Outcome of an Algorithm of Surgical Interventions of Temporomandibular Joint Intra Articular Pathology and their Relationships to Etiologic and Diagnostic Category. A prospective Analysis
Etiology and diagnostic category are the most important factors when studying specific results related to patients with intra articular Temporomandibular joint (TMJ) disorders. It is extremely important to study the results of surgical interventions as they relate both to the patient's etiologic type and to diagnostic category. For example, in the patient with a Type 1 etiology, direct microtrauma, (bruxism and day time clenching) and a diagnosis of wilkes III (disc displacement without reduction), it would be important to note the surgical result after the procedures of arthroscopic and disc repositioning have been performed. Obviously, the patient who has a Type 3 (direct macrotrauma) injury with internal derangement and no overlying parafunctional habits should have a better long-term surgical result than the Type 1 patient because the problem is more joint specific. This study will report on the results of surgical interventions and their relationships to etiologic type and diagnostic category.
2. Materials and methods:
A prospective evaluation of a total of 379 patients suffering from internal derangement (ID) of TMJ with different etiological factors according to McCain classification, and different diagnostic categories, according to Wilkes classification were selected. These patients underwent surgical procedures according to an algorithm of care starting with basic single puncture arthroscopy to total joint replacement. Those procedures were performed in Baptist Hospital, Miami, Florida, USA, starting from July 2007 to March 2012.
3. Methods of data analysis
This study was assessed by careful categorization of cases according to the five etiologic types (parafunctional habits, direct microtrauma, direct macrotrauma, indirect macrotrauma, systemic diseases) developed for clinical use based on patient's history.
Also, different stages of internal derangements of all cases have been specified by Wilkes classification into 5 stages according to clinical, radiographic, and arthroscopic examinations.
Such findings were correlated to the general outcome of surgical procedures using clinical assessment in terms of improvement in the painless range of mandibular motion (ROM: inter-incisal distance in millimeters), pain on loading (Mahan sign: direct, indirect) and functional jaw pain was evaluated by using a visual analog scale (VAS) ranging from 0 to 100, taking in consideration the impact of different etiological and diagnostic factors of ID over an average of 3 months to 5 years follow up period.
Independent sample t test was used to compare preoperative to postoperative ratio and interval data. Spearman rho correlation was used to test relations between the studied variables. Z test was used to determine the possibility to estimate the outcome in a larger population of such case series.
4. Results:
There was a statistical significant improvement in the outcome of primary single puncture arthroscopy procedure in regards of TMJ pain and function as well as ROM.(p =0.001)
No significant statistical correlation was found between etiology, diagnosis and outcome, however it might be possible in certain etiology, diagnosis complexes to determine the outcome. For example, patients with etiology combination types 1 and 3 presenting with Wilkes stage II solely would show a better outcome of primary arthroscopy in such diagnostic category. (Z= 1.732 > Z critical =1.645). Current study also showed that Wilkes II patients with other etiological combinations did worse and required 2nd surgical intervention.
5. Conclusions:
Current study showed that the results of specific surgical algorithm have important relationships to etiologic type and diagnostic category which can make decision making of the type of surgical intervention easier and more promising regarding the general outcome.
6. 2 references
- Joseph P. McCain. Principles and practice of temporomandibular joint arthroscopy. Mosby-Year- Book, Inc.1996.
- Wilkes CH. Internal derangements of the temporomandibular joint. Pathological variations. Northwest Dent. 1990; 69(2): 25-32.