIDs arenaproxen (Naprosyn), ibuprofen (Motrin), diflunisal(Dolobid), and piroxicam (Feldene). These medicationscan be effective in reducing inflammation in both mus-cles and joints and in most cases provide satisfactory painrelief. These drugs are not associated with severe addic-tion problems, and their use as an analgesic is stronglypreferred over narcotic medications. It is important toremember that these medications work best when admin-istered on a timetable rather than on a pain-dependentschedule. Patients should be instructed to take the medi-cine on a regular basis, obtaining an adequate blood levelthat should then be maintained for a minimum of 7 to 10days. Discontinuation or tapering of the medicine canthen be attempted.

The COX-2 inhibitors such as celecoxib (Celebrex) androfecoxib (Vioxx) have gained popularity in the treat-ment of inflammation and pain. Prostaglandins pro-duced by COX-1 activity appear to be required for normalphysiologic function, whereas those produced by COX-2activation mediate pain and inflammation. The COX-2inhibitors are intended to reduce pain and inflammationwithout affecting prostaglandin-dependent functions.These drugs have been associated with significant sideeffects, including gastric and cardiac complications.

Analgesic medicines for TMJ patients may range fromacetaminophen to potent narcotics. One important prin-ciple of treatment for all pain and dysfunction patients is

to remember that the problem may be chronic and thatmedication could produce long-term addiction. Becauseof the sedative and depressive effects of narcotics andtheir potential for addiction, these medications should berestricted to short-term use in patients with severe, acutepain. In such instances medications such as acetamino-phen with codeine should be sufficient. This medicationshould not be used for longer than 10 days to 2 weeks.

Muscle relaxants may provide significant improvementin jaw function and relief of masticatory pain. However,muscle relaxants have a significant potential for depres-sion and sedation and can produce long-term addiction.In many patients with acute pain or exacerbation of mus-cular hyperactivity, muscle relaxants can be considered forshort periods, such as 10 days to 2 weeks. The lowest effec-tive dose should be used. Diazepam (Valium) 2 to 5 mg orcyclobenzaprine (Flexeril) 10 mg generally provides ade-quate relief of muscular symptoms in patients with TMD.

Tricyclic antidepressants in low doses appear to be use-ful in the management of patients with chronic pain. Tri-cyclic antidepressants prevent the reuptake of amineneurotransmitters, such as serotonin and norepineph-rine, causing an inhibition of pain transmission. Recent-ly, anecdotal evidence has suggested that these antide-pressants may be effective in decreasing nocturnal brux-ism. It appears that nighttime bruxing may be in part aresult of disruption of normal sleep patterns. The use ofamitriptyline (Elavil) in small doses (10 to 25 mg at bed-time) may improve sleep patterns, decrease bruxism, andresult in decreased joint and muscle pain.

Medications that must be administered by injectionmay occasionally be helpful in managing muscular andjoint pain and inflammation. Recently the use of Botu-linum Toxin A has shown promise in decreasing mastica-tory muscle hyperactivity.18'19 Botulinum Toxin (Botox) isa neurotoxin produced by the bacterium Clostridium botu-linum. This neurotoxin produces a paralytic effect on mus-cles by inhibiting the release of acetylcholine at the neuro-muscular junction. In very low doses, Botox can be safelyadministered by injection directly into the affected musclearea, decreasing muscle contraction activity and the asso-ciated pain. The effect of Botox is temporary, lasting from

FIG. 30-20 Jaw exercising device. Patient can use Therabite appli-ance to increase range of jaw motion.

a few weeks to several months. In many cases injection ofBotox must be repeated to obtain long-term pain relief.

Injection of steroids directly into the joint has beensuggested as an effective way to decrease pain and inflam-mation, because these compounds are known to inhibitproinflammatory cytokines.20 There continues to besome debate about the long-term effect of steroids in thejoint and the possibility that further degeneration may beassociated with steroid injection.21 Further research isrequired in this area.

