TMJ Research: 2002-2006  
     
J Oral Maxillofac Surg. 2006 Nov;64(11):1624-30.
The Functional Long-Term Results After Bilateral Sagittal Split Osteotomy (BSSO) With and Without a Condylar Positioning Device.
Gerressen M, Zadeh MD, Stockbrink G, Riediger D, Ghassemi A.
Resident, Department of Oral, Maxillofacial and Plastic Facial Surgery, Universitatsklinikum der RWTH Aachen, Aachen, Germany.

PURPOSE: The goal of this retrospective study was to examine whether utilization of condylar positioning devices in bilateral sagittal split osteotomy leads to long-term benefits for temporomandibular joint function as compared with the manual positioning technique. PATIENTS AND METHODS: The joint function of 49 patients (98 joints) who underwent bilateral sagittal split osteotomy or bimaxillary osteotomy at the University Hospital of Aachen between 1993 and 2003 was analyzed by recording joint movements with axiography supported by clinical examination of the temporomandibular joint. In 10 patients out of 28 with mandibular advancement and in 10 out of 21 with mandibular setback the Luhr positioning device was used intraoperatively to reproduce the condylar position. The joints of the remaining patients were positioned manually. The received data were statistically evaluated by using unrelated t test at P = .05. RESULTS: In mandibular advancement the manually positioned group showed significantly less signs of temporomandibular disorders, while there were slight advantages in axiographically measured joint track lengths for the patients who were operated with positioning devices. After mandibular setback surgery clinical analysis as well as axiography presented comparable results in both groups. CONCLUSION: The use of a positioning device did not provide a better functional outcome long term in either mandibular advancement or setback surgery. With the manual positioning technique, an at least equally good temporomandibular joint function was attained.

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J Oral Rehabil. 2006 Oct;33(10):713-21.
Treatment outcome of short- and long-term appliance therapy in patients with TMD of myogenous origin and tension-type headache.
Ekberg EC, Nilner M.
Department of Stomatognathic Physiology, Faculty of Odontology, Malmo University, Malmo, Sweden. ewacarin.ekberg@od.mah.se

The aim was to compare the short- and long-term effect of a stabilization appliance with a control appliance in myofascial pain patients suffering from episodic or chronic tension-type headache. Sixty patients (mean age 29 +/- 12 years) with temporomandibular disorders (TMD) of myogenous origin and headache were studied in this prospective controlled study. Seventy-seven per cent of the patients reported episodic and 23% chronic tension-type headache at the start of the study. The 60 patients were randomly assigned to a treatment group (stabilization appliance) or to a control group (control appliance). The patients were interviewed regarding symptoms of headache and myofascial pain and clinically examined for masticatory muscle tenderness. At the 10-week and the 6- and 12-month evaluations of appliance therapy, the treatment outcome of tension-type headache was studied. At the 10-week evaluation, 17 patients dropped-out from the control group by requesting another appliance and receiving a stabilization appliance. Another patient in the control group dropped out later during the trial. In an intent-to-treat analysis, significant differences in improvement of headache between treatment and control groups were found at the follow-ups. A 30% reduction of muscles tender to palpation correlated significantly to improvement of headache at all follow-ups. The stabilization appliance seems to have a positive effect on tension-type headache, both in a short- and in a long-term perspective in patients with TMD with pain of myogenous origin.

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Mund Kiefer Gesichtschir. 2006 Sep;10(5):341-6.
[Arthrocentesis-a highly efficient therapy for acute TMJ arthropathy.]
[Article in German]
Wiesend M, Kanehl S, Esser E.
Implantologisches Zentrum, Asthetische Gesichtschirurgie, Klinik fur Mund-, Kiefer- und Gesichtschirurgie, Am Finkenhugel 1, 49076, Osnabruck, Germany, mkg-chirurgie@klinikum-osnabrueck.de.

PURPOSE: This clinical study deals with the efficiency of arthrocentesis in acute arthropathy of the temporomandibular joint (TMJ). PATIENTS AND METHODS: In total 142[Symbol: see text]patients (41.5[Symbol: see text]years average) were included in the examination. Inclusion criteria were a restriction of mouth opening <[Symbol: see text]40[Symbol: see text]mm and/or TMJ pain >[Symbol: see text]3 on a visual analog scale (VAS). The first examination took place the day before surgery; follow-up was performed 1[Symbol: see text]day and 4[Symbol: see text]weeks after arthrocentesis. Study parameters were active mouth opening, TMJ pain on preauricular or intra-auricular palpation, myalgia of the temporalis or masseter muscle, and a deviation clicking or crepitation during mouth opening. Arthrocentesis was performed in all patients under general anesthesia by a double puncture, continuous rinsing technique in an inferolateral approach as recommended by Murakami. The upper temporomandibular joint space was rinsed with 250[Symbol: see text]ml of a physiological sterile saline solution and a pressure of 200[Symbol: see text]mmHg. RESULTS: Arthrocentesis resulted in a highly significant increase of mouth opening and a highly significant reduction of TMJ pain on palpation (p<[Symbol: see text]0.001). CONCLUSION: It can be postulated that TMJ arthrocentesis represents a highly efficient therapy of acute TMJ arthropathy. Whether the results have to be judged as a palliative short-time therapy or if even long-term results can be achieved has to be proved by long-term follow-up studies.

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J Am Dent Assoc. 2006 Aug;137(8):1108-14.
The treatment of painful temporomandibular joint clicking with oral splints: a randomized clinical trial.
Conti PC, dos Santos CN, Kogawa EM, de Castro Ferreira Conti AC, de Araujo Cdos R.
Bauru School of Dentistry, University of Sao Paulo, Brazil. pcconti@fob.usp.br

BACKGROUND: The authors compared the efficacy of bilateral balanced and canine guidance (occlusal) splints in the treatment of temporomandibular joint (TMJ) pain in subjects who experienced joint clicking with a nonoccluding splint in a double-blind, controlled randomized clinical trial. METHODS: The authors randomly assigned 57 people with signs of disk displacement and TMJ pain into three groups according to the type of splint: bilateral balanced, canine guidance and nonoccluding. The authors followed the groups for six months using analysis of a visual analog scale (VAS), palpation of the TMJ and masticatory muscles, mandibular movements and joint sounds. They used repeated analysis of variance and a chi(2) test to test the hypothesis. RESULTS: The type of guidance used did not influence the pain reduction, yet both occlusal splints were superior to the nonoccluding splint, on the basis of the VAS. Despite similar outcomes in relation to opening, left lateral and protrusive movements, TMJ and muscle pain on palpation, subjects who used the occlusal splints had improved clinical outcomes. The frequency of joint noises decreased over time, with no significant differences among groups. Subjects in the groups using the occlusal splints reported more comfort. CONCLUSION: The type of lateral guidance did not influence the subjects' improvement. All of the subjects had a general improvement on the VAS, though subjects in the occlusal splint groups had better results that did subjects in the nonoccluding splint group.

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J Am Dent Assoc. 2006 Aug;137(8):1099-107; quiz 1169.
The efficacy of traditional, low-cost and nonsplint therapies for temporomandibular disorder: a randomized controlled trial.
Truelove E, Huggins KH, Mancl L, Dworkin SF.
Department of Oral Medicine, School of Dentistry, University of Washington, Seattle, 98195, USA. edmondt@u.washington.edu

BACKGROUND: Treatment recommendations for patients with painful temporomandibular disorders (TMDs) range from conservative treatments such as physiotherapy to aggressive and irreversible treatments such as restorative reconstruction and joint surgery. METHODS: The authors randomized 200 subjects diagnosed with TMD into three groups: usual conservative, dentist-prescribed self-care treatment without any intraoral splint appliance (UT); UT plus a conventional flat-plane hard acrylic splint (HS); and UT plus a soft vinyl (a low-cost athletic mouth guard) splint (SS). Subjects completed questionnaires and clinical examinations at three, six and 12 months. RESULTS: The authors observed no significant differences among the groups in TMD-related pain levels or other common signs and symptoms of TMD at baseline (BL) or at any follow-up. The changes from BL were comparable for all three groups. The authors did not note any significant differences at any follow-up for compliance with study protocols or for occurrences of adverse effects from either splint type. For HS versus SS, there were significant differences in rates of splint use, but these differences were not accompanied by differences in either self-reported symptoms or in clinical findings. CONCLUSIONS: All patients improved over time, and traditional splint therapy offered no benefit over the SS splint therapy. Neither splint therapy provided a greater benefit than did self-care treatment without splint therapy. CLINICAL IMPLICATIONS: These findings suggest that clinicians who treat patients with TMD should consider prescribing low-cost nonsplint self-care therapy for most patients.

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J Am Dent Assoc. 2006 Aug;137(8):1108-14.
The treatment of painful temporomandibular joint clicking with oral splints: A randomized clinical trial.
Conti PC, Dos Santos CN, Kogawa EM, Conti AC, de Araujo Cdos R.

BACKGROUND: The authors compared the efficacy of bilateral balanced and canine guidance (occlusal) splints in the treatment of temporomandibular joint (TMJ) pain in subjects who experienced joint clicking with a nonoccluding splint in a double-blind, controlled randomized clinical trial. METHODS: The authors randomly assigned 57 people with signs of disk displacement and TMJ pain into three groups according to the type of splint: bilateral balanced, canine guidance and nonoccluding. The authors followed the groups for six months using analysis of a visual analog scale (VAS), palpation of the TMJ and masticatory muscles, mandibular movements and joint sounds. They used repeated analysis of variance and a chi(2) test to test the hypothesis. RESULTS: The type of guidance used did not influence the pain reduction, yet both occlusal splints were superior to the nonoccluding splint, on the basis of the VAS. Despite similar outcomes in relation to opening, left lateral and protrusive movements, TMJ and muscle pain on palpation, subjects who used the occlusal splints had improved clinical outcomes. The frequency of joint noises decreased over time, with no significant differences among groups. Subjects in the groups using the occlusal splints reported more comfort. CONCLUSION: The type of lateral guidance did not influence the subjects' improvement. All of the subjects had a general improvement on the VAS, though subjects in the occlusal splint groups had better results that did subjects in the nonoccluding splint group.

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J Am Dent Assoc. 2006 Aug;137(8):1089-98.
The treatment of temporomandibular disorders with stabilizing splints in general dental practice: One-year follow-up.
Wassell RW, Adams N, Kelly PJ.

BACKGROUND: The authors evaluated temporomandibular disorder (TMD) outcomes in general dental practice one year after treatment with stabilizing splints (SS) or nonoccluding control splints (CS). METHODS: Seventy-two randomly allocated subjects completed initial treatment. The outcomes measures were a pain visual analog scale (VAS), muscle tenderness, temporomandibular joint (TMJ) tenderness, interincisal opening, TMJ clicks and headaches. After initial treatment, 81 percent of the subjects were found to have been treated satisfactorily. The dentists referred the remaining subjects to a dental hospital. At one year, the authors recalled 52 of the original subjects for evaluation. RESULTS: Improvements after initial treatment were maintained at one year for all outcomes, except for TMJ clicking, which returned to pretreatment levels. Eighty-one percent of the subjects rated their treatment as either good or excellent in reducing jaw pain. The authors found that subjects were aware of more of their TMJ clicks than dentists observed at the one-year clinical examination, but most subjects thought their clicking or the associated pain had been reduced. Fifty-five percent subjects had used their splints in the previous six months, but only 31 percent of these had done so daily. There were no significant differences between splint groups. CONCLUSION: At one year, a good response to TMD treatment in general practice had been maintained, but many subjects still had clicking TMJs. CLINICAL IMPLICATIONS: Trained dentists can manage TMD satisfactorily, with only a small proportion of patients needing specialist attention.

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Phys Ther. 2006 Jul;86(7):955-73. Comment in:
Phys Ther. 2006 Jul;86(7):910-1.
A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibular disorder.
Medlicott MS, Harris SR.
Lion's Gate Hospital, North Vancouver, British Columbia, Canada. mmedlicott@hotmail.com

BACKGROUND AND PURPOSE: This systematic review analyzed studies examining the effectiveness of various physical therapy interventions for temporomandibular disorder. METHODS: Studies met 4 criteria: (1) subjects were from 1 of 3 groups identified in the first axis of the Research Diagnostic Criteria for Temporomandibular Disorders, (2) the intervention was within the realm of physical therapist practice, (3) an experimental design was used, and (4) outcome measures assessed one or more primary presenting symptoms. Thirty studies were evaluated using Sackett's rules of evidence and 10 scientific rigor criteria. Four randomly selected articles were classified independently by 2 raters (interrater agreement of 100% for levels of evidence and 73.5% for methodological rigor). RESULTS: The following recommendations arose from the 30 studies: (1) active exercises and manual mobilizations may be effective; (2) postural training may be used in combination with other interventions, as independent effects of postural training are unknown; (3) mid-laser therapy may be more effective than other electrotherapy modalities; (4) programs involving relaxation techniques and biofeedback, electromyography training, and proprioceptive re-education may be more effective than placebo treatment or occlusal splints; and (5) combinations of active exercises, manual therapy, postural correction, and relaxation techniques may be effective. DISCUSSION AND CONCLUSION: These recommendations should be viewed cautiously. Consensus on defining temporomandibular joint disorder, inclusion and exclusion criteria, and use of reliable and valid outcome measures would yield more rigorous research.

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J Oral Maxillofac Surg. 2006 Jun;64(6):949-51.
Arthrocentesis for temporomandibular joint pain dysfunction syndrome.
Brennan PA, Ilankovan V.
Queen Alexandra Hospital, Portsmouth, UK. peter.brennan@porthosp.nhs.uk

The management of refractory temporomandibular joint (TMJ) pain is both challenging and controversial. A number of simple, noninvasive approaches have been used in the management of this condition with variable success. In patients who fail to respond to conventional conservative measures, in a joint that is not deemed to be grossly mechanically deranged, we advocate the use of TMJ arthrocentesis. In our practice, this is followed by intra-articular morphine infusion in an attempt to give long-term pain relief. Arthrocentesis is a simple technique with minimal morbidity that can be tried instead of more invasive procedures. To date we have used arthrocentesis of the upper joint space, with intra-articular morphine injection in over 500 TMJs. Approximately 90% of patients have found the procedure beneficial, with pain often being reduced 1 year after the procedure. We recommend arthrocentesis as an effective, minimally invasive technique in patients with continuing pain in the TMJ that is unresponsive to conservative management. We additionally advocate the use of intra-articular morphine as a long acting analgesic in these patients. Although arthrocentesis is a well documented technique and there have been many studies published in relation to the use of intra-articular morphine in orthopedic surgery, further research is required, to delineate its use in the TMJ more fully.

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Tissue Eng. 2006 May;12(5):1183-96.
Tissue Engineering of the TMJ disc: a review.
Allen KD, Athanasiou KA.
Department of Bioengineering, Rice University, Houston, Texas 77251-1892, USA.

The potential impact of a tissue-engineered temporomandibular joint (TMJ) disc is immense. Currently, patients suffering from a severely dysfunctional TMJ have few options. Facing the general lack of safe, effective TMJ disc implants, many patients undergo discectomy, a procedure that removes the injured TMJ disc in hopes of reducing debilitating symptoms associated with severe TMJ disorders. This procedure may not be ideal as the TMJ is left without an important functional component. Tissue engineering is a promising approach for the creation of viable, effective implants. The first attempt to investigate TMJ disc cells on a biomaterial was conducted in 1991. The first TMJ tissue-engineered constructs to be tested biochemically and biomechanically were formed in 1994; however, in examining this study in retrospect, it is clear how little TMJ knowledge was available at that time. Within the last 10 to 15 years, multiple studies have investigated critical TMJ disc characteristics, and while this characterization is not complete, these data have created a solid foundation for tissue-engineering research. Thus, the last 5 years have yielded core studies investigating the principal elements of tissue engineering: scaffold, cell source, and biological/biomechanical stimuli. Although TMJ disc tissue engineering is still in its formative years, its future is quite promising. Key studies are now being conducted that will assist in the establishment of a solid TMJ disc tissue-engineering approach. As the challenges of tissue engineering are faced and met, the ultimate goal of creating a functional biological implant nears.

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J Craniofac Surg. 2006 May;17(3):605-10.
Severe proliferative congenital temporomandibular joint ankylosis: a proposed treatment protocol utilizing distraction osteogenesis.
Bartlett SP, Losee JE, Quinn PD.
Division of Plastic Surgery, University of Pennsylvania Medical Center, Pennsylvania 19104, USA. scott.bartlett@uphs.upenn.edu

The classical treatment for temporomandibular joint (TMJ) ankylosis in children: 1) joint release; 2) arthroplasty; 3) reconstruction; and 4) postoperative physical therapy (PT), is often unsuccessful. Postoperative physical therapy is difficult in the young patient due to poor cooperation. Moreover, there is a subgroup of patients who have a refractory congenital proliferative bony process that is the cause of their disease. In these patients, a role for distraction osteogenesis (DO) has been defined. We present a series of young patients with congenital proliferative TMJ ankylosis. Some have failed classic treatment. In such cases, DO is used to expand the mandibular size and soft tissue matrix. This creates a static open bite, facilitates mid-facial growth, and avoids compromise of the airway, speech, nutrition, and oral hygiene. To maintain these objectives, mandibular DO may be repeated as the child matures. Once skeletal maturity is reached, DO is used to normalize occlusion and further expand the soft tissue envelope prior to definitive reconstruction and aggressive post-op PT. In seven patients, this protocol has been used. Five patients are currently in the active phase of growth and undergoing interim treatment with mandibular DO. Two patients have reached skeletal maturity and have completed the protocol of DO with definitive arthroplasty and reconstruction. DO is a valuable aid in the treatment of the problematic child with congenital proliferative TMJ ankylosis. Interim DO, prior to definitive arthroplasty and reconstruction, can provide a static open bite that prevents progressive deformity and its associated functional disturbances.

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J Craniofac Surg. 2006 May;17(3):516-22.
Temporomandibular joint bony ankylosis: comparison of treatment with transport distraction osteogenesis or the matthews device arthroplasty.
Gabbay JS, Heller JB, Song YY, Wasson KL, Harrington H, Bradley JP.
Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, CA 90095, USA.

Temporomandibular joint (TMJ) bony ankylosis with micrognathia is a rare congenital condition that is difficult to treat and may result in recurrence. In a series of affected patients, we compared two new methods of treatment: transport distraction osteogenesis and Matthews Device arthroplasty. All patients had computed tomography scan documented bilateral TMJ bony ankylosis. Group I (transport distraction osteogenesis) underwent distraction advancement of the mandible (for micrognathia) followed by resection of the condyles, recontouring of the glenoid fossas with interposition temporoparietal-fascial flaps, and transport distraction osteogenesis of mandibular rami segments. Group II (Matthews Device arthroplasty) underwent all of the above procedures except for transport distraction osteogenesis. Instead, the Matthews Devices were anchored to the temporal bone and mandibular rami. Hinged arms allowed for motion at the reconstructed TMJ. In both groups, patients underwent extensive postoperative therapy. Preoperative, postoperative, and follow-up lateral cephalograms were obtained, and incisor opening distances were recorded. All patients but one had severe micrognathia (n = 9). For group I (transport distraction osteogenesis), mean age was 6.8 years. and mean advancement was 28.5 mm. For group II (Matthews Device arthroplasty) mean age was 8.2 years, and mean advancement was 23.5 mm. In group I (transport distraction osteogenesis), mean incisor opening was 1 mm preoperatively and 27.5 mm postoperatively; however, it relapsed to 14.3 mm by 12.5 months follow-up (48% relapse). Mean incisor opening in group II (Matthews Device arthroplasty) was 3.9 mm preoperatively and 33.4 mm postoperatively and remained at 30.6 mm after 11.1 months follow-up (8% relapse). One patient in group I (transport distraction osteogenesis) underwent surgical revision because of relapse. Our data showed that for congenital TMJ bony ankylosis both transport distraction osteogenesis and Matthews Device arthroplasty techniques were successful initially; however, the Matthews Device arthroplasty avoided long-term relapse.

