Göran W. Gynther

Disk derangement and inflammatory changes in the posterior disk attachment of the temporomandibular joint: A histologic study☆

Temporomandibular joint disk derangements were investigated in 42 patients (47 joints) with respect to occurrence and degree of histologic inflammation in the posterior disk attachment and compared with reference material obtained at autopsy. Sensitivity and specificity for arthroscopy versus macroscopic observation at arthrotomy in regard to inflammation were also investigated. On histologic examination, inflammation was found in 1 joint (5.5%) in the reference material and 30 joints (64%) in the patients where pronounced inflammation was found in 6 joints (20%). Arthroscopy revealed inflammation more accurately (sensitivity 0.94%, specificity 0.86%) than macroscopic observation at arthrotomy (sensitivity 0.58%; specificity 0.90%).

Diskectomy in treatment of internal derangement of the temporomandibular joint: Follow-up at 1, 3, and 5 years

The efficacy of temporomandibular joint diskectomy without implants was evaluated clinically in patients with internal derangements. Seventy-two patients were examined preoperatively and 1 year postoperatively; 40 were also examined 3 years postoperatively and 15 at 5 years after surgery. Success rates were calculated according to a modification of the criteria established in 1984 by the American Association of Oral and Maxillofacial Surgery. The success rate was 83% at the 1-year follow-up. Temporomandibular joint pain was alleviated and chewing capacity was normalized in 60 patients. The outcome in 12 patients was classified as unsuccessful, mainly on the basis of residual muscle and joint pain. At the 3-year follow-up only two patients were classified as unsuccessful and none at the 5-year follow-up. Unsuccessful patients had higher frequencies of muscle soreness and osteoarthrosis than successful patients. Postoperative complications were infrequent and minor.

Implant treatment without bone grafting in severely resorbed edentulous maxillae.

PURPOSE This article describes the surgical technique for implant treatment in severely resorbed edentulous maxillae without any alveolar reconstruction before or combined with implant placement. PATIENTS AND MATERIAL Fifteen patients with severely resorbed edentulous maxillae were treated with osseointegrated implants and fixed dental prostheses. All patients were initially considered to be treated with bone grafting because of a lack of sufficient bone volume for conventional treatment. Preoperative radiographic examinations showed that the height of the alveolar crest was on average 7.4 mm at the 4-mm-width level (Classes V to VI). RESULTS By fenestration of the maxillary sinus and uncovering the nasal floor, the maxillary bone could be visualized and used maximally for installation of implants. By angulation of the implants and permitting two to five uncovered fixture threads on the palatal aspect, implants of optimal length could be installed. Eighty-six implants were placed (four to six implants in every patient). One implant was lost during the observation time (range, 36 to 54 months; mean, 45 months). All patients had stable fixed prostheses at the end of the observation time. CONCLUSION This cost-effective surgical technique may be considered as an alternative to more resource-demanding techniques such as bone grafting in patients with severely resorbed edentulous maxillae. However, further prospective comparative studies are necessary for full evaluation.

Dental implant installation without antibiotic prophylaxis

The objective of this study was to retrospectively compare the outcomes of dental implant treatment with and without antibiotic prophylaxis. Two groups of patients with edentulous or partially edentulous maxillas or mandibles (or both) were treated with dental implants. One group, consisting of 147 patients (790 implants), was given prophylaxis with oral phenoxymethylpenicillin; 1 g of antibiotic was administered 1 hour preoperatively, and 1 g was administered every 8 hours for 10 days postoperatively. The other group, consisting of 132 patients (664 implants) was not given any antibiotics preoperatively or postoperatively. There were no significant differences with respect to early and late postoperative infections or with respect to implant survival between the two groups. It appears that antibiotic prophylaxis for routine dental implant surgery offers no advantage for the patient.

Temporomandibular joint involvement in generalized osteoarthritis and rheumatoid arthritis: a clinical, arthroscopic, histologic, and immunohistochemical study

Twenty patients having generalized osteoarthritis (GOA) and symptomatic temporomandibular joints (TMJs) were compared with 22 patients having rheumatoid arthritis (RA) and TMJ symptoms, and also with an age-matched reference tissue material obtained at autopsy from 17 TMJs. Muscle tenderness was commoner in GOA. Arthroscopically, high frequencies of synovitis, degenerative changes, and fibrosis were observed in both groups, with more pronounced inflammatory and degenerative changes in RA patients, despite a shorter duration of TMJ symptoms. A correlation was noted between lateral joint tenderness and pronounced synovitis in RA patients. Histologic and immunohistochemical examinations added useful information to arthroscopy and showed similarly high frequencies of synovial inflammation in GOA and RA patients, differing clearly from those in the reference material. Connective-tissue degeneration was commoner in GOA patients. GOA and RA probably have different causes, but, interestingly, the tissue reaction was similar in the TMJs, although pronounced inflammatory and degenerative changes seemed to develop faster in RA.

Radiographic changes in the temporomandibular joint in patients with generalized osteoarthritis and rheumatoid arthritis.