Physical Therapy

Physical therapy can be extremely useful in the manage-ment of patients with temporomandibular pain and dys-function. The most common modalities used includeEMG biofeedback and relaxation training, ultrasound,spray and stretch, and pressure massage.

Relaxation training, although perhaps not physicaltherapy in the strictest sense, can be extremely effectivein reducing symptoms caused by muscular pain andhyperactivity. During the educational phase, patients aremade aware of the contribution of stress and muscularhyperactivity to pain. Relaxation techniques can be usedto reduce the effects of stress on muscle and joint pain.EMG monitoring of the patient's muscular activity can beused as an effective teaching tool by providing instantfeedback demonstrating relaxation therapy, reduction ofmuscular hyperactivity, and the resultant improvementin symptoms of pain.

Ultrasound is an effective way to produce tissue heat-ing with the use of ultrasonic waves, which alter bloodflow and metabolic activity at a deeper level than thatprovided by simple surface moist-heat applications.22 Theeffect of ultrasonic tissue heating is theoretically relatedto increase in tissue temperature, increase in circulation,increase in uptake of painful metabolic by-products, anddisruption of collagen cross-iinking, which may affectadhesion formation. All of these effects may result in amore comfortable manipulation of muscles and a widerrange of motion. In addition, intraarticular inflammationmay also be reduced with ultrasonic applications. Ultra-sonic treatments are usually provided by a physical ther-apist in combination with other treatment modalities.The typical routine for application of ultrasound is theuse of 0.7 to 1.0 watts per cm2 applied for approximately

10 minutes over the affected areas (i.e., temporalis andmasseter muscles and TMJ) (Fig. 30-21). Ultrasonic treat-ments are most effective when repeated every other dayor every third day for several consecutive treatments.

Spray and stretch is an effective method for improvingrange of motion. The theory behind spray and stretch isthe concept that stimulating large cutaneous nerve fiberscan produce an overriding or distracting effect on paininput from smaller fibers that originate in the musclesand joints.23 By spraying a vapocoolant material, such asfluormethane, over the lateral surface of the face, themuscles of mastication can be passively or activelystretched with a reduced level of pain (Fig. 30-22).

Friction massage involves the use of firm cutaneouspressure sufficient to produce a temporary degree ofischemia. This ischemia and the resultant hyperemia havebeen described as a method for inactivation of triggerpoints, which are areas responsible for pain referred tomuscles in the head and neck area.23 More frequently thistechnique may be useful in disrupting small fibrous con-nective tissue adhesions that may develop within the mus-cles during healing after surgery and injury or as a result ofprolonged muscular shortening from restricted motion.

Physical therapists and other practitioners sometimesuse transcutaneous electronic nerve stimulation (TENS)to provide pain relief for chronic pain patients whenother techniques have been unable to eliminate or reducepain symptoms (Fig. 30-23).

The exact mechanism of action of TENS is not com-pletely understood. The technique was initially based onthe concept that stimulation of superficial nerve fiberwith TENS may be responsible for overriding pain inputfrom structures such as masticatory muscles and the TMJs.Interestingly, many patients who use TENS units experi-ence pain relief that is longer in duration than the timeduring which the unit is actually applied. This may be aresult of the release of endogenous endorphin compoundsthat can provide extended periods of decreased pain.

Each of the physical therapy modalities may beextremely useful in initial attempts to reduce TMJ painand increase range of motion. The low cost of physicaltherapy compared with other medical treatment, the like-lihood that some benefit will occur, and the minimal riskassociated with these techniques are strong arguments forfrequent use of physical therapy in the management ofpatients with TMD.

FIG. 30-21 A, Ultrasound unit for temporomandibular joint and facial pain physical therapy. B, Appli-cation of ultrasound to masseter muscle area.

