Temporomandibular Joint Meniscopexy With Mitek Mini Anchors

Transcription

J Oral Maxillofac Surg
69:2739-2745, 2011
Temporomandibular Joint Meniscopexy
With Mitek Mini Anchors
Carlos Alberto Ruiz Valero, DDS,*
Carlos Andres Marroquin Morales, DDS,†
Jaime Andres Jimenez Alvarez, DDS,‡
Javier Eduardo Gomez Sarmiento, DDS,§
and Arthur Vallejo, DDS储
Purpose: The purpose of this study is to show long-term results with the use of Mitek mini anchors
(DePuy Mitek, Raynham, MA) in the surgical treatment (meniscopexy or discoplasty) of internal derangements that lead to a dysfunctional temporomandibular joint (TMJ).
Patients and Methods: We evaluated 50 patients, 32 women and 18 men, ranging in age from 19 to
53 years, with a mean age of 33.5 years. All patients included in the study were diagnosed with anterior
disc displacement without reduction. Each patient underwent surgical meniscopexy and placement of
Mitek mini anchors with No. 2-0 nylon monofilament sutures. The variables taken into account in this
study include range of mouth opening, painful symptoms (evaluated with the visual analog verbal scale),
and the presence of any clicks in the TMJ.
Results: Preoperative analysis showed painful symptoms in 100% of evaluated patients, the presence of
clicks of the TMJ in 76%, and a mean mouth opening range of 23.5 mm. Postoperative analysis showed that
92% of the patients had no painful symptoms, 90% did not have any associated clicks in the TMJ, and the mean
mouth opening range on postoperative evaluation was 38.3 mm, with a mean increase of 14.8 mm.
Conclusions: We conclude that surgical placement of Mitek mini anchors represents an alternative that can
be considered a tool of great utility for discoplasty procedures, showing evident clinical improvement.
© 2011 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 69:2739-2745, 2011
Anchors are devices made of biocompatible metal
alloys, with the main function being that of uniting
soft tissues over bony structures, thus restoring function and returning esthetics. The first metallic anchors
were designed and developed in the mid 1980s for
orthopedic surgery, enabling the connection or union
of tendons and ligaments to the affected bone.1
Since their initial development, anchors have been
used in a variety of orthopedic procedures, for example, shoulder stabilization, tenodesis, meniscus fixation to the knee,2 hand surgery,3 and procedures
*Oral and Maxillofacial Surgeon and Chief, Oral and Maxillofacial
Surgery Department, Hospital Universitario Clínica San Rafael,
Bogotá, Colombia; Coordinator, Oral and Maxillofacial Surgery Postgraduate Program, Universidad El Bosque, Bogotá, Colombia; and
Private Practice, Bogotá, Colombia.
†Oral and Maxillofacial Surgeon, Pontificia Universidad Javeriana,
Bogota, Colombia; and Private Practice, Pasto, Colombia.
‡Oral and Maxillofacial Surgeon, Universidad El Bosque, Bogotá,
Colombia; Professor, Oral and Maxillofacial Surgery, Universidad El Bosque, Bogotá, Colombia; and Private Practice, Bogotá,
Colombia.
involving the elbow. Moreover, they have become a
useful alternative in other medical specialties such as
esthetic surgery,4,5 reconstructive surgery,6 and orbital surgery7,8; in urology for bladder suspensions; in
facial trauma surgery for intermaxillary fixation9; for
corrections of obstructive sleep apneas10; and in the
temporomandibular joint (TMJ) for procedures such
as discoplasty of the TMJ disc.11-15
Mitek mini anchors (DePuy Mitek, Raynham, MA)
consist of an axis or body and 2 retention devices. The
axis is made of 90% titanium metal alloy, 6% alumi§Oral and Maxillofacial Surgeon, Universidad El Bosque, Bogotá,
Colombia; and Private Practice, Bogotá, Colombia.
储Senior Resident, Department of Oral and Maxillofacial Surgery,
Universidad El Bosque, Bogotá, Colombia.
Address correspondence and reprint requests to Dr Vallejo:
Department of Oral and Maxillofacial Surgery, Hospital Universitario Clínica San Rafael, Cra. 8, No. 17-45 Sur, Bogota, Colombia, PBX (57)(1)3282300; e-mail: [email protected]
© 2011 American Association of Oral and Maxillofacial Surgeons
0278-2391/11/6911-0013$36.00/0
doi:10.1016/j.joms.2011.02.090
2739
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TMJ MENISCOPEXY WITH MINI ANCHORS
num, and 4% vanadium.13 The 2 retention devices are
made of nickel and titanium. These 2 metals enable a
high level of memory and elasticity, important for maintaining the desirable postoperative position. In addition,
the mini anchor has a diameter in its axis of 1.8 mm and
length of 5.0 mm, and it has an eyelet for the suture. The
2 previously mentioned retention devices are attached
to the axis or body of the implant and retract against the
axis when the anchor is being placed in the bone cortex, which then returns to its original position once it
penetrates into the bone marrow space.12
Previous studies have shown long-term stability and
prove that the effectiveness of Mitek mini anchors in
the TMJ is a result of the capacity for adequate bone
integration after final positioning, despite undergoing
immediate intermittent forces.13
Cárdenas et al,16 in a long-term follow-up study,
documented minimal positional changes for the Mitek
mini anchors after initial implant placement. Similarly,
they proved the capacity for bone integration was
adequate and complete without any evidence of inflammatory processes or formation of fibrous connective tissue along the implant’s surface. They also observed that the sutures used for disc repositioning
were held intact in place for 59 months.13,14
FIGURE 2. Modified endaural approach marked with methylene
blue when digital traction is released, showing how the incision is
hidden.
Ruiz Valero et al. TMJ Meniscopexy With Mini Anchors. J Oral
Maxillofac Surg 2011.
Anterior disc displacement without reduction
(ADDwoR) of the TMJ is a relatively common finding, and generally, the treatment option for these
patients involves surgery, which can include multiple procedures such as arthrocentesis, vertical subsigmoid osteotomy, or meniscopexy.16,17
The purpose of this study is to show long-term
results using Mitek mini anchors for disc meniscopexy in the TMJ.
Patients and Methods
FIGURE 1. Anterior digital traction for initial surgical markings
with methylene blue.
This was a retrospective, descriptive, non-experimental study of 50 patients, 32 women and 18 men, ranging
in age from 19 to 53 years, with a mean age of 33.5
years. Patient pooling was developed from the main
author’s private practice and institutional patients, during an 8-year period from January 1995 to January 2003.
Inclusion criteria included 1) American Society of
Anesthesiology status I patients (ie, healthy patients)
with ADDwoR based on clinical examination and
magnetic resonance imaging (MRI); 2) no previous
surgery involving the TMJ; and 3) the presence of
pain, clicking of the TMJ, or limited mouth opening.
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RUIZ VALERO ET AL
FIGURE 3. Schema of position of Mitek mini anchor (A) and placement of two No. 2-0 nylon sutures at posterior segment of TMJ disc sutured
to mini anchor placed on most lateral superior and posterior aspect of mandibular condyle (B). M, medial aspect of mandibular condyle; Lat,
lateral aspect of condyle.
Ruiz Valero et al. TMJ Meniscopexy With Mini Anchors. J Oral Maxillofac Surg 2011.
All patients were operated on by the same surgeon
(C.A.R.V.), using the modified endaural approach,
also designed by the senior author of this study.18
SURGICAL TECHNIQUE
All patients underwent surgery under general anesthesia with nasotracheal intubation, and sterile surgical preparation and draping were implemented for all
patients. With digital traction of the preauricular region, surgical markings with methylene blue were
placed in a cephalic to caudal manner. The markings
start at the anterior third of the circumference of the
helix, heading toward the crus of the helix, crossing this
anatomic structure in the esthetic unit and continuing
toward the internal surface of the tragus until the point
where the tragus meets the ear lobule (Figs 1, 2).
A total of 5 mL of lidocaine (1% with 1:200,000 epinephrine) is infiltrated in the preauricular region at the
level of the helix and the tragus with the purpose of 1)
hydrodissection that facilitates incision placement and
2) vasoconstriction. The surgeon begins the incision
using a No. 15 scalpel, moving in a cephalic to caudal
manner and parallel to the anatomic disposition of the
auricular cartilages, separating the skin and subcutaneous tissue. The dissection is extended 2 cm anteriorly in
the subcutaneous tissue plane with a No. 15 scalpel. The
first assistant separates the created flap in an anterior
manner with 2 Senn-Miller retractors. The next surgical
plane is the superficial temporal fascia (confluence of
the superficial musculoaponeurotic system) under
which the facial nerves are located. With an Adson
tissue forceps, the superficial temporal fascia is grasped
5 mm anterior to the tragus and a perforation is made
with a mosquito clamp and separated. The branches of
the facial nerves move in an oblique and superior direction; for this reason, the fascia dissection (blunt dissec-
tion) is performed in an oblique and superior manner
toward the zygomatic arch. The first assistant, using the
Senn-Miller retractors, enters the dissected plane and
retracts in an anterior and inferior manner, performing
FIGURE 4. Initial bone perforation for Mitek mini anchor implant
placement located at most lateral, superior, and posterior aspect of
mandibular condyle.
2742
band of the disc (Fig 6). In addition, we always coagulate the posterior bilaminar area. No. 4-0 Vicryl sutures
(Ethicon, Somerville, NJ) are placed to reposition the
surgical planes; correct repositioning and suturing of the
joint capsule are of the utmost importance for appropriate wound and synovial membrane tissue healing. The
skin is then reapproximated and sutured with single
interrupted No. 6-0 nylon sutures (Fig 7).
The preoperative and postoperative evaluation parameters taken into account were as follows:
1. Presence of pain, quantified by use of the visual
analog verbal scale
2. Presence of TMJ clicks during function
3. Range of mouth opening in millimeters measured
from the incisal edge of the inferior incisors to the
corresponding incisal edge of the superior incisors
Patient medical history data were organized into 2
different timelines: 1) before the surgical procedure
and 2) 24 months after surgery.
Results
FIGURE 5. Mitek mini anchor placement at most lateral, superior,
and posterior aspect of mandibular condyle via modified endaural
approach.
All 50 patients included in this study underwent
bilateral TMJ surgery with joint disc meniscopexy
blunt dissection of the surgical plane. The second plane
is elevated and dissected in the same fashion, arriving
toward the temporal fascia (which appears white and
shiny); at this level, the TMJ capsule is found, where a
T-shaped incision is performed with an electrosurgical
pencil. Dissection is performed with a Molt 9 or Freer
periosteal elevator liberating the insertion of the anterior
ligament, thus enabling entrance into the superior articular space.
At this point, we suggest that the surgeon proceed
with an eminectomy using a straight osteotome to
increase the superior articular space and achieve improved visualization of the articular disc, which should
be liberated from adherences, if present, and also liberated laterally from the joint capsule.
Disc liberation enables posterior movement and
repositioning of the TMJ disc (Fig 3). For Mitek mini
anchor placement, we extended inferiorly with an
incision that is made on the joint capsule to assess the
inferior joint space, locating the condylar head and
placing the Mitek mini anchor on the most posterior,
superior, and lateral aspects of the mandibular condyle (Figs 4, 5). TMJ disc plication is achieved by use
of two No. 2-0 nylon sutures placed on the posterior
FIGURE 6. Location for TMJ disc plication with No. 2-0 nylon
suture to Mitek mini anchor.
RUIZ VALERO ET AL
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FIGURE 9. Evaluation of preoperative (PRE) and postoperative
(POST) pain.
FIGURE 7. Final flap repositioning and placement of 7 No. 6-0
Prolene single interrupted sutures (Ethicon).
with Mitek mini anchors, for a total of 100 joints
intervened. The following joint pathologies were diagnosed: ADDwoR, ADDwoR in association with
chronic subluxation in 6 patients, ADDwoR in association with mild osteoarthrosis in 3 patients, and
ADDwoR in association with persistent joint dislocation in 2 patients (Fig 8).
All 50 patients noted painful symptoms before surgery, recording a minimum value of 3 and a maximum
value of 9 on the visual analog verbal scale, with a mean
of 5.34. During the postoperative evaluation, only 8% (4
patients) mentioned painful symptoms in the TMJ, with
a minimum value of 3 and a maximum value of 7, with
a mean of 5. Of the 50 patients included in this study, 46
(92%) had improvement of their symptoms and did not
note any postoperative pain (Fig 9).
Of the 50 patients evaluated, 76% (38 patients) had
TMJ clicking during the initial phase of physical examination (before surgery) compared with 24% (12
patients) who did not mention any sounds or clicks.
During the postoperative physical examination, only
10% (5 patients) had joint clicks, showing an important improvement in 90% (45 patients) of the individuals included in this study who did not note any type
of articular sound (Fig 10).
Before surgery, the mouth opening range presented a minimum of 8 mm and a maximum of 40
mm, with a mean of 23.5 mm, versus a minimum
opening value after surgery of 32 mm and a maximum
of 45 mm, with a mean of 38.3 mm. Thus mean
FIGURE 8. Patient diagnoses treated with surgical placement of
Mitek anchors. AB, anterior block; CSL, chronic subluxation; OA,
osteoarthrosis; RL, recurrent luxation.
FIGURE 10. Evaluation of preoperative (PRE) and postoperative
(POST) TMJ sounds.
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FIGURE 11. Comparative graph showing preoperative and postoperative mouth opening range.
Ruiz Valero et al. TMJ Meniscopexy With Mini Anchors. J Oral Maxillofac Surg 2011.
postoperative improvement of 14.8 mm was noted
(Figs 11, 12).
It was necessary to remove 1 Mitek mini anchor
from 1 patient’s right TMJ 1 year postoperatively,
because of difficulties with the surgical technique that
were not related to the anchor system.
We found that all 50 patients had dental and skeletal
Class I relationships, and 30 patients presented with
minor occlusal alterations (eg, buccal, lingual, or palatal). In addition, 10 patients presented with dental crowding: 5 had superior dental arch crowding, and the other 5
presented with inferior dental arch crowding (these patients underwent intervention without any prior treatment). Ten patients presented with partial edentulism and
were treated before surgery with oral rehabilitation.
Discussion
Internal derangements that affect the TMJ have a
prevalence rate of approximately 20%. ADDwoR is a
clinical condition in which the disc of the joint is dislocated in an anterior and medial position in relation to the
mandibular condyle and does not return to its normal
position when performing normal joint movement.17
Clinically, the patient has limited mouth opening because of the abnormal disc position, which does not
FIGURE 12. Mean preoperative (Pre) and postoperative (Post)
mouth opening and mean improvement.
allow appropriate translocation or functional movement
of the mandibular condyle. Moreover, there are painful
symptoms that the patient can have when trying to
open his or her mouth due to compression in the bilaminar zone, as well as the presence or even absence of
TMJ clicks and sounds, among other clinical symptoms
and signs evident during the physical examination.
The most appropriate and effective method to confirm diagnosis of TMJ derangements and osteoarthrosis is based on MRI.19
Initial conservative treatment in TMJ dysfunction
includes a soft diet, pharmacologic management with
nonsteroidal anti-inflammatory drugs, local heat therapy, occlusal splints, occlusal adjustments and local
infiltrations with corticosteroids or anesthetics, orthodontics, and/or oral rehabilitation management. All of
these aim at diminishing symptoms and pain, thus
facilitating the patient’s TMJ function, but ADDwoR
of the TMJ does not correct itself completely with this
type of conservative therapy, and this is when TMJ
disc replacement surgery becomes an option.20-24
The first report of a meniscopexy dates back to
1887, when Annandale repositioned the joint disc and
secured the lateral displaced structure to the external
margin of the joint capsule. In 1918 Behan described
his technique to reposition the TMJ disc, maintaining
harmony in the mandibular condyle. Plication of the
disc at that time was not a frequently used procedure.
Wilkes, in 1978, enhanced TMJ arthrography to visualize the position and the integrity of the TMJ disc.
This led to a clearer understanding of the pathophysiology of TMJ disc disorders and therefore allowed
faster and more accurate diagnosis.20
This study evaluated treatment results in 50 patients (100 joints) who were affected by ADDwoR
with indications for surgical meniscopexy, by use of the
modified endaural approach.18 Mitek mini anchors were
placed to facilitate repositioning of the joint disc over
the condylar head, thus facilitating physiologic movement and function of the joint structures.
Our study coincides with findings reported by
other authors in terms of mean age versus clinical
RUIZ VALERO ET AL
manifestations of dysfunctional TMJs; our patients’
ages ranged between 19 and 53 years, with a mean of
33.5 years, correlating with the study by Mehra and
Wolford,11 where the mean age of patients was 32.6
years, ranging between 14 and 57 years. In addition, it
also relates to the study of Sato et al,17 where the age
range for patients with ADDwoR was between 16 and
45 years, with a mean age of 29.2 years, and to that of
Anderson et al,20 reporting a mean age of 28.1 years and
a range between 14 and 48 years. Similarly, the distribution of gender in this study showed a ratio of 1:1.7 (18
men vs 32 women), coinciding with the 1:2 male-female
ratio reported in the literature that confirms a greater
prevalence of ADDwoR in female patients.11,16,17,25
On the other hand, this study has shown important
differences in symptoms before surgery and after the
procedure—postoperative absence of pain in 92% of
patients, mean improvement in mouth opening of
14.8 mm, and absence of clicks in 90% of individuals
evaluated—which correspond with other studies using Mitek mini anchors in the TMJ.
Analyzing the presence of postoperative articular
sounds, we find a correlation with the study of Mehra
and Wolford,11 where the authors report a 91% postoperative success rate, with improvement in pain,
articular sounds, and mouth opening range. In addition, Fernandez Sanromán et al25 report subjective
TMJ pain improvement, with an increase in mouth
opening range on postoperative assessment; however, they reported persistent articular sounds in 8 of
the 12 patients included in their study, which is a
higher incidence rate for postoperative articular
sounds when compared with our study.
We did not evaluate our patients postoperatively
with follow-up MRI. In contrast, Fernandez Sanromán
et al25 evaluated their patients with postoperative MRI
scans and found that the repositioned disc remained
in place in 10 of 12 patients, whereas the other 2
patients had persistent anterior disc displacement.
Occlusal changes noted by patients after surgery
were managed in a conservative fashion in all of our
patients, with occlusal splints, physiotherapy, and/or
occlusal adjustments postoperatively.
We conclude that Mitek mini anchors represent an
alternative with great utility for procedures such as
meniscopexy of the TMJ, showing excellent results in
terms of improving function and patient quality of
life. The improvement in postoperative pain, joint
clicks, and mouth opening range is significant. There
is a lack of published studies in the literature to
establish a real comparison to our results.
References
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2745
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Temporomandibular Joint Meniscopexy With Mitek Mini Anchors

Transcription

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