This is the first study concerned with radiographic characteristics in patients with generalized osteoarthritis and signs and symptoms of temporomandibular joint involvement. For comparison, patients with rheumatoid arthritis and temporomandibular joint involvement were used. The patient material comprised 20 patients with generalized osteoarthritis (20 joints) and 21 patients with rheumatoid arthritis (21 joints). The radiographic methods were corrected sagittal tomography (hard tissue changes, joint space, and condylar position), frontal tomography (hard tissue changes), and individualized oblique lateral transcranial projections (condylar translation). Sixteen (80%) joints in the group of patients with generalized osteoarthritis and 15 (71%) joints in the group with rheumatoid arthritis revealed structural changes. The condyle was the predominant location. No radiographic criterion was pathognomonic for generalized osteoarthritis or rheumatoid arthritis. However, osteophytes, flattening of the condyle, or a reduced joint space was observed more often in joints with generalized osteoarthritis, whereas erosions in the condyle were more common in joints with rheumatoid arthritis. The radiographic findings in patients with generalized osteoarthritis are more similar to those seen in patients who have the common form of temporomandibular joint osteoarthritis than to those in patients with rheumatoid arthritis.

Efficacy of arthroscopic lysis and lavage in patients with chronic locking of the temporomandibular joint

This prospective 1-year follow-up investigated the efficacy of temporomandibular joint lysis and lavage in relation to arthroscopic diagnoses. The study comprised 42 patients. Clinical evaluation was performed before surgery and at regular intervals up to 1 year postoperatively. Diagnostic arthroscopy and immediately subsequent lysis and lavage were performed under local anesthesia in all patients. Only unilateral upper compartment arthroscopies were executed. The results were evaluated according to the 1984 criteria of the American Association of Oral and Maxillofacial Surgeons. Osteoarthrosis was diagnosed arthroscopically in 30 joints (71%), 21 of which (70%) had more pronounced changes. Synovitis, mainly of a mild, localized type, was diagnosed in 39 joints (93%). More pronounced synovitis was found arthroscopically in 12 (31%). Adhesions were found in 20 joints (48%) and were significantly correlated with joints displaying osteoarthrosis (P < 0.001). The overall success rate for arthroscopic lysis and lavage was 50% (21/42 joints). The best response to lysis and lavage was in joints with arthroscopic diagnosis of pronounced synovitis (8/12 joints; 67%). All 21 joints regarded as unsuccessful were operated with diskectomy without implants. The success rate at 1-year follow-up was 18 joints (86%).

Synovitis in internal derangement of the temporomandibular joint: Correlation between arthroscopic and histologic findings

PURPOSE To define arthroscopic criteria for synovitis (SYN) reflecting specific histologic changes. Arthroscopic observations in the temporomandibular joint of patients with internal derangement were compared with histologic patterns in synovial biopsies obtained during arthroscopy. PATIENTS AND METHODS Arthroscopic biopsies were obtained in 31 joints of 31 patients using an oriented semiblind technique. The histologic changes in the biopsies were compared with those in age-matched reference material obtained at autopsy. RESULTS Microscopic examination of the reference material showed inflammation in three specimens (18%), whereas it showed inflammation in 22 patient specimens (71%). Biopsies from the patients also exhibited more pronounced inflammation. According to conventional criteria, arthroscopy showed mild SYN (increased vascularity) in 51%, moderate changes in 39%, and more pronounced changes in 10% of the joints. The presence of moderate or pronounced arthroscopic signs of SYN (capillary hyperemia and synovial hyperplasia), correlated well with the histologic diagnosis of SYN. This was in contrast to patients with mild arthroscopic SYN (increased vascularity). CONCLUSION Increased vascularity seen during arthroscopy must be questioned as a sign of SYN. More reliable criteria seem to be capillary hyperemia and synovial hyperplasia.

Synovial inflammation in arthroscopically obtained biopsy specimens from the temporomandibular joint : A review of the literature and a proposed histologic grading system

Data indicate that the synovial lining of the temporomandibular joint (TMJ) in some respects differs from other joints. The normal variation in morphology of the synovial lining of the TMJ is quite great, whereas the variation in pattern of pathologic changes appears to be relatively small (ie, synovial inflammation is not of the severity as that in other joints). In the current review, a system for histologic grading of synovial inflammation is proposed. The system is based on semiquantitative evaluation of the following set of parameters: 1) synovial lining cell layers; 2) vascularity (number or size of vascular profiles); and 3) Inflammatory cell infiltrate (commonly lymphocytes).

Rheumatoid arthritis and disk derangement of the temporomandibular joint: A comparative arthroscopic study

Consecutive patients with clinical diagnoses of disk derangement and rheumatoid arthritis with temporomandibular joint (TMJ) signs and symptoms were compared by clinical, radiographic, and arthroscopic examination. Synovial biopsies were obtained from patients with arthroscopic features of synovial inflammation. No clinical sign or symptom was found to be specific of rheumatoid involvement although joint crepitation was most frequently found in rheumatic patients (p less than 0.001). Tomographic features of subchondral bone involvement were more frequently revealed in TMJs of rheumatic patients (p less than 0.001). At arthroscopy rheumatic patients often showed pronounced arthrotic changes and inflammation. In contrast to patients with disk derangement, fibrosis of the TMJ was frequent (p less than 0.001). Histologic examination of obtained synovial specimens correlated well with arthroscopic findings, and more pronounced inflammation was present in specimens from rheumatic patients.