Splints

Occlusal splints are generally considered a part of thereversible or conservative treatment phase in the man-agement of TMD patients. Splint designs vary; however,most splints can be classified into two distinct groups:(1) autorepositioning splints and (2) anterior reposition-ing splints.

Autorepositioning splints. The autorepositioningsplints, also called anterior guidance splints, superior reposi-tioning splints, or muscle splints, are most frequently usedto treat muscle problems or eliminate TMJ pain when nospecific internal derangement or other obvious patholo-gy can be identified. However, these splints may be usedin some cases, such as anterior disk displacement or DJD,in an attempt to unload or reduce the force placed direct-iy on the TMJ area. Nitzan has shown that properlydesigned splints can be effective in reducing intraarticu-lar pressure.12 The splint is usually designed to providefull-arch contact without working or balancing interfer-ences and without ramps or deep interdigitation, whichwould force the mandible to function in one specificocclusal position (Fig. 30-24). This splint allows thepatient to seek a comfortable muscle and joint positionwithout excessive influence of the occlusion. An exam-ple of this type of splint would be in a patient with aclass II malocclusion and significant overjet who contin-ually postures forward to obtain incisor contact duringmastication. Many of these patients complain of muscu-lar symptoms and describe a feeling that they do nothave a consistent, repeatable bite relationship. Wearing

an autorepositioning splint allows full-arch dental con-tact with the condyles in a more posterior retruded posi-tion, which frequently results in reduction in muscleand joint symptoms.

Anterior repositioning splints. Anterior reposition-ing splints are constructed so that an anterior rampingeffect forces the mandible to function in a protrudedposition (Fig. 30-25). This type of splint is most useful inproviding temporary relief and, in rare cases, a long-term

FIG. 30-22 Spray-and-stretch technique. Vapocoolant is appliedwhile patient performs increased range-of-motion exercises usingTherabite appliance.

FIG. 30-23 Transcutaneous electronic nerve stimulation. A, Unit used for applying electricalstimulation to face. B, Placement of electrodes over masseter muscle area for application of elec-tric stimulus.

FIG. 30-24 Au ation obtainedwith condyle sli g forced inter-digitation of teet photograph ofautorepositionin

cure for anterior disk displacethese cases the anterior positiosion of the mandible necessary and condyle relationships (afteing click has occurred).

The splint is usually worn 2months. Theoretically after thelong period, the posterior ligmaintain the disk in proper reDespite theoretical expectationally ineffective in producing pedisplacement. However, even curative, they often provide sifort in the acute stages of TMJ

PERMANENT OCCLUSION

After completion of a coursemany patients may be candidacation of the occlusion. This

torepositioning splint. A, Diagram representing maximum interdigitghtly down and forward. B, Repositioning of mandible by eliminatinh results in posterior and superior repositioning of condyle. C, Clinical g splint.

ment with reduction. Inn is determined by protru-to produce the proper diskr the protruding or open-

4 hours a day for several disk is repositioned for aaments may shorten andlationship to the condyle.s, these splints are gener-rmanent reduction of diskwhen the splints are notgnificant relief of discom-dysfunction.

MODIFICATION

of reversible treatment,tes for permanent modifi- permanent modification

appears to be most appropriate when patients have hadsignificant improvement in masticatory function andreduction in pain as a result of temporary alteration ofocclusal position with splint therapy. Permanent occlu-sion modification may include occlusal equilibration,prosthetic restoration, orthodontics, and orthognathicsurgery. Although the relationship between occlusionabnormalities and TMD is unclear, it does appear thatpermanent modification of the occlusion in indicatedpatients may provide long-term improvement in symp-toms of pain and dysfunction.

TEMPOROMADIBULAR JOINTSURGERYDespite the fact that many patients with internal jointpathology will improve with reversible nonsurgical treat-ment, some patients will eventually require surgical inter-vention to improve masticatory function and decreasepain. Several techniques are currently available for cor-rection of a variety of TMj derangements.

