Shanyong Zhang

Septic Arthritis of the Temporomandibular Joint: A Retrospective Review of 40 Cases

PURPOSE Septic arthritis of the temporomandibular joint is an uncommonly reported entity. The aim of the present study was to review the cases treated at our clinic, analyze the characteristics of this disease and the responses to management, and recommend a protocol for managing suspected cases. PATIENTS AND METHODS A total of 40 consecutive patients were included from 1995 to 2007. Their demographics, predisposing factors, clinical manifestations, radiologic findings, joint fluid analysis results, treatment, and outcomes were reviewed. RESULTS The 40 patients included 26 men and 14 women, with an average age of 36 years. Original infections were found in 15 patients (local spread in 4 and hematogenous dissemination from a distant site in 11). All patients complained of trismus and tenderness in the temporomandibular joint. Sudden malocclusion was found in 33 patients. Joint space widening and limitation of condyle movement were demonstrated by plain film in 33 patients. Increased joint effusion was confirmed by magnetic resonance imaging in 7 patients. Joint fluid was obtained from 35 patients. A high level of neutrophils and fibrin were found under microscopy with hematoxylin-eosin staining. Staphylococcus saprophyticus and S. aureus were cultured from 5 patients. Arthrocentesis under low pressure was applied to 35 patients, and arthroscopy was used in 9 patients. Major sequelae occurred in 11 patients, including fibrosis in 2 and postinfectious osteoarthritis in 9. CONCLUSIONS Septic arthritis of the temporomandibular joint mainly arises from hematogenous spread, but the original infection is often occult. Antibiotic therapy, arthrocentesis under low pressure, and joint immobilization are recommended for patients in the acute stage. The common sequela is osteoarthritis.

Application of Rapid Prototyping for Temporomandibular Joint Reconstruction

PURPOSE To introduce the preliminary application of rapid prototyping (RP) for temporomandibular joint (TMJ) surgery. MATERIALS AND METHODS This study included 11 consecutive patients (13 joints) seeking TMJ replacement. All patients had previously undergone 3-dimensional computed tomography (CT) scanning (0.625-mm slice thickness) of the craniofacial skeleton. The data from CT scanning in DICOM (Digital Imaging and Communications in Medicine) format were input into the interactive Simplant CMF software program (Materialise Medical, Leuven, Belgium). Preoperative planning included segmentation and osteotomies. The movements of the jaw bones were simulated by use of Simplant CMF. The affected mandible was reconstructed based on the contralateral side. Then, the titanium plate was shaped on the reconstructed model before surgery. The bone graft was transplanted by the shaped titanium plate during the operation to reconstruct the TMJ. Twenty-four patients who underwent traditional surgery were used as the control group. The operative time of the 2 groups was analyzed with the SPSS software package, version 13.0 (SPSS, Chicago, IL), with the Student t test. The data from CT scanning in the experimental group before and after surgery were compared by paired t test. RESULTS All the incisions healed primarily without any complications. All patients were satisfied with the operation, because of their symmetric faces and good occlusion. Postoperative magnetic resonance imaging confirmed the position of the transplanted costochondral cartilage in the glenoid fossa. A group t test showed that the operative time was longer in the control group (mean, 7.09 hours) than that in the RP group (mean, 5.67 hours). Three parameters (condyle-incisor, condyle-mental foramen, and condyle-angle) from the postoperative CT scan were analyzed by paired t test, and there was no significant difference between the 2 sides. CONCLUSION RP technology provides an advanced method for TMJ reconstruction that can make the TMJ reconstruction more accurate and symmetric, improve the mandibles function, and consequently, enhance the reconstructive effect.

New arthroscopic disc repositioning and suturing technique for treating internal derangement of the temporomandibular joint: part II--magnetic resonance imaging evaluation.

PURPOSE To evaluate the efficiency of an arthroscopic suturing technique for stabilizing anteriorly displaced discs in patients with internal derangement of the temporomandibular joint (TMJ) by magnetic resonance (MR) imaging. PATIENTS AND METHODS Six hundred thirty-nine patients (764 joints) diagnosed as having stages II to V of internal derangement were treated with arthroscopic disc repositioning and suturing from August 2004 to March 2007. Consecutive MR images were used to evaluate internal derangement before and approximately 1 to 7 days after the operation for all 639 patients. The disc position of the TMJ was judged according to the success criteria, which included 3 different sagittal planes (lateral, central, and medial). Operative efficiency in those patients, whose discs of the TMJ were affirmed to be in a normal position in all 3 planes, was evaluated to be excellent. Those patients whose discs were in a normal position in 2 planes were evaluated to be good. The others were evaluated to be poor. Cases evaluated as excellent and good were considered success cases (if the disc is displaced only in 1 or 2 planes before operation, the efficiency of the operation would be evaluated as a success only if the whole disc was in normal position). RESULTS Postoperative consecutive MR images for all 764 joints confirmed that 95.42% (729/764) of the joints were excellent, 3.14% (24/764) were good, and only 1.44% (11/764) were poor. Repeated arthroscopic surgery or open surgery was carried out for the joints that were evaluated as poor. CONCLUSION This study indicates that the TMJ arthroscopic suturing technique is effective in repositioning the TMJ disc as confirmed by an MR imaging examination, but long-term follow-up is necessary.