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Cranio. 2006 Apr;24(2):130-6.
Response of temporomandibular joint intermittent closed lock to different treatment modalities: A multicenter survey.
Yoda T, Sakamoto I, Imai H, Ohashi K, Hoshi K, Kusama M, Kano A, Mogi K, Tsukahara H, Morita S, Miyamura J, Yoda Y, Ida Y, Abe M, Takano A.
Dept. of Oral-Maxillofacial Surgery, Saitama Medical School, 38 Morohongo, Moroyama, Saitama 350-0495, Japan. yoda@saitama-med.ac.jp

This study investigated the clinical picture and different treatment methods and results at a number of institutions with the aim of establishing an effective method of treatment for intermittent closed lock (intermittent lock) of the temporomandibular joint (TMJ). The subjects were 104 patients (29 males, 65 females) diagnosed with intermittent lock among 1787 temporomandibular disorder patients. The cases were classified into two types based on the time and occasion when the intermittent lock occurred. The sudden onset type developed in 69.2%, and the habitually occurring type in 29.8%. The most common treatment was disk repositioning exercises alone (in 41 cases) followed by stabilization splints during sleeping. The highest efficacy rate (60.0%) was obtained with the combination of disk repositioning exercise and a repositioning splint followed by a rate of 52.6% with stabilization splints and 41.7% with disk repositioning exercise alone.

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Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006 Feb;101(2):170-4. Epub 2005 Oct 12.
One-year clinical course following visually guided irrigation for chronic closed lock of the temporomandibular joint.
Hamada Y, Kondoh T, Holmlund AB, Nakajima T, Horie A, Saito T, Nomura Y, Seto K.
First Department of Oral and Maxillofacial Surgery, School of Dental Medicine, Tsurumi University, Yokohama, Japan. hamada-y@tsurumi-u.ac.jp

OBJECTIVE: This study aimed to explore the clinical course following visually guided irrigation (VGIR) for chronic closed lock (CCL) of the temporomandibular joint (TMJ) as well as the factors of importance for clinical outcome. Evaluation emphasis was placed on the period needed for the patients to reach the success criteria. STUDY DESIGN: Sixty-one patients with unilateral CCL comprised the study group. The cumulative success rate of VGIR and the additional surgical treatments following VGIR were studied. The 61 patients were divided into either the good outcome (g) group or poor outcome (p) group on the basis of whether they reached the success criteria within 3 months postoperatively, and clinical and arthroscopic factors were correlated with the clinical outcome of VGIR. RESULTS: The cumulative success rate of VGIR increased up to the 6-month follow-up (success rate of 72.1%) but did not change after that point in time. A repeated VGIR (success rate of 87.5%) was performed in 8 patients. Open TMJ surgery (success rate of 87.5%) was performed in 8 patients, 7 of whom had an interfering condylar osteophyte. A pronounced reduction of preoperative painless range of mandibular motion (P-ROM) and advanced osteoarthritis (OA) were more frequently found in the p-group than in the g-group. The multivariate adjusted odds ratio showed that a decreased preoperative P-ROM was significantly predictive for a poor outcome of VGIR. CONCLUSIONS: The efficacy of VGIR is clinically acceptable as an initial surgical treatment for TMJ CCL. A 6-month follow-up period ought to be sufficient for outcome assessment of VGIR. A pronounced reduction of preoperative P-ROM should be considered as a risk factor for delay of the postoperative improvement, and OA changes may sometimes affect the clinical outcome of VGIR.

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Int J Oral Maxillofac Surg. 2006 Feb 27; [Epub ahead of print]
Intraoral distraction osteogenesis for the correction of facial deformities following temporomandibular joint ankylosis: a modified technique.
Sadakah AA, Elgazzar RF, Abdelhady AI.
Tanta Dental Hospital and School, Tanta University, Egypt.

The aim of this study was to evaluate the feasibility of transoral bimaxillary distraction osteogenesis before releasing temporomandibular joint (TMJ) ankylosis using intraoral mandibular distractors. Nine patients (5 males, 4 females) aged 14-35 (mean 19) years were included. A bilateral Le Fort I osteotomy was performed together with a mandibular osteotomy on the affected side(s). An intraoral distractor(s) was inserted in the lower jaw, followed by an intermaxillary fixation (IMF) to maintain preoperative dental occlusion. The distractor was activated, after a latency period of 5-7 days, 2 times daily by 0.5mm. There followed a consolidation period of 6-8 weeks. TMJ ankylosis was then released via a peri-auricular incision, a gap arthroplasty was performed, and mandibular movement was established after removal of the IMF and distractor. Optimal results were achieved clinically and radiologically with minimal relapse and complications. Apart from minor complaints, the distraction process was smooth and tolerable in all cases. Total mandibular elongation ranged from 17 to 25mm (20.7mm). Occlusal canting decreased to 0 degrees in 7 patients and to 1 degrees in 2 patients (mean 0.2 degrees ). After a mean follow-up period of 17 months, a mean postoperative mouth opening of 34.7mm was achieved (0.6mm preoperatively) and no re-ankylosis was detected. Intraoral distraction of a deformed mandible and maxilla before releasing TMJ ankylosis is a feasible and perhaps advantageous technique.

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Photomed Laser Surg. 2006 Feb;24(1):45-9.
Management of Mouth Opening in Patients with Temporomandibular Disorders through Low-Level Laser Therapy and Transcutaneous Electrical Neural Stimulation.
Nunez SC, Garcez AS, Suzuki SS, Ribeiro MS.
Centro de Lasers e Aplicacoes, IPEN-CNEN/SP, Sao Paulo, Brazil.

Objective: The aim of this study was to evaluate the effectiveness of low-level laser therapy (LLLT) and transcutaneous electrical neural stimulation (TENS) on the improvement of mouth opening in patients with temporomandibular disorder (TMD). Background Data: TMDs are conditions that affect the form and/or function of the temporomandibular joint (TMJ), masticatory muscles, and dental apparatus. Often TMD is associated with pain localized in the TMJ and/or in the muscles of the face and neck. Methods: This clinical trial was performed in 10 patients, 18-56 years old, diagnosed with TMD of multiple causes. All patients received both methods of treatment in two consecutive weeks. LLLT was delivered via a 670-nm diode laser, output power 50 mW, fluence 3 J per site/4 sites (masseter muscle, temporal muscle, mandibular condyle, and intrauricular). TENS therapy was applied with a two-electrode machine at 20 W, maximum frequency of 60 Hz, adjusted by the patient according to their sensitivity. The amplitude of mouth opening was recorded before treatment and immediately after using a millimeter rule; the measurements were performed from the incisal of the upper incisors to the incisal of the lower incisors. A paired t-test was applied to verify the significance of the results. Results: A significant improvement in the range of motion for both therapies was observed immediately after treatment. Comparing the two methods, the values obtained after LLLT were significantly higher than those obtained after TENS (p < 0.01). Conclusions: Both methods are effective to improve mouth opening. Comparing the two methods, LLLT was more effective than TENS applications.

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Rev Bras Otorrinolaringol (Engl Ed). 2005 Jan-Feb;71(1):32-7. Epub 2006 Jan 2.
Comparative study of eminectomy and use of bone miniplate in the articular eminence for the treatment of recurrent temporomandibular joint dislocation.
Cardoso AB, Vasconcelos BC, Oliveira DM.
Dental Sciences School, Universidade de Pernambuco.

Dislocation of the temporomandibular joint occurs when the mandibular condyle exits the glenoidal cavity and remains anteriorly locked to the articular eminence. It is repetitive (recurrent dislocation), usually associated with mandibular hypermobility and inclination of the articular eminence. AIM: This study intended to clinically and radiologically assess the technique of eminectomy and the use of a miniplate on the articular eminence for the treatment of recurrent dislocation of the temporomandibular joint of patients operated on at Oswaldo Cruz University Hospital from January to September 2003. STUDY DESIGN: Retrospective cohort. MATERIAL AND METHOD: The sample consisted of 11 patients. Eminectomy was performed on nine joints of five patients and the placement of a miniplate on the articular eminence was performed on 11 joints of six patients. Data collection was carried out through analysis of patient's medical charts and new postoperative visit. RESULTS: The results showed that there were no major postoperative complications with either technique. Maximum mouth opening was greater with eminectomy procedure and none of the patients operated on presented any recurrence of dislocation. CONCLUSION: It is concluded that both techniques were effective in the treatment of recurrent dislocation of the temporomandibular joint.

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Rheumatol Int. 2006 Jan 26;:1-7 [Epub ahead of print]
Temporomandibular disorders seen in rheumatology practices: a review.
Atsu SS, Ayhan-Ardic F.
Department of Prosthodontics, Faculty of Dentistry, University of Kirikkale, Kirikkale, Turkey.

Temporomandibular disorders are recognized as the most common nontooth-related chronic orofacial pain conditions. This article reviews the recent temporomandibular disorders literature and summarizes the temporomandibular disorders seen in rheumatology practices. Arthritis is a common condition affecting the temporomandibular joint. Although degenerative and rheumatoid arthritis are the most frequently encountered infectious arthritis, metabolic arthritis, spondyloarthropathies and the traumatic arthritis have also been reported. Distinguishing between different temporomandibular disorders is as important as the clinical course, long-term prognosis, and therapy. Diagnostic criteria are generally based on signs and symptoms of the patient. The American Academy of Orofacial Pain established the first well-defined diagnostic classification. In addition, Research Diagnostic Criteria for Temporomandibular Disorders have been developed using similar classification. In the treatment of temporomandibular disorders, conservative and noninvasive treatments are endorsed for the initial care of nearly all TMD patients because the majority of patients with TMD achieve good relief of symptoms with conservative treatment.

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Med Oral Patol Oral Cir Bucal. 2006 Jan 1;11(1):E66-9.
Treatment of temporomandibular joint ankylosis by gap arthroplasty.
[Article in English, Spanish]
Vasconcelos BC, Bessa-Nogueira RV, Cypriano RV.
Faculdade de Odontologia de Pernambuco, Universidade de Pernambuco, Brazil. belmiroc@terra.com.br

PURPOSE: The purpose of this paper is to show that gap arthroplasty improve mouth opening when treating TMJ ankylosis. PATIENTS AND METHODS: Eight patients with TMJ ankylosis were treated by gap arthroplasty. The patients were evaluated by at least twenty-four months (minimum 24 and maximum 48 months). RESULTS: Of the eight patients (eleven joints), five (62.5%) had unilateral involvement and three patients (37.5%) had bilateral involvement. The mean age was 20 years -/+ 9 (range 3 to 30 years). The mean maximal incisal opening (MIO) in the preoperative period was 9.25 -/+ 6.41 mm and in the postoperative period it was 29.88 -/+ 4.16 mm. The complication of temporary facial nerve paresis was encountered in two patients (25%). No recurrence was observed in our series. CONCLUSIONS: Trauma was the major cause of tempomandibular joint ankylosis in our sample. Gap arthroplasty showed good results when treating TMJ ankylosis.

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Appl Psychophysiol Biofeedback. 2005 Dec;30(4):333-45.
Efficacy of biofeedback-based treatments for temporomandibular disorders.
Crider A, Glaros AG, Gevirtz RN.
Department of Psychology, Williams College, Williamstown, Massachusetts, USA. acrider@williams.edu

Bibliographic searches identified 14 controlled and uncontrolled outcome evaluations of biofeedback-based treatments for temporomandibular disorders published since 1978. This literature includes two randomized controlled trials (RCTs) of each of three types of biofeedback treatment: (1) surface electromyographic (SEMG) training of the masticatory muscles, (2) SEMG training combined with adjunctive cognitive-behavioral therapy (CBT) techniques, and (3) biofeedback-assisted relaxation training (BART). A detailed review of these six RCTs, supplemented with information from non-RCT findings, was conducted to determine the extent to which each type of intervention met treatment efficacy criteria promulgated by the Association for Applied Psychophysiology and Biofeedback (AAPB). We conclude that SEMG training with adjunctive CBT is an efficacious treatment for temporomandibular disorders and that both SEMG training as the sole intervention and BART are probably efficacious treatments. We discuss guidelines for designing and reporting research in this area and suggest possible directions for future studies.

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J Dent Educ. 2005 Nov;69(11):1242-50.
Stabilization splint therapy for the treatment of temporomandibular myofascial pain: a systematic review.
Al-Ani Z, Gray RJ, Davies SJ, Sloan P, Glenny AM.
TMD Unit, School of Dentistry, University of Manchester, Manchester, UK M15 6FH. ziad.al-ani@manchester.ac.uk

The aim of this review is to establish the effectiveness of stabilization splint (SS) therapy in reducing symptoms in patients with myofascial pain. Searching of electronic databases, handsearching of relevant key journals, and screening of reference lists of included studies were undertaken. There was no language restriction, and unpublished research was sought. The selection criteria were randomized controlled trials comparing splint therapy to either no treatment or another active treatment. Data extraction and validity assessment were carried out independently and in duplicate. Studies were grouped according to treatment type. Twenty potentially relevant Randomized Controlled Trials (RCTs) were identified. Only twelve met the inclusion criteria. There is insufficient evidence either for or against the use of stabilization splint therapy over other active interventions for the treatment of temporomandibular myofascial pain. However, it appears that stabilization splint therapy may be beneficial for reducing pain severity at rest and on palpation and depression when compared to no treatment. The authors suggested the need for well conducted RCTs that pay attention to method of allocation, blind outcome assessment, sample size, and duration of follow-up. Various measures were adopted to assess the outcomes of treatment. Standardization of the methods used to measure outcomes of the treatment of myofascial pain should be established in future RCTs.

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Arthritis Rheum. 2005 Nov;52(11):3563-9.
Utility of corticosteroid injection for temporomandibular arthritis in children with juvenile idiopathic arthritis.
Arabshahi B, Dewitt EM, Cahill AM, Kaye RD, Baskin KM, Towbin RB, Cron RQ.
Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

OBJECTIVE: To assess the effects of computed tomography (CT)-guided injection of corticosteroid into the temporomandibular joint (TMJ) in children with juvenile idiopathic arthritis (JIA) and clinical and magnetic resonance imaging (MRI) evidence of TMJ inflammation. METHODS: Twenty-three children ages 4-16 years with JIA and MRI evidence of TMJ inflammation received CT-guided TMJ injections of corticosteroid (triamcinolone acetonide [n = 16] or triamcinolone hexacetonide [n = 7]). Jaw pain or dysfunction and maximal incisal opening (MIO) distance were assessed before and after injection. Fourteen patients had followup MRI studies of the TMJ 6-12 months after injection. RESULTS: Of the 13 patients with symptoms of jaw pain prior to corticosteroid treatment, 10 (77%) had complete resolution of pain (P < 0.05). Prior to corticosteroid injection, MIO in all 23 patients was below age-matched normal values. After injection, the MIO was improved by at least 0.5 cm in 10 patients (43%) (P = 0.0017). Patients under 6 years of age at the time of injection showed the best response, with a postinjection MIO similar to that in age-matched controls (P = 0.2267). There was involvement of 23 TMJs in the 14 patients who had followup MRI studies; resolution of effusions was observed in 11 (48%) of the TMJs. Other than short-term facial swelling in 2 patients, there were no side effects. CONCLUSION: The majority of children with symptomatic TMJ arthritis improved after intraarticular corticosteroid injection. Approximately half the patients experienced significant improvement in MIO and TMJ effusion. These data suggest that corticosteroid injection may be a useful procedure for the prevention and treatment of morbidities associated with TMJ arthritis in JIA.

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J Oral Rehabil. 2005 Nov;32(11):800-7.
Low intensity laser therapy in the treatment of temporomandibular disorders: a double-blind study.
Venancio Rde A, Camparis CM, Lizarelli Rde F.
Department of Dental Materials, Dental School at Araraquara, State University of Sao Paulo (UNESP), Araraquara, Sao Paulo, Brazil. robertavenancio@bol.com.br

This study aimed to evaluate the effectiveness of low intensity laser therapy (LILT) in 30 patients presenting temporomandibular joint (TMJ) pain and mandibular dysfunction in a random and double-blind research design. The sample, divided into experimental group (1) and placebo group (2), was submitted to the treatment with infrared laser (780 nm, 30 mW, 10 s, 6.3 J/cm(2)) at three TMJ points. The treatment was evaluated throughout six sessions and 15, 30 and 60 days after the end of the therapy, through visual analogue scale (VAS), range of mandibular movements and TMJ pressure pain threshold. The results showed a reduction in VAS (p < 0.001) and through the ANOVA with repeated measures it was observed that the groups did not present statistically significant differences (P = 0.2060), as the averages of the evaluation times (P = 0.3955) and the interaction groups evaluation times (P = 0.3024), considering the MVO. The same occurred for RLE (P = 0.2988, P = 0.1762 and P = 0.7970), LLE (P = 0.3265, P = 0.4143 and P = 0.0696), PPTD (P = 0.1558, P = 0.4695 and P = 0.0737) and PPTE (P = 0.2376, P = 0.3203 and P = 0.0624). For PE, there were not statistically significant differences for groups (P = 0.7017) and the interaction groups evaluation times (P = 0.6678), even so in both groups the PE varied with time (P = 0.0069).

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J Oral Rehabil. 2005 Oct;32(10):729-34.
Conservative treatment of temporomandibular joint osteoarthrosis: intra-articular injection of sodium hyaluronate.
Guarda-Nardini L, Masiero S, Marioni G.
Department of Maxillofacial Surgery, University of Padua, Padua, Italy. luca.guarda@unipd.it

Promising short-term results in the treatment of temporomandibular joint osteoarthrosis with intra-articular injections of sodium hyaluronate (SH) have been reported in preliminary studies. The present prospective study compared long-term outcomes of temporomandibular joint SH injections with those of a conventional non-surgical treatment (bite-plane). Data from three groups of 20 patients with degenerative temporomandibular joint disease were considered. Group A underwent one cycle of five injections of 1 mL SH. Group B underwent a bite-plane treatment for at least 6 months. We considered a control group of 20 patients who refused any treatments. The description of the outcomes was based on objective and subjective parameters after a 6-month follow-up. Sodium hyaluronate and bite-plane treatments significantly improved patients conditions in all considered parameters. No significant differences in outcomes were confirmed by the statistical analysis. The tolerability of SH treatment resulted to be significantly higher. The analysis of results of serial controls in the SH treated group disclosed a significant worsening in pain at rest by comparing 1 and 6 months follow-up. Sodium hyaluronate infiltration resulted a valid non-surgical treatment for temporomandibular joint degenerative disease. Five well-tolerated intra-articular SH injections achieved equivalent results to those of a 6 months bite-plane treatment. We did not diagnose any complications of SH intra-articular injections. Longer time follow-up is necessary to determine the stability of SH properties.

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Reumatismo. 2005 Jul-Sep;57(3):201-7.
[Temporomandibular joint involvement in juvenile idiopathic arthritis: treatment with an orthodontic appliance.]
[Article in Italian]
Bellintani C, Ghiringhelli P, Gerloni V, Gattinara M, Farronato G, Fantini F.
Cattedra e Reparto di Ortognatodonzia, Clinica Odontoiatrica, Universita degli Studi di Milano, Italia. bellintanicla@libero.it.

OBJECTIVE: About 65% of children suffering from juvenile idiopathic arthritis (JIA) shows a more or less marked involvement of temporo-mandibular joint (TMJ) with altered mandibular growth, resorption of the condyles, occlusary instability, reduced chewing ability and facial dysmorphia. The purpose of our study is to prevent and to treat the progressive evolution of JIA on craniofacial growth and morphology with a functional appliance; surgery should be considered only in so far as the adequacy of TMJ movement is concemed. METHODS: From 1992 until now 72 children with proved JIA and TMJ involvement have been treated (50 females, 22 males, aged 6 to 16 years old). TMJ involvement was bilateral in 61% and unilateral in 39% of patients. A diagnostic workup was carried out involving tomograms of TMJ and cephalometric radiograph and analysis. The authors used a bimaxillary activator in the attempt to modify the unfavourable growth pattern and provide a gradual ante-rotation of the jaw. RESULTS: Almost all JIA patients showed satisfactory long term results, easing of pain, reduced skeletal discrepancy, increased function and good facial profile. CONCLUSIONS: The long term results of this study indicate that orthopaedic therapy might control the vicious circle of the malocclusion in children with JIA, preventing exacerbation of mandibular clockwise rotation. Surgical intervention for the improvement of TMJ function should be considered only if a severe restricted state is imminent.

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Ned Tijdschr Tandheelkd. 2005 Aug;112(8):279-82.
[Jaw position in stabilization splint treatment of musculoskeletal disorders]
[Article in Dutch]
Steenks MH, The GL, Aaftink HM.
zorglijn Gnathologie, zorgeenheid Mondziekten, Kaakchirurgie en Bijzondere Tandheelkunde, divisie Heelkundige Specialismen van het Universitair Medisch Centrum Utrecht. m.h.steenks@med.uu.nl

Stabilization splints are often used to treat musculoskeletal disorders of temporomandibular joints. Historically, the centric relation is advocated as the reference position for a stabilization splint. Centric relation as the reference position is subject of discussion, since this position has been defined for a healthy stomatognathic system. In case of temporomandibular disorders, the temporomandibular joints and muscles are compromised. Apart from degenerative changes in all components of the temporomandibular joints, the presence of pain may influence the establishment of a therapeutic position. In this article the biological plausibility of the centric relation as a reference position in patients suffering from temporomandibular disorders, is discussed. It is advocated to maintain the existing occlusion.

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J Oral Maxillofac Surg. 2005 Sep;63(9):1295-303.
Conservative therapy in patients with anterior disc displacement without reduction using 2 common splints: a randomized clinical trial.
Schmitter M, Zahran M, Duc JM, Henschel V, Rammelsberg P.
Assistant Professor, Department of Prosthodontics, University of Heidelberg, Heidelberg, Germany.

PURPOSE: We performed a comparative evaluation of different types of splint therapy for anterior disc displacement without reduction (ADDWR) of the temporomandibular joint. PATIENTS AND METHODS: Seventy-four patients agreed to participate (65 females and 9 males). All patients were examined using a clinical temporomandibular joint disorder examination protocol, including muscle palpation, mandibular range-of-motion measurement, and joint sound detection. Additionally, the patients marked their pain (during chewing, mandibular movements, and rest position) and limitation levels on a visual analog scale. Bilateral magnetic resonance images were acquired, confirming ADDWR in at least one joint. After clinical examination and imaging, randomized splint therapy was provided: 38 patients received a centric splint, while 36 received a distraction splint. After 1, 3, and 6 months of therapy, outcome was evaluated using the Wilcoxon signed rank test for matched pairs. Success after 6 months was defined as improvement in active mouth opening of greater than 20% and pain reduction (on chewing) of at least 50%. Success was statistically verified using logistic regression test. RESULTS: The improvements in mouth opening were significant in both groups. The improvements in pain on chewing, pain during other functions, pain at rest, functional limitation on chewing, and other functions were also comparable in both groups. However, the logistic regression test suggested that patients using centric splints were treated more successfully than the others (confidence interval, 1.014 to 8.741, odds ratio = 2.785). CONCLUSIONS: Centric splints seem to be more effective than distraction splints. Therefore, before the surgical treatment of ADDWR, centric splints should be used instead of distraction splints.

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J Oral Maxillofac Surg. 2005 Aug;63(8):1174-9.
Prospective multicenter comparison of 4 temporomandibular joint operations.
Hall HD, Indresano AT, Kirk WS, Dietrich MS.
Department of Oral and Maxillofacial Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.

PURPOSE: This study was designed to compare the outcomes of 4 operations used for the treatment of painful temporomandibular joints with an internal derangement. PATIENTS AND METHODS: A prospective, controlled study of arthroscopy, condylotomy, discectomy, and disc repositioning was conducted at 3 sites. All sites used the same inclusion and exclusion criteria. Trained, independent examiners assessed pain, diet, and range of motion before operation and 1 month and 1 year after operation. RESULTS: There were statistically significant reductions in the amount of pain ( P < .001) and daily time in pain ( P < .001) that were similar for all 4 operations 1 month and 1 year after the procedures. The degrees of change after each of the 4 procedures were not statistically different from each other (amount: P = .453 and time: P = .416). Ability to chew, as measured by diet visual analog scale, was substantially improved 1 year after operation ( P < .001). The degrees of change for diet at 1 year also were not different from each other ( P = .314). There were, however, statistically significant differences ( P < .05) in range of motion that varied with procedure. CONCLUSIONS: All 4 operations were followed by marked improvements in pain and diet. The amounts of improvement varied slightly by operation, but these differences were not statistically significant. There were small but statistically significant differences between procedures for range of motion. If these findings are confirmed, they have an important implication for procedure selection.

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J Oral Maxillofac Surg. 2005 Aug;63(8):1115-22.
Characterization of patients with disc displacement without reduction unresponsive to nonsurgical treatment: a preliminary study.
Iwase H, Sasaki T, Asakura S, Asano K, Mitrirattanakul S, Matsuka Y, Imai Y.
UCLA School of Dentistry, 10833 LeConte Avenue, 63-078 CHS, Los Angeles, CA 90095-1668, USA. iwase@ucla.edu

PURPOSE: Arthrocentesis and arthroscopic lysis and lavage have been described as effective treatment modalities for temporomandibular joint (TMJ) disc displacement without reduction (DDw/oR). More commonly, nonsurgical intervention is offered as the desired first-line treatment; however, a certain group of DDw/oR patients receiving nonsurgical treatment may remain unresponsive, thereby prolonging suffering and treatment dissatisfaction. The purpose of this study is to characterize these nonresponders by evaluating the characteristic pretreatment findings peculiar to this group. PATIENTS AND METHODS: This retrospective study was based on the review of pretreatment clinical and magnetic resonance imaging (MRI) findings of 52 DDw/oR patients who were treated with stabilization appliance, jaw-stretching exercise, and nonsteroidal anti-inflammatory medication. On the last treatment visit, each patient was classified as either a responder (R) or nonresponder (NR) based on the satisfaction or dissatisfaction with the treatment received, respectively. Pretreatment data were then examined and analyzed by logistic regression to identify which clinical and MRI findings were specifically related to the NR group. RESULTS: Logistic regressions indicated that NR had significantly higher odds ratio for pretreatment pain-free mouth opening of less than 30 mm (odds ratio [OR] = 7.385), "stuck" disc (OR = 4.521), and unchanged disc shape during mouth opening (OR = 4.050). Multiple logistic regression analyses revealed that these factors combined gave the highest likelihood ratio of 15.90 ( P = .001), indicating a strong possibility that these factors are associated with the NR group. CONCLUSIONS: Nonresponders can be characterized by their pretreatment pain-free mouth opening (<30 mm) in combination with MRI confirmation of "stuck" disc and unchanged disc shapes during mouth opening.

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Orthop Nurs. 2005 Jul-Aug;24(4):259-69.
Energy healing: a complementary treatment for orthopaedic and other conditions.
Dinucci EM.
Ellen M. DiNucci, MA, Stanford University, Stanford, CA.

Complementary and alternative therapies continue to grow in popularity among healthcare consumers. Among those modalities is energy healing (EH) (). EH is an adjunctive treatment that is noninvasive and poses little downside risk to patients. Well more than 50 major hospitals and clinics throughout the United States offer EH to patients (DiNucci, research table on healthcare facilities that offer Reiki, unpublished data, 2002). The National Institutes of Health is funding numerous EH studies that are examining its effects on a variety of conditions, including temporomandibular joint disorders, wrist fractures, cardiovascular health, cancer, wound healing, neonatal stress, pain, fibromyalgia, and AIDS (). Several well-designed studies to date show significant outcomes for such conditions as wound healing () and advanced AIDS (), and positive results for pain and anxiety (; ), among others (). It is also suggested that EH may have positive effects on various orthopaedic conditions, including fracture healing, arthritis, and muscle and connective tissue (). Because negative outcomes risk is at or near zero throughout the literature, EH is a candidate for use on many medical conditions.

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J Oral Rehabil. 2005 Jul;32(7):474-9.
Comparative prospective study on splint therapy of anterior disc displacement without reduction.
Stiesch-Scholz M, Kempert J, Wolter S, Tschernitschek H, Rossbach A.
Department of Prosthetic Dentistry, Hannover University Medical School, Hannover, Germany. stiesch.meike@mh-hannover.de

A prospective randomized study was carried out to compare the therapeutic success of two different types of splint in patients with painful anterior disc displacement of the temporomandibular joint. The patients in Group I (n = 20) received stabilization splint therapy and the patients in Group II (n = 20) pivot splint therapy. Clinical investigation of the craniomandibular system was performed before and 1, 2 and 3 months after therapy and this was accompanied by subjective evaluation by the patients of their symptoms, using a validated questionnaire with visual analogue scales (VAS). There was a significant increase in maximum jaw opening and a significant reduction in subjective pain in both groups during the course of therapy (Wilcoxon test, P < 0.05). Active jaw opening increased by a mean of 8.05 mm in the group of patients treated with a stabilization splint (Group I). The comparable figure with pivot splint therapy (Group II) was 8.26 mm. The VAS scale value in Group I was reduced by 30.54 units and in Group II by 39.36 scale units. However, neither of these differences between the groups was statistically significant (Mann-WhitneyU-test, P > 0.05). It can be concluded that both types of splint provided effective therapy in patients with anterior disc displacement.

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J Oral Rehabil. 2005 Jul;32(7):467-73.
The prevalence of signs and symptoms of temporomandibular disorders in very old subjects.
Schmitter M, Rammelsberg P, Hassel A.
Poliklinik fur Zahnarztliche Prothetik, Im Neuenheimer Feld, Heidelberg, Germany. marc_schmitter@med.uni-heidelberg.de

Previous studies on the prevalence of signs of temporomandibular disorders (TMD) in elderly people have used non-standardized and invalidated examination protocols. The prevalence of the different signs of TMD in this group is therefore still unclear. The aim of this study was to evaluate the prevalence of signs of TMD in subjects of advanced aged, using a standardized and validated examination protocol. Additionally, young subjects were examined as a control group. Fifty-eight old peoples' home inhabitants and 44 young subjects were examined using a standardized and validated examination protocol. Differences between the groups were assessed using Mann-Whitney U-test or t-test. Geriatric subjects more often exhibited objective symptoms of TMD (38% exhibited joint sounds on opening), but rarely suffered from pain (pain at rest: 0%, joint pain: 0%, muscle pain: 12%). In contrast, young subjects rarely exhibited objective symptoms (joint sounds: 7%), but suffered more frequently from pain (facial: 7%, joint pain: 16%, muscle pain: 25%). The mandibular range of motion was higher in young subjects. Differences between the groups with respect to joint sounds, muscular palpation pain and mandibular range of motion were significant. Although older subjects more frequently exhibited objective signs (joint sounds) of TMD, they rarely suffered from pain. In contrast, younger subjects rarely exhibited objective TMD signs but more frequently suffered from subjective signs (muscular pain on palpation) and facial pain.

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J Oral Maxillofac Surg. 2005 Jul;63(7):897-902.
Preservation of disc for treatment of traumatic temporomandibular joint ankylosis.
Long X, Li X, Cheng Y, Yang X, Qin L, Qiao Y, Deng M.
Department of Oral and Maxillofacial Surgery, College and Hospital of Stomatology, Key Laboratory for Oral Biomedical Engineering, Ministry of Education, Wuhan University, Wuhan, China. longxing_china@hotmail.com

PURPOSE: A new operating method was used to treat traumatic temporomandibular joint (TMJ) ankylosis, to restore the structure of the TMJ, to improve the secondary maxillofacial deformity, and prevent recurrence of TMJ ankylosis. PATIENTS AND METHODS: Thirty-six patients (20 females, 16 males; aged 5 to 54 years old) with TMJ ankylosis type II or III of 1 to 16 years' duration, with a maximal mouth opening from 0 to 15 mm preoperatively participated. The new method was to separate bony fusion between condyle and glenoid fossa, remove the condylar fragment that displaced medially or anteroinferiorly, mobilize the remains of the disc over the condylar stump and suture it with articular capsule, and shave the surface of the condylar stump and glenoid fossa smooth. RESULTS: Follow-up was performed from 1 to 7 years postoperatively in 21 cases. No recurrences occurred in patients whose TMJ disc was retained during operation. Patients had an average maximal mouth opening of 33.7 mm postoperatively. An 11-year-old patient showed an improved facial symmetry after surgery. CONCLUSION: By restoring the normal structure of the TMJ and preservation of the disc, recurrence of traumatic TMJ ankylosis and facial deformity in younger patients can be prevented.

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J Oral Rehabil. 2005 May;32(5):326-31.
Clinical and radiological follow-up results of patients with untreated TMJ closed lock.
Imirzalioglu P, Biler N, Agildere AM.
Department of Prosthodontics, Baskent University, Faculty of Dentistry, Ankara, Turkey. pervini@baskent.edu.tr

The purpose of this study was to compare clinical and radiological findings of untreated closed lock patients at least 22 months after initial diagnosis. Ten patients with closed lock in at least one joint who had received no treatment were included in the study. Clinically maximum mouth opening, joint pain and joint sounds were recorded. Radiologically position of the disc, disc morphology, bone degeneration and presence of fluid were determined on magnetic resonance imaging. Clinical and radiological examinations were repeated 2-5 years after initial examinations. Results were statistically compared using either the non-parametric McNemar test or the Wilcoxon signed-rank test. There were significant improvements in both mouth opening capacity and prevalence of joint pain, while no significant change in radiological examination. The results of this study suggested that closed lock patients undergo active adaptation in clinical symptoms.

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Br J Oral Maxillofac Surg. 2005 Apr;43(2):118-22.
Follow up of mandibular costochondral grafts after release of ankylosis of the temporomandibular joints.
Medra AM.
Department of Cranio-Maxillo-Facial, Oral & Plastic Surgery, Faculty of Dentistry, Alexandria University, Alexandria, Egypt. prof_ahmedmedra@hotmail.com

The records of 55 patients with ankylosis of the temporomandibular joint (25 unilateral and 30 bilateral); were selected at random. In these patients, the resected condyles had been replaced with costochondral grafts and the patients were followed clinically and radiographically for 7-10 years. Of the 85 grafts, we found take and good remodeling in 50 (59%), reankylosis in 8 (9%), resorption of the graft in 21 (25%) and overgrowth of the graft in 3 (4%). Mouth opening was satisfactory (more than 25 mm) in 32 of the 55 patients (58%), unsatisfactory (between 5 and 25 mm) in 10 (18%), and the operation was a failure in 13 (24%).

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J Oral Maxillofac Surg. 2005 Apr;63(4):471-8.
Arthroscopic lysis and lavage in different stages of internal derangement of the temporomandibular joint: correlation of preoperative staging to arthroscopic findings and treatment outcome.
Smolka W, Iizuka T.
Department of Cranio-Maxillofacial Surgery, University of Berne, CH-3010 Berne, Switzerland. wenko.smolka@insel.ch

PURPOSE: The study was designed to evaluate the outcome of standard arthroscopic lysis and lavage for internal derangement with various levels of severity by comparing the preoperative staging with arthroscopic findings and subsequent success rates. PATIENTS AND METHODS: Temporomandibular joint disorder in 23 patients (26 joints) who underwent arthroscopic lysis and lavage was preoperatively classified as Wilkes stages II-V based on the clinical and radiologic (magnetic resonance imaging) findings. Recorded arthroscopic findings were scored and compared with the stages. The patients were examined both preoperatively and after a mean follow-up of 22.7 months, using objective and subjective criteria. RESULTS: The arthroscopic findings showed a correlation between increasing scores and advancing stage. Postoperatively, the patients could be clearly classified into 2 groups with either satisfactory or poor clinical outcome. Overall success rate was 78.3% (18/23). The success rates were slightly lower for patients with advanced stages than for those of stages II and III. Patients totally unresponsive to the treatment were found in all stages. CONCLUSION: Arthroscopic lysis and lavage is a preferred treatment for different stages of internal derangement. Preoperative staging and corresponding characteristics of the arthroscopic findings do not seem to correlate with the prognosis of the treatment outcome.

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Int J Oral Maxillofac Surg. 2005 Mar;34(2):107-113.
The role of surgery in the management of disorders of the Temporomandibular Joint: a critical review of the literature; Part 1.
Dimitroulis G.
St. Vincent's Hospital Melbourne, Suite 5, 10th Floor, 20 Collins Street, Melbourne, Vic. 3000, Australia.

Despite the controversy surrounding the role of surgery in the management of Temporomandibular Disorders (TMD), studies in peer review journals continue to support the role of surgery as a legitimate means of treating pain and dysfunction in the Temporomandibular Joint (TMJ). To better understand the role of surgery in the management of TMJ disorders, a critical review of the literature will be presented in two parts. Part 1 reviews the evolution of TMJ surgery together with the biological evidence for surgical disease. History teaches us that we are destined to repeat the mistakes of the past if we fail to properly reflect on what has already been achieved and where the failures have occurred. With the help of molecular biology, the future of TMD management may comprise more carefully targeted and less radical treatment modalities.

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Med Sci Monit. 2005 Jan 24;11(2):CR71-74 [Epub ahead of print]
Short term pain reduction with acupuncture treatment for chronic orofacial pain patients.
Goddard G.
Department of Oral and Maxillofacial Surgery, University of California at San Francisco, San Francisco, CA, U.S.A.

Background: Acupuncture has been used for treatment of many pain conditions. National Institutes of Health (NIH), in its consensus statement on acupuncture of November of 1997, states that promising results have been shown for postoperative dental pain. NIH states that in other situations such as myofascial pain, acupuncture may be useful as an adjunct treatment or an acceptable alternative treatment. The vast majority of chronic orofacial pain conditions are temporomandibular disorders (TMD). Myofascial pain is one of the most common TMD's. TMD's are a set of musculoskeletal disorders affecting the temporomandibular joint, masticatory muscles or both. TMD's are comprised of diverse diagnoses with similar signs and symptoms affecting the masticatory system that can be acute, recurrent or chronic conditions. TMD's are rarely life threatening, but can impact heavily on a person's quality of life. Few studies have been done on outcomes of acupuncture treatment for chronic orofacial pain. Material/Methods: A chart review of 29 patients (twenty two females and seven males), age 22 to 60, who had acupuncture treatment for chronic orofacial pain was completed. Patients had rated their pain before and after acupuncture treatment on a numerical analog scale. Results: The mean value of pain scores before treatment was 5.28 and after treatment was 2.26. There was a significant difference of pain scores between before treatment and after treatment (Wilcoxon signed rank test, P<0.0001). Conclusions: Acupuncture provided a significant short-term pain reduction in patients with chronic Orofacial pain.