FIG. 30-25 , Disk interposi-tion between e. Anterior posi-tion of mand ship. C, Clinicalphotograph

Arthrocentesis

Arthrocentesis involves plaand therefore is not actuallever, because it is somewhaformed by oral and maxilcussed here.

Most patients undergoinlocal anesthesia and intravtechniques have been dessis.10'24 The most common ming one needle into the samount of lactated Ringer's the joint space and can theed for diagnostic purposes, tended, and a second needjoint space. This allows largmately 200 ml) to lavage th

During the arthrocentemanipulated. At the costeroids, local anesthesia, o

Anterior repositioning splint. A, Diagram of anteriorly displaced disk. B condyle and articular eminence, with anterior repositioning splint in placible allows function with condyle in appropriate condyle and disk relationof anterior repositioning splint.

cing needles into the TMJy a surgical procedure. How-t invasive and generally per-lofacial surgeons, it is dis-

g arthrocentesis do so withenous (IV) sedation. Severalcribed for TMJ arthrocente-

ethod involves initially plac-uperior joint space. A smallsolution is injected to distendn be withdrawn and evaluat-if desired. The joint is redis-le is placed into the superiorer amounts of fluid (approxi-e joint.sis the jaw can be gentlynclusion of the procedure,r a combination of both can

be injected into the joint space before the needles arewithdrawn. Discomfort after the procedure is managedwith mild analgesics or NSAIDs. Some type of exerciseregimen or physical therapy is accomplished during therecovery period.

Many types of internal joint pathology appear torespond well to arthrocentesis. The most common useappears to be in patients with anterior disk displacementwithout reduction. Treatment appears to be very effec-tive, with results similar to or better than other types ofarthroscopic and open surgical procedures. Nitzandemonstrated that arthrocentesis produced significantimprovement in incisal opening and reduction of pain inpatients with persistent and severe closed lock.24

The success seen with arthrocentesis has several poten-tial explanations. When disk displacement occurs, nega-tive pressure may develop within the joint, causing a"suction cup" effect between the disk and fossa. Distend-ing the joint obviously eliminates the negative pressure.In some cases of more chronic disk displacement, some

adhesion may develop between the disk and fossa. Witharthrocentesis the distension under pressure can releasethese adhesions. Capsular constriction may occur as aresult of joint hypomobility and can be stretched withpressure distension. Finally, there may be an accumula-tion of some of the chemical mediators described previ-ously. The simple flushing action in the joint may elimi-nate or decrease biochemical factors contributing toinflammation and pain.

ArthroscopyArthroscopic surgery has become one of the most popu-lar and effective methods of diagnosing and treating TMJdisorders.25 This technique involves placement of a smallcannuia into the superior joint space. An arthroscopewith light source is then inserted through the cannulainto the superior joint space (Fig. 30-26). The arthroscopeis then connected to a video camera and monitor, whichallow excellent visualization of all aspects of the glenoid

FIG. 30-26 A, Arthroscope placed in superior joint space. B, Operating room set up for arthroscopy.C, View of superior joint space. Interiorly, disk tissue can be clearly visualized. Superiorly, fibrous tissuecovering fossa is disrupted as result of separation of adhesions with arthroscopic surgical techniques.D, Close-up view of synovial tissue hypertrophy.

Continued

FIG. 30-26—cont'd E, Diagram of arthroscope and working cannula using surgical microscissorsplaced through cannula to cut fibrous band. F, View through arthroscope of motorized shaver usedto remove fibrous tissue from articular surface. G, Arthroscopic surgery using laser fiber insertedthrough working cannula.

fossa and supetechniques arjoint for diagadhesions, co

More sophhave been degeon to correcrent surgical of at least twOne cannula with the artthrough the othe joint (Fig. through the sutures, mediized instrumefibers can alsflamed tissue manipulation,cautery, and an attempt toAlthough it apdisks do not disk position, appear to haarthroscopic s

Arthroscopment of a vaderangementsadhesions, Darthroscopic that of open less surgical complications

As with mplaced on som

FIG. 30-27 Open temporomandibular joint (TMJ) surgical procedure to replace displaced disk.A, Preauricular incision through skin subcutaneous tissue and TMJ capsule, exposing anteriorly dis-placed disk. B, Wedge of tissue is removed from posterior attachment area, and disk is repositionedand sutured into its correct position.

rior aspect of the disk. Initial arthroscopice limited primarily to visualization of thenostic purposes and lysis of fibrous jointmbined with lavage of the joint.isticated arthroscopic operative techniquesveloped, increasing the ability of the sur-t a variety of intracapsular disorders. Cur-

techniques usually involve the placemento cannulas into the superior joint space.is used for visualization of the procedurehroscope, while instruments are placedther cannula to allow instrumentation in30-26, E through G). Instrumentation usedarthroscope includes forceps, scissors,

cation needles, cautery probes, and motor-ntation, such as burs and shavers. Lasero be used to eliminate adhesions and in-and incise tissue within the joint. Disk

disk attachment release, posterior bandsuture techniques have been developed in reposition or stabilize displaced disks.26

pears that attempts to reposition displacedresult in anatomic restoration of normalpatients undergoing this type of treatmentve significant clinical improvement afterurgery.27

ic surgery has been advocated for treat-riety of TMJ disorders, including internal, hypomobility as a result of fibrosis orJD, and hypermobility. The efficacy oftreatment appears to be very similar tojoint procedures, with the advantage ofmorbidity and fewer and less severe

.25'28

ost TMJ surgical procedures, patients aree type of physical therapy regimen after

Disk-Repositioning Surgery

During the late 1970s and 1980s one of the most com-monly performed TMJ surgical procedures was disk repo-sitioning and plication. The indication for this procedureis anterior disk displacement that has not responded tononsurgical treatment and that most frequently results inpersistent painful clicking joints or closed locking (i.e.,anterior disk displacement with or without reduction).Although these disorders are more frequently managedsurgically with arthrocentesis or arthroscopy, many sur-geons still prefer this type of surgical correction. In thisoperation the displaced disk is identified and repositionedinto a more normal position by removing a wedge of tis-sue from the posterior attachment of the disk and suturingthe disk back to the correct anatomic position (Fig. 30-27).In some cases this procedure is combined with recontour-ing of the disk, articular eminence, and mandibularcondyle. After surgery, patients generally begin a nonchewdiet for several weeks, progressing to a relatively normaldiet in 3 to 6 months. A progressive regimen of jaw exer-cises is also instituted in an attempt to obtain normal jawmotion within 6 to 8 weeks after surgery.

In general the results of open arthroplasty have beengood, with 80% to 95% of the patients experiencing lesspain and improved jaw function.29 Unfortunately thissurgery does not produce improvement in all patients,with 10% to 15% of patients describing no improvementor a worsening of the condition.

Disk Repair or Removal

In some cases the disk is so severely damaged that theremnants of disk tissue must be removed. Diskectomywithout replacement was one or the earliest surgicalprocedures described for treatment of severe TMJ inter-nal derangements.30 With current technology, thediskectomy procedure can be performed through arthro-

FIG. 30-28 Dermal graft used to patch small perforation of disk.

scopic techniques described earlier. Although this tech-nique has been widely used, there seems to be a widevariation in clinical results, with some joints showingminimal anatomic changes and significant clinicalimprovement to joints that demonstrate severe degener-ative changes with continued symptoms of pain anddysfunction.

