Osteochondroma of the temporomandibular joint: a case report

Osteochondroma of the mandibular condyle has been found in the oral and maxillofacial region rarely. This paper describes a case of osteochondroma of the mandibular condyle in a 20-year-old woman, who was referred to our service with facial asymmetry, prognathic deviation of chin, cross-bite to the contralateral side, changes in condylar morphology, limited mouth opening, and malocclusion. Computed tomography (CT) was performed for better evaluation to the pathological conditions on the temporomandibular joint. Based on the clinical examination, patient history, and complementary exams, the hypothesis of osteochondroma was established. Condylectomy was performed using a preauricular approach with total removal of the lesion. After 3 years of postoperative follow up and orthodontic therapy, the patient is symptom-free, and has normal mouth opening with no deviation in the opening pattern.

Juvenile idiopathic arthritis with involvement of the temporomandibular joint: the role of image examinations

PURPOSE: Juvenile idiopathic arthritis (JIA) has unknown etiology, and the involvement of the temporomandibular joint (TMJ) is rare in the early phase of the disease. The present article describes the use of computed tomography (CT) and magnetic resonance (MRI) images for the diagnosis of affected TMJ in JIA. CASE DESCRIPTION: A 12-year-old, female, Caucasian patient, with systemic rheumathoid arthritis and involvement of multiple joints was referred to the Imaging Center for TMJ assessment. The patient reported TMJ pain and limited opening of the mouth. The helical CT examination of the TMJ region showed asymmetric mandibular condyles, erosion of the right condyle and osteophyte-like formation. The MRI examination showed erosion of the right mandibular condyle, osteophytes, displacement without reduction and disruption of the articular disc. CONCLUSION: The disorders of the TMJ as a consequence of JIA must be carefully assessed by modern imaging methods such as CT and MRI. CT is very useful for the evaluation of discrete bone changes, which are not identified by conventional radiographs in the early phase of JIA. MRI allows the evaluation of soft tissues, the identification of acute articular inflammation and the differentiation between pannus and synovial hypertrophy.

Changes in temporomandibular joint disc position and form following Herbst and fixed orthodontic treatment

Objective: To determine the changes in the position and form of the temporomandibular joint articular disc in adolescents with Class II division 1 malocclusion and mandibular retrognathism treated with the Herbst appliance (phase I) and fixed orthodontic appliance (phase II). Materials and Methods: Thirty-two consecutive adolescents went through phase I of treatment and 23 completed phase II. The temporomandibular joints were evaluated qualitatively by means of magnetic resonance images at the beginning of treatment (T1), during phase I (T2), at the end of phase I (T3), and at the end of phase II (T4). Results: Significant changes in disc position were not observed with the mouth closed between T1 X T3 (P = .317), T3 X T4 (P = .287), or T1 X T4 (P = .261). At T2, on average, the disc was positioned regressively. With the mouth open, no difference was observed between T1 X T3 (P = .223) or T1 X T4 (P = .082). We did observe a significant difference between T3 X T4 (P < .05). Significant changes in the disc form were found with the mouth closed between T1 X T2 (P < .001) and T2 X T3 (P < .001). Conclusions: At the end of the two-phase treatment, in general terms, the position and form of the initial articular discs were maintained; however, in some temporomandibular joints some seemingly adverse effects were observed at T4. (Angle Orthod. 2010;80:843-852.)

Mandibular Function is Severely Impaired in Systemic Sclerosis Patients

Aims: To evaluate the presence of temporomandibular disorders (TMD) in systemic sclerosis (SSc) patients and its possible association with the severity of skin involvement. Methods: The presence of TMD was evaluated in 35 SSc women and 30 age- and sex-matched healthy controls by means of the anamnestic (A(i)) and clinical (D(i)) Helkimo indices; the jaw mobility was further analyzed (M(I)). Skin involvement was scored by the Modified Rodnan Skin Score (MRSS). Results: Signs and symptoms of TMD were more frequent in SSc patients than in controls, the frequency distribution of the different clinical dysfunction indices differing significantly (P < .001) between patients (D(i)0 8.6%, D(i)I 48.6%, D(i)II 22.8%, and D(i)III 20%) and controls (D(i)0 50%, D(i)I 33.3%, and D(i)II 16.7%). Cyclophosphamide for severe and rapidly progressive cutaneous fibrosis was prescribed in six out of seven patients with severe signs (D(i)III), in contrast this treatment was indicated for only two out of 25 patients with mild to moderate signs (D(i)I and D(i)II, P <. 001). Impaired jaw mobility was more frequent in SSc patients than controls (P < .001). It was severe in 77.1% (M(I)II) and mild in 22.9% (M(1)I) of the cases, in contrast to controls (M(I)0 33.4%, M(I)I 53.3%, and M(I)II 13.3%; P < .001). Approximately half of SSc patients with severe (M(I)II) but none of those with mild impairment were on cyclophosphamide treatment for severe cutaneous fibrosis (P = .02). Conclusion: Severe signs of TMD according to the anamnestic and clinical Helkimo indices were very frequent in SSc patients. J OROFAC PAIN 2010;24:197-202

