Surgical therapy can be recommended for some types of internal derangement of the temporomandibular joint (TMJ) or degenerative arthrosis of the TMJ. Temporomandibular articular discectomy may also be saitable for terminal stage internal derangement of the TMJ. Recent studies suggest the beneficial use of autogenous auricular cartilage interpositional graft after discectomy. In this report, four cases of degenerative joints were treated by discectomy with ear cartilage interpositional graft, because they made little remission with preservative therapies. Their preoperative MR Images showed anterior disk displacement without reduction. Postoperative courses have been good. Their trismus improved with widening of the maximal range of opening. Chewing and opening pain were reduced. Postoperative evaluation was carried out. The criteria for TMJ meniscus surgery of the American Association of Oral and Maxillofacial Surgeons was applied to each case. As a result, three cases were excellent and one case was good. To achieve these results, careful long term follow up is needed.

View full abstract

We reported the treatment efficacy of the arthroscopic lysis and lavage operation applied to three cases of prolonged condylar fracture of the mandible. All three cases had severe pain during function and opening limitation of the injured TMJ. In two cases fragment deviation of the condyle on the radiographic series was observed. All injured TMJ were excluded from severe fibrous adhesive change by a pumping technique into the upper joint compartments prior to arthroscopic surgery.
All cases were operated with arthroscopic lysis and lavage into upper joint compartments under general anesthesia. The fibrillation, adhesion, synovial hyperemia and tearing of articular cartilage were found arthroscopically in these cases.
In all cases, functional pain was relieved and the range of opening motion increased. In two cases, favorable disc mobility was obtained on the postoperative MRI. However, one case did not obtain the disc mobilization after arthroscopic surgery.

View full abstract

Though various conservative treatments for temporomandibular disorders (TMD) can reduce pain to some extent in most patients, complete pain relief can hardly be achieved. For one reason, psychosomatic and social factors are considered to influence that kind of pain.
To estimate the influence of these contributing factors on therapeutic effects, we studied 116 patients with unilateral TMD who were treated only by conservative methods for more than 6 months. Y-G tests and some questionnaires concering psychosomatic, social and environmental situations were performed at their first visit, and the therapeutic effects were judged after 6 months. The Classification of TMD proposed by the Japanese Society for. Temporomandibular Joint was used with limited modifications. According to the therapeutic effects, the patients were classified into an excellent group and a non-excellent one. The former had achieved both complete pain relief and more than 40mm mouth opening, and the latter had not.
As a results, patients' subjective symptoms, uneasiness and bruxism appeared to greatly influence their therapeutic effects, especially the patients with TMD classifications of type I and type III with clicking. Y-G tests, traumatic history at the head and neck and oral habits had no significant influence on the effects.
In conclusion, it was considered that the TMD should be treated paying due regard to various contributing factors such as psychosomatic ones.

View full abstract

Proper understanding of the disease is important for finding the proper treatment for internal derangement of the temporomandibular joint (TMJ) and for evaluating its result. The efficacy of clinical investigation using a fine needle fiberscope for the diagnosis of temporomandibular intracapsular lesion is reported.
(1) This fiberscope was made by Medical Science Co., Ltd. and is 0.8mm in outside diameter.
(2) Adverse affects to the patient was kept to a minimum because this diagnostic arthroscopic method enabled examination at the same time as double-contrast arthrotomography under local anesthesia.
(3) This method was effective in the diagnosis of synovitis and fibrillation within the superior cavity. It was possible to observe capsular adhesion, but it was not possible to diagnose disc displacement, disc deformation, or perforation of the posterior attachment of the disc.
(4) In the comparison with the superior articular cavity, investigation of the inferior articular cavity was more difficult due to limited view range. Therefore, further improvement of the method is required to obtain using results in the investigation of the inferior articular cavity.
(5) None of patients experienced side effects, and diagnostic arthroscopy was found to be a safe, viable method.

View full abstract

Splint therapy is effective for the treatment of patients with TMDs. However, occlusal reconstruction is necessary for patients who exhibit recurrence of TMD after splint therapy. In this article, two cases of orthodontic treatment for occlusal reconstruction after splint therapy are presented.
The first case was a 13-year 4-month old girl with reciprocal clicking and pain in both TMJs. The second case was a 13-year 5-month old girl with closed lock in the left TMJ. In both cases, occlusal reconstruction with edgewise treatment was performed to maintain the splint-induced condylar position. After orthodontic treatment, no symptoms of TMD were observed in both cases without splints. However, disk repositioning was not achieved in the second case.
It is indicated that orthodontic treatment for occlusal reconstruction is useful for TMD patients, although disk repositioning is not achieved in all cases.