In advanced internal joint pathology, the disk may beseverely damaged and perforated but may have adequateremaining tissue so that a repair or patch procedure canbe accomplished (Fig. 30-28). A variety of autogenous tis-sue sources have been used for disk repair, includinggrafts of dermal or fascial tissue.31

In many cases the disk was previously replaced withalloplastic implant material. However, significant failureshave been seen with many of these implant materials,including implant fragmentation, foreign-body reaction,synovitis, and gross erosion of bony articular surfaces.These problems led to a renewed interest in autogenoustissue replacement after disk removal. Autogenous graft-ing techniques include the use of auricular cartilage,temporalis fascia, and the combination of muscle andfascial flaps (Fig. 30-29).32 Although well-done long-termstudies of the outcome of each of these techniques arelimited, most patients realize some degree of improve-ment in pain and function after treatment with theseprocedures,

Condylotomy for Treatmentof Temporomandibular joint DisordersThe condylotomy is an osteotomy completed in a man-ner identical to the vertical ramus osteotomy described inChapter 25. When used for treatment of TMJ problemsthe osteotomy is completed, but no wire or screw fixationis placed, and the patient is placed into intermaxillaryfixation for a period ranging from 2 to 6 weeks. The the-

ory behind this operation is that muscles attached to theproximal segment (i.e., segment attached to the condyle)will passively reposition the condyle, resulting in a morefavorable relationship between the condyle, disk, andfossa.33

This technique has been advocated primarily for treat-ment of disk displacement with or without reduction.DJD and subluxation or dislocation have also been sug-gested as possible indications for use of this technique.Although this method of surgical treatment has beensomewhat controversial, it appears to provide significantclinical improvement in a variety of TMJ disorders.

Total Joint Replacement

In some cases, joint pathology results in destruction ofjoint structures so that reconstruction or replacement ofcomponents of the TMJ is necessary (Fig. 30-30, A).

Examples of such situations include severe degenera-tive or rheumatoid arthritic disorders, severe cases ofankylosis, neoplastic pathology, posttraumatic destruc-tion of joint components, and multiple failed surgicalprocedures. Surgical techniques may involve replacementof the condyle or fossa but most commonly include bothelements.

One method of joint reconstruction involves graftingautogenous tissue using a costochondral bone graft.-54

These grafts are most frequently used in growing individ-uals but also can be used effectively in the treatment of avariety of adult disorders. Figure 30-30, B shows the useof a costochondral graft for replacement of a severelydegenerated mandibular condyle. In this situation thegraft replaces only the condylar portion of the joint anddoes not address significant abnormalities of the fossa.

Problems with costochondral grafting include recur-rent ankylosis, degenerative changes of the graft, and (insome cases) excess and asymmetric growth of the graft.

FIG. 30-29 A, Diagram of auricular cartilage harvested frominferior portion of ear, used as a graft material in temporo-mandibular joint after removal of disk tissue. B, Clinicalphotograph.

FIG- 30-30 Total joint replacement. A, Severe degeneration of condyle, resulting in malocclusion,pain, and limited opening. B, Costochondral bone graft placed along posterior aspect of mandible toreconstruct severely damaged condyle. Tissue grafts or alloplastic implants can be used as disk replace-ment technique in combination with costochondral grafting.

Continued

FIG. 30-30—cont'd C, Stereolithic model with wax pattern for cus-tom temporomandibular joint condyle and fossa replacement. D, Dia-grammatic representation of total joint reconstruction with prostheticreplacement of both condyle and fossa components.

In the past several types of prosthetic joint replace-ment have been available.35 Long-term results of pros-thetic joint replacements have been somewhat disap-pointing because of a variety of technical and biologicproblems. However, for many patients with significantdestruction of TMJ structures who have had poor resultsfrom other surgical treatment, no other viable surgicaloptions exist. In these cases the joint destruction resultsin severe pain, limited motion or complete ankylosis, andsevere malocclusions (see Fig. 30-30, A). Current techno-logic advances include the use of three dimensional (3-D)reconstructed stereolithic models and custom fabricationof a total joint prosthesis, including the fossa andcondyle (Fig. 30-30, C and D). These recent advantageshave provided significant improvement in the outcomeafter total joint replacement.36'37

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