SAPHO syndrome with temporomandibular joint ankylosis: clinical, radiological, histopathological, and therapeutical correlations

The SAPHO syndrome is characterized by specific clinical manifestations of synovitis, acne pustulosis, hyperostosis, and osteitis. It is a rare disease with a combination of osseous and articular manifestations associated with skin lesions. We describe a patient with SAPHO syndrome of the mandible and involvement of the temporomandibular joint (TMJ ankylosis). The findings from orthopantomography, computed tomography (CT), and clinical and histopathological examinations are compared and analyzed to improve the final diagnosis. Our patient was submitted to a bilateral high condylectomy and coronoidectomy to correct the open mouth limitation. No previous report of SAPHO syndrome associated with secondary TMJ ankylosis was found in the literature.

Tooth abnormalities and soft tissue alterations in patients with G/BBB syndrome

OBJECTIVE: The G/BBB syndrome is an X-linked recessive disorder characterized by eye anomalies, laryngotracheoesophageal cleft, congenital heart disease, genitourinary anomalies and gastrointestinal disorders. Patients may also present cleft lip and palate, high-arched palate and thin upper lip. This study aimed to investigate the occurrence of tooth abnormalities and soft tissue changes in patients with G/BBB syndrome. DESIGN: Cross-sectional. SUBJECTS AND METHODS: Twenty-one patients with G/BBB syndrome were analyzed as to the presence of tooth abnormalities and soft tissue alterations. MAIN OUTCOME MEASURES: The prevalence of tooth agenesis and supernumerary teeth was compared to patients without morphofunctional alterations, matched for gender and age. RESULTS: All patients had complete cleft lip and palate; 95.23% of patients presented tooth abnormalities, mainly hypoplastic alterations, with predominance of alterations of number, followed by alterations of structure, shape and position. The frequency of tooth agenesis and supernumerary teeth was significantly higher compared with the control group; 11 patients presented incisiform supernumerary teeth in the mandibular anterior region. Ankyloglossia was observed in 11 of 21 patients. CONCLUSION: The presence of mandibular anterior supernumerary teeth and ankyloglossia should be investigated in the clinical evaluation of patients with suspected diagnosis of the G/BBB syndrome. Oral Diseases (2008) 14, 747-753

Tooth abnormalities and soft tissue changes in patients with velocardiofacial syndrome

Objective. The objective of this study was to investigate the prevalence of tooth abnormalities and soft tissue changes in patients with velocardiofacial syndrome. Study design. Twenty-six patients with velocardiofacial syndrome were examined to investigate the presence of tooth abnormalities and soft tissue alterations. The occurrence of tooth agenesis and supernumerary teeth was compared to patients without morphofunctional alterations, matched for gender and age. Results. Of all patients, 76.92% exhibited at least one tooth abnormality, with predominance of hypoplastic alterations, especially represented by hypodevelopment of the lingual cusp of mandibular first premolars and enamel opacities. The occurrence of tooth agenesis and supernumerary teeth was similar in both study and control groups. Conclusion. the present results suggest an association between hypodevelopment of the lingual cusp of mandibular first premolars and enamel opacities, yet these findings still require corroboration. Future studies should further investigate these aspects in larger samples compared to control groups, as well as employing molecular genetics techniques.