View full abstract

The purpose of this study was to investigate the association between temporomandibular disorders (TMD) and the craniofacial morphorogy of orthodontic patients. 133 patients with TMD (TMD group) and 162 patients without TMD (control group) were selected as subjects. Each TMD subject presented at least one of such TMD symptoms as TMJ sounds, TMJ pain, muscle tenderness and difficulty of jaw movement. The subjects were divided into nine types of malocclusion by vertical and horizontal occlusal relations. Craniofacial morphology was evaluated by cephalometric analysis, and the values of cephalometric measurements were compared between TMD and control groups. The following results were obtained.
(1) In open bite with anterior crossbite or maxillary protrusion, the mandibular plane angle was significantly larger in the TMD group than in the controls. In open bite without any anteroposterior occlusal problems, the gonial angle was significantly larger in the TMD group than in the controls.
(2) No significant differences in craniofacial morphology were found in the remaining types of malocclusion.
It is suggested that abnormality of craniofacial morphology is pertinent to the occurrence of TMD in certain types of malocclusion, in terms of the influences on mandibular or condylar position.

View full abstract

The present study was designed to analyze the three-dimensional condylar position in untreated orthodontic patients with malocclusion, and further to investigate the association between the condylar position and craniof acial morphology.
Fifty untreated orthodontic patients without TMD (20 males and 30 females, age 7-15 Y) were selected as subjects. Seven-layered tomograms of the TMJs and lateral cephalograms were taken of the subjects before treatment. By use of a series of tomograms, the shortest distances between the condyle and the glenoid fossa (Condyle to Glenoid Fossa Distance, CGFD) were calculated in five areas, i.e. anterior, posterior, middle, lateral and medial areas, and then the ratio of the anterior CGFD to posterior one (A/P ratio) and ratio of lateral CGFD to the medial one (L/M ratio) were calculated. Further, the correlation coefficient between these data and cephalometric analysis data was calculated.
The following results were obtained. No significant differences in the CGFDs were found between the three groups. However, a significant difference in the A/P ratio was found between the skeletal 1 and 2 groups. Further, positive correlation between the posterior CGFD and Gonial angle, and negative correlations between the middle and posterior CGFDs and Ramus pl. to FH angle were significantly found at the 5% level of confidence.

View full abstract

The present study was designed to analyze the three-dimensional condylar position (Condyle to Glenoid Fossa Distance, CGFD) in untreated orthodontic patients with internal derangement of the TMJ, and further to investigate the association between the condylar position and craniofacial morphology.
Thirty-one patients (6 males and 25 females) with unilateral internal derangement of the TMJ were selected as subjects. Seven-layered tomograms of the TMJs were taken of the subjects before treatment.
In order to evaluate the three-dimensional position of the condyle to the glenoid fossa, a 3-D analyzing system was used for the present study. In this system, the condyle and glenoid fossa were represented as a three-dimensional surface model and the shortest distance between the condyle and glenoid fossa (CGFD) was measured. The CGFDs were calculated in five areas on the condyle, i.e. anterior, middle, posterior, lateral and medial regions. Further, the ratio of the anterior CGFD to the posterior one (A/P ratio) and that of the lateral CGFD to the medial one (L/M ratio) were calculated to evaluate the condylar position in the TMJ in the anteroposterior and mediolateral directions. These values of the symptomatic side were compared with those of the asymptomatic side. The correlations between the values for condylar position and cephalometric measurements were also investigated.
The following results were obtained. No significant differences in the CGFDs, A/P ratio and L/M ratio were found between the symptomatic and asymptomatic sides. Further, positive correlation between the posterior CGFD and Gonial angle, and negative correlations between the A/P ratio and Gonial angle and between the anterior CGFD and Mandibular plane to FH angle were significantly found at the 5% level of confidence.

View full abstract

Acupuncture to the meridian point of “Gekan” has been used to treat the patients of temporomandibular joint disorder. In recent studies (Arao et al 1990, 1991, 1992) instead of using a needle, the author irradiated several times with a low power laser (Nd-YAG at 350mW) for Type I and Type II patients. This relieved the pain somewhat, but since the treatment results were determined by the subjective judgement of the patient, the authors evaluated the results objectively. We used thermography to evaluate the symptomatic change, and using the Laser Doppler Flowmeter (LDF), we measured the surface blood flow of the skin in the area of the temporomandibular joint.
In this study, for the Type III patients with closed lock, we used a low power laser. Each patient, was treated by low power laser for “Gekan” for 15 minutes from the first examination. After the pain of the tempororandibular region was remedied, we manipulated the mandible. The results were that in several months, the symptoms of temporomandibular joint disorder ceased. But from the MRI findings, the disk position did not change.
These results suggest that low power laser treatment for patients with temporomandibular joint disorder is useful not only for Type I and Type II patients, but also for Type III patients with closed lock.
We suggest that it is necessary to continue this line of research for a long period, and to treat a greater number of cases.

View full abstract

TMJ sound is one of the major symptoms caused by TMJ internal derangements. Consequently, a quantitative study is mandatory and significant from a clinical standpoint. The purpose of this study is to determine an assessment standard using TMJ sounds in regard to functional disorders caused by TMJ components.
Sound waveforms during mandibular movements are generally non-stationary signals which have frequency and time characteristics.
However, conventional Fouries analysis has not included these time elements. Therefore, in this study, a frequency analyzing method by time sequences was devised for obtaining objective assessments using TMJ sounds in functional disorders caused by TMJ components. The method was used with three subjects and the results were compared with information from MR imaging. The results are as follows,
(1) A new analyzing method based on mandibular movements allowed us to record the time period of occurrence of TMJ sounds and frequency modes between sounds at an initial session and other sectional sessions.
(2) Comparing subjects whoes mandibular condition was shown as different by MR imaging, this analyzing method also showed differences in waveforms and frequency modes.
(3) An application of this new analyzing method seems to he clinically useful.

View full abstract

This clinical trial was performed preliminarily in order to investigate the drug's efficacy, safety and clinical usefulness in patients with temporomandibular joint arthrosis. The dose range for clinical use was examined.
Patients were administered any one of doses of 0.50, 0.75, 1.00 and 1.25ml of SI-6601A (1% of sodium hyaluronate) by intra-articular injection five times continuously at weekly intervals.
(1) Out of 110 patients enrolled, 4 patients were excluded and 8 patients dropped out of the study or discontinued the medication. The Final Global Improvement Rate (FGIR) and the Final Global Usefulness Rate (FGUR) were analyzed in 23 patients of the 0.50ml group, 22 patients of the 0.75ml group, 26 patients of the 1.00ml group and 27 patients of the 1.25ml group. The Overall Safety Rate (OSR) was studied in 106 patients.
(2) ‘Moderate’ and ‘Marked’ improvement of the FGIR was seen in 44.9% of all patients. the 1.25ml group showed the highest rate (59.3%).
(3) The incidence of adverse effects was 3.8% (4/106) in all patients. The complaints were earache, rash and increasing of GPT, but none of them was severe.
(4) ‘Useful’ and ‘Very useful’ FGUR was seen in 43.9% of all patients. The 1.25ml group showed the highest rate (59.3%).
(5) Impossible injections of the allocated dose were impossible for one patient of the 1.00ml group and for 3 patients of the 1.25ml group. Then 1.25ml of SI-6601A was estimated as the maximum volume against the superioarticular cavity of the TMJ.
(6) In conclusion, SI-6601A with an injection volume ranging from 0.50ml to 1.25ml a time was shown to be useful in the treatment of TMJ arthrosis.

View full abstract

A multicenter randomized comparative study was conducted on 155 patients with temporomandibular joint arthrosis (TMJ) to find the optimal dose regimen for SI-6601A (intra-articular injective preparation of sodium hyaluronate).
Patients were administered any one of doses of 0.25ml (SL group), 0.75ml (SM group), and 1.25ml (SH group) of SI-6601A (1% of sodium hyaluronate) by intra-articular injection five times continuously at weekly intervals.
(1) Out of 155 patients enrolled, 11 patients were excluded and 8 patients dropped out of the study or discontinued the medication. The Final Global Improvement Rate (FGIR) and the Final Global Usefulness Rate (FGUR) were analyzed in 45 patients of the SL group, 45 patients of the SM group and 46 patients of the SH group. The Overall Safety Rate (OSR) was studied in 48 patients in each group.
(2) There was no significant difference among the 3 groups in the patients' demography at the time of the first drug administration.
(3) ‘Moderate’ and ‘Marked’ improvement of FGIR was seen in 40.0% for the SL group, 40.0% for the SM group and 54.3% for the SH group. The SH group had the highest rate.
(4) The incidence of adverse effects was 3.5% (5/144) in all patients. The complaints were nausea and headache, but none of them was severe.
(5) The clinical usefulness score was ‘Useful’ and ‘Very useful’ in 37.8% of the SL group, in 40.0% of the SM group and in 56.5% of the SH group. The SH group had the highest rate.
(6) Injections of the allocated dose were impossible for 2 patients of the SM group and in 2 patients of the SH group. Then 1.25ml of SI-6601A was estimated as the maximum volume against the superior articular cavity of the TMJ.
(7) In conclusion, SI-6601A was shown to be useful in the treatment of TMJ arthrosis, and an optimal dose of 1.25ml injection volume a time was suggested.

View full abstract

A Randomized comparative study by centralized telephone method was conducted on 317 patients with temporomandibular joint arthrosis to determine the efficacy, safety and usefulness of SI-6601A using 1.25ml of 1% sodium hyaluronate (HA group) or of 0.01% sodium hyaluronate (CT group) by intra-articular injection five times continuously at weekly intervals.
(1) The total number of patients enrolled was 317. Among those patients, 297 were adopted for the analysis of final global improvement and usefulness, and 309 for the analysis of overall safety.
(2) With respect to the final global improvement, the effective rate (more than “moderately improved”) for the HA group was 61.0% (94/154), and 33.6% (48/143) for the CT group. The HA group was significantly superior to the CT group.
(3) With respect to overall safety, the incidence of side effects was 3.2% (5/158) for the HA group, 1.3% (2/151) for CT group, and no significant difference was observed between the two groups.
(4) With respect to usefulness, the rate of usefulness (“more than moderately useful”) was 60.4% (93/154) for the HA group, and 35.7% (51/143) for the CT group. The HA group was significantly superior to the CT group.
(5) As for the change of global improvement, the HA group was significantly superior to the CT group. As for improvement in symptoms, the HA group tended to be superior to the CT group in “maximal mouth opening with or without pain”.
(6) The incidence of adverse effects was 3.2% (5/158) for the HA group and 1.3% (2/151) for the CT group, but none of them was severe.
In conclusion, SI-6601A is considered to be useful in the treatment of temporomandibular joint arthrosis.

View full abstract

The purpose of this clinical analysis is to determine the prevalence and clinical features specific to different types of TMJ lesions. The subjects of this study were of 1029 cases of TMJ lesions, accumulated between the establishment of our Department, Apr. 1974, and the end of 1991, almost 18 years. 13512 patients had visited in this clinic during this period, so the morbidity of the TMJ lesions was 7.62%.
Athrosis, which has been generally so called in Japan, is the most common lesion, with 821 cases (79.8%). There were 161 trauma cases, (15.6%), consisting of condylar 199 cases of fracture, 31 of luxation and 11 of traumatic arthritis. There were 35 cases (3.4%) of inflammation, consisting of 33 cases of rheumatoid arthritis, 1 case of purulentic arthritis, and 1 case of arthritis due to a specific infection. Developmental anomalies and ankylosis were found in 5 cases each. The other 3 cases were temporomandibular joint dysfunction: due to malunion after the fracture of the maxillary bone in 2 cases and to osteoradionecrosis in 1 case. Neoplasms of the TMJ have been described as those not only of the component tissues of TMJ, such as bone, cartilage, synovial tissue, and capsule, but also those metastasized from the other organs and infiltrated from the adjacent tissues or organs. However, there has been no case of the neoplasms consisting of the components, and it was possibly difficult to count the cases of the neoplasms metastasized or infiltrated from other organ tissues.
Compareing the trends for gender, there were twice as many females as males. However, condylar fracture and traumatic arthritis were observed move in males than females. On the trends for age, rheumatoid arthritis was the highest, with 51.2 years as the mean age, followed by luxation, at 41.5 years. The youngest was traumatic arthritis, with 22.7 years.

View full abstract

The purpose of this study was to evaluate the effects of arthrocentesis on closed lock patients with pain. The 16 patients (aged from 12-66 years) diagnosed as closed lock with MRI were treated with an intra-articular irrigation of 200ml of saline and a single injection of steroid (2mg Dexamethasone). Clinical follow-up examinations were done at 2, 4 weeks and long term after the treatment. Pain and dysfunction were evaluated with the Visual Analog Scale. The degree of TMJ dysfunction was classified as none, slight, moderate, and severe. The changing of the classification was compared before and after the intra-articular irrigation.
The results were as follows.
(1) Spontaneous pain and interference with daily life were significantly improved at the 2 weeks follow-up.
(2) Maximum mouth opening and pain on chewing were significantly improved at the 4 weeks follow-up.
(3) Pain on opening was significantly improved at the long term follow-up.
(4) TMJ dysfunction, classified as severe before the treatment decreased considerably at the long term follow-up.
(5) The overall therapeutic rate was 6% at 2 weeks, 25% at 4 weeks and 94% at the long term follow-up.
It is suggested that arthrocentesis is clinically effective on closed lock patients with pain.

View full abstract

The purpose of this study was to examine the relationship between the incidence of temporomandibular dysfunction symptoms, elicited by questionnaire, and mandibular deviation in the postero-anterior cephalogram of these patients with malocclusion.
Data were obtained from 433 orthodontic patients (140 males and 293 females, aged 10-53 years).
According to age, the patients were divided into three groups: G1 (137 patients, aged 10-14 years), G2 (95 patients, aged 15-18 years) and G3 (201 patients, aged 19-53 years). In each group, the characteristics of the craniofacial morphology were examined. Furthermore, the incidence of TMJ pain, disturbance of mandibular movement, or TMJ noise with mandibular deviation were examined.
The results obtained were as follows:
(1) The incidence of temporomandibular disorders was 41.1% of the total samples, 16.8% in G1, 39.0% in G2 and 58.7% in G3.
(2) In general the occlusal plane inclined superiorly toward the mandibular displaced side. The mandibular displaced side was more frequently found on the left side than on the right side.
(3) In G3, the more the mandibular deviation, the more the incidence of TMJ disorders. This incidence was found neither in G1 nor in G2.

View full abstract

We report a case of sagittal fracture of the mandibular condyle with concomitant external auditory canal injury.
The case was a 23 year old man who had a fracture of the mandibular body and left mandibular condyle as a result of a traffic accident. Open reduction was performed on the mandibular body fracture. Subsequent to the open reduction, attention was given to the bleeding from the left external ear, ear obstruction and tinnitus. Using double-contrast arthrographic CT, inner and outer fractured bone segments were noted, the joint compartment was expanded to the inner and outer side and the medial wall was ruptured due to the presence of the fractured bone segments. Furthermore, the left back side bone of the external auditory canal was broken.
The diagnosis from the patient's visif to the otolaryngological section of our hospital was indicated that the eardrum was intact, but that a portion of the skin in the external auditory canal was torn off due to bleeding and that the bone was exposed. By removing the clotted blood several times from the external auditory canal, his hearing could be improved. This was followed by, arthroscopy and open reduction of the left temporomandibular joint region with extraoral anchorage using Kirschner's wire.
Since the patient's left hearing decreased again, however, we took a simple CT of the head region.
The CT results revealed that a piece of bone had closed the external auditory canal. In our otolaryngological department, the patient was thus operated on to remove the bone fragment and a repair of the external auditory canal was initiated under GOI general anesthesia. After the operation, the patient's hearing improved. Thirty days after the TMJ operation, the intermaxillary fixation was released and open-mouth training began, and the patient was discharged. Now fourteen months postoperatively, there has been no decline in hearing and no spontaneous or oppressive pain from the left TMJ region. The mouth opening height is 41mm with a 6mm left side shift, but occlusion is good. From the postoperative CT, the joint compartment has disappeared and the mandibular condylar bone has been partly absorbed. However, it's shape reveals that it has been functionally remodeled.

View full abstract