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Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005 Jan;99(1):24-9.
Comparison of the clinical outcomes of patients having sounds in the temporomandibular joint with skeletal mandibular deformities treated by vertico-sagittal ramus osteotomy or vertical ramus osteotomy.
Fujimura K, Segami N, Sato J, Kaneyama K, Nishimura M.
Department of Oral and Maxillofacial Surgery, Kanazawa Medical University, Ishikawa, Japan. 1-kkk@kanazawa-med.ac.jp

OBJECTIVE: This article describes the effects of the intraoral vertico-sagittal ramus osteotomy (IVSRO) procedure on the jaw of patients with temporomandibular joint (TMJ) disorders. STUDY DESIGN: IVSRO was performed on 15 patients (30 sides) who had mandibular protrusion or asymmetry with TMJ dysfunction. IVRO was performed on another 15 patients (30 sides). All of the 30 patients had sounds in the TMJ uni- or bilaterally. The relative positions of the condyle and disc and the range of motion of the condyles were determined by magnetic resonance imaging (MRI) before and 12 months after the operations. RESULTS: Sounds such as clicking improved in 92% (24/26) of the joints in the IVSRO group, and in 83% (20/24) of the joints in the IVRO group 12 months after the operation. The positional relationship between the condyle and disc on the MR images improved in 82% (9/11) of the joints with reduction of the anterior disc displacement; in 60% (3/5) of the joints without reduction of the anterior disc displacement in the IVSRO group; in 75% (9/12) of the joints with reduction of the anterior disc displacement; and in 40% (2/5) of the joints without reduction of the anterior disc displacement in the IVRO group. Immediately after the operation, the condyle was displaced anterio-inferiorly in all joints in both groups, but gradually returned to close to the preoperative position. There were no significant differences between the 2 groups regarding the extent of shift of the condylar head at 2 weeks and 12 months after the operation. CONCLUSION: The clinical outcomes of the IVSRO procedure are similar to those of the IVRO procedure. Therefore, IVSRO may be a suitable procedure for patients having TMJ dysfunction with skeletal mandibular deformities, particularly when an IVRO is unsuitable.

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Int J Oral Maxillofac Surg. 2004 Dec;33(8):755-60.
The interpositional dermis-fat graft in the management of temporomandibular joint ankylosis.
Dimitroulis G.
Department of Special Surgery, St. Vincents Hospital Melbourne, The University of Melbourne, Melbourne 3000, Vic., Australia.

The aim of this retrospective clinical study is to present the clinical experience of using dermis-fat interpositional grafts in the surgical management of temporomandibular joint (TMJ) ankylosis in adult patients. Eleven adult patients who presented with ankylosis of the TMJ were identified and included in the study. All patients underwent a TMJ gap arthroplasty which involved the removal of a segment of bone and fibrous tissue between the glenoid fossa and neck of the mandibular condyle. The resultant gap was filled with an autogenous dermis-fat graft procured from the patient's groin. All patients were followed up for a minimum of 2 years. Five of the 11 patients were found to have osseous ankylosis while 6 patients had fibro-osseous ankylosis. Two patients had bilateral TMJ ankylosis that were also treated with costochondral grafts which were overlaid with dermis-fat graft. The average interincisal opening was 15.6mm on presentation which improved to an average of 35.7mm following surgery. Patients were followed up from 2 to 6 years post-operatively (mean 41.5 months) with only 1 re-ankylosis identified out of the 13 joints treated. This study found that the use of the autogenous dermis-fat interpositional graft is an effective procedure for the prevention of re-ankylosis up to 6 years following the surgical release of TMJ ankylosis.

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Quintessence Int. 2004 Nov-Dec;35(10):811-4.
Pre- and posttreatment analysis of clinical symptoms of patients with temporomandibular disorders.
Babadag M, Sahin M, Gorgun S.
Department of Oral Diagnosis and Radiology, Faculty of Dentistry, Ankara University, Ankara, Turkey.

OBJECTIVE: This study treated patients with temporomandibular disc displacement with reduction (with pain, limited mandibular movement, and clicking sound symptoms) using a combination of analgesics, injection, mandibular exercise, and occlusal splints. METHOD AND MATERIALS: Twenty-five patients with temporomandibular joint (TMJ) disorders were evaluated for pretreatment complaints and clinical findings, such as TMJ sounds, mandibular deviation, limited mouth opening, and bilateral magnetic resonance imaging results. Diagnostic treatment was then planned; all patients received occlusal splints, and 10 patients received injections. RESULTS: Evaluations were conducted 1 year after the initial diagnosis and treatment. Complaints (especially of pain) by the patients who received injections had reduced significantly. After 6 months of occlusal splinting, clinical findings of patients with TMJ disc displacement had greatly improved. To manage parafunctional habits of the patients, night plate usage was continued. Therefore, clinical symptom reduction was maintained. CONCLUSION: The use of mandibular manipulation technique can decrease the anterior disc displacement of the TMJ.

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J Craniofac Surg. 2004 Sep;15(5):879-84; discussion 884-5.
Treatment of temporomandibular joint ankylosis in children: is it necessary to perform mandibular distraction simultaneously?
Lopez EN, Dogliotti PL.
Department of Plastic Surgery and Burn Unit, Hospital de Pediatria SAMIC Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina. enadal@fibertel.com.ar

Temporomandibular joint (TMJ) ankylosis in children disturbs not only mandibular growth, but also facial skeletal development. Costochondral graft was used to ensure growth, but it had proven to be unpredictable. The authors evaluate retrospectively 41 patients who underwent temporomandibular joint reconstruction during the last 10 years. Twenty were treated by costochondral graft, 15 by arthroplasty, and 6 by other surgical procedures, and they were excluded. The etiology was septic in 54% of the cases. Follow-up was at least 12 months in all cases. Arthroplasty was a quicker and easier procedure than the costochondral graft, reducing operating time, risk of blood transfusion, and hospital stays and costs. It also was associated with less risk of reankylosis, 13%vs 25%. Furthermore, it was associated with a minor morbidity and secondary complications. Seventy-five percent of the patients treated with bone graft required additional secondary surgery. Radiographically, the authors observed a remodeled neocondyle at the level of proximal mandibular end in cases treated by arthroplasty.On clinical examination, patients showed variable degrees of facial deformity and an unknown potential of mandibular growth after TMJ arthroplasty. The authors also observed improved clinical and radiologic appearance after ankylosis correction. Is it reasonable to perform ankylosis release and mandibular distraction simultaneously without knowing which patients will be able to experience growth with time? In that case it would be necessary a predict growth to apply the exact amount of mandibular distraction for obtaining stable results. Timing of mandibular distraction, after TMJ arthroplasty is performed and mandibular function restored, must be specific to each patient's needs, assuring the best distraction conditions and planning. The authors present their treatment protocol, including TMJ joint arthroplasty with temporal muscle interposition, and mandibular distraction osteogenesis, as a second procedure, to correct residual asymmetry or retrognathism if necessary.

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J Oral Maxillofac Surg. 2004 Sep;62(9):1088-96.
Long-term outcomes after total alloplastic temporomandibular joint reconstruction following exposure to failed materials.
Mercuri LG, Giobbie-Hurder A.
Division of Oral and Maxillofacial Surgery, Department of Surgery, Stritch School of Medicine, Loyola University Medical Center, Maywood, IL 60153, USA. lmercur@lumc.edu

PURPOSE: Total alloplastic temporomandibular joint (TMJ) reconstruction is often necessary because of the significant bony destruction resulting from failed Proplast-Teflon (Vitek, Houston, TX) and/or Silastic (Dow Corning, Arlington, TX) foreign body inflammatory reactions. Multiply operated and functionless, TMJ patients likewise have undergone total alloplastic reconstruction. Many of these patients were also exposed to failed TMJ implant materials. It was the purpose of this study to evaluate a population representative of both these groups of patients reconstructed with the Techmedica (now, TMJ Concepts, Ventura, CA) Total TMJ System to determine whether the long-term subjective and objective outcomes were affected by either the presence of the previously failed TMJ implant materials, the number of prior procedures, or both. PATIENTS AND METHODS: One hundred ninety-eight patients who had been implanted with 332 Techmedica System total joints between 1990 and 1994 where divided into 4 groups based on their prior exposure to failed TMJ implant materials: group I, Proplast-Teflon (82 patients, 135 joints); group II, Silastic (28 patients, 46 joints); group III, both Proplast-Teflon and Silastic (25 patients, 46 joints); and group IV, no prior exposure to Proplast-Teflon or Silastic (63 patients, 105 joints). The mean follow-up was 60.2 +/- 40.3 months (range, 2 to 120 months). To determine whether exposure to either or both failed implant materials affected the long-term subjective and objective outcome variables, the groups were compared statistically using multivariate mixed modeling with age, sex, number of prior operations, years with TMJ problem, prior implant type, and implant sides as independent variables, and the relevant baseline measure as covariates. RESULTS: For the subjective variables, patients exposed to Proplast-Teflon or Silastic had significantly higher mean pain scores long-term. The type of prior failed TMJ implant material was not statistically significant with regard to function. Patients exposed to Proplast-Teflon reported poorer diet consistency scores long-term. Objectively, patients with 5 or fewer prior TMJ surgeries exposed to neither failed implant or Silastic reported better long-term mean maximum interincisal opening than did those patients exposed to Proplast-Teflon or both failed materials. However, for patients with 6 or more prior TMJ surgeries, those exposed to Proplast-Teflon or both failed materials reported less decrease in mean maximum interincisal opening over time. CONCLUSION: These data confirm what has been observed clinically, that in the population studied, multiply operated patients previously exposed to failed Proplast-Teflon alone or both failed Proplast-Teflon and Silastic have poorer reported long-term outcomes with alloplastic reconstruction. However, the total alloplastic TMJ reconstruction devices used in this study remained functional.

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Pain. 2004 Sep;111(1-2):13-21.
Treatment of painful temporomandibular joints with a cyclooxygenase-2 inhibitor: a randomized placebo-controlled comparison of celecoxib to naproxen.
Ta LE, Dionne RA.
Pain and Neurosensory Mechanisms Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, 10 Center Drive, Room 1N-103, Bethesda, MD 20892, USA.

To compare the efficacy and adverse effects of celecoxib, a cyclooxygenase-2 (COX-2) inhibitor, with naproxen, a non-steroidal anti-inflammatory drug, and placebo in the treatment of painful temporomandibular joints (TMJs). In this randomized, double-blind, placebo-controlled trial, 68 subjects with painful TMJs secondary to disc-displacement with reduction, received celecoxib 100 mg twice a day; naproxen, 500 mg twice a day; or placebo for 6 weeks. Subjects were evaluated with standard measures of efficacy: pain intensity measured by visual analogue scale, maximal comfortable mandibular opening, and quality of life (SF-36), at baseline (1 week after discontinuing previous analgesic therapy) and again after 6 weeks of drug treatment. Naproxen significantly reduced the symptoms of painful temporomandibular joint disc-displacement (TMJ DD) with reduction as determined by most efficacy measures. Significant improvement in pain intensity occurred within 3 weeks of treatment, and was sustained throughout the 6-week study. Clinically significant improvement in mandibular range of motion was observed for naproxen compared to celecoxib and placebo. Celecoxib showed slightly better pain reduction than placebo, but was not significantly effective for temporomandibular disorder pain. Celecoxib and naproxen were well tolerated, with similar number of reported adverse effects. Dual COX-1 and COX-2 inhibition with naproxen was demonstrated to be effective for the treatment of painful TMJs, as seen by significant improvement in clinical signs and symptoms of TMJ DD with reduction compared to celecoxib and placebo. Inhibition of both COX isozymes is needed to achieve effective analgesia for this type of musculoskeletal pain.

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J Orofac Pain. 2004 Summer;18(3):203-13.
Short-term clinical outcomes and patient compliance with temporomandibular disorder treatment recommendations.
Wig AD, Aaron LA, Turner JA, Huggins KH, Truelove E.
Harvard University School of Dental Medicine, Boston, Massachusetts, USA.

AIMS: To evaluate short-term patient compliance with 5 conservative temporomandibular disorder (TMD) treatments (jaw relaxation, jaw stretching, heat application, cold application, and occlusal splint use) and the association of compliance with changes in pain intensity, pain-related activity interference, and jaw use limitations. METHODS: Eighty-one TMD patients were given 1 to 5 treatment recommendations as part of usual care in a TMD specialty clinic. Compliance with each recommendation and pain, pain-related activity interference, and jaw use limitation measures were calculated from electronic interviews conducted 3 times daily for 2 weeks. RESULTS: Median compliance with individual treatment modalities ranged from 7.7% for heat application to 92.7% for jaw relaxation; median overall compliance was 54.8%. Participants with higher initial pain intensity and jaw use limitations were significantly more compliant with their recommended treatment regimen (P < .05). The authors controlled for age, gender, education, and initial jaw use limitations. Overall compliance was associated significantly and positively with 2-week jaw use limitations (P = .03). A trend toward a statistically significant positive association was found between compliance and 2-week pain intensity (P = .09). CONCLUSION: Compliance varied widely across patients and therapies. Patients with higher initial pain and jaw use limitation levels were more compliant with treatment recommendations. Although compliance was associated with slight increases in pain and jaw use limitations in this preliminary study, further research is needed to evaluate the longer-term effects of compliance with recommended therapies.

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Refuat Hapeh Vehashinayim. 2004 Jul;21(3):52-8, 94.
[Efficacy of treatment with hard and soft occlusal appliance in TMD]
[Article in Hebrew]
Littner D, Perlman-Emodi A, Vinocuor E.
Dept. of Occlusion and Behavioral Science, The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University.

Temporomandibular disorders (TMD) include clinical disorders involving the masticatory muscles, the temporomandibular joints (TMJ) and the adjacent structures. TMD was recognized as a main source for pains in the orofacial area, which are not caused from dental origin, and is defined by the American Academy of Orofascial Pain (AAOP) as a sub-group within the frame of musculoskeletal disorders. The main etiology for TMD has not been found yet. The customary treatments for this disorder include treatment with occlusal splints, physiotherapy, medicaments, behavioral-cognitive treatment, hypnosis, acupuncture and surgery that should be considered only if all conservative treatments were unsuccessful. Occlusal splint is the most common and efficient treatment for TMD patients proved by many studies with a successful rate of 70-90%. The following article reviews the different opinions in the treatment of TMD with special attention to hard and soft occlusal appliances. Based upon much research, and despite the many disagreements regarding its efficacy, the hard splint is a customary application which has the most successful outcome in patients who suffer from functional disorders of the masticatory system. The stabilization splint has an important benefit for being a non-penetrating and reversible appliance. However, despite this, the dentist should evaluate the joint or muscular problem, and seriously consider the various available treatments before deciding to use the appliance as a means of treatment.

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Prog Orthod. 2004;5:44-53.
The role of mandibular repositioning splint in the orthodontic treatment of patients with TMJ dysfunction.
[Article in English, Italian]
Garino F, Capurso U, Garino GB.
info@drgarino.it

OBJECTIVES: to evaluate the effectiveness of mandibular repositioning splints in the young and adult patients with TMJ dysfunction. SUBJECTS AND METHODS: 23 adult and 14 adolescent patients with TMJ dysfunction selected by Helkimo's index and the criteria of the American Academy of Craniomandibular disorders. RESULTS: upon anamnestic follow up, almost a total disappearance of the functional pain was reported by all patients, while for the headache, a cyclic onset was present, but with an uncertain etiology. Patients had a complete control of the mandibular movements with some articular sounds. But a modicum of muscular tenderness remained possibly due to the psyche of the patient. DISCUSSION: the prevalence of dysfunction in the growing patients was an intriguing observation. Not Angle's classification, but the presence of open bite, deep bite, or unilateral cross was the significant etiological factors.

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Pain. 2004 Sep;111(1-2):13-21.
Treatment of painful temporomandibular joints with a cyclooxygenase-2 inhibitor: a randomized placebo-controlled comparison of celecoxib to naproxen.
Ta LE, Dionne RA.
Pain and Neurosensory Mechanisms Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, 10 Center Drive, Room 1N-103, Bethesda, MD 20892, USA.

To compare the efficacy and adverse effects of celecoxib, a cyclooxygenase-2 (COX-2) inhibitor, with naproxen, a non-steroidal anti-inflammatory drug, and placebo in the treatment of painful temporomandibular joints (TMJs). In this randomized, double-blind, placebo-controlled trial, 68 subjects with painful TMJs secondary to disc-displacement with reduction, received celecoxib 100 mg twice a day; naproxen, 500 mg twice a day; or placebo for 6 weeks. Subjects were evaluated with standard measures of efficacy: pain intensity measured by visual analogue scale, maximal comfortable mandibular opening, and quality of life (SF-36), at baseline (1 week after discontinuing previous analgesic therapy) and again after 6 weeks of drug treatment. Naproxen significantly reduced the symptoms of painful temporomandibular joint disc-displacement (TMJ DD) with reduction as determined by most efficacy measures. Significant improvement in pain intensity occurred within 3 weeks of treatment, and was sustained throughout the 6-week study. Clinically significant improvement in mandibular range of motion was observed for naproxen compared to celecoxib and placebo. Celecoxib showed slightly better pain reduction than placebo, but was not significantly effective for temporomandibular disorder pain. Celecoxib and naproxen were well tolerated, with similar number of reported adverse effects. Dual COX-1 and COX-2 inhibition with naproxen was demonstrated to be effective for the treatment of painful TMJs, as seen by significant improvement in clinical signs and symptoms of TMJ DD with reduction compared to celecoxib and placebo. Inhibition of both COX isozymes is needed to achieve effective analgesia for this type of musculoskeletal pain.

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Prog Orthod. 2004;5:44-53.
The role of mandibular repositioning splint in the orthodontic treatment of patients with TMJ dysfunction.
Garino F, Capurso U, Garino GB.

Objectives: to evaluate the effectiveness of mandibular repositioning splints in the young and adult patients with TMJ dysfunction. Subjects and methods: 23 adult and 14 adolescent patients with TMJ dysfunction selected by Helkimo's index and the criteria of the American Academy of Craniomandibular disorders. Results: upon anamnestic follow up, almost a total disappearance of the functional pain was reported by all patients, while for the headache, a cyclic onset was present, but with an uncertain etiology. Patients had a complete control of the mandibular movements with some articular sounds. But a modicum of muscular tenderness remained possibly due to the psyche of the patient. Discussion: the prevalence of dysfunction in the growing patients was an intriguing observation. Not Angle's classification, but the presence of open bite, deep bite, or unilateral cross was the significant etiological factors.

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J Craniomaxillofac Surg. 2004 Aug;32(4):236-42.
Treatment of temporomandibular joint ankylosis by a modified fossa prosthesis.
Guven O.
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Ankara, Ankara, Turkey. oguven@dentistry.ankara.edu.tr

BACKGROUND AND OBJECTIVE: Treatment of temporomandibular joint ankylosis is a challenge and suffers from a high incidence of recurrence. Although treatment of ankylosis has been tried as early as nearly 200 years ago, no single technique produced satisfactory results. An alternative technique and a modified spacer system are described in this paper. MATERIAL AND METHODS: Fifteen patients, nine of whom had unilateral and the remaining six had bilateral ankylosis were evaluated. Modified fossa implants were used in all cases. RESULTS: The highest incidence of ankylosis was observed in the 11-20 year age group (nine patients). Falls during childhood was the common aetiological factor. Eight patients had been previously operated upon. Postoperative interinsicial opening values were remarkably different from the preoperative ones and the long-term results were satisfactory. CONCLUSION: With continued research and development in the treatment of ankylosis, temporomandibular joint implants will become more predictable and reliable. This specially designed fossa implant seems to be promising in the treatment of TMJ ankylosis.

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Br Dent J. 2004 Jul 10;197(1):35-41; discussion 31; quiz 50-1.
Treatment of temporomandibular disorders by stabilising splints in general dental practice: results after initial treatment.
Wassell RW, Adams N, Kelly PJ.
Department of Restorative Dentistry, The School of Dental Sciences, Framlington Place, Newcastle upon Tyne NE2 4BW. r.w.wassell@ncl.ac.uk

INTRODUCTION: Little is known about how effective general dental practitioners (GDPs) are in treating temporomandibular disorders (TMD). The overall aim of this study was to compare the lower stabilising splint (SS) with a non-occluding control (CS) for the management of TMD in general dental practice. METHOD: A total of 93 TMD patients attending 11 GDPs were randomly allocated to SS or CS. Diagnosis was according to International Headache Society Criteria. Outcome criteria included pain visual analogue scale (VAS), number of tender muscles, aggregate joint tenderness, inter-incisal opening, TMJ clicks and headaches. Splints were fitted one week after baseline and patients were followed-up every three weeks to three months; those not responding to CS after six weeks (< 50% VAS reduction) were crossed over to SS for a further three months. RESULTS: Documentation was returned from nine GDPs for 72 patients (38 for SS, 34 for CS). At six weeks, mean improvements were noted for all outcome criteria, but less so for clicking. There were no significant differences between splints [chi(2)]. Seventeen CS patients had < 50% VAS reduction and were provided with SS in the cross-over group. CS patients with >50% VAS reduction were significantly younger than CS patients who crossed-over (ANOVA, p=0.009) and had significantly less diagnoses of TMJ clicking (chi(2), p<0.05). At the conclusion of the trial 16 patients were referred for specialist management: 11 non-responders (< 50% VAS reduction), one of whom needed occlusal adjustment and five responders also needing occlusal adjustment. CONCLUSIONS: At six weeks SS gave similar relief to CS for all outcome criteria. Patients who crossed-over from CS to SS were more likely to be older and have clicking TMJs. At the end of treatment nine of 11 non-responders to SS had a diagnosis of disc displacement with reduction. However, 80% TMD patients were managed effectively by GDPs using splints for periods of up to five months.

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Int J Oral Maxillofac Surg. 2004 Jul;33(5):433-41.
Stabilisation of sagittal split advancement osteotomies with miniplates: a prospective, multicentre study with two-year follow-up. Part I. Clinical parameters.
Borstlap WA, Stoelinga PJ, Hoppenreijs TJ, van't Hof MA.
Department of Oral and Maxillofacial Surgery, UMC St. Radboud, Nijmegen, The Netherlands. W.Borstlap@mkc.umcn.nl

The principal aim of this study was to assess the postoperative stability of bilateral sagittal split osteotomies (BSSO) using two miniplates. Part I reports on the clinical results including treatment characteristics, nerve functions, TMJ function, occlusional relapse and patient satisfaction. This prospective study evaluated a group of 222 patients who underwent a BSSO for mandibular advancement. The same treatment protocol was used at seven participating institutions at which the patients were treated. A stable occlusion without appreciable relapse was seen in 84% after 2 years of follow-up. A considerable minority (16%) had occlusal relapse. There were no clinical parameters that pointed towards a high risk for relapse except age. The mean operation age of the relapse group was 20.7 years (SD 6.7) and in the stable group 26.1 years (SD 8.2). The function of the inferior alveolar nerve 2 years postoperatively was reported to be normal in approximately 88% of the patients, while 94% had no complaints about nerve dysaesthesia. In approximately 56% of the patients with pre-existing TMJ-dysfunction these signs and symptoms had disappeared. Another group of patients, however, without TMJ-dysfunction preoperatively (22%) developed signs or symptoms of TMJ-dysfunction postoperatively. The sagittal split osteotomy fixed with miniplates appeared to be a relatively safe and reliable procedure giving rise to a high degree of patient satisfaction, despite the fact that some occlusal relapse was seen.

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J Altern Complement Med. 2004 Jun;10(3):468-80.
Clinical research on acupuncture: part 1. What have reviews of the efficacy and safety of acupuncture told us so far?
Birch S, Hesselink JK, Jonkman FA, Hekker TA, Bos A.
Foundation for the Study of Traditional East Asian Medicine, Amsterdam, The Netherlands. 71524.3461@compuserve.com

OVERVIEW AND METHODS: This paper discusses those medical conditions in which clinical trials of acupuncture have been conducted, and where meta-analyses or systematic reviews have been published. It focuses on the general conclusions of these reviews by further examining official reviews conducted in the United States, United Kingdom, Europe, and Canada each of which examined available systematic reviews. While all reviews agree that the methodological rigor of acupuncture clinical trials has generally been poor and that higher quality clinical trials are necessary, this has not completely hampered the interpretation of the results of these clinical trials. In some conditions the evidence of efficacy has clearly reached a sufficient critical mass from enough well-designed studies to draw clear conclusions; for the rest, the evidence is difficult to clearly interpret. This paper also examines conclusions from the same international reviews on the safety and adverse effects of acupuncture. Here, conclusions are more easily drawn and there is good agreement about the safety of acupuncture. RESULTS AND CONCLUSIONS: General international agreement has emerged that acupuncture appears to be effective for postoperative dental pain, postoperative nausea and vomiting, and chemotherapy-related nausea and vomiting. For migraine, low-back pain, and temporomandibular disorders the results are considered positive by some and difficult to interpret by others. For a number of conditions such as fibromyalgia, osteoarthritis of the knee, and tennis elbow the evidence is considered promising, but more and better quality research is needed. For conditions such as chronic pain, neck pain, asthma, and drug addiction the evidence is considered inconclusive and difficult to interpret. For smoking cessation, tinnitus, and weight loss the evidence is usually regarded as negative. Reviews have concluded that while not free from serious adverse events, they are rare and that acupuncture is a relatively safe procedure. Copyright Mary Ann Liebert, Inc.

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Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004 May;97(5):546-51; discussion 552.
Outcomes of 152 temporomandibular joints following arthroscopic anterolateral capsular release by holmium: YAG laser or electrocautery.
Kaneyama K, Segami N, Sato J, Murakami K, Iizuka T.
Department of Oral and Maxillofacial Surgery, Kanazawa Medical University, Ishikawa, Japan. k-k@kanazawa-med.ac.jp

OBJECTIVE: The aim of this study was to investigate the clinical results and efficacy of arthroscopic anterolateral capsular release achieved through the use of a holmium:YAG laser or electrocautery for the management of patients with internal derangements of the temporomandibular joint (TMJ). STUDY DESIGN: We studied internal derangement (106 joints) and osteoarthritis (46 joints) of the TMJ in 129 patients. Preoperatively, the mean mouth-opening degree was 31 mm and 129 TMJs exhibited moderate to severe arthralgia. All patients underwent arthroscopic anterolateral capsular release achieved with a holmium:YAG laser (84 TMJs) or through electrocautery (68 TMJs). RESULTS: At the end of each patient's respective follow-up period, which ranged from 2 to 72 months (mean, 19 months), the mean mouth-opening degree was 43 mm (P<.0001). Also during that time, 105 joints were discovered to exhibit no arthralgia and 36 had mild arthralgia. The total success rates with 2 sets of criteria were 92.8% and 95.6%. CONCLUSIONS: Arthroscopic anterolateral capsular release is a minimally invasive and effective surgical method for the treatment of patients with TMJ intracapsular disorders.

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Cranio. 2004 Apr;22(2):137-44.
Use of Theraflex-TMJ topical cream for the treatment of temporomandibular joint and muscle pain.
Lobo SL, Mehta N, Forgione AG, Melis M, Al-Badawi E, Ceneviz C, Zawawi KH.
Craniofacial Pain Center, Tufts University School of Dental Medicine, One Kneeland Street, Box 1, Boston, MA 02111, USA. silvia.lobo_lobo@tufts.edu

This randomized, double-blind study was designed to evaluate the effectiveness of the topical cream Theraflex-TMJ (NaBob/Rx, San Mateo, CA) in patients with masseter muscle pain and temporomandibular joint (TMJ) pain. Fifty-two subjects (5 males and 47 females) were instructed to apply a cream over the afflicted masseter muscle(s) or over the jaw joint(s) twice daily for two weeks. Theraflex-TMJ cream was used by the experimental group, while a placebo cream was used by the control group. The means of pain ratings were calculated prior to the application of the cream (baseline), after ten days of tx (period 1), and 15 days of tx (period 2) days of treatment and five days after stopping the treatment (follow-up). There was a significant decrease in reported pain levels from baseline in the experimental group for period 1 (p < 0.01), period 2 (p < 0.001), and follow-up (p < 0.01). For the control group, no significant differences were found between the different time periods (p > 0.05). There was evidence of minor side effects such as skin irritation and/or burning on the site of the application in two subjects in the experimental as well as two subjects in the control groups. The data strongly suggest that Theraflex-TMJ topical cream is safe and effective for reducing pain in the masseter muscle and the temporomandibular joint.

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Hua Xi Kou Qiang Yi Xue Za Zhi. 2004 Apr;22(2):135-7.
[An outcome analysis of two methods of intra-capsular injection of sodium hyaluronate for temporomandibular disorders]
[Article in Chinese]
Li XD, Shi ZD, Tian WD.
Dept. of Oral and Maxillofacial Surgery, West China College of Stomatology, Sichuan University, Chengdu 610041, China.

OBJECTIVE: To analyze the treatment outcome of the two methods of intra-capsular injection of temporomandibular joints, the upper capsule alone and both the upper and lower capsules, for different subtypes of temporomandibular disorders. METHODS: A retrospective cohort study was designed, based on the outpatients and the data which were obtained from West China Stomatological Hospital, Sichuan University. SPSS10.0 software was used to analyze the data, which were collected before the operation and one week after the operation. RESULTS: 294 patients were followed up. The group of double capsules injection gained better prospect, not only on the mouth-opening but also the pain-cured, especially in two subgroups such as the anterior dislocation of disc without reduction and the osteoarthritis of TMJ. CONCLUSION: It seems that the double capsules injection of sodium hyaluronate for TMD can gain better outcome than the upper capsule injection, but a clinical randomized controlled test and a long-term follow-up study of the two methods are needed to verify this finding.

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J Oral Rehabil. 2004 Apr;31(4):287-92.
Occlusal adjustment for treating and preventing temporomandibular joint disorders.
Koh H, Robinson PG.
Department of Dental Public Health and Community Dental Education, GKT School of Dentistry, London, UK.

summary To assess the effectiveness of occlusal adjustment (OA) for treating temporomandibular disorders (TMD) in adults and preventing TMD. The Cochrane Controlled Trials Register, MEDLINE and EMBASE were comprehensively searched using the Cochrane methods. Reports and review articles were retrieved. Unpublished reports or abstracts were considered from the SIGLE database. All randomized or quasi-randomized controlled trials comparing OA with placebo, reassurance or no treatment in adults with TMD. The outcomes were global measures of symptoms, pain, headache and limitation of movement. Data collection and analysis followed the Cochrane Oral Health Group's statistical guidelines. Results showed no difference between OA and control group in symptom-based outcomes for treatment or incidence of symptoms for prevention. There is no evidence that OA treats or prevents TMD. OA cannot be recommended for the management or prevention of TMD. Future trials should use standardized diagnostic criteria and outcome measures when evaluating TMD.

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J Oral Maxillofac Surg. 2004 Mar;62(3):320-8.
Surgical management of advanced degenerative arthritis of temporomandibular joint with metal fossa-eminence hemijoint replacement prosthesis: an 8-year retrospective pilot study.
Park J, Keller EE, Reid KI.
Division of Oral and Maxillofacial Surgery, Mayo Clinic, Rochester, MN 55905, USA.

PURPOSE: The purpose of this study was 2-fold: to evaluate the surgical outcome and surgical morbidity of the temporomandibular joint (TMJ) metal fossa-eminence hemijoint prosthesis replacement, implanted in patients with degenerative arthritis, and to establish whether future, more rigorous clinical trial assessment of the hemijoint replacement is warranted. MATERIALS AND METHODS: Eighty-four patients (79 females and 5 males) involving 108 joints (60 unilateral, 24 bilateral) were operated on, and 112 joint metal fossa-eminence prostheses were placed. Information was gathered from patient response questionnaires and clinicoradiographic medical chart review. Change in pain intensity (preoperative versus current) was measured by 2 methods: 1) pain experience (1 to 6) and 2) pain intensity (visual analog scale, 1 to 10). Chewing ability, jaw opening, and joint noise were evaluated (visual analog scales, 1 to 10). Surgical morbidity and implant survival were documented. RESULTS: The average period from initial TMJ symptoms to metal fossa-eminence implant surgery was 12.3 years. The average number of previous TMJ surgeries was 1.9. Pain was reduced 56% and 61.2% by 2 methods. Chewing ability, jaw opening, and joint noise were improved by 53.4%, 50.2%, and 64%, respectively. Nine of 112 implants were explanted during the study period. Patient satisfaction for the clinical outcome was 8.3 on a scale of 0 to 10. CONCLUSION: The surgical placement of the Co-Cr-Mo metal fossa-eminence prosthesis (partial joint replacement) provides significant focal preauricular pain relief and reduces TMJ dysfunction secondary to advanced degenerative arthritis. The results of this case series supports further investigation of this form of surgical management in a rigorously controlled prospective fashion.

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Br J Oral Maxillofac Surg. 2004 Apr;42(2):142-8.
Long-term results of functional open surgery for the treatment of internal derangement of the temporomandibular joint.
Vazquez-Delgado E, Valmaseda-Castellon E, Vazquez-Rodriguez E, Gay-Escoda C.
Orafacial Pain Center, College of Dentistry, University of Kentucky, USA.

We studied 20 consecutive patients with internal derangements of the temporomandibular joint (TMJ), a median of 51 months after open operation on the joint and a rehabilitation programme. The design was a retrospective clinical study. The maximal opening and lateral active movements and the presence of clicking and joint pain were recorded preoperatively, after complete rehabilitation, and at the time of follow-up. Patients completed visual analogue scales of pain before operation and at the time of follow-up. Operation and postoperative rehabilitation reduced the variability of the opening and lateral movements, significantly increased maximal opening, and reduced clicking and pain.

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J Prosthet Dent. 2004 Feb;91(2):180-7.
A multicenter clinical trial on the use of pulsed electromagnetic fields in the treatment of temporomandibular disorders.
Peroz I, Chun YH, Karageorgi G, Schwerin C, Bernhardt O, Roulet JF, Freesmeyer WB, Meyer G, Lange KP.
Department of Prosthetic Dentistry and Oral Gerontology, Humboldt University, Berlin, Germany. ingrid.peroz@charite.de

STATEMENT OF THE PROBLEM: Pulsed electromagnetic fields have shown therapeutic benefit in the treatment of numerous forms of osteoarthritis but have not been evaluated for their effects on the temporomandibular joint (TMJ). PURPOSE: The aim of this study was to examine the effects of pulsed electromagnetic fields in the treatment of patients with temporomandibular disorders (TMD). MATERIALS AND METHODS: A multicenter clinical trial compared active treatment of 36 patients using pulsed electromagnetic fields to placebo treatment of 42 patients with TMD with pain in 1 or both TMJs and/or limited opening of less than 40 mm. Subjective parameters including pain intensity, pain frequency, degree of limitation, restriction of daily life, and intensity and frequency of joint noises were evaluated using a visual analog scale. Trained, blinded examiners assessed the clinical parameters according to Research Diagnostic Criteria for temporomandibular disorders before treatment (baseline), directly after nine 1-hour treatments on consecutive working days, 6 weeks after treatment, and 4 months after treatment. Statistical evaluation was done using the Friedman test, and by paired comparison between baseline and follow-up examinations using the U test (P < .05). RESULTS: Seventy-six patients completed the study. For both the active and placebo treatment, significant improvements were seen in the subjective data (P < .01). Patients with anterior disk displacement without reduction also showed significant improvements in active mouth opening (P = .015), patients with ostheoarthritis only showed improvements in some of the subjective parameters (P < .03), and patients with anterior disk displacement with reduction showed no improvement at all. CONCLUSIONS: Pulsed electromagnetic fields had no specific treatment effects in patients with temporomandibular disorders.

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Am J Orthop. 2004 Feb;33(2 Suppl):23-8.
Hyaluronan therapy: looking toward the future.
Kelly MA, Moskowitz RW, Lieberman JR.
Insall Scott Kelly Institute for Orthopaedics and Sports Medicine at Beth Israel Medical Center in New York, New York, USA.

Hyaluronan therapy has numerous medical applications, including the treatment of joint arthropathies, wound healing, prevention of postsurgical adhesions, treatment of urinary incontinence, ophthalmic surgery, and tissue augmentation and engineering. Studies have been conducted and are ongoing to evaluate the efficacy of intra-articular hyaluronans in disease modification in osteoarthritis of the knee; efficacy in disease states other than osteoarthritis; as adjunct therapy after joint surgery; and in joints other than the knee--namely the shoulder, hand, hip, temporomandibular joint, spine, foot, and ankle. Preliminary results have been promising and parallel what has been found in treatment of osteoarthritis of the knee. Research also continues into the development of chemically modified derivatized hyaluronan to optimize responses and enhance duration of action, as well as to expand the uses of this therapeutic modality.

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Cranio. 2004 Jan;22(1):10-20.
Efficacy of pulsed radio frequency energy therapy in temporomandibular joint pain and dysfunction.
Al-Badawi EA, Mehta N, Forgione AG, Lobo SL, Zawawi KH.
Dept. of Pediatric Dentistry, Tufts University School of Dental Medicine, 8th Floor, One Kneeland St., Boston, MA 02111, USA. ealbadawi@aol.com

This randomized double-blind study evaluated the effectiveness of pulsed radio frequency energy therapy (PRFE) in patients with temporomandibular joint arthralgia. Forty subjects (age range 22 to 55 yrs.) were assigned randomly into two equal groups: (1) Experimental group received PRFE using the Energex unit (Energex, Inc. Emerson, New Jersey) and (2) Control group received PRFE placebo treatment using a sham device. Both groups received six applications to the TMJ area over two weeks. Data were analyzed for the following times: baseline, first and second follow-up visits. Numerical Rating Scale scores for TMJ pain showed a significant reduction over time for the experimental group (mean = 6.13 to 3.05, p < 0.001). There was also a significant effect for the controls (mean = 5.35 to 4.20, p = 0.01). The effect for experimental subjects was a mean reduction of 3.07 versus 1.15 for controls. The significant reduction in controls was attributed to the placebo effect. The experimental group showed a significant increase in mouth opening (mean = 34.95 to 41.70 mm, p = 0.002), right lateral movement (mean = 7.85 to 10.80 mm, p = 0.001) and left lateral movement (mean = 7.65 to 10.85 mm, p < 0.0001). No significant (p > 0.1) change in the control group occurred for mouth opening (mean = 38.50 to 39.65 mm), right lateral movement (mean = 8.60 to 8.75 mm) and left lateral movement (mean = 8.50 to 8.80 mm). No side effects were reported during the treatment and the two week follow-up. These results suggest strongly that PRFE is a safe and effective treatment for TMJ arthralgia as well as for increasing mandibular range of motion.

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Zhonghua Kou Qiang Yi Xue Za Zhi. 2004 Jan;39(1):5-8.
[Function of disk reposition in the treatment of traumatogenic temporomandibular joint ankylosis]
[Article in Chinese]
Li ZB, Li Z, Shang ZJ, Zhao JH, Dong YJ.
Department of Oral and Maxillofacial Surgery, School of Stomatology, Wuhan University, Wuhan 430079, China. Email: Lizubing0827@163.com

OBJECTIVE: To investigate the method and results of disk reposition in the treatment of traumatogenic TMJ ankylosis. METHODS: In 19 cases of traumatogenic ankylosis of TMJ, the dislocated disks were repositioned during anthroplasty. In the operation, the dissection of dislocated disk was performed carefully around the TMJ. The disk was repositioned to its anatomic location over the top of condylar stump, then the lateral aspect of the disk was sutured to the soft tissue of zygomatic root. RESULTS: At the last follow-up examination, interincisal opening distance ranged from 24 to 43 mm in all cases (mean 32.63 mm), which approached or reached the normal level. No recurrence and TMJ symptom were found during the period of follow-up. CONCLUSIONS: The disk repositioning in treatment of traumatogenic TMJ ankylosis is a feasible and effective approach to reconstruct the structure and function and prevent recurrence.

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J Orofac Pain. 2003 Fall;17(4):301-10.
Pharmacologic interventions in the treatment of temporomandibular disorders, atypical facial pain, and burning mouth syndrome. A qualitative systematic review.
List T, Axelsson S, Leijon G.
Orofacial Pain Unit, Department of Stomatognathic Physiology, Malmo University, SE-214 21 Malmo, Sweden. thomas.list@od.mah.se

AIMS: To carry out a systematic review of the literature in order to assess the pain-relieving effect and safety of pharmacologic interventions in the treatment of chronic temporomandibular disorders (TMD), including rheumatoid arthritis (RA), as well as atypical facial pain (AFP), and burning mouth syndrome (BMS). METHODS: Study selection was based on randomized clinical trials (RCTs). Inclusion criteria included studies on adult patients (> or = 18 years) with TMD, RA of the temporomandibular joint (TMJ), AFP, or BMS and a pain duration of > 3 months. Data sources included Medline, Cochrane Library, Embase, and Psych Litt. RESULTS: Eleven studies with a total of 368 patients met the inclusion criteria. Four trials were on TMD patients, 2 on AFP, 1 on BMS, 1 on RA of the TMJ, and 3 on mixed groups of patients with TMD and AFP. Of the latter, amitriptyline was effective in 1 study and benzodiazepine in 2 studies; the effect in 1 of the benzodiazepine studies was improved when ibuprofen was also given. One study showed that intra-articular injection with glucocorticoid relieved the pain of RA of the TMJ. In 1 study, a combination of paracetamol, codeine, and doxylamine was effective in reducing TMD pain. No effective pharmacologic treatment was found for BMS. Only minor adverse effects were reported in the studies. CONCLUSION: The common use of analgesics in TMD, AFP, and BMS is not supported by scientific evidence. More large RCTs are needed to determine which pharmacologic interventions are effective in TMD, AFP, and BMS.

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J Oral Maxillofac Surg. 2003 Nov;61(11):1253-6.
Can arthrocentesis release intracapsular adhesions? Arthroscopic findings before and after irrigation under sufficient hydraulic pressure.
Yura S, Totsuka Y, Yoshikawa T, Inoue N.
Oral and Maxillofacial Surgery, Tonami General Hospital, 1-6 Shintomi-cho, Tonami-city, Toyama-ken 939-1395, Japan. yura@p1.coralnet.or.jp

PURPOSE: To investigate the effect of release of intra-articular adhesions of arthrocentesis, we examined patients with closed lock of the temporomandibular joint by arthroscopy before and after irrigation. PATIENTS AND METHODS: In 6 closed lock cases in which adhesions in the upper joint space were observed by arthroscopy before arthrocentesis, arthroscopic examination was performed again to confirm whether the adhesion was released after the procedure. Range of mouth opening and joint pain were examined to determine the clinical efficiency of the procedure. RESULTS: Adhesion was not released by irrigation under low pressure but could be released by irrigation under high pressure. After irrigation under low and high pressure, the maximum mouth opening of the patients improved from 0 to 1 mm (average, 0.3 mm) and 2 to 6 mm (average, 3.7 mm), respectively. CONCLUSIONS: The results indicate that arthrocentesis with sufficient pressure could be effective for closed lock cases with adhesions in the upper joint compartment.

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J Oral Maxillofac Surg. 2003 Oct;61(10):1171-8.
Interleukin-1beta, interleukin-1 receptor antagonist, and interleukin-1 soluble receptor II in temporomandibular joint synovial fluid from patients with chronic polyarthritides.
Alstergren P, Benavente C, Kopp S.
Department of Clinical Oral Physiology, Institute of Odontology, Karolinska Institutet, Huddinge, Sweden. per.alstergren@ofa.ki.se

PURPOSE: The aim of this study was to investigate whether interleukin-1beta (IL-1beta), interleukin-1 receptor antagonist (IL-1ra), or soluble IL-1 receptor II (sIL-1RII) in synovial fluid or plasma is associated with joint pain or signs of tissue destruction in patients with temporomandibular joint (TMJ) involvement of polyarthritides. PATIENTS AND METHODS: Forty-three patients with TMJ involvement of polyarthritides were included. TMJ resting pain, tenderness to palpation, pressure pain threshold, pain on mandibular movement, and anterior open bite were assessed. TMJ synovial fluid samples and plasma were obtained for analysis of IL-1beta, IL-1ra, and sIL-1RII. RESULTS: IL-1beta was detected in 18% of the synovial fluid samples and in 44% of the plasma samples. The concentrations of IL-1ra in plasma were lower than in the synovial fluid, whereas the opposite condition was found for sIL-1-RII. IL-1ra in synovial fluid and plasma was associated with low intensity of TMJ pain. sIL-1RII in synovial fluid was associated with low degree of anterior open bite, whereas sIL-1RII in plasma was associated with widespread musculoskeletal pain, TMJ pain and tenderness, and decreased pressure pain threshold over the TMJ. CONCLUSION: IL-1ra and sIL-1RII are present in different proportions in TMJ synovial fluid and blood plasma from patients with TMJ involvement of polyarthritis. Both of these molecules seem to influence the clinical features of these forms of TMJ inflammation.

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Schmerz. 2003 Oct;17(5):325-31.
[Managing patients with chronic orofacial pain in the outpatient departments of dental and maxillofacial surgeons. Results of a survey]
[Article in German]
Wirz S, Wartenberg HC, Wittmann M, Baumgarten G, Knufermann P, Korthaus T, Putensen C, Nadstawek J.
Klinik und Poliklinik fur Anasthesiologie und Spezielle Intensivmedizin, Rheinische Friedrich-Wilhelms-Universitat Bonn. s.wirz@web.de

OBJECTIVE: The aim of this study was to evaluate the significance attributed by dental and maxillofacial surgeons to the ambulatory management of chronic orofacial pain syndromes. MATERIALS AND METHODS: All the dentists and oral and maxillofacial surgeons working in ambulatory capacities within a county of the German Rhine Area were asked to answer a questionnaire on demographic data, diagnostic and therapeutic principles, and the use of analogue scales, surgical, minimal-invasive or pharmacological procedures. RESULTS AND DISCUSSION: Seventy-two ambulatory institutions reported 985 patients suffering from temporomandibular disorders (40.2%), headache-syndromes associated with facial pain (18.2%), and atypical odontalgia respectively phantom tooth pain (17.0%). Patients were characterized by prior dental treatment or trauma (41.9%), female gender (66.8%), middle age (81.1%, 20-60 years), very frequent change of therapists (54.6%) and long-term perseverance of pain (61.1% >6 months). Only 7% of therapists used visual or numerical analogue scales to assess pain intensity. Therapeutic procedures consisted of analgesics (15.7%) and further surgical procedures (47.7%). Pain therapists were rarely involved (12.5%). CONCLUSION: Dental and maxillofacial surgeons should apply an interdisciplinary and multimodal approach to diagnostics and therapy at an earlier stage in order to optimize the pain management of patients with chronic orofacial pain.

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Atlas Oral Maxillofac Surg Clin North Am. 2003 Sep;11(2):129-44.
Arthroscopy of the temporomandibular joint: technique and operative images.
White RD.

Over the years, little has changed in the preoperative indications and treatment for these patients. They must have failed a course of nonsurgical care, including physical therapy and medication up to 6 months. They must have had imaging done confirming intra-articular joint pathology (disc displacement, disc immobility for the most part, and joint effusions in some instances). Important technical issues include the use of two cannulas placed approximately 1 cm apart. Cannulas are not routinely placed initially into the anterior recess. Heavy downward pressure applied to the posterior ligament with a blunt obturator is used to assure mobility of the disc, and electrocautery or laser energy is used on the surface of the posterior ligament synovium for hemostasis and denervation (pain control). Corticosteroids are used infrequently. To avoid scuffing or damaging the joint surfaces unnecessarily, lysis is done using triangulation methods. Advanced instrumentation is used as the need arises but not used routinely. These patients can expect a predictably successful outcome with minimal recovery time and complications.

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J Orofac Pain. 2003 Summer;17(3):224-36.
Use of complementary and alternative medicine for temporomandibular disorders.
DeBar LL, Vuckovic N, Schneider J, Ritenbaugh C.
Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, Oregon 97227, USA. lynn.debar@kpchr.org

AIMS: Despite many reports about complementary and alternative medicine (CAM) use in the general population, little information exists about specific CAM therapies used for particular health conditions. This study examines the use of CAM therapies among patients with temporomandibular disorders (TMD). METHODS: We surveyed 192 patients with documented TMD as part of a larger project on the effectiveness of various CAM modalities for TMD patients. The survey asked about use of and attitudes toward specific CAM therapies for treating TMD and other patient-identified health conditions. The survey also measured physical health, health behavior, and psychosocial functioning. RESULTS: Nearly two thirds of the respondents (62.5%; n = 120) reported using CAM therapies for TMD or a related condition. Of all the therapies reported, massage was rated as the most frequent and among the most satisfactory and helpful. In general, respondents who used CAM for their TMD reported being most satisfied with the "hands on" CAM therapies (massage, acupuncture, and chiropractic care). The vast majority of respondents reported using CAM approaches for TMD simultaneously with conventional care (95.6%; 66 of 69). Those using CAM for TMD tended to be older, had a history of multiple medical problems, and reported more positive psychologic functioning. Respondents who most often reported CAM treatment as "very helpful" for their TMD were likely to be healthier (i.e., reporting higher levels of exercise and fewer sleep disturbances). CONCLUSION: Given the frequent use of CAM treatments by our respondents, allopathic providers should inquire about the adjunctive use of CAM among their TMD patients.

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Ann Readapt Med Phys. 2003 Jul;46(6):333-7.
[Bruxism, temporo-mandibular dysfunction and botulinum toxin]
[Article in French]
Chikhani L, Dichamp J.
Service de stomatologie et chirurgie maxillo-faciale de l'hopital europeen Georges-Pompidou, 21, rue Leblanc, 75015 Paris, France. Luc.Chikhani@wanadoo.fr

Tooth grinding and tooth clenching are unvoluntary mainly nocturnal habits that result in an hypertrophy of masseter and temporalis muscles with an unbalance between opening and closing muscles of the jaw and lead to an alteration of mandibular condyles movements and to hyper pressure in the temporo-mandibular joints (TMJ) which can generate severe pain. Intra muscular injections of botulinum toxin permit to restablish the balance between closing and opening muscles, to relieve pain, to treat masseteric hypertrophy with improvement of face outline and to recover a normal cinetic of temporo-mandibular joints. Moreover, botulinum toxin injections permit to quit habits of tooth grinding and clenching and one single session of injections is curative for 2/3 of the patients. There are no side effects apart from slight diffusion to superficial muscles of the face resulting in a "fixed" smile for about 6 to 8 weeks. So injections of botulinum toxin in masseter and temporalis muscles are an efficient treatment of bruxism and TMJ dysfunction, cheap with no lasting side effect.

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Coll Antropol. 2003 Jun;27(1):361-71.
Influence of occlusal stabilization splint on the asymmetric activity of masticatory muscles in patients with temporomandibular dysfunction.
Alajbeg IZ, Valentic-Peruzovic M, Alajbeg I, Illes D.
Department of Prosthetic Dentistry, School of Dental Medicine, University of Zagreb, Zagreb, Croatia.

The aim of present study was to evaluate the symmetry of masticatory muscles' activity at various clenching levels in the intercuspal position in patients with functional disorders and in healthy subjects. The purpose was also to determine the effect of full-arch maxillary stabilization splint on the asymmetry of masticatory muscle activity in patients with temporomandibular dysfunction. In this study 6 TMD patients and 12 healthy subjects were investigated. Surface EMG recordings were obtained from left and right anterior temporal, left and right masseter and from the sub-mandibular group in the region of the anterior belly of the digastric muscle on the left and right side during clenching with the maximum 100% voluntary contraction (MVC) as well as during clenching at 50% and 25% of the maximum activity in the position of maximal intercuspation of teeth. In order to quantify asymmetrical masticatory muscle activity, the asymmetry index (AI) was calculated for each subject and for each muscle from the average anterior temporal, masseter and digastric potentials recorded during each test (100% MVC, 50% MVC and 25% MVC). In the group of patients EMG recordings were repeated during and after the splint therapy. The asymmetries of masticatory muscle activity was present in both groups, but in the group of TMD patients the asymmetry indices for anterior temporal muscle at 100% MVC (p = 0.049) and 50% MVC (p = 0.031) were significantly higher. Results have shown that the use of splint suppressed the asymmetry of all muscles, as during the splint therapy the asymmetry indices were lowered. After the therapy, the level of temporal muscle symmetry during submaximal clenching in the intercuspal position increased significantly (p = 0.046). This investigation points out that electromyography may be a valuable method of documenting that asymmetric activity of masticatory muscles improves after occlusal splint therapy in patients with TMD.

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Shanghai Kou Qiang Yi Xue. 2003 Feb;12(1):58-61.
[A clinical study on septic arthritis of temporomandibular joint: treatment]
[Article in Chinese]
Yang C, Cai XY, Zhang ZY, Qiu WL, Ha Q, Wang XD.
Dept. of Oral & Maxillofacial Surgery, Afficiated Ninth People's Hospital, Shanghai Second Medical University, Shanghai 200011, China. yangchi63@hotmial.com

OBJECTIVE: To investigate the procedure and effect on treating septic arthritis of temporomandibular joint (TMJ). METHODS: 30 patients were treated by antibiotic therapy, resting of the jaw, and local therapies. The local therapies included arthrocentesis with single needle in 20 joints, arthrocentesis with double needles in 13, arthrocentesis accompanied by submandibular drainage of the infratemporal space abscess in 1, and arthroscopy in 4. The therapeutic effects were judged by joint cavity puncture, mouth opening, jaw pain, and jaw function, and so on. Sequelae were evaluated. RESULTS: The overall success rate of the treatment was 100% (30/30). The success rates of the 4 different management were: 14/20 in arthrocentesis with single needle, 9/13 in arthrocentesis with double needles, 1/1 in arthrocentesis combined with submandibular drainage, and 4/4 in arthroscopy, respectively. The sequelae were mild, and most of the cases had only postinfectious osteoarthritis. CONCLUSIONS: Low pressure arthrocentesis, antibiotic therapy and resting of the jaw were important components of treatment in acute septic arthritis. If infratemporal space abscess was found, submandibular drainage should be done. Arthroscopy could be recommended to those who haven't got good results by arthrocentesis or those who have already had some sequelae, such as TMJ fibrous ankylosis.

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Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003 May;95(5):552-8.
Visually guided temporomandibular joint irrigation in patients with chronic closed lock: clinical outcome and its relationship to intra-articular morphologic changes.
Hamada Y, Kondoh T, Holmlund AB, Iino M, Nakajima T, Seto K.
First Department of Oral and Maxillofacial Surgery, School of Dental Medicine, Tsurumi University, 2-1-3 Tsurumi, Tsurumi-ku, Yokohama 230-8501, Japan. hamada-y@tsurumi-u.ac.jp

OBJECTIVE: The aim of this study was to evaluate the clinical outcome after visually guided irrigation (VGIR) of the temporomandibular joint (TMJ) and its relationship with postoperative arthroscopic changes. STUDY DESIGN: Of the original 69 patients, thirty patients (30 TMJs) underwent VGIR of the TMJ a second time. After the first VGIR, the clinical outcome was assessed, and 18 patients were assigned to the good outcome group. The remaining 12 patients were assigned to the poor outcome group. The arthroscopic findings related to the articular surface, synovial lining, and fibrous adhesion scores were recorded. Then, the arthroscopic findings in the first and second VGIR were compared. RESULTS: The intra-articular tissue status between the first and second VGIR was unchanged in approximately 40% of all joints. No significant differences with respect to an improvement in tissue status were found when the good outcome and poor outcome groups were compared. CONCLUSIONS: In patients with chronic closed lock of the TMJ, a clinical improvement after VGIR does not seem to be accompanied by improved intra-articular tissue status.

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Cranio. 2003 Apr;21(2):116-20.
Therapeutic response of benzodiazepine, orphenadrine citrate and occlusal splint association in
TMD pain.
Rizzatti-Barbosa CM, Martinelli DA, Ambrosano GM, de Albergaria-Barbosa JR.
Faculty of Odontologia de Piracicaba, Dept de Protese e Periodontia, Avenida Limeira, 901 Bairro Areiao, CEP 13414.900 Piracicaba, SP, Brazil. rizzatti@fop.unicamp.br

Loss of function, muscle inflammation, and pain are some of the signs and symptoms of temporomandibular dysfunction (TMD). Pharmacological strategies to minimize the clinical manifestation of these disorders often focus on blocking or inhibiting the pain-causing symptom. Resources such as muscle-relaxants, anxiety-relief drugs, and splint therapy are often used to reduce muscular hyperactivity related to TMD muscle pain. This study compares the effect of a randomly ordered association of occlusal splint therapy (S), nonsteroid anti-inflammatory with a muscle-relaxant drug (orphenadrine citrate) (O), and an anxiety-relief drug (benzodiazepine) (B), to ease painful TMD muscle symptoms. Clinical and anamnestic analyses were recorded in accordance with the Helkimo TMD index and applied before and after treatments. Twenty-one group two Helkimo TMD adult female patients were treated, all of whom were subjected to the three random therapeutic associations proposed: SBO, BOS, and OSB. The same operator applied the three specific associations over a period of 21 days in the proposed sequence, seven days for each therapy. The results show that all the groups presented the best results in terms of relief from pain after the therapeutic association (28.5% showed a decrease and 47.6% showed an absence of symptoms). No significant difference was observed among association therapeutic protocols.

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Scand J Rheumatol. 2003;32(2):114-8.
Effectiveness of low-level laser therapy in temporomandibular disorder.
Kulekcioglu S, Sivrioglu K, Ozcan O, Parlak M.
Department of Physical Medicine and Rehabilitation, Uludag University School of Medicine, Bursa, Turkey.

OBJECTIVE: To investigate the effectiveness of low-level laser therapy in the treatment of temporomandibular disorder and to compare treatment effects in myogenic and arthrogenic cases. METHODS: Thirty-five patients were evaluated by magnetic resonance imaging and randomly allocated to active treatment (n=20) and placebo treatment (n= 15) groups. In addition to a daily exercise program, all patients were treated with fifteen sessions of low-level laser therapy. Pain, joint motion, number of joint sounds and tender points were assessed. RESULTS: Significant reduction in pain was observed in both active and placebo treatment groups. Active and passive maximum mouth opening, lateral motion, number of tender points were significantly improved only in the active treatment group. Treatment effects in myogenic and arthrogenic cases were similar. CONCLUSION: Low-level laser therapy can be considered as an alternative physical modality in the management of temporomandibular disorder.

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Clin Oral Investig. 2003 Mar;7(1):52-5. Epub 2003 Jan 25.
Treatment of recurrent temporomandibular joint dislocation with intramuscular botulinum toxin injection.
Ziegler CM, Haag C, Muhling J.
Department of Oral and Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany. cmziegler@t-online.de

Recurrent dislocation of the mandibular condyle poses a difficult problem for affected patients. In the course of time, dislocations often become more frequent and more difficult to avoid. Even with good patient compliance, conservative treatment is often not sufficient. Operative procedures have also been described for the treatment of temporomandibular joint dislocation. However, these interventions are invasive, involving open arthrotomy with possible complications, and cannot safely guarantee a successful outcome. On the other hand, botulinum toxin injections into the lateral pterygoid muscles offer the option of a predictable and prolonged period without renewed dislocation. We present the results of this treatment carried out in 21 patients with recurrent temporomandibular joint dislocation. Four patients were treated following unsuccessful physical therapy and the use of occlusal splints. The remaining 17 patients were treated for a number of conditions resulting in dislocation, including some with senile dementia and mental impairment in whom compliance with conservative measures was poor or completely absent. Injections were given on a 3-month basis in order to have a sustained effect. Within the study period of 6 months to 3 years, only two of the 21 patients suffered further dislocation. There were no side effects recorded as a result of treatment.

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J Oral Maxillofac Surg. 2003 Jun;61(6):685-90; discussion 690.
Comparison of 2 temporomandibular joint total joint prosthesis systems.
Wolford LM, Dingwerth DJ, Talwar RM, Pitta MC.
Department of Oral and Maxillofacial Surgery, Baylor College of Dentistry, Texas A&M University, Dallas, TX, USA. lwolford@swbell.net

PURPOSE: The study goal was to evaluate the comparative outcomes of patients treated with temporomandibular joint (TMJ) total joint prostheses, using either the Christensen prosthesis (TMJ Inc, Golden, CO) (CP) or the TMJ Concepts prosthesis (TMJ Concepts Inc, Camarillo, CA; formerly Techmedica Inc) (TP). Patients and Methods: Forty-five consecutive patients treated with either CP or TP total joint prostheses were evaluated. The CP group consisted of 23 patients (40 prostheses; average patient age, 38.8 years). The TP group consisted of 22 patients (38 prostheses; average patient age, 38.5 years). The average number of previous operations for the CP group was 3.9, whereas it was 2.6 for the TP group. The CP and TP groups had an average follow-up of 20.8 and 33.0 months, respectively. Patients were evaluated for incisal opening and occlusal and skeletal stability. A visual analog scale was used for subjective assessment of TMJ pain (0 = no pain, 10 = worst pain), jaw function (0 = normal function, 10 = no function), and diet (0 = no limitations, 10 = liquids only). Statistical analysis was performed using an independent t test, and a value of P <.05 was considered significant. RESULTS: The average postsurgical incisal opening for the CP group was 30.1 mm (increase of 6.7 mm), and that for the TP group was 37.3 mm (increase of 9.9 mm), indicating significant increase of the TP group (P =.008). The average postsurgical pain level for the CP group was 6.0, a decrease of 1.8, and that for the TP group was 4.1, a decrease of 3.1, indicating significant improvement for the TP group (P =.042). Postsurgical average jaw function for CP was 5.5, an improvement of 1.2. The postsurgical TP average was 3.9, an improvement of 3.0, showing significant improvement for the TP group (P =.008). Average postsurgical diet rating for the CP group was 5.4, an improvement of 1.8. The TP group average was 3.9, an improvement of 2.0, indicating significant improved eating ability for the TP group (P =.021). Skeletal and occlusal stability were good in both groups. CONCLUSION: The TP group had statistically significant improved outcomes compared with the CP group relative to postsurgical incisal opening, pain, jaw function, and diet. Both groups showed good skeletal and occlusal stability. Copyright 2003 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Sug 61:685-690, 2003

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Int J Oral Maxillofac Surg. 2003 Feb;32(1):24-9.
Temporomandibular joint ankylosis: report of 14 cases.
Manganello-Souza LC, Mariani PB.
Santa Casa de Sao Paulo Medical School, Department of Oral and Maxillofacial Surgery, Sao Paulo, SP, Brazil. mangane@attglobal.net

The authors present a review of 14 patients with temporomandibular joint ankylosis treated between March 1992 and February 1997. Etiology of the ankylosis was trauma in four patients, ear infection in two, systemic infection in one case, congenital in another, and unknown in six. Patients were divided into two groups, according to their age: 16 years and under and over 16 years of age. The basic principle of surgical treatment in both groups is ample access for osseous resection and coronoidectomy. Costochondral grafts were used in group one (nine patients), while interposition of a silicone block, was performed in the second group (five patients). Follow-up evaluations were from twelve to 53 months (average 28.2 months). One case of recurrence occurred in the first group and no recurrences in the second group. The average long-term mouth opening in both groups was 32.8 mm.

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Pain. 2003 Feb;101(3):267-74.
Reduction of TMD pain by high-frequency vibration: a spatial and temporal analysis.
Roy EA, Hollins M, Maixner W.
Department of Psychology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA. ear001@dental.umaryland.edu

Under some conditions, vibration delivered to the skin can reduce pain (vibratory analgesia). Previous studies of this phenomenon in a clinical context have been somewhat variable in terms of stimulus control, and have not examined the way in which the spatial distribution of pain is affected. In the present study, we used rigorously controlled conditions to examine vibratory analgesia in participants (N=17) with painful temporomandibular disorders (TMD). Results of 20- and 100-Hz vibration were compared with data from a no-vibration control condition. The results document for the first time that vibratory analgesia occurs in TMD chronic pain conditions. We measured its time course using continuous visual analog scale (VAS) recording, and its spatial aspects by asking subjects to indicate painful regions on standardized drawings. VAS ratings and drawings both showed that pain is reduced by 100-Hz, but not by 20-Hz, vibration. The effectiveness of the high-frequency vibration cannot be attributed to a mechanism involving Pacinian corpuscles, since these receptors are lacking in the skin of the orofacial region. Spatial analyses revealed that ipsilateral and contralateral effects of vibration were statistically equivalent, suggesting that vibratory analgesia relies at least in part on central nervous system processes rather than local mechanisms.

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Br J Oral Maxillofac Surg. 2003 Feb;41(1):29-31.
An audit of 405 temporomandibular joint arthrocentesis with intra-articular morphine infusion.
Kunjur J, Anand R, Brennan PA, Ilankovan V.
Oral and Maxillofacial Surgery, Poole Hospital NHS Trust, Longfleet Road, Poole, Dorset, UK.

The management of refractory pain in the temporomandibular joint (TMJ) is both challenging and controversial. Arthrocentesis is a simple technique that can be used instead of more invasive procedures in patients with pain that fails to respond to conventional conservative measures. We undertook an audit of 405 arthrocenteses in 298 patients over a 10-year period who had refractory pain in the TMJ. The pain was assessed subjectively by a visual analogue scale, both before arthrocentesis and at 1 and 6 months, and 1 year afterwards. A significant reduction in pain score was found after arthrocentesis (P < 0.001) and 269 patients (90%) found the procedure beneficial. We recommend arthrocentesis as an effective, minimally invasive technique in patients with continuing pain in the TMJ that is unresponsive to conservative management. Copyright 2003 The British Association of Oral and Maxillofacial Surgeons

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Cochrane Database Syst Rev. 2003;(1):CD003812.
Occlusal adjustment for treating and preventing temporomandibular joint disorders.
Koh H, Robinson PG.
Department of Dental Public Health & Community Dental Education, Guy's, King's and St. Thomas' School of Dentistry, King's College London, London, UK, SE5 8AN. holykoh@dr.com

BACKGROUND: There has been a long history of using occlusal adjustment in the management of temporomandibular disorders (TMD). It is not clear if occlusal adjustment is effective in treating TMD. OBJECTIVES: To assess the effectiveness of occlusal adjustment for treating TMD in adults and preventing TMD. SEARCH STRATEGY: We searched the Cochrane Oral Health Group's Trials Register (April 2002); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2002); MEDLINE (1966 to 8th April 2002); EMBASE (1980 to 8th April 2002) and handsearched journals of particular importance to this review. Additional reports were identified from the reference lists of retrieved reports and from review articles of treating TMD. There were no language restrictions. Unpublished reports or abstracts were considered from the SIGLE database. SELECTION CRITERIA: All randomised or quasi-randomised controlled trials (RCTs) comparing occlusal adjustment to placebo, reassurance or no treatment in adults with TMD. The outcomes were global measures of symptoms, pain, headache and limitation of movement. DATA COLLECTION AND ANALYSIS: Data were independently extracted, in duplicate, by two reviewers, Holy Koh (HK) and Peter G Robinson (PR). Authors were contacted for details of randomisation and withdrawals and a quality assessment was carried out. The Cochrane Oral Health Group's statistical guidelines were followed and relative risk values calculated using random effects models where significant heterogeneity was detected (P<0.1). MAIN RESULTS: Over 660 trials were identified by the initial search. Six of these trials, which reported results from a total of 392 patients, were suitable for inclusion in the review. From the data provided in the published reports, symptom-based outcomes were extracted from trials on treatment. Data on incidence of symptoms were extracted from trials on prevention. Neither showed any difference between occlusal adjustment and control group. REVIEWER'S CONCLUSIONS: There is an absence of evidence, from RCTs, that occlusal adjustment treats or prevents TMD. Occlusal adjustment cannot be recommended for the management or prevention of TMD. Future trials should use standardised diagnostic criteria and outcome measures when evaluating TMD.

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Cochrane Database Syst Rev. 2003;(1):CD002970.
Hyaluronate for temporomandibular joint disorders.
Shi Z, Guo C, Awad M.
Department of Oral Maxillofacial Surgery, West China Stomatological Hospital, Sichuan University, 14# Block three, Renmin Nanlu, Chengdu, Sichuan Province, China. shizd0664@sina.com

BACKGROUND: Temporomandibular joint disorders (TMD) refer to a group of heterogeneous pain and dysfunction conditions involving the masticatory system, reducing life quality of the sufferers. Intra-articular injection of hyaluronate for TMD has been used for nearly two decades but the clinical effectiveness of the agent has not been summarized in the form of a systematic review. OBJECTIVES: To assess the effectiveness of intra-articular injection of hyaluronate both alone and in combination with other remedies on temporomandibular joint disorders. SEARCH STRATEGY: Intensive electronic and handsearches were carried out. The Oral Health Group's Trials Register (September 2001), The Cochrane Library CENTRAL database (Issue 3, 2001), MEDLINE (1966- May 2001), PubMed ( up to March 2002), EMBASE (1974 - August 2001), SIGLE (1980 - December 2001), CBMdisc (1983 - July 2001, in Chinese) and Chinese Medical Library were searched. All the Chinese professional journals in the oral health field were handsearched and conference proceedings consulted. There was no language restriction. SELECTION CRITERIA: Randomized or quasi-randomized controlled trials (RCTs), with single or double blind, design testing the effectiveness of hyaluronate for patients with temporomandibular joint disorders. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data, and three reviewers independently assessed the quality of included studies. The first authors of the selected articles were contacted for additional information. MAIN RESULTS: Seven studies were included in the review. Three studies, including 109 patients with temporomandibular disorders, compared hyaluronate with placebo. Long term effects (three months or longer) are in favour of hyaluronate for the improvement of clinical signs/overall improvement of TMD (RR=1.71, 95%CI: 1.05, 2.77) from two of the studies (n=71). However, this conclusion was not stable enough at sensitivity analysis. Three studies provided data from 124 patients for the comparison of hyaluronate with glucocorticoids (one study also included a placebo group). Hyaluronate had the same short term and long term effects on the improvement of symptoms, clinical signs or overall conditions of the disorders as glucocorticoids. When comparing the effect of arthroscopy or arthrocentesis with and without hyaluronate, results were inconsistent. Hyaluronate had a potential in improving arthroscopic evaluation scores. Mild and transient adverse reactions such as discomfort or pain at the injection site were reported in the hyaluronate groups. No quality of life data were reported REVIEWER'S CONCLUSIONS: There is insufficient, consistent evidence to either support or refute the use of hyaluronate for treating patients with TMD. Further high quality RCTs of hyaluronate need to be conducted before firm conclusions with regard to its effectiveness can be drawn.

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J Oral Maxillofac Surg. 2003 Jan;61(1):41-8; discussion 48.
Simple disc reshaping surgery for internal derangement of the temporomandibular joint:
5-year follow-up results.
Kondoh T, Hamada Y, Kamei K, Seto K.
First Department of Oral and Maxillofacial Surgery, School of Dentistry, Tsurumi University, Yokohama, Japan. kondo-t@tsurumi-u.ac.jp

PURPOSE: The goal of this study was to evaluate the clinical results of simple disc reshaping (SDR) surgery alone for treating dysfunctional internal derangement of the temporomandibular joint. PATIENTS AND METHODS: Eleven patients with symptomatic unilateral anterior disc displacement with disc deformation were treated using reshaping of the inferior surface of the disc without disc repositioning. This was performed as an open-joint procedure. All patients were evaluated clinically for joint pain and jaw motion 5 years after surgery. Structural changes of the joint tissues such as disc displacement and deformation were evaluated using magnetic resonance imaging. The postoperative results were compared with preoperative findings. RESULTS: Joint pain during mastication or opening was reported by all patients before surgery. In 10 of 11 patients (91%), the joint pain disappeared postoperatively. Preoperatively, all 11 patients had limitation of mouth opening: the mean opening was 24.9 mm (standard deviation [SD], 4.13 mm). Postoperatively, the mean opening increased to 43.0 mm (SD, 3.00 mm). Based on the preoperative magnetic resonance imaging, all cases were diagnosed as anterior disc displacement without reduction and with disc deformation. Five years postoperatively, the disc configuration had maintained the reshaped status with decreased thickness of the deformed disc in 5 patients, and was changed to an almost normal biconcave shape in 3 patients. In the remaining 3 patients, the disc was unchanged from its preoperative condition. The position of the disc was unchanged in 8 patients, and in 3 patients disc position improved to near normal. CONCLUSION: The 5-year follow-up results suggest that SDR is a stable and favorable surgical procedure. Successful outcomes were attained in 91% of the patients. Copyright 2003 American Association of Oral and Maxillofacial Surgeons

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J Oral Maxillofac Surg. 2003 Jan;61(1):3-10; discussion 10-2.
Meta-analysis of surgical treatments for temporomandibular articular disorders.
Reston JT, Turkelson CM.
Department of Health Technology Assessment, ECRI, Plymouth Meeting, PA 19462-1298, USA.

PURPOSE: Temporomandibular joint articular disorders may cause severe pain and dysfunction. We addressed the following questions. Can any surgical procedures effectively treat these disorders? If so, which procedures are most effective? MATERIALS AND METHODS: We performed meta-analyses of surgical trial results to determine whether certain surgical procedures are effective in specific patient groups. To compensate for the lack of parallel control groups in published studies and for the improvement that has been observed in untreated patients, we used historical data from nonsurgical trials to derive 3 estimates of historical control group improvement (0%, 37.5%, and 75%). To our knowledge, this is the first meta-analytic evaluation of surgical treatments for temporomandibular joint disorders. RESULTS: Among patients refractory to nonsurgical therapies, surgical arthrocentesis and arthroscopy were effective for patients with disc displacement without reduction at all assumed control group improvement rates. Disc repair/repositioning had a statistically significant effect at all but the highest improvement rate. In patients with disc displacement with reduction, arthroscopy and disc repair/repositioning had statistically significant effects at all but the highest assumed rate of control group improvement. There were no statistically significant differences between the effects of any treatments. CONCLUSIONS: Surgical treatments appear to provide some benefit to patients refractory to nonsurgical therapies. The most reliable evidence supports the effectiveness of arthrocentesis and arthroscopy for patients with disc displacement without reduction. Better designed trials are needed before one can accurately determine the magnitude of the benefits of surgery. Copyright 2003 American Association of Oral and Maxillofacial Surgeons

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Clin J Pain. 2002 Nov-Dec;18(6 Suppl):S198-203.
Treatment of temporomandibular disorders with botulinum toxin.
Schwartz M, Freund B.
The Crown Institute, Toronto, Ontario, Canada. Schwartz@CrownInstitute.com

Temporomandibular disorder (TMD) is a collective term used to characterize a heterogeneous group of conditions involving the temporomandibular joint (TMJ) and its contiguous tissues. Although the pathologies behind TMDs have not been completely explained, the symptoms associated with these disorders are similar and are most commonly manifest as pain in the orofacial region. In preliminary studies, botulinum toxin has been used successfully to treat various pain syndromes, including TMDs. Because of the complex nature of TMDs and proximity of affected muscles to facial nerves, correct injection technique and appropriate dosing guidelines are very important for successful results. This article describes common TMDs and their treatment with botulinum toxin. Dosing guidelines and illustrations of affected muscles and target injection sites are provided.

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J Oral Maxillofac Surg. 2002 May;60(5):519-24; discussion 525.
A review of 56 cases of chronic closed lock treated with temporomandibular joint arthroscopy.
Dimitroulis G.
Oral and Maxillofacial Surgeon, Department of Surgery, St Vincents Hospital, Unviersity of Melbourne, Melbourne, Australia. geodim@netspace.net.au

PURPOSE: The aims of this prospective clinical study were to look at the features that constitute chronic closed lock of the temporomandibular joint (TMJ) and to assess the effectiveness of TMJ arthroscopic lavage and lysis in the management of this condition. PATIENTS AND MATERIALS: Sixty joints in 56 patients who presented with mandibular hypomobility suggestive of chronic closed lock were prospectively examined and treated with TMJ arthroscopic lavage and lysis during a 3-year period from 1996 to 1999. RESULTS: Eighty-seven percent (49 of 56) of patients were found to have chronic closed lock of the TMJ. The most common intra-articular findings were fibrillation (76%) and synovitis (54%). TMJ arthroscopic lavage and lysis were found to be effective in the management of chronic closed lock in 84% (47 of 56) of patients, with an average 66% reduction in pain levels and a mean improvement of 9.8 mm in interincisal mouth opening up to 6 weeks after the procedure. CONCLUSIONS: Chronic mandibular hypomobility is a clinical sign that is often but not always caused by chronic closed lock of the TMJ. The intra-articular findings of this study suggest that cartilage degradation and synovial inflammation are important components of chronic closed lock of the TMJ that respond well to arthroscopic lavage. Patients with mandibular hypomobility not caused by closed lock of the TMJ (ie, myofascial pain and dysfunction, osteoarthrosis, and others) are less likely to derive benefit from arthroscopic lavage and lysis, so other treatment methods should be considered. Copyright 2002 American Association of Oral and Maxillofacial Surgeons.

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Rev Stomatol Chir Maxillofac. 2002 Dec;103(6):335-43.
[Temporomandibular ankylosis. A treatment method using the interposition of a Dacron device]
[Article in French]
Gogalniceanu D, Vicol C, Popescu E, Costan V.
Departement de Chirurgie Orale et Maxillo-Faciale, Hopital Sf Spiridon, Iasi, Roumanie.

BACKGROUND: Temporomandibular ankylosis with its multiple anatomo-clinical forms is a relatively rare disease. Its major morphopathological, therapeutical and psychological implications rank it among severe illnesses. Its treatment is exclusively surgical. The major therapeutical indication in ankylosis of type I and II Topazian is the neoarticular modelling osteotomy with interposition. MATERIAL AND METHODS: As a material for interposition, over the last 7 years, we have used in 15 patients with 18 ankylosis, concave rectangular Dacron fragments adequately shaped after being taken from a vascular prothesis. RESULTS: The qualities of this material are confirmed by the obtained results: quick resuming of the normal mobility of the mandible, lack of postoperative complications and recurrences. The material is cheap and easy to be obtained. The technique to be used is simple. DISCUSSION: The Dacron texture is soft, elastic in all respects, thick enough, resistant, with long lasting elasticity and integrity, physically and chemically sTable, well tolerated by the body and without foreign body rejection. It is easy to be cut, shaped, modelled and adapted to the bone stump. It is sterilized by autoclaving. It is also well integrated into the host tissue being penetrated by the connective tissue which fastens it to the surface of the neocondyle preventing a relapse. It plays the role of a joint cartilage.

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Rev Stomatol Chir Maxillofac. 2002 Jun;103(3):148-50.
[Retrospective study of two years of surgery for temporomandibular joint pain dysfunction syndrome]
[Article in French]
Lemiere E, Maes JM, Rousie D, Ruhin B, Vereecke F, Ferri J.
Service de Stomatologie et Chirurgie Maxillo-Faciale, Hopital Roger Salengro, CHRU de Lille, 59037 Lille.

BACKGROUND: Assessment of temporomandibular joint (TMJ) surgery is a controversial topic. We analyzed our long-term surgical results in a set of patients who underwent TMJ surgery in our unit from January 1995 through December 1996. We used a simple methodology based on 4 criteria: pain, mouth opening, type of feeding and patient satisfaction. MATERIAL AND METHODS: We reviewed 21 operated patients who had been managed by an orthodontist after surgery. The post-surgical follow-up was 4 years. Patient age at surgery ranged from 14 to 51 years; the sex ratio was 1/9 M/F. Seventeen patients suffered a closed-lock, 2 had fibrous ankylosis of the disc. Fifteen patients underwent bilateral TMJ arthrotomy with joint fixation and, very often, mandibulo-condylar-plasty to counteract the bony compression inside the joint. We rated outcome as "very good" if four factors were found: resolution or improvement of pain, more than 40 mm post-surgery mouth opening or at least 10 mm improvement for patients with less than 40 mm post-surgical mouth opening, normal feeding, subjective satisfaction rated as very or quite good. Outcome was thus rated as very good (4 factors), quite good (3 factors), good (2 factors), poor (1 factor), failure (0 factors). RESULTS: Resolution of pain was achieved in 55% of the patients with an improvement in the others. All patients recovered normal feeding. Mouth opening remained limited for two patients. Subjective patient satisfaction was very or quite good in 80% of the cases. Outcome was rated very good in 9 patients, quite good in 7, and good in 5. There were no patients with poor outcome or failure. Analysis of the good outcome group showed that 3 had experience a post-surgery trauma, one had not complied with rehabilitation therapy, and one suffered from undiagnosed rheumatoid polyarthritis. CONCLUSION: According to the literature, TMJ surgery is an effective means of treating pain and reducing dysfunction. We obtained good and stable outcome in patients who participated in our postoperative follow-up. The TMJ is a fragile joint particularly susceptible to trauma.

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Int J Prosthodont. 2002 Nov-Dec;15(6):564-70.
A 6- and 12-month follow-up of appliance therapy in TMD patients: a follow-up of a controlled trial.
Ekberg E, Nilner M.
Department of Stomatognathic Physiology, Faculty of Odontology, Malmo University, Sweden. EwaCarin.Ekberg@od.mah.se

PURPOSE: This study compared the long-term effects of treatment with a stabilization appliance and treatment with a control appliance in patients with temporomandibular disorders (TMD). MATERIALS AND METHODS: In a controlled trial, 60 TMD patients with temporomandibular joint (TMJ) pain were evaluated after 10 weeks of treatment with either a stabilization appliance or a control appliance. At the 10-week follow-up, the 60 patients were assigned to one of three groups according to their demand for treatment. Group T, the treatment group, comprised 30 patients treated with a stabilization appliance; group C, the control group, comprised nine patients treated with a control appliance; and group M, the mixed treatment group, comprised 21 patients treated with first a control appliance and then a stabilization appliance. Signs and symptoms were evaluated in all three groups at 6- and 12-month follow-ups. RESULTS: At the 6- and 12-month follow-ups, a significant reduction in TMJ pain as measured on a visual analogue scale was found in all three groups, and a significant decrease in signs and symptoms was found in groups T and M. CONCLUSION: After 6 and 12 months of use, the stabilization appliance was found to still be effective in the alleviation of signs and symptoms in patients with TMD. Many patients in group C changed to a stabilization appliance at the 1 0-week follow-up, which significantly reduced the number of patients in this group. Most patients reported positive change in overall subjective symptoms in this trial. The stabilization appliance can therefore be recommended for patients with TMD.

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J Oral Maxillofac Surg. 2002 Dec;60(12):1440-8.
Long-term follow-up of the CAD/CAM patient fitted total temporomandibular joint reconstruction system.
Mercuri LG, Wolford LM, Sanders B, White RD, Giobbie-Hurder A.
Professor of Surgery, Division of Oral and Maxillofacial Surgery, Department of Surgery, Stritch School of Medicine, Loyola University Medical Center, Maywood, IL 60153, USA. lmercur@lumc.edu

PURPOSE: The purpose of this study was the assessment of the long-term safety and effectiveness of the Techmedica (Camarillo, CA) CAD/CAM Total Temporomandibular Joint Reconstruction System (now called the TMJ Concepts Patient Fitted Total Temporomandibular Joint Reconstruction System, Ventura, CA). PATIENTS AND METHODS: A survey was mailed to the available addresses of 170 (79%) of the 215 patients who had been implanted with the Techmedica System devices between 1990 and 1994. Seventy-nine (46%) surveys were returned by the US Postal Service as undeliverable. Three patients (1.4%) were reported as deceased in returns from relatives. Therefore, of the remaining 91 possible responses, 60 (65.9%) were returned. Fifty-eight (58) surveys, considered complete and valid (96.7%), representing 97 (39 bilateral, 19 unilateral) devices with a mean follow-up of 107.4 +/- 15.5 months (range, 60 to 120 months) were analyzed. Subjective data related to pain, mandibular function, diet consistency, and present quality of life were collected using visual analog scales. Objective measures of mandibular interincisal opening and lateral excursions were obtained from direct measurements using the Therabite (Therabite, Philadelphia, PA) measuring scale provided in the survey with instructions as to its use. RESULTS: Analysis of the subjective data at 10 years revealed a 76% reduction in mean pain scores and a 68% increase in mean mandibular function and diet consistency scores (P <.0001). Analysis of objective data revealed a 30% improvement in mandibular range of motion after 10 years (P =.0009). Long-term quality of life improvement scores were statistically related to the number of prior temporomandibular joint operations the patients had undergone. CONCLUSION: These data indicate that the CAD/CAM Patient Fitted Total Temporomandibular Joint Reconstruction System has proved to be a safe and effective long-term management modality in the patient population surveyed for this study. Copyright 2002 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 60:1440-1448, 2002

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J Oral Maxillofac Surg. 2002 Dec;60(12):1400-11; discussion 1411-2.
Long-term study of temporomandibular joint surgery with alloplastic implants compared with nonimplant surgery and nonsurgical rehabilitation for painful temporomandibular joint disc displacement.
Fricton JR, Look JO, Schiffman E, Swift J.
Received from the Department of Diagnostic and Surgical Sciences, University of Minnesota School of Dentistry, Minneapolis, MN., 55455, USA. frict001@umn.edu

PURPOSE: The purpose of this study was to determine the long-term objective and subjective outcomes of temporomandibular joint (TMJ) implant surgery for the treatment of painful TMJ disc displacement using temporary Silastic (Dow Corning Corporation, Midland, MI), permanent Silastic, or Proplast (Vitek, Houston, TX) implants to replace the disc. These cases were compared with other cases of the same diagnosis treated with either nonsurgical rehabilitation or nonimplant surgery involving discectomy or disc repair procedures. MATERIALS AND METHODS: A cross-sectional study was conducted among 466 patients who received treatment for unilateral or bilateral TMJ disc displacement before January 1, 1990. The 5 treatment groups noted above were compared for long-term outcomes. Objective outcome measurements for jaw function were performed using a calibrated examiner and the Craniomandibular Index (CMI). Subjective (self-reported) outcomes were obtained relative to jaw function (Mandibular Function Impairment Questionnaire [MFIQ]), symptom severity (Symptom Severity Index [SSI]), and the impact of pain (Global Pain Impact [GPI] scale). RESULTS: The results, adjusted for gender, baseline tomogram score, and baseline symptom scores, showed that the nonsurgical rehabilitation group (n = 159) and the group having TMJ surgery without implants (n = 149) had statistically better results than the group who underwent surgery with a Proplast implant (n = 94). These between-group differences included both objective signs (CMI), and subjective reports of jaw function (MFIQ), symptom severity (SSI), and global pain impact (GPI). The MFIQ score associated with the nonsurgical rehabilitation group was also statistically better than for the Silastic implant groups, including both the temporary (n = 31) and permanent (n = 33) implants. Clinical differences between groups were slight. CONCLUSION: This study suggests that the use of interpositional disc implants in TMJ surgery is not associated with improved outcomes when compared with nonimplant surgery or nonsurgical rehabilitation. Copyright 2002 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 60:1400-1411, 2002

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J Oral Maxillofac Surg. 2002 Dec;60(12):1389-99.
Clinical evaluation of patients with temporomandibular joint implants.
Ta LE, Phero JC, Pillemer SR, Hale-Donze H, McCartney-Francis N, Kingman A, Max MB, Gordon SM, Wahl SM,
Dionne RA.
Postdoctoral Fellow, Pain and Neurosensory Mechanisms Branch, National Institutes of Health, Bethesda, MD 20892, USA.

PURPOSE: An undetermined number of patients with temporomandibular joint (TMJ) symptoms have been treated with intra-articular disc implants composed of Teflon ethylene/propylene or Teflon polytetrafluoroethylene and aluminum oxide (Proplast-Teflon; Vitek, Houston, TX). These implants have shown the potential to fragment in situ resulting in nonbiodegradable particles that stimulate a giant cell reaction and lead to degeneration of local structures, pain, and limitation of mandibular opening. We examined the possible relationship between TMJ implants and persistent pain, responses to sensory stimuli, quality of life, and systemic immune dysfunction. PATIENTS AND METHODS: This case series (32 patients) were referred from university-based orofacial pain centers and private practices from across the United States. Laboratory and clinical assessments evaluated orofacial pain symptoms, neurologic function, clinical signs and symptoms of rheumatologic disease, physical function, systemic measures of immune function, and behavioral measures. RESULTS: We found that TMJ implant patients appeared to have altered sensitivity to sensory stimuli, a higher number of tender points with a diagnosis of fibromyalgia, increased self-report of chemical sensitivity, higher psychologic distress and significantly lower functional ability. Systemic illness or autoimmune disease was not evident in this series of TMJ implant patients. CONCLUSIONS: Significant problems were noted on clinical assessment of TMJ implant patients. This is a US government work. There are no restrictions on its use.

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J Orofac Pain. 2002 Fall;16(4):259-76.
A randomized clinical trial of a tailored comprehensive care treatment program for
temporomandibular disorders.
Dworkin SF, Turner JA, Mancl L, Wilson L, Massoth D, Huggins KH, LeResche L, Truelove E.
University of Washington, Departments of Oral Medicine and Psychiatry and Behavioral Sciences, Box 356370, Seattle, WA 98195, USA. dworkin@u.washington.edu

AIMS: To test the usefulness of tailoring cognitive-behavioral therapy (CBT) for patients with temporomandibular disorders (TMD) who demonstrated poor psychosocial adaptation to their TMD condition, independent of physical diagnosis. METHODS: A randomized clinical trial compared a 6-session CBT intervention delivered in conjunction with the usual TMD treatment to the usual conservative treatment by TMD specialist dentists. For study inclusion, Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD), Axis II criteria, were used to target patients with elevated levels of TMD pain-related interference with daily activities, independent of physical diagnosis (i.e., Axis I). RESULTS: At the post-treatment assessment, about 4 months after the baseline evaluations, the comprehensive care group, when compared to the usual treatment group, showed significantly lower levels of characteristic pain intensity, significantly higher self-reported ability to control their TMD pain, and a strong trend (P = .07) toward lower pain-related interference in daily activities. From post-intervention to 1-year follow-up, all subjects showed improvement. At the 1-year follow-up, the comprehensive care group, while not losing any of its early gains, was not significantly different from the usual care group with regard to reported levels of pain, ability to control pain, and levels of interference in activities. For many of these psychosocially disabled TMD patients, pain and interference 1 year after treatment remained at the same or higher levels than those observed at baseline among a group of patients selected for a separate randomized clinical trial on the basis of better psychosocial adaptation. CONCLUSION: The 6-session CBT intervention for patients with heightened psychologic and psychosocial disability was effective in improving pain-related variables over the course of the CBT in conjunction with usual treatment, but was too brief an intervention to result in further improvement after the sessions ended. Patient ratings of treatment satisfaction and helfulness were high for both groups, but they were significantly higher for the comprehensive care group.

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Stomatologiia (Mosk). 2002;81(3):33-8.
[Hormonal correction in combined therapy of temporomandibular joint dysfunction in women]
[Article in Russian]
Pisarevskii IuL, Belokrinitskaia TE, Khyshiktuev BS, Semeniuk VM, Kholmogorov VS.

Pain dysfunction syndrome of the temporomandibular joint (TMJ) in women is often accompanied by mammary and reproductive disorders associated with endocrine disturbances. 30 female patients aged 19-35 years suffering from of the pain dysfunction syndrome TMJ combined with intact dentition and orthognathic occlusion were studied. Dental examination was followed by gynecologic examination. According to the treatment the patients were divided into 2 groups. Group I included women who were administered conventional treatment (orthopedic treatment, drug and physiotherapy). In group II patients conventional therapy was also combined with monophase oral contraceptive "Femoden". Efficacy of treatment in group I was 46.67%; while group II patients showed a 100% favourable effect. Besides, combination of dental and gynecologic therapy was found to exert a 2.1 times more stable clinical effect us compared to conventional treatment. Hormone correction in women with reproductive pathology results in prolonged control of the pain dysfunction syndrome TMJ due to steroid normalization (hypothalamic, hypophysial, ovary steroid normalization) and has no side effects.

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Acta Odontol Scand. 2002 Aug;60(4):248-54.
Efficiency of occlusal appliance therapy in secondary otalgia and temporomandibular disorders.
Kuttila M, Le Bell Y, Savolainen-Niemi E, Kuttila S, Alanen P.
marjaana.kuttila@otonhammmas.fi

In clinical practice, it is commonly assumed that occlusal splints have therapeutic value in the treatment of temporomandibular disorders CTMD), but the evidence based on randomized controlled trials is scarce. This study evaluated the short-term (10-week) efficacy of a stabilization splint in subjects with recurrent secondary otalgia and active TMD treatment need using a randomized, controlled, double-blind design. Thirty-six subjects were randomly allocated to the two treatment groups: the stabilization splint and the control splint group. After 10 weeks' treatment, the intensity of secondary otalgia, measured on a VAS scale (from 0 to 100 mm), decreased statistically significantly in the stabilization splint group (t 2.12; P 0.006), but not in the control group. Improvement in active TMD treatment need in subjects showing moderate or severe signs and symptoms of TMD was reported significantly more often in the stabilization splint group than in the control splint group (chi2 5.71; P.017). A statistically significant decrease in the Helkimo clinical dysfunction index was seen in the subjects with stabilization splint (Z-2.63; P.009), but not in the subjects with control splint. The results indicate that the use of a stabilization splint is beneficial with regard to secondary otalgia and active TMD treatment need.

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Dent Today. 2002 Aug;21(8):52-7.
Initial management of temporomandibular disorders.
Syrop SB.
Division of Oral and Maxillofacial Surgery, Columbia University, Weil Medical College, USA.

The existing dental literature does not support the superiority of any one type of treatment to manage TMD. Few studies meet rigorous scientific standards of the randomized clinical trial. This has led to enormous controversy. The initial management of TMD does not have to be controversial. Noninvasive, reversible modalities can be employed that carry very little risk and a high degree of success (Table 4). The success rate of this approach has been studied and determined to be 75% to 90%. Of course, not every patient will get better with this approach. For those who do not improve more advanced techniques must be used, and referral to specialists in TMD, neurology, and rehabilitation medicine may be required. A few patients will need surgery. Initial treatment of TMD requires relatively simple modalities, such as patient education, adherence to a soft diet, reducing oral habits, self-directed home physical therapy, muscle relaxation, the use of medication, and the proper use of bite plates. The majority of TMD patients will respond successfully to these basic treatments.

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J Oral Maxillofac Surg. 2002 Sep;60(9):996-1002; discussion 1002-3.
Treatment of painful temporomandibular joint dysfunction with the sagittal split ramus osteotomy.
Pruitt JW, Moenning JE, Lapp TH, Bussard DA.
Indiana University School of Dentistry, Indianapolis, USA. jpruitt@iomsa.com

PURPOSE: We describe a new indication for the sagittal split ramus osteotomy with rigid fixation to treat patients with painful dysfunction of the temporomandibular joint. PATIENTS AND METHODS: Ten patients for whom nonsurgical management failed were found to have a mandibular condyle positioned postero-superior within the glenoid fossa with reduced joint space on corrected-axis tomograms. The sagittal split ramus osteotomy was used to reposition the proximal segment and to increase joint space. Preoperative and long-term postoperative (average, 44.7 months) symptoms and tomographic findings were retrospectively compared. RESULTS: Significant pain relief occurred postoperatively in all patients. One patient had a relapse after initial improvement. No patient developed a malocclusion. The long-term radiographic condyle-fossa relationship tended to return to its preoperative position with no relapse of clinical symptoms, except in the 1 patient. CONCLUSION: The sagittal split ramus osteotomy with rigid fixation is another procedure that can be used to treat painful temporomandibular joint dysfunction by changing the position of the mandibular condyle in the glenoid fossa. Copyright 2002 American Association of Oral and Maxillofacial Surgeons

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Br J Oral Maxillofac Surg. 2002 Aug;40(4):296-9.
Reconstruction of the temporomandibular joint autogenous compared with alloplastic.
Saeed N, Hensher R, McLeod N, Kent J.
Specialist Registrar, Department of Oral and Maxillofacial Surgery, Cheltenham General Hospital, Sandford Road, Cheltenham, GL53 7AN, UK. oral.surgery@orh.nhs.uk

The aims of and indications for temporomandibular joint (TMJ) reconstruction are well-established but the method of reconstruction is controversial. We describe a retrospective, two-centre audit of 49 patients treated with costochondral grafting and 50 patients treated with alloplastic joints. The characteristics of the patients were similar in both centres and the minimum follow-up period was 2 years. For each patient a number of variables were recorded including both subjective scores (pain and interference with eating) and objective data (interincisal distance). Patients in both groups showed an improvement in symptoms but more patients required reoperation in the autogenous group.

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