Soft Tissue Reduction During Open Treatment of Intracapsular Condylar Fracture of the Temporomandibular Joint: Our Institution's Experience

PURPOSE To evaluate the effect of soft tissue reduction during open surgery of intracapsular condylar fracture (ICF) of the temporomandibular joint (TMJ). MATERIALS AND METHODS A total of 129 patients (164 TMJs) with ICF were treated from June 2004 to May 2009. Osteosynthesis was performed by different methods without stripping the lateral pterygoid muscle (LPM). The disc was reduced with or without transecting adhesions, release of the epimysium of the LPM, and anchorage to the condyle. Retrodiscal tissue tear was repaired. The patients were evaluated by computed tomography, magnetic resonance imaging, and clinical signs pre- and postoperatively. RESULTS Inferomedial displacement of the condylar segment and disc occurred in 97.6% of cases. Adhesion of the superior joint space was found in 37 of 160 TMJs (23.1%). Retrodiscal tissue tear combined with disc displacement was found in 119 of 160 TMJs (74.4%). The condylar stump was found to be superolaterally displaced in 30.6% (49/160) and laterally dislocated out of the fossa in 41.9% (69/160). A lateral capsular tear was observed in 87 of 160 TMJs (54.4%). The condylar fragments and the discs were reduced and fixed completely with preservation of the attachment of the LPM. Coronal CT revealed that 95.6% (130/160 cases) of ICFs were correctly reduced and fixed. Postoperative magnetic resonance imaging showed that the disc was reduced to its normal position in 40 of 42 TMJs. Long-term complications of 45 patients included fibrous ankylosis in 1 case (0.8%), mouth opening limitation (<2.5 cm) in 5 cases, (3.9%), condyle resorption in 3 cases (2.3%) that needed plate removal, facial nerve injury in 3 cases (2.3%), TMJ click in 2 cases (1.6%), mouth open with deviation in 7 cases (5.4%), and malocclusion in 1 case (0.8%). CONCLUSION Anatomic reduction of soft tissue was of benefit for biomechanical function of the TMJ and decreased the complications of open surgery.

Temporomandibular joint disc repositioning using bone anchors: an immediate post surgical evaluation by magnetic resonance imaging.

BackgroundOpen joint procedures using bone anchors have shown clinical and radiograph good success, but post surgical disc position has not been documented with MRI imaging. We have designed a modified technique of using two bone anchors and 2 sutures to reposition the articular discs. This MRI study evaluates the post surgical success of this technique to reposition and stabilize the TMJ articular discs.MethodsConsecutive 81 patients with unilateral TMJ internal derangement (ID) (81 TMJs) were treated between December 1, 2003, and December 1, 2006, at the Department of Oral and Maxillofacial Surgery, Ninth Peoples Hospital, Shanghai, Jiao Tong University School of Medicine. All patients were subjected to magnetic resonance imaging before and one to seven days post surgery to determine disc position using the modified bone anchor technique.ResultsPostoperative MRIs (one to seven days) confirm that 77 of 81 joints were identified as excellent results and one joint was considered good for an overall effective rate of 96.3% (78 of 81 joints). Only 3.7% (3 of 81) of the joints were designated as poor results requiring a second open surgery.ConclusionsThis procedure has provided successful repositioning of the articular discs in unilateral TMJ ID at one to seven days post surgery.

Arthroscopic management of septic arthritis of temporomandibular joint.

This article reports on 7 patients with septic arthritis of the temporomandibular joint (TMJ) who were managed with arthroscopy between 1998 and 2007. The common symptoms were trismus and pain. A series of imaging studies showed widening of joint space in 1 patient with plain film; MRI demonstrated increased joint effusion in 4 patients; accompanying cellulitis in adjacent tissues was discerned by CT in 2 patients. Under the arthroscope, a reddened and swollen synovial membrane was found in 2 patients who were in the acute stage, whereas strong adhesions, destruction of cartilage, and bony defects were discovered in other 5 patients in the chronic stage. Additionally, the disc was ruptured in 3 patients, and fibrosis was confirmed for 2 patients. Lavage, lysis of adhesion, and debridement of articular surface were common procedures for treatments. The average follow-up period was 57.4 months, and no recurrence was found. Arthroscopy has proven to be a useful method for management of septic arthritis of TMJ, especially for patients in the chronic stage.

Prevention and Treatment for the Rare Complications of Arthroscopic Surgery in the Temporomandibular Joint

PURPOSE To analyze the rare complications of arthroscopic surgeries in the temporomandibular joint (TMJ) and to investigate the preventive and treating methods. PATIENTS AND METHODS In this study, 2,034 consecutive patients (2,431 joints), diagnosed as TMJ internal derangement, were treated by arthroscopic surgeries when visiting the TMJ clinic at the Ninth Peoples Hospital, School of Medicine, Shanghai Jiao Tong University, between May 2001 and September 2009. The clinical complications were analyzed to investigate cause, prevention, and control measures. RESULTS Of all 2,034 cases, the complications were shown as follows: 5 joint hemorrhages of the lateral pterygoid muscle vascular, injuries of the lateral pterygoid muscle nerve in 5 joints, 3 joints with broken instruments, rejection reaction in 2 joints, and perforation of tympanic membrane in 2 joints. CONCLUSIONS Arthroscopic surgery was a safe and effective method to treat TMJ internal derangement; its complications were limited and acceptable, but an experienced operator was required for this surgical technique.

Expression of VEGF-receptors in TMJ synovium of rabbits with experimentally induced internal derangement.

Our aim was to evaluate the expression of vascular endothelial growth factor receptors (VEGFRs) in the synovium of the temporomandibular joints (TMJ) of rabbits with experimentally induced internal derangement. Internal derangement was experimentally induced in 52 rabbit TMJ, and established on the right side of TMJ while the left side was used as the control. Each joint and its control was evaluated by magnetic resonance imaging (MRI) and endoscopy. The synovial tissues on both sides were harvested after one, two, three, and four weeks. The expression of VEGFRs mRNA was investigated in the experimental joint and its control using real-time polymerase chain reaction (PCR). Internal derangement was successfully confirmed in 45 of the 52 of the experimental joints (87%) on the right side by MRI and endoscopy. In the first and fourth week, the VEGFR-2 mRNA expression was higher in the experimental joints than in the controls (P=0.008 and P=0.02). Meanwhile, the VEGFR-1 mRNA expression was up-regulated in the experimental group compared with the controls during the fourth week (P=0.02). However, we found no significant differences in VEGFR-3 mRNA expression in the two groups during the first and fourth weeks. During the second and third weeks, the mRNA expression of the three receptors did not differ significantly among the groups. Our data have shown increased expression of VEGFR-1 and VEGFR-2 mRNA in the synovium of rabbit TMJ with internal derangement, which indicates that VEGFR-1 and VEGFR-2 may have important roles in the processes of internal derangement and formation of adhesions.

Malocclusion as a common occurrence in temporomandibular joint arthroscopic disc repositioning: outcomes at 49 days after surgery.

PURPOSE To evaluate the incidence, clinical manifestation, and prognosis of malocclusion after arthroscopic disc repositioning and suturing of the temporomandibular joint (TMJ). PATIENTS AND METHODS The study included 211 patients (270 joints) with internal derangement of the TMJ who underwent arthroscopic disc repositioning and suturing from November 2005 to August 2006. The occlusion was checked and recorded preoperatively and at different intervals (0, 3, 7, 14, 21, 28, 35, 42, and 49 days after surgery) for all patients. The incidence of malocclusion after surgery was determined for every follow-up period. The χ(2) test was applied to assess the statistical significance of the changes of the incidence of malocclusion. RESULTS The incidences of malocclusion were 100%, 80.1%, 67.8%, 46.9%, 28.9%, 18.0%, 15.7%, 14.6%, and 14.2% at 0, 3, 7, 14, 21, 28, 35, 42, and 49 days after surgery, respectively. There was a significant difference between neighboring follow-up periods within 28 days after surgery, whereas there was no significant difference from 28 to 49 days after surgery (P > .05). The main clinical manifestations of malocclusion were posterior open bite on the surgery side, incisal prematurities, and mandible midline deviated or nondeviated. CONCLUSION Malocclusion commonly occurs after TMJ arthroscopic disc repositioning and suturing. However, it will improve within 28 days after surgery in most patients. If malocclusion lasts over 28 days, appropriate treatments should be considered.

Treatment of Hemimandibular Fibrous Dysplasia With Radical Excision and Immediate Reconstruction With Free Double Costochondral Graft

F f ibrous dysplasia is a benign pathologic condition of he bone that frequently affects the craniofacial skelton. Monostotic fibrous dysplasia is the most comon form of this disease and is characterized by the nvolvement of only 1 bone with no systemic maniestations. In the maxillofacial area, it is more freuently found in the body of the mandible and in the osterior maxilla. Its histologic characteristics inludes the substitution of normal bone by tissue comosed of collagen and fibroblasts, with variable mounts of a mineralized substance. Because it is a benign lesion, it is clear from clinical tudies that the treatment necessary for this condition epends on its location in the craniofacial skeleton, its ffect on function, and, ultimately, cosmesis. The leions of fibrous dysplasia can be surgically reconoured for esthetic or functional purposes once they ave become dormant. Radical resection and recon-