Temporomandibular Joint Ankylosis in an Infant: A Rare Cause of Difficult Airway

1.Pre-assessment data of the patient A 2-year-old boy, weighing 15 kg was admitted with a history of limited mouth opening(inter-incisor distance of 6 mm), hypoplastic and retrognathic mandible (bird face deformity) and facial asymmetry from left temporomandibular joint ankylosis (TMJA). He was born at term, after an uneventful pregnancy, and there was no report of trauma during caesarean section. No other possible aetiologies were identified. He was scheduled for mandibular osteotomy. Preoperative ENT examination revealed adenotonsillar hypertrophy. 2. Anaesthetic Plan A fiberoptic nasal intubation was performed under deep inhalation anaesthesia with sevoflurane, with the patient breathing spontaneously. Midazolam (0.05 mg.kg-1) and alfentanil (0.03 mg.kg-1) were given and anaesthesia was maintained with O2/air and sevoflurane. No neuromuscular blocking agent was administered since the surgical team needed facial nerve monitoring. 3. Description of incident During surgery an accidental extubation occurred and an attempt was made to reintubate the trachea by direct laryngoscopy. Although the osteotomy was nearly completed, the vocal cords could not be visualized (Cormack-Lehane grade IV laryngoscopic view). 4. Solving the problem Re-intubation was finally accomplished with the flexible fiberscope and the procedure was concluded without any more incidents. Extubation was performed 24 hours postoperatively with the patient fully awake. After surgery mouth opening improved to inter-incisor gap of 15 mm. 5. Lessons learned and take home message Two airways issues present in this case can lead to difficultventilation and intubation: TMJA and adenotonsillar hypertrophy. These difficulties were anticipated and managed accordingly. The accidental extubation brought to our attention the fact that, even after surgical correction, this airway remains challenging. Even with intensive jaw stretchingexercises there is a high incidence of re-ankylosis, especially in younger patients. One should bear that in mind when anaesthetizing patients with TMJA.

Five years of sleep apnea treatment with a mandibular advancement device. Side effects and technical complications

Objective: To determine the variation in prevalence of temporomandibular disorders (TMD), other side effects, and technical complications during 5 years of sleep apnea treatment with a mandibular advancement device. Materials and Methods: Forty patients diagnosed with obstructive sleep apnea received an adjustable appliance at 70% of the maximum protrusion. The protrusion was then progressively increased. TMD (diagnosed according to the Research Diagnostic Criteria for TMD), overjet, overbite, occlusal contacts, subjective side effects, and technical complications were recorded before and a mean of 14, 21, and 58 months after treatment and analyzed by the Wilcoxon test (P Less-than .05). Results: Fifteen patients still used the oral appliance at the 5-year follow-up, and no significant variation in TMD prevalence was observed. Subjective side effects were common, and a significant reduction was found in overjet, overbite, and in the number of occlusal contacts. Furthermore, the patients made a mean of 2.5 unscheduled dental visits per year and a mean of 0.8 appliance repairs/relines per year by a dental technician. The most frequent unscheduled visits were needed during the first year and were a result of acrylic breakage on the lateral telescopic attachment, poor retention, and other adjustments to improve comfort. Conclusions: Five-year oral appliance treatment does not affect TMD prevalence but is associated with permanent occlusal changes in most sleep apnea patients during the first 2 years. Patients seek several unscheduled visits, mainly because of technical complications.

Psychological stress alters the ultrastructure and increases IL-1β and TNF-α in mandibular condylar cartilage

Psychological factors can be correlated with temporomandibular disorders (TMDs), but the mechanisms are unknown. In the present study, we examined the microstructural changes and expression of proinflammatory cytokines in mandibular condylar cartilage of the temporomandibular joint (TMJ) in a psychological stress animal model. Male Sprague-Dawley rats (8 weeks old, 210 ± 10 g) were randomly divided into 3 groups: psychological stress (PS, N = 48), foot shock (FS, N = 24), and control (N = 48). After inducing psychological stress using a communication box with the FS rats for 1, 3, or 5 weeks, PS rats were sacrificed and compared to their matched control littermates, which received no stress and were killed at the same times as the PS rats. Body and adrenal gland weight were measured and corticosterone and adrenocorticotropic hormone levels were determined by radioimmunoassay. After hematoxylin-eosin staining for histological observation, the ultrastructure of the TMJ was examined by scanning electron microscopy. Transcription and protein levels of interleukin-1β (IL-1β) and tumor necrosis factor-α (TNF-α) were evaluated by ELISA and semi-quantitative RT-PCR. The PS group showed a significantly higher adrenal gland weight after 3 weeks of stress and higher hormone levels at weeks 1, 3, and 5. Histopathological changes and thinning cartilage were apparent at weