CRANIO® The Journal of Craniomandibular & Sleep Practice
ISSN: 0886-9634 (Print) 2151-0903 (Online) Journal homepage: http://www.tandfonline.com/loi/ycra20
Surgical Treatment of Temporomandibular Joints in Patients with Chronic Arthritic Disease: Preoperative Findings and One-Year Follow-Up Tore Bjørnland, Tore A. Larheim & Hans R. Haanæs To cite this article: Tore Bjørnland, Tore A. Larheim & Hans R. Haanæs (1992) Surgical Treatment of Temporomandibular Joints in Patients with Chronic Arthritic Disease: Preoperative Findings and One-Year Follow-Up, CRANIO®, 10:3, 205-210, DOI: 10.1080/08869634.1992.11677911 To link to this article: https://doi.org/10.1080/08869634.1992.11677911
Published online: 18 Feb 2016.
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• ORAL SURGERY
SURGICAL TREATMENT OF TEMPOROMANDIBULAR JOINTS IN PATIENTS WITH CHRONIC ARTHRITIC DISEASE: PREOPERATIVE FINDINGS AND ONE-YEAR FOLLOW-UP Tore Bj~rnland, D.D.S., Tore A. Larheim, D.D.S., Odont.Dr., Hans R. Haames, D.D.S., M.D., Odont.Dr.
0886-9634/9211 0030205$03.00/0, THE JOURNAL OF CRANIOMANDIBULAR PRACTICE, Copyright © 1992 by Williams & Wilkins
Manuscript received November 15, 1991 ; accepted March 2, 1992 Address for reprint requests: Tore Bjemland, D.D.S. Department of Oral Surgery and Oral Medicine Faculty of Dentistry University of Oslo P.O.B. 1109-Biindem 0317 Oslo 3 Norway
ABSTRACT: Twenty-nine temporomandibular joints (TMJs) in 19 patients with chronic arthritic disease were surgically treated. Nine patients had rheumatoid arthritis (including two with juvenile type), six had ankylosing spondylitis and four had psoriatic arthropathy. Using a preauricular approach, diskectomies with synovectomies were performed in 23 joints (14 patients) with chronic arthritic abnormalities. Diskectomies without synovectomies were performed in six joints (five patients), which proved to have internal derangements unrelated to their chronic arthritic disease. Joints with chronic arthritis showed considerable variation in inflammatory reactions, but were characterized by increased vascularization, synovial proliferation to the articulating surfaces and mostly pannus formation and bone resorption. A response in pain relief was seen in 85% of the patients three months Dr. Tore Bjtlrnland received his postoperatively and in 79% of the patients 12 months postD.D.S. degree from Faculty of Dentistry. University of Bergen, Norway, in operatively, indicating that diskectomy with synovectomy 1976. He completed the oral surgery may be favorable in patients with severe TMJ problems residency program in Oslo, Norway, in due to involvement of chronic arthritic disease. 1984, and from 1985 to 1988 he was a research fellow in Oral Surgery, Faculty of Dentistry, Oslo. Since 1988 he has been an assistant professor in the Department of Oral Surgery and Oral Medicine, Faculty of Dentistry, University of Oslo. He has been president of the Norwegian Association of Oral Surgery since 1989 and is the Norwegian representative in the European House of Representatives in Oral and Maxillofacial Surgery.
C
linical and radiographic findings of the temporomandibular joint (TMJ) in patients with chronic arthritic disease have been described in several studies. 1-5 Recently, imaging modalities for the assessment of soft-tissue abnormalities in symptomatic TMJs in such patients have become available. 6·7 However, little attention has been paid to the TMJ treatment ofthis group of patients. 8- 10 Synovectomy is a common procedure in patients with chronic arthritic disease. 11 - 13 However, surgical treatment with diskectomy and synovectomy of the TMJ has only been described in a case report. 14 Reconstruction of the TMJ has been reported in cases with advanced destruction.15 Some cases of bony TMJ ankylosis due to chronic arthritis, surgically treated, have additionally been reported.l6.17 In the following, the authors report their initial experiences with surgical treatment of symptomatic TMJs in a series of 19 patients with chronic arthritic disease.
Dr. Tore A. Larheim received his D.D.S. degree in 1973 from the Faculty of Dentistry, University of Oslo, Norway. He became a research assistant in 1976 in the Department of Oral Radiology at the same university, received his Odont.Dr. (Ph.D.) degree in 1981, and then became associate professor of oral radiology. From 1985 he has been professor and chairman of the Department of Oral Radiology, Faculty of Dentistry, University of Oslo. He is a member of the Norwegian Dental Association, the International Association of DentoMaxillo-Facial Radiology, and an associate member of the Norwegian Society of Radiology and Norwegian Society of Rheumatology.
Material and Methods The 19 patients had severe TMJ problems and a total 205
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of 29 TMJs were treated with surgery. The patients had been examined by rheumatologists who had stated a diagnosis of chronic arthritis in one or more other joints before they were referred for TMJ examination. This group of patients represented only a small number of the patients with chronic arthritic disease and TMJ symptoms referred to the authors' departments. The patients consisted of 17 women and two men, ranging in age from 17 to 64 years (mean age was 37 years). Nine patients had rheumatoid arthritis (including two with juvenile type), six had ankylosing spondylitis, and four had psoriatic arthropathy. The duration of the chronic arthritic disease varied from one to 23 years (the mean was 10 years), and the duration of TMJ symptoms varied from one to 12 years (with a mean of four years). Preoperative signs and symptoms of these joints are listed in Table 1. Preoperative imaging was performed with methods previously described. 18 Radiographic examination was made of all patients, including panoramic and lateral transcranial radiography, as well as hypocycloidallateral tomography. Supplementary examinations were made of 15 patients; arthrotomography in 13, computed tomography in six, and/or magnetic resonance imaging (MRI) in eight patients. Imaging evaluation included assessment of disk position and shape, perforation, joint space irregularities, and bone abnormalities. Attempts were made to classify the TMJs as arthritic or nonarthritic. Evaluation of possible arthritic changes of the neck was always made before the operations and included lateral radiographs in flexion and extension. Two patients had a planned tracheostomy because of neck stiffness. The remaining 17 patients had general nasoendotracheal anesthesia. The criteria for surgery included TMJ pain and impaired function not alleviated by previous therapy such
as: splints, physical therapy, intra-articular injection of steroids and pharmacotherapy, in addition to imaging interpretation of soft-tissue abnormalities with or without involvement of bone. Preoperatively 15 patients were classified as arthritic and four were classified as nonarthritic concerning their TMJ abnormalities. The nonarthritic joints showed internal derangements (anterior disk displacements). The planned surgical treatment was synovectomy and diskectomy with debridement of joints preoperatively assessed as arthritic, including SILASTIC® implants* in two cases of bony ankylosis. Bilateral procedures were made in five patients: two patients with bony ankylosis in one joint and fibrous ankylosis in the contralateral, and three patients with indistinguishable symptoms from the right and left joints. In joints where the preoperative findings indicated nonarthritic internal derangements, only diskectomies were planned. During the surgical procedure, systematic assessment of the soft and hard tissues and the function of the joint were recorded: visible synovitis; increased vascularization, synovial proliferation to the articulating surfaces and pannus formation, as well as disk position and shape, fibrous adhesions, destructions and remodeling of the condyle and fossa, and translation of disk and condyle. Results The observations are summarized in Table 2. Of the 29 joints (19 patients), 23 TMJ s (14 patients) showed chronic arthritic disease at surgery (Table 2). The findings were characteristic soft-tissue abnormalities; increased vascularization of the capsule, attachments and synovial membrane, thickening of the synovial membrane and proliferation to the articulating surfaces and mostly pannus formation. *SILASTJCI!I>-Dow Coming Corporation, Midland, Michigan.
Table 1 Clinical TMJ Status at Preoperative and Postoperative Examinations in 19 Patients (29 Joints) with Chronic Arthritic Disease Preoperative
Signs and symptoms* TMJ pain TMJ pain and myalgia No pain Joint sounds No sounds Open bite (n patients) Vertical opening (mm) Mean Range *n
206
n
= 29
Postoperative 3 Months 12 Months
n
= 29
n
Table 2 Peroperative Observations in the Temporomandibular Joint (TMJ) of 19 Patients* with Chronic Arthritic Disease
= 29
Surgical TMJ Diagnosis
Synovial proliferation/ pannus formation Fibrous adhesions Fibrous ankylosis Bone resorption Bony ankylosis Normal disk position Anterior disk position Completely destroyed disk
8 19 2 9 20 2
2 2 25 10 19 2
3 2 24 II 18 2
19 2 to 31
32 25 to 45
33 I to 45
= number of joints. THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
Arthritic TMJs (n = 23)
Nonarthritic TMJs (n = 6)
21 16 2 21 2 13 5 5
0 5 0 6 0 0 6 0
*n = 29 joints.
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Figure 2 Figure 1 Preoperative TMJ examination of a 28-year-old woman with juvenile rheumatoid arthritis. A, Lateral tomogram shows normal bone. B, Arthrotomogram with maximally opened mouth (severely impaired) shows contrast medium in both compartments (upper compartment filled through perforation. preoperatively assessed to be in the central thin part of the disk), small compartments (0.45 ml contrast medium injected), some irregularity in the outline of the contrast medium, indicating synovial proliferation, and a normal disk position.
The inflammatory reactions were seen in both joint compartments and showed considerable variations, from increased vascularization with synovial proliferation (and normal bone) (Figure 1), to severe pannus formation (and bone resorption) (Figure 2). Increased vascularization of the surgical fields made the surgery more difficult to perform compared to diskectomy in patients with only internal derangement. More tedious ligation and coagulation of vessels were necessary, but no excessive bleeding was seen. Only two joints showed an increased amount of synovial fluid. In five joints the disk was completely destroyed without any visible remnants (Table 2). The remaining 18 joints showed a disk shape that varied from apparently normal to increased or decreased thickness. Four perforations seemed to be in the central region of the disk (Figure 1) and only two perforations were found in the junction between the disk and the posterior attachment. The disk position was found to be normal in 13 of the 18 joints (Table 2) and (Figure 1). Internal derangement was additionally found in the other five; a nonreducing disk displacement in four, and a reducing disk displacement in one joint. Twenty-one of the 23 joints with chronic arthritis had bone abnormalities (Table 2). The changes varied from small erosions to severe condylar destructions and flattening with evident remodeling. One patient with advanced destruction of the condyle showed bone apposition of both the fossa and the tubercle. Two joints showed bony ankylosis (Figure 3). Six joints (five patients) did not show any signs of chronic arthritic disease (Table 2). The soft-tissue changes consisted of internal derangement; a nonreducing disk displacement with perforations in four joints and a reducing disk displacement in two joints. All perforaJULY 1992, VOL. 10, NO. 3
Left TMJ arthroplasty of a 24-year-old woman with ankylosing spondylitis. A, Upper joint space with the disk in place after the removal of fibrous adhesions between the fossa and the disk. 8, Condyle with pannus formation and thickening of the synovial membrane at the anterior and superior part of the condyle, and resorptions of the condyle. C, After synovectomy and diskectomy the joint space and mobility of the joint is increased.
tions seemed to occur in the junction between the disk and the posterior attachment. Five joints had fibrous adhesions. All joints had bone abnormalities with resorptions of the condyle. Complications Complications were seen in three (15%) ofthe patients. The most serious complication was seen in a patient whose vocal cords had been affected during the intubation. The voice normalized after the removal of inflammatory tissue on the vocal cords. In another patient a possible subluxation of the neck occurred during the intubation or the surgery. The patient had to wear a neck collar for about four months and had, in the beginning, some pain in the neck and arms but without paresis or paresthesia. The symptoms disappeared after approximately six months. One patient with fibrous ankylosis developed bony
Figure 3 Left TMJ arthroplasty of a 32-year-old man with ankylosing spondylitis and bony ankylosis. A, A gap arthroplasty is made with the removal of approximately 5 mm of the condyle. B, Insertion of SILASTIC® implant secured with two Titanium® screws.t tTitanium® screws-0. Leibinger, Miihlheim-Stetten, Germany.
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ankylosis approximately 10 months after the first operation. A bilateral procedure was then performed and the jaw mobility was measured at 30 mm one year after the operation, though with some pain at maximal opening. Postoperative Results All the patients were seen daily for four to six days after the operation and thereafter weekly for the first month. They were then seen at three and 12 months postoperatively (Table 1). Surgery had an effect on pain at rest and motion in 16 patients (85%) three months postoperatively. Two patients with fibrous ankylosis reported feeling only ''somewhat better'' and one patient with fibrous ankylosis reported no effect on pain after the first three postoperative months. At 12 months postoperatively four patients (five joints) had pain in the TMJ and/or associated muscles (21% of the patients). The range of motion increased on the average 8 mm (with a range of 2 to 22 mm) during the first three to four days and gradually during the next weeks giving an increased mean value of 13 mm (range of 2 to 23 mm) three months postoperatively (Table 1). At 12 months postoperatively the mean range of motion had increased 14 mm (with a range of I to 28 mm in 18 patients and decreased 1 mm in one patient). The joint sounds increased slightly postoperatively (Table 1) and were crepitus, whereas preoperatively two joints had crepitus, two joints had crepitus and clicking, and five joints had clicking. Discussion Though many clinical radiographic TMJ studies of patients with chronic arthritic diseases are available, macroscopic histologic evidence of chronic arthritic TMJ involvement has only been demonstrated in autopsy studies19 and in a case report. 14 The present study clearly showed that both soft-tissue abnormalities and bone abnormalities due to chronic arthritic involvement are frequent findings in the TMJs, as observed in other joints similarly involved. 12·20 Synovial proliferation as the most characteristic surgical finding is also in accordance with a single case report, showing rheumatoid TMJ arthritis without fibrous or bony ankylosis.14 As experienced from the present series and for obvious reasons, synovial proliferations are not found in advanced cases. Soft-tissue abnormalities, as indicated by arthrotomographic examination (Figure 1), were, on the other hand, seen in two joints without bone abnormalities. The value of arthrotomography for early TMJ involvement of chronic arthritis was thus demonstrated.
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Since a correct TMJ diagnosis is very important for the surgical planning of patients with chronic arthritic disease, the soft tissue should be evaluated by arthrotomography or MRI. In advanced cases, however, such as suspected bony ankylosis, computed tomography seems to be more valuable. 18 The disk position was most frequently normal in joints involved by chronic arthritic disease, supporting recent imaging studies.6·7 Interestingly, a rather high frequency (38%) of these joints had perforations, mostly in the central thin portion of the disk. Perforation occurred even in a joint with normal bone (Figure 1), indicating a disk fixed to the condyle due to synovial proliferation and adhesions. Almost one third of the joints with chronic arthritis was accompanied by internal derangements. This has been indicated by imaging, 6·7 but is surgically demonstrated for the first time in the present series. The anterior disk position may be an incidental finding. Recently, however, a longitudinal MRI study of an arthritic TMJ in a patient with psoriatic arthropathy showed development of disk displacement, which was suggested to be related to the arthritic disease process. 21 Whether or not there is a causal relationship, it is possible that a TMJ may be more problematic for the patient if the disease involvement is accompanied by anterior disk displacement. To differentiate between an arthritic TMJ accompanied by anterior disk displacement and internal derangement without concomitant arthritic signs may, however, be difficult or impossible, even with advanced imaging modalities. 18 Synovial proliferations and fibrous adhesions cannot be reliably distinguished with arthrotomography or detected with MRI. 18 In two joints the disk position was interpreted as being anterior at imaging, but normal at surgery. 18 Surgical observation of a normal disk position, grouped displaced at imaging, can be made if the condylar resorption is not taken into consideration. Another possibility may be that the posterior attachment is adapted to the anterior disk displacement by connective tissue hyalinization, simulating a normal position clinically. 22·23 This study clearly demonstrated that severe TMJ problems in patients with chronic arthritis may be due to internal derangements, indistinguishable from internal derangements in other patients. This has also been indicated by recent imaging studies on patients with chronic arthritis, evaluating not only the bone but also the soft tissue. 6·7 However, most earlier TMJ studies in this field have not discussed the possibility that the clinical and radiographic abnormalities observed could be due to another condition than the patient's arthritic disease. Surgical treatment of arthritic disease in the TMJ with diskectomy and synovectomy proved to be very effective
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on TMJ pain and jaw mobility in this short-term study. This corresponds well with the result of synovectomies of other joints in patients with arthritic disease, where the clinical improvement primarily consisted of relief of pain and better function. 13 ·20·24 Follow-up studies of synovectomies in the knee joint also suggest a delay in the destruction of bone. 20·25 It is recommended to remove all inflamed synovial membrane and to perform a total knee meniscectomy. 20 Therefore, in this series synovectomies routinely included diskectomies. In one joint, however, the disk seemed to be entirely normal and was left in place, with the removal of the inflamed synovial tissue. Such a procedure should be considered only in joints without synovial proliferations in the disk. The authors' case will be thoroughly examined at postoperative visits, particularly with regard to the possible development of bone changes postoperatively. The surgical TMJ treatment was effective, despite the great variation of arthritic abnormalities, from small synovial proliferation to severe bone destruction. This is in contrast to other joints where severe destruction of the articulating surfaces often leads to a higher degree of disability, 20 ·24 ·26 and where joint replacement with arthroplasty, rather than synovectomy, is the treatment of choiceY Great variations were also seen between pain and the objective findings of arthritic TMJ disease, i.e., bone resorption, open bite and restricted jaw mobility. TMJ pain was a greater problem in patients with minor joint abnormalities compared with arthritic TMJs with advanced abnormalities, where an open bite or a micrognathic mandible seems to be the major finding. 3·28 This may also explain why only two patients in this material had an anterior open bite. The right time for surgical intervention is difficult to determine. The authors have experienced the fact that arthritic TMJ disease may fluctuate considerably. This is recently shown in a case report on arthritic TMJ disease 21 and is also in accordance with other joints similarly involved.20 Since short-term effects have been reported in the TMJ treatment of patients with arthritic disease; splint therapy and steroid injection, 10·29 as well as transcutaneous electrical nerve stimulation therapy, 8 are recommended in the first place. One should always observe the patients clinically and radiologically for some time before the surgery is performed. However, synovectomy in an early stage of the disease may probably prevent more severe joint destruction, with the development of an open bite or fibrous/ bony ankylosis, as found in some patients. Observations following surgery in the knee joint have indicated that early synovectomy may prevent the destruction of cartiJULY 1992, VOL. 10, NO.3
lage and bone. 20 One patient with fibrous ankylosis developed bony ankylosis after unilateral TMJ surgery. This patient was operated on bilaterally in a later procedure. One might speculate whether a bilateral procedure would have prevented the development of a bony ankylosis in the first place because of better functioning immediately after surgery. In joints with arthritic disease and advanced bone destruction, or fibrous ankylosis, bilateral involvement was always seen. The high frequency of bilateral TMJ surgery corresponds well with the findings of Larheim et al.,Z who found that 72% of patients with arthritic disease had bilateral radiographic involvement. This is in contrast to the high frequency of unilateral surgery on internal derangement reported by Isacsson et alY and Eriksson and Westesson. 30 Though surgical treatment of internal TMJ derangement most frequently seems to be unilateral in contrast to surgical treatment of arthritic TMJ disease, imaging studies have demonstrated that bilateral TMJ derangement often occursY It should be stressed that even in patients with arthritic disease, bilateral TMJ problems may be due to nonarthritic internal derangement, as experienced in one patient in the present series. In the treatment of arthritic patients with nonarthritic TMJs, physical therapy, splint therapy and steroid injection are recommended. 29 The indications for diskectomies will be the same as in other patient populations. 30 In summary, most patients with arthritic disease and symptomatic TMJ involvement will, in the authors' experience, not be candidates for diskectomy and synovectomy. As previously discussed, the disease activity may fluctuate considerably and TMJ problems may have low priority compared with other joints more severely involved. This may explain the great variations found in studies of the TMJ involvement in patients with arthritic disease.' The authors' short-term results with surgical TMJ treatment of patients with arthritic disease have so far been very encouraging, but future studies are needed to show the long-term effect on pain, function, and progression of the disease in this area.
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Lindblad S, Hedfors E: lntraarticular variation in synovitis. Local macroscopic and microscopic signs of inflammatory activity are significantly correlated. Arthritis Rheum 1985; 28:977-986 Pahle JA, Kvames L: Shoulder replacement arthroplasty. Ann Chir Gynaeco/ 1985; 74 (suppl 198):85-89 Stabrun A, Larheim TA. Hiiyeraal HM, Riisler M: Reduced mandibular dimensions and asymmetry in juvenile rheumatoid arthritis. Pathogenetic factors. Arthritis Rheum 1988; 31:602-611 Kopp S, Wenneberg B: Effects of occlusal treatment and intra-articular injections on temporomandibular joint pain and dysfunction. Acta Odontol Scand 1981; 39:87-96 Eriksson L, Westesson P-L: Diskectomy in the treatment of anterior disk displacement of the temporomandibular joint. A clinical and radiologic one-year follow-up study. J Prosthet Dent 1986; 55:106-116 Sanchez-Woodworth RE, Tallents RH, Katzberg RW, Guay JA: Bilateral internal derangements of temporomandibular joint: Evaluation by magnetic resonance imaging. Oral Surg Oral Med Oral Patho/ 1988; 65:281-285
Dr. Hans R. Haames received his D.D.S. and M.D. degrees from the Dental and Medical Faculties, University of Oslo, in 1963 and 1976, respectively. He was Chief Resident in the Department of Oral and Maxillofacial Surgery at Vanderbilt University, School of Medicine, in Nashville, Tennessee, from 1977 to 1978. He became a professor in the Department of Oral Surgery and Oral Medicine, Oslo University, Dental Faculty, in 1979. Since 1985 he has been chairman of the department. He was president of the Norwegian Association of Oral Surgery from 1980 to 1986, a member of the board of the Scandinavian Association of Oral and Maxillofacial Surgery from /983 to 1986, and a member of the Norwegian Research Committee from 1986 to /99/.
JULY 1992, VOL. 10, NO.3
ISSN: 0886-9634 (Print) 2151-0903 (Online) Journal homepage: http://www.tandfonline.com/loi/ycra20
Surgical Treatment of Temporomandibular Joints in Patients with Chronic Arthritic Disease: Preoperative Findings and One-Year Follow-Up Tore Bjørnland, Tore A. Larheim & Hans R. Haanæs To cite this article: Tore Bjørnland, Tore A. Larheim & Hans R. Haanæs (1992) Surgical Treatment of Temporomandibular Joints in Patients with Chronic Arthritic Disease: Preoperative Findings and One-Year Follow-Up, CRANIO®, 10:3, 205-210, DOI: 10.1080/08869634.1992.11677911 To link to this article: https://doi.org/10.1080/08869634.1992.11677911
Published online: 18 Feb 2016.
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• ORAL SURGERY
SURGICAL TREATMENT OF TEMPOROMANDIBULAR JOINTS IN PATIENTS WITH CHRONIC ARTHRITIC DISEASE: PREOPERATIVE FINDINGS AND ONE-YEAR FOLLOW-UP Tore Bj~rnland, D.D.S., Tore A. Larheim, D.D.S., Odont.Dr., Hans R. Haames, D.D.S., M.D., Odont.Dr.
0886-9634/9211 0030205$03.00/0, THE JOURNAL OF CRANIOMANDIBULAR PRACTICE, Copyright © 1992 by Williams & Wilkins
Manuscript received November 15, 1991 ; accepted March 2, 1992 Address for reprint requests: Tore Bjemland, D.D.S. Department of Oral Surgery and Oral Medicine Faculty of Dentistry University of Oslo P.O.B. 1109-Biindem 0317 Oslo 3 Norway
ABSTRACT: Twenty-nine temporomandibular joints (TMJs) in 19 patients with chronic arthritic disease were surgically treated. Nine patients had rheumatoid arthritis (including two with juvenile type), six had ankylosing spondylitis and four had psoriatic arthropathy. Using a preauricular approach, diskectomies with synovectomies were performed in 23 joints (14 patients) with chronic arthritic abnormalities. Diskectomies without synovectomies were performed in six joints (five patients), which proved to have internal derangements unrelated to their chronic arthritic disease. Joints with chronic arthritis showed considerable variation in inflammatory reactions, but were characterized by increased vascularization, synovial proliferation to the articulating surfaces and mostly pannus formation and bone resorption. A response in pain relief was seen in 85% of the patients three months Dr. Tore Bjtlrnland received his postoperatively and in 79% of the patients 12 months postD.D.S. degree from Faculty of Dentistry. University of Bergen, Norway, in operatively, indicating that diskectomy with synovectomy 1976. He completed the oral surgery may be favorable in patients with severe TMJ problems residency program in Oslo, Norway, in due to involvement of chronic arthritic disease. 1984, and from 1985 to 1988 he was a research fellow in Oral Surgery, Faculty of Dentistry, Oslo. Since 1988 he has been an assistant professor in the Department of Oral Surgery and Oral Medicine, Faculty of Dentistry, University of Oslo. He has been president of the Norwegian Association of Oral Surgery since 1989 and is the Norwegian representative in the European House of Representatives in Oral and Maxillofacial Surgery.
C
linical and radiographic findings of the temporomandibular joint (TMJ) in patients with chronic arthritic disease have been described in several studies. 1-5 Recently, imaging modalities for the assessment of soft-tissue abnormalities in symptomatic TMJs in such patients have become available. 6·7 However, little attention has been paid to the TMJ treatment ofthis group of patients. 8- 10 Synovectomy is a common procedure in patients with chronic arthritic disease. 11 - 13 However, surgical treatment with diskectomy and synovectomy of the TMJ has only been described in a case report. 14 Reconstruction of the TMJ has been reported in cases with advanced destruction.15 Some cases of bony TMJ ankylosis due to chronic arthritis, surgically treated, have additionally been reported.l6.17 In the following, the authors report their initial experiences with surgical treatment of symptomatic TMJs in a series of 19 patients with chronic arthritic disease.
Dr. Tore A. Larheim received his D.D.S. degree in 1973 from the Faculty of Dentistry, University of Oslo, Norway. He became a research assistant in 1976 in the Department of Oral Radiology at the same university, received his Odont.Dr. (Ph.D.) degree in 1981, and then became associate professor of oral radiology. From 1985 he has been professor and chairman of the Department of Oral Radiology, Faculty of Dentistry, University of Oslo. He is a member of the Norwegian Dental Association, the International Association of DentoMaxillo-Facial Radiology, and an associate member of the Norwegian Society of Radiology and Norwegian Society of Rheumatology.
Material and Methods The 19 patients had severe TMJ problems and a total 205
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of 29 TMJs were treated with surgery. The patients had been examined by rheumatologists who had stated a diagnosis of chronic arthritis in one or more other joints before they were referred for TMJ examination. This group of patients represented only a small number of the patients with chronic arthritic disease and TMJ symptoms referred to the authors' departments. The patients consisted of 17 women and two men, ranging in age from 17 to 64 years (mean age was 37 years). Nine patients had rheumatoid arthritis (including two with juvenile type), six had ankylosing spondylitis, and four had psoriatic arthropathy. The duration of the chronic arthritic disease varied from one to 23 years (the mean was 10 years), and the duration of TMJ symptoms varied from one to 12 years (with a mean of four years). Preoperative signs and symptoms of these joints are listed in Table 1. Preoperative imaging was performed with methods previously described. 18 Radiographic examination was made of all patients, including panoramic and lateral transcranial radiography, as well as hypocycloidallateral tomography. Supplementary examinations were made of 15 patients; arthrotomography in 13, computed tomography in six, and/or magnetic resonance imaging (MRI) in eight patients. Imaging evaluation included assessment of disk position and shape, perforation, joint space irregularities, and bone abnormalities. Attempts were made to classify the TMJs as arthritic or nonarthritic. Evaluation of possible arthritic changes of the neck was always made before the operations and included lateral radiographs in flexion and extension. Two patients had a planned tracheostomy because of neck stiffness. The remaining 17 patients had general nasoendotracheal anesthesia. The criteria for surgery included TMJ pain and impaired function not alleviated by previous therapy such
as: splints, physical therapy, intra-articular injection of steroids and pharmacotherapy, in addition to imaging interpretation of soft-tissue abnormalities with or without involvement of bone. Preoperatively 15 patients were classified as arthritic and four were classified as nonarthritic concerning their TMJ abnormalities. The nonarthritic joints showed internal derangements (anterior disk displacements). The planned surgical treatment was synovectomy and diskectomy with debridement of joints preoperatively assessed as arthritic, including SILASTIC® implants* in two cases of bony ankylosis. Bilateral procedures were made in five patients: two patients with bony ankylosis in one joint and fibrous ankylosis in the contralateral, and three patients with indistinguishable symptoms from the right and left joints. In joints where the preoperative findings indicated nonarthritic internal derangements, only diskectomies were planned. During the surgical procedure, systematic assessment of the soft and hard tissues and the function of the joint were recorded: visible synovitis; increased vascularization, synovial proliferation to the articulating surfaces and pannus formation, as well as disk position and shape, fibrous adhesions, destructions and remodeling of the condyle and fossa, and translation of disk and condyle. Results The observations are summarized in Table 2. Of the 29 joints (19 patients), 23 TMJ s (14 patients) showed chronic arthritic disease at surgery (Table 2). The findings were characteristic soft-tissue abnormalities; increased vascularization of the capsule, attachments and synovial membrane, thickening of the synovial membrane and proliferation to the articulating surfaces and mostly pannus formation. *SILASTJCI!I>-Dow Coming Corporation, Midland, Michigan.
Table 1 Clinical TMJ Status at Preoperative and Postoperative Examinations in 19 Patients (29 Joints) with Chronic Arthritic Disease Preoperative
Signs and symptoms* TMJ pain TMJ pain and myalgia No pain Joint sounds No sounds Open bite (n patients) Vertical opening (mm) Mean Range *n
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n
= 29
Postoperative 3 Months 12 Months
n
= 29
n
Table 2 Peroperative Observations in the Temporomandibular Joint (TMJ) of 19 Patients* with Chronic Arthritic Disease
= 29
Surgical TMJ Diagnosis
Synovial proliferation/ pannus formation Fibrous adhesions Fibrous ankylosis Bone resorption Bony ankylosis Normal disk position Anterior disk position Completely destroyed disk
8 19 2 9 20 2
2 2 25 10 19 2
3 2 24 II 18 2
19 2 to 31
32 25 to 45
33 I to 45
= number of joints. THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
Arthritic TMJs (n = 23)
Nonarthritic TMJs (n = 6)
21 16 2 21 2 13 5 5
0 5 0 6 0 0 6 0
*n = 29 joints.
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Figure 2 Figure 1 Preoperative TMJ examination of a 28-year-old woman with juvenile rheumatoid arthritis. A, Lateral tomogram shows normal bone. B, Arthrotomogram with maximally opened mouth (severely impaired) shows contrast medium in both compartments (upper compartment filled through perforation. preoperatively assessed to be in the central thin part of the disk), small compartments (0.45 ml contrast medium injected), some irregularity in the outline of the contrast medium, indicating synovial proliferation, and a normal disk position.
The inflammatory reactions were seen in both joint compartments and showed considerable variations, from increased vascularization with synovial proliferation (and normal bone) (Figure 1), to severe pannus formation (and bone resorption) (Figure 2). Increased vascularization of the surgical fields made the surgery more difficult to perform compared to diskectomy in patients with only internal derangement. More tedious ligation and coagulation of vessels were necessary, but no excessive bleeding was seen. Only two joints showed an increased amount of synovial fluid. In five joints the disk was completely destroyed without any visible remnants (Table 2). The remaining 18 joints showed a disk shape that varied from apparently normal to increased or decreased thickness. Four perforations seemed to be in the central region of the disk (Figure 1) and only two perforations were found in the junction between the disk and the posterior attachment. The disk position was found to be normal in 13 of the 18 joints (Table 2) and (Figure 1). Internal derangement was additionally found in the other five; a nonreducing disk displacement in four, and a reducing disk displacement in one joint. Twenty-one of the 23 joints with chronic arthritis had bone abnormalities (Table 2). The changes varied from small erosions to severe condylar destructions and flattening with evident remodeling. One patient with advanced destruction of the condyle showed bone apposition of both the fossa and the tubercle. Two joints showed bony ankylosis (Figure 3). Six joints (five patients) did not show any signs of chronic arthritic disease (Table 2). The soft-tissue changes consisted of internal derangement; a nonreducing disk displacement with perforations in four joints and a reducing disk displacement in two joints. All perforaJULY 1992, VOL. 10, NO. 3
Left TMJ arthroplasty of a 24-year-old woman with ankylosing spondylitis. A, Upper joint space with the disk in place after the removal of fibrous adhesions between the fossa and the disk. 8, Condyle with pannus formation and thickening of the synovial membrane at the anterior and superior part of the condyle, and resorptions of the condyle. C, After synovectomy and diskectomy the joint space and mobility of the joint is increased.
tions seemed to occur in the junction between the disk and the posterior attachment. Five joints had fibrous adhesions. All joints had bone abnormalities with resorptions of the condyle. Complications Complications were seen in three (15%) ofthe patients. The most serious complication was seen in a patient whose vocal cords had been affected during the intubation. The voice normalized after the removal of inflammatory tissue on the vocal cords. In another patient a possible subluxation of the neck occurred during the intubation or the surgery. The patient had to wear a neck collar for about four months and had, in the beginning, some pain in the neck and arms but without paresis or paresthesia. The symptoms disappeared after approximately six months. One patient with fibrous ankylosis developed bony
Figure 3 Left TMJ arthroplasty of a 32-year-old man with ankylosing spondylitis and bony ankylosis. A, A gap arthroplasty is made with the removal of approximately 5 mm of the condyle. B, Insertion of SILASTIC® implant secured with two Titanium® screws.t tTitanium® screws-0. Leibinger, Miihlheim-Stetten, Germany.
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ankylosis approximately 10 months after the first operation. A bilateral procedure was then performed and the jaw mobility was measured at 30 mm one year after the operation, though with some pain at maximal opening. Postoperative Results All the patients were seen daily for four to six days after the operation and thereafter weekly for the first month. They were then seen at three and 12 months postoperatively (Table 1). Surgery had an effect on pain at rest and motion in 16 patients (85%) three months postoperatively. Two patients with fibrous ankylosis reported feeling only ''somewhat better'' and one patient with fibrous ankylosis reported no effect on pain after the first three postoperative months. At 12 months postoperatively four patients (five joints) had pain in the TMJ and/or associated muscles (21% of the patients). The range of motion increased on the average 8 mm (with a range of 2 to 22 mm) during the first three to four days and gradually during the next weeks giving an increased mean value of 13 mm (range of 2 to 23 mm) three months postoperatively (Table 1). At 12 months postoperatively the mean range of motion had increased 14 mm (with a range of I to 28 mm in 18 patients and decreased 1 mm in one patient). The joint sounds increased slightly postoperatively (Table 1) and were crepitus, whereas preoperatively two joints had crepitus, two joints had crepitus and clicking, and five joints had clicking. Discussion Though many clinical radiographic TMJ studies of patients with chronic arthritic diseases are available, macroscopic histologic evidence of chronic arthritic TMJ involvement has only been demonstrated in autopsy studies19 and in a case report. 14 The present study clearly showed that both soft-tissue abnormalities and bone abnormalities due to chronic arthritic involvement are frequent findings in the TMJs, as observed in other joints similarly involved. 12·20 Synovial proliferation as the most characteristic surgical finding is also in accordance with a single case report, showing rheumatoid TMJ arthritis without fibrous or bony ankylosis.14 As experienced from the present series and for obvious reasons, synovial proliferations are not found in advanced cases. Soft-tissue abnormalities, as indicated by arthrotomographic examination (Figure 1), were, on the other hand, seen in two joints without bone abnormalities. The value of arthrotomography for early TMJ involvement of chronic arthritis was thus demonstrated.
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Since a correct TMJ diagnosis is very important for the surgical planning of patients with chronic arthritic disease, the soft tissue should be evaluated by arthrotomography or MRI. In advanced cases, however, such as suspected bony ankylosis, computed tomography seems to be more valuable. 18 The disk position was most frequently normal in joints involved by chronic arthritic disease, supporting recent imaging studies.6·7 Interestingly, a rather high frequency (38%) of these joints had perforations, mostly in the central thin portion of the disk. Perforation occurred even in a joint with normal bone (Figure 1), indicating a disk fixed to the condyle due to synovial proliferation and adhesions. Almost one third of the joints with chronic arthritis was accompanied by internal derangements. This has been indicated by imaging, 6·7 but is surgically demonstrated for the first time in the present series. The anterior disk position may be an incidental finding. Recently, however, a longitudinal MRI study of an arthritic TMJ in a patient with psoriatic arthropathy showed development of disk displacement, which was suggested to be related to the arthritic disease process. 21 Whether or not there is a causal relationship, it is possible that a TMJ may be more problematic for the patient if the disease involvement is accompanied by anterior disk displacement. To differentiate between an arthritic TMJ accompanied by anterior disk displacement and internal derangement without concomitant arthritic signs may, however, be difficult or impossible, even with advanced imaging modalities. 18 Synovial proliferations and fibrous adhesions cannot be reliably distinguished with arthrotomography or detected with MRI. 18 In two joints the disk position was interpreted as being anterior at imaging, but normal at surgery. 18 Surgical observation of a normal disk position, grouped displaced at imaging, can be made if the condylar resorption is not taken into consideration. Another possibility may be that the posterior attachment is adapted to the anterior disk displacement by connective tissue hyalinization, simulating a normal position clinically. 22·23 This study clearly demonstrated that severe TMJ problems in patients with chronic arthritis may be due to internal derangements, indistinguishable from internal derangements in other patients. This has also been indicated by recent imaging studies on patients with chronic arthritis, evaluating not only the bone but also the soft tissue. 6·7 However, most earlier TMJ studies in this field have not discussed the possibility that the clinical and radiographic abnormalities observed could be due to another condition than the patient's arthritic disease. Surgical treatment of arthritic disease in the TMJ with diskectomy and synovectomy proved to be very effective
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on TMJ pain and jaw mobility in this short-term study. This corresponds well with the result of synovectomies of other joints in patients with arthritic disease, where the clinical improvement primarily consisted of relief of pain and better function. 13 ·20·24 Follow-up studies of synovectomies in the knee joint also suggest a delay in the destruction of bone. 20·25 It is recommended to remove all inflamed synovial membrane and to perform a total knee meniscectomy. 20 Therefore, in this series synovectomies routinely included diskectomies. In one joint, however, the disk seemed to be entirely normal and was left in place, with the removal of the inflamed synovial tissue. Such a procedure should be considered only in joints without synovial proliferations in the disk. The authors' case will be thoroughly examined at postoperative visits, particularly with regard to the possible development of bone changes postoperatively. The surgical TMJ treatment was effective, despite the great variation of arthritic abnormalities, from small synovial proliferation to severe bone destruction. This is in contrast to other joints where severe destruction of the articulating surfaces often leads to a higher degree of disability, 20 ·24 ·26 and where joint replacement with arthroplasty, rather than synovectomy, is the treatment of choiceY Great variations were also seen between pain and the objective findings of arthritic TMJ disease, i.e., bone resorption, open bite and restricted jaw mobility. TMJ pain was a greater problem in patients with minor joint abnormalities compared with arthritic TMJs with advanced abnormalities, where an open bite or a micrognathic mandible seems to be the major finding. 3·28 This may also explain why only two patients in this material had an anterior open bite. The right time for surgical intervention is difficult to determine. The authors have experienced the fact that arthritic TMJ disease may fluctuate considerably. This is recently shown in a case report on arthritic TMJ disease 21 and is also in accordance with other joints similarly involved.20 Since short-term effects have been reported in the TMJ treatment of patients with arthritic disease; splint therapy and steroid injection, 10·29 as well as transcutaneous electrical nerve stimulation therapy, 8 are recommended in the first place. One should always observe the patients clinically and radiologically for some time before the surgery is performed. However, synovectomy in an early stage of the disease may probably prevent more severe joint destruction, with the development of an open bite or fibrous/ bony ankylosis, as found in some patients. Observations following surgery in the knee joint have indicated that early synovectomy may prevent the destruction of cartiJULY 1992, VOL. 10, NO.3
lage and bone. 20 One patient with fibrous ankylosis developed bony ankylosis after unilateral TMJ surgery. This patient was operated on bilaterally in a later procedure. One might speculate whether a bilateral procedure would have prevented the development of a bony ankylosis in the first place because of better functioning immediately after surgery. In joints with arthritic disease and advanced bone destruction, or fibrous ankylosis, bilateral involvement was always seen. The high frequency of bilateral TMJ surgery corresponds well with the findings of Larheim et al.,Z who found that 72% of patients with arthritic disease had bilateral radiographic involvement. This is in contrast to the high frequency of unilateral surgery on internal derangement reported by Isacsson et alY and Eriksson and Westesson. 30 Though surgical treatment of internal TMJ derangement most frequently seems to be unilateral in contrast to surgical treatment of arthritic TMJ disease, imaging studies have demonstrated that bilateral TMJ derangement often occursY It should be stressed that even in patients with arthritic disease, bilateral TMJ problems may be due to nonarthritic internal derangement, as experienced in one patient in the present series. In the treatment of arthritic patients with nonarthritic TMJs, physical therapy, splint therapy and steroid injection are recommended. 29 The indications for diskectomies will be the same as in other patient populations. 30 In summary, most patients with arthritic disease and symptomatic TMJ involvement will, in the authors' experience, not be candidates for diskectomy and synovectomy. As previously discussed, the disease activity may fluctuate considerably and TMJ problems may have low priority compared with other joints more severely involved. This may explain the great variations found in studies of the TMJ involvement in patients with arthritic disease.' The authors' short-term results with surgical TMJ treatment of patients with arthritic disease have so far been very encouraging, but future studies are needed to show the long-term effect on pain, function, and progression of the disease in this area.
References I.
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Carlsson GE, Kopp S, Oberg T: Arthritis and allied diseases of the temporomandibular joint. In Zarb GA. Carlsson GE (eds), Temporomandibular Joint. Function and Dysfunction. Copenhagen: Munksgaard, 1979; 269-320 Larheim T A, Johannessen S, Tveito L: Abnormalities of the temporomandibular joint in adults with rheumatic disease. A comparison of panoramic, transcranial and transpharyngeal radiography with tomography. Dentomaxillofac Radio/1988; 17:109-113 Wenneberg B. Kopp S: Clinical findings in the stomatognathic system in ankylosing spondylitis. Scand J Dent Res 1982; 90:373-381
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Lindblad S, Hedfors E: lntraarticular variation in synovitis. Local macroscopic and microscopic signs of inflammatory activity are significantly correlated. Arthritis Rheum 1985; 28:977-986 Pahle JA, Kvames L: Shoulder replacement arthroplasty. Ann Chir Gynaeco/ 1985; 74 (suppl 198):85-89 Stabrun A, Larheim TA. Hiiyeraal HM, Riisler M: Reduced mandibular dimensions and asymmetry in juvenile rheumatoid arthritis. Pathogenetic factors. Arthritis Rheum 1988; 31:602-611 Kopp S, Wenneberg B: Effects of occlusal treatment and intra-articular injections on temporomandibular joint pain and dysfunction. Acta Odontol Scand 1981; 39:87-96 Eriksson L, Westesson P-L: Diskectomy in the treatment of anterior disk displacement of the temporomandibular joint. A clinical and radiologic one-year follow-up study. J Prosthet Dent 1986; 55:106-116 Sanchez-Woodworth RE, Tallents RH, Katzberg RW, Guay JA: Bilateral internal derangements of temporomandibular joint: Evaluation by magnetic resonance imaging. Oral Surg Oral Med Oral Patho/ 1988; 65:281-285
Dr. Hans R. Haames received his D.D.S. and M.D. degrees from the Dental and Medical Faculties, University of Oslo, in 1963 and 1976, respectively. He was Chief Resident in the Department of Oral and Maxillofacial Surgery at Vanderbilt University, School of Medicine, in Nashville, Tennessee, from 1977 to 1978. He became a professor in the Department of Oral Surgery and Oral Medicine, Oslo University, Dental Faculty, in 1979. Since 1985 he has been chairman of the department. He was president of the Norwegian Association of Oral Surgery from 1980 to 1986, a member of the board of the Scandinavian Association of Oral and Maxillofacial Surgery from /983 to 1986, and a member of the Norwegian Research Committee from 1986 to /99/.
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