Omar Sheikh1

Greg Logan1

Deepak Komath2

Patrick Grossman3

Peter Ayliffe4

1 London North West Hospitals, London, UK2 Royal Free Hospital3 Lister House Private Practice4 Great Ormond Street Hospital, University CollegeHospital, London, UK

Corresponding author:Omar SheikhLondon North West HospitalsWatford Road,London, HA13UJ, UKE-mail: osheikh@nhs.net

Summary

Chronic disc displacement may lead to long-termpain. Temporomandibular joint surgery is re-served for those patients whose symptoms re-main severe despite conservative treatment. Welooked at the of effect of modified meniscopexyon patients with chronic disc displacement with-out reduction who did not respond to non-surgi-cal pain management treatment. In this retrospec-tive study a total of 59 joints was treated and allpatients except one underwent splint assisted bi-lateral meniscopexy: this patient had splint as-sisted unilateral meniscopexy.At the time of presentation and following treat-ment all patients underwent clinical examinationand were required to complete a pain and func-tional questionnaire. All patients reported im-provement following treatment.

Key words: temporomandibular joint, splint,meniscopexy.

Introduction

Temporomandibular disorders (TMD) are a heteroge-neous group of pathologies and the most commonorofacial pain conditions of non-dental origin affectingthe temporomandibular joint (TMJ), the masticatorymuscles or both (1).

Signs and symptoms commonly include TMJ pain,muscle pain, clicking, crepitus, restricted mouthopening, deviation on opening or closing and hea -daches. Tinnitus has also been reported as symp-tom with studies reporting that when the most com-mon causes of tinnitus are excluded, it is correct toevaluate the functionality of the temporo-mandibularjoint (2).Disruption of joint function by excessive/overloadingcauses chronic irritation to the discs and synoviumresulting in inflammation and disc displacement (3).Up to 75% of the population exhibits one recordablesign of TMD with 5-33% of subjects reporting subjec-tive symptoms. Symptoms peak between 20-40 yearsof age with a ratio of 3.3:1 females to males (4).TMD is a multifactorial disease. Studies have quotedvariable levels of trauma and dental treatment previ-ous to the development of symptoms. Some patientsalso have an element of systemic disease such asjoint hypermobility or arthritis with one study quotingthe figure at 13.1% (5). Given a lack of consensus regarding best treatmentmethods, the American Association of Oral and Max-illofacial Surgeons (AAOMS) issued a statement re-garding TMD syndrome. This categories TMD into 1.extracapsular disorders, muscular in origin includingparafunction and pain referred from systemic muscleconditions and 2. intracapsular disorders involving discdisplacement. Degenerative changes including os-teoarthritis, rheumatoid arthritis, TMJ dislocation, anky-losis and fractures are also responsible for TMD (6).Initial management is non surgical and includes phys-ical therapy, occlusal appliance therapy, drug therapy(topical and systemic), intraarticular injection andarthrocentesis, diet alteration and life style adapta-tion. Splint therapy has been reported with successby Tsuga 1989, Gray 1991, Davies 1997 and showsto reduce muscle activity and providing neuromuscu-lar balance to the TMJ (7-9).A Cochrane review of 12 randomised controlled trialsdemonstrated no significant difference in the effec-tiveness of stabilisation splint treatment compared toother active treatments. This review also stated thatocclusal adjustments make no difference to outcome.TMJ surgery is reserved for those patients whosesymptoms remain severe despite conservative treat-ment. Surgical options include:- disc repair and disc repositioning procedures

(meniscopexy)- menisectomy with/without autogenous implants- condylectomy- condylotomy- eminectomy.

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No one procedure is a panacea for all TMJ patholo-gies (10).In contrast to open joint procedures, arthrocentesisand arthroscopy are less invasive, comparatively eas-ier and less expensive (11). A review of arthrocentesis and arthroscopy found nostatistically significant difference between these inter-ventions in terms of pain. However the complicationrate for TMJ arthrocentesis is considered to be lessthan that for TMJ arthroscopy (12).Guo et al. (2009) state there is insufficient evidence(should conservative management fail) to support orrefute other strategies (13).Our retrospective study focused on disc displacementwithout reduction (DDWoR) which can happen whenthe ligaments are stretched beyond their elastic po-tential. It can be described as a ‘door jam’ preventingnormal joint movement.

Materials and methods

Inclusion criteria:Patients that had disc displacement without reductionconfirmed on an MRI scan. Patients that did not re-spond to splint therapy.Patients that did not respond to conservative mea-sures such as physiotherapy for a minimum of 6months, the average having such measures up to 18months. Various options for surgery including arthrocentesisand arthroscopy were discussed with the patients.Due to the prolonged nature of symptoms it was feltthat modified meniscopexy to restore normal anatomyof the joint would provide the best result for these pa-tients. Prior to surgery, all patients underwent an MRI scanfollowed by 3 months of fulltime splint treatment. Thescans of all but 7 patients were classified accordingto Wilkes below:Patients were considered for surgery if demonstrat-ing:- decreased inter-incisal opening- severe pain during function- audible crepitus- consistent muscle hyperactivity with unstable tem-

poromandibular joints- no medical contraindications to surgery- no mental/emotional contraindications to surgery.

Patients

The study included 26 females and 4 males of which,9 were self referred, 16 referred by their general den-tal practitioner, 5 from maxillofacial surgeons and 1from a chiropractor. All patients completed:- a TMJ medical, social and family history- a diagnostic pain questionnaire- a pictographic representation by the patient indi-

cating pain sites (head, neck, face and shoulders)

- clinical examination of the head and neck includ-ing palpation of 90 osseous and muscularanatomical landmarks; a record was also made ofmaximum mouth opening, left and right lateral ex-cursions, spontaneous pain, pain on movement,presence of clicking/crepitus and/or locking.

In total 59 joints were treated and all patients exceptone underwent bilateral meniscopexy, this patienthad unilateral meniscopexy.Following surgery all patients underwent clinical ex-amination and were required to complete a pain andfunctional questionnaire. The categories in the painquestionnaire were None, Rare, Slight, Occasional,Moderate and Constant.The meantime interval from surgery to completing thequestionnaire was 8.5 years, with a range of 22 monthsto 16 years.

Presurgical technique

Prior to surgery all patients underwent splint therapyfor 3 months. The mandibular flat plane pivot-typesplint was worn 24 hours a day, 7 days a week andonly removed for cleaning. The purpose of the splint,the height of which is determined by the swallowtechnique, is to decompress the TMJ, thereby creat-ing superior joint space, obviating the need for condy-lar surgery. Only the upper mesiopalatal cusps of the terminalmolars contact the splint creating a bilateral occlusalinterference that limits postero-superior movement ofthe condyle and reducing loading forces on thecondylar head (Fig. 1). Any osteoarthritic process inthe inferior compartment is therefore reduced or evenarrested. One week before surgery the splint is resur-faced to a highly indexed version locating themandible into an idealised relationship to the maxillaand this so-called anterior repositioning splint is wornduring surgery.

Surgical technique

A modified preauricular approach is used and thendissection proceeds to the superficial temporal fascia,then blunt dissection anteriorly in this plane. Afteridentifying the lateral capsular ligament, a horizontalincision is required at its superior aspect to enter thesuperior joint space. The disc is then located (Fig. 2).Further dissection to the lateral aspect of the articulareminence and anterior to this may be required forthis. The disc is then relocated and sutured laterallyand posteriorly to the capsular ligament. No wedgeresection of the retrodiscal tissues is needed unlessthey prevent relocation of the disc into its normal po-sition.Prior to closure the joint is flushed with 2% lignocaineand 1:100,000 adrenaline. The mandible manipulatedup and down making sure that the occlusal surfacesof the maxillary teeth correspond to the index in the

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mandibular repositioning splint. This allows open in-spection for movement of the meniscus and determi-nation of the stability of sutures and surgical reposi-tioning.

Postsurgical treatment

Aggressive physical therapy is initiated within 24hours of surgery with a Therabite Exerciser. Patientsare instructed to use it for 5 minutes every half hour(during waking hours) for the first 2 weeks and for 5

minutes per hour for the following 10 weeks. Patientsare expected to have an active mouth opening of 48-52 mm after 90 days. Most patients prefer a soft dietfor the first few weeks although no restrictions areplaced.The repositioning splint is worn 24 hours a day in-cluding eating, for up to 12 months postoperatively.As postsurgical oedema reduces and the masticatorymusculature relaxes, adjustments to the splint needto be undertaken initially every 3-4 weeks for the firstfew months. At 12 months when full healing has beenattained, splint therapy is concluded and any restora-tive or orthodontic treatment can then be undertaken.Analyses of the results were conducted retrospective-ly by independent researchers. Information was ob-tained from the patients’ clinical notes, pre-treatmentand post-treatment pain questionnaires, MRI andhospital reports. The determination for success oftreatment was two fold, firstly the patients’ subjectiveevaluation and secondly the objective change inphysical signs.

Results

The overall subjective improvement reported by thepatients was measured on a visual analogue scale(VAS) as part of the post surgical questionnaire: inthis study the mean improvement was 86% on a VASof 1-10, with 1 being nil improvement and 10 maxi-mum improvement. The minimum improvement was40% and the maximum was 100%. The majority ofpatients felt that they had benefited from the proce-dure (Tab. 1). Shows overall improvement of the patients’ quality oflife in response to 5 questions: the majority of pa-tients exhibited improved opening except for one pa-tient whose opening decreased by 10 mm, this pa-tient had a pre-operative mouth opening of 60 mm

Annali di Stomatologia 2016;VII (3):73-78 75

Splint-assisted disc plication surgery

Figure 1. Splint in situ demonstrat-ing occlusal interference thereby de-creasing load on condylar head.

Figure 2. Location of disc: relocation and suturing laterallyand posteriorly to the capsular ligament.@ C

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that decreased to 50 mm. She had constant pain onopening and a dull ache at rest, this was reduced torarely. The mean increase in mouth opening was 8.6mm and the maximum increase was 20 mm (Tab. 2).The AAOMS states that the average inter-incisal dis-tance is 50-60 mm and this measurement is an objec-tive assessment of joint function. In this study the aver-age pre-op distance=37.5 mm (range of 25-60 mm).This method improves mouth opening and functionbut not every patient achieved the 50-60 mm rangereported by AAOMS.Clicking of the TMJ was as reviewed and is present-ed in Table 3: 53.3% of patients reported constantclicking preoperatively whilst none reported constantclicking postoperatively, confirming a marked im-provement in symptoms.Table 4, shows that constant spontaneous jaw painreduced in all but 3.3% of patients: 36.7% of patientspresented with crepitus preoperatively with completeresolution for all patients after surgery.

TMJ locking prior to treatment was a constant prob-lem for 20% of the patient group with 33.3% statingthis was of moderate or occasional concern. Following surgery, TMJ locking and crepitus was re-solved for the entire group.Both locking and crepitus are objective observationsand less open to bias or interpretation unlike psycho-logical factors which may depend on the patients’ sta-tus at the time of questioning.Neck pain is frequently associated with TMJ pain.TMJD whilst not causative can exacerbate an existingneck pain. 60% of patients reported constant neckpain pre-treatment, with only 3.3% of patients report-ing constant pain post-treatment. However, aftertreatment 70% still experienced occasional/rare pain.Pain is the most reported symptom of TMJD (6).The improvement in reported pain pre and post treat-ment.14 of the 30 patients reported constant joint pain pre-operatively while 4 never reported pain. Post-opera-

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Table 1. Pre-treatment Wilkes classification.

Stage 1 Stage 2 Stage 3 Stage 4 Stage 50 0 14 22 9

Table 2. Global post-operative subjective impressions.

Overall improvementQuestion: Better Same WorseOverall my physical well-being is? 74% 19.3% 6%Overall my mental/emotional state is? 64.5% 29% 6%Overall my ability to deal with stress is? 48.3% 48.3% 4.4%Overall my enjoyment of life is? 70.9% 22.5% 6.6%Overall my quality of life is? 77% 19% 4%

Table 3. Overall improvement in TMJ Clicking.

Frequency of clicking Constant Rare Occasionally NeverPre op Clicking 53.3% 13.3% 3.3% 30%Post-op Clicking 0% 0% 6.7% 93.3%

Table 4. Spontaneous jaw pain Pre and Post treatment.

Pre-treatment pain Post-treatment painNone 2 7Rare 3 9Slight 0 1Occasional 1 10Moderate 2 2Constant 22 1

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tively 7 patients never experienced joint pain and only1 patient reported constant pain (Tab. 5).Chronic pain sufferers did not report complete resolu-tion of symptoms which may suggest that the mostsignificant improvement is conferred on those pa-tients with a lower pre-operative level of pain. One patient suffered temporary right facial nerve palsypost-surgery with loss of ability to raise the right eye-brow. There were no post-treatment orthodontic compli-cations. At the time of surgery two tears were seen inthe disc itself and two tears in retro-discal tissue.

Discussion

This study reviewed a group of patients (n=30) treat-ed by the senior Authors who presented with disc dis-placement without reduction, either unilateral or bilat-eral. Anterior repositioning splints can be used to cre-ate superior joint space as well as an idealised maxil-lo-mandibular relationship which is subsequently sta-bilized by disc relocation. The need to wear the splintprior to surgery is mandatory as it is during surgery toprevent relapse of the disc into the painful pre-surgi-cal position. Patients with disc displacement without reductionshow condyles that are superiorly positioned in thefossa reducing superior joint space. Occlusion, al-though not a causative factor, maintains the patholog-ical condyle/fossa relationship by virtue of intercuspa-tion. Creation of superior joint space is key to provid-ing disc space and stability thereafter. Previous at-tempts at creating space have involved condylarsurgery but this does not address muscle spasm.Furthermore, such surgery carries complications in-cluding adhesion formation, bone degeneration andankyloses (14).Splint therapy allows non-invasive creation of superi-or joint space, elongation of the masticatory musclestogether with a functional maxillomandibular relation-ship. The surgeon and orthodontist opted for the mini-mally invasive soft tissue procedure of disc plicationas it poses fewer post-surgical complications as com-pared with more invasive techniques. Invasive tech-niques can damage the connective tissue covering ofosseous tissues thereby reducing the possibility forremodeling and healing (15). The surgical protocol differs from other publishedstudies in the following ways:- all surgery was preceded by 3 months of full-time

splint therapy;- surgical intervention is strictly a soft tissue proce-

dure;

- access is confined to the superior joint space;- the relocated disc is sutured posterolaterally to the cap-

sule and not posteriorly to the retrodiscal tissues;- the splint is worn during surgery;- aggressive physical therapy commences 24 hours

post surgery (16, 17);- the splint is worn full-time post surgery for 12

months prior to any orthodontic/restorative proce-dures;

- As postsurgical oedema reduces and the mastica-tory musculature relaxes, the splint is adjustedevery 3-4 weeks for the first few months.

The multiple adjustments of the splint gradually re-duce superior joint space allowing the disc to retainits correct anatomical position and prevent the discrelapsing anteriorly, preventing a relatively commoncomplication. The suture posterolaterally also aidsthis. Other studies have discussed the use of Mitekscrews and double pass sutures to stabilise the artic-ular disc in its correct anatomical position. Howeververy rarely did these methods result in a ‘click free’joint for every patient post surgery in their respectivestudy groups (18-20).The weakness of the study is that the pre- and post-surgical questionnaire was not aligned with OHIP andtherefore limited in scope.Furthermore, outcomes were reliant on subjectiveand functional improvements which could not be di-rectly associated to disc repositioning, since no post-operative MRI scans were taken.

Conclusion

To ensure long-term stability and relief of symptoms,all aspects of disc derangement aetiology must beaddressed. Patients in this study presented with discdisplacement without reduction, occlusal dishar-monies, degenerative change, muscle spasm and ab-normal condylar position. By restoring normal joint anatomy with subsequentorthodontic stabilisation treatment which provided oc-clusal support, predictable long-term results can beachieved for this group of challenging patients.Whilst not a cure-all procedure, splint assisted disc pli-cation surgery can be recommended for refractory pa-tients with chronic disc displacement without reduction.

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Table 5. It shows the improvement in reported pain pre vs post operatively.

Frequency of Pain Constant Moderate Occasionally Rare NeverPre operatively 66.67% 10% 6.67% 10% 6.67%Post operatively 3.33% 6.67% 33.33% 33.33% 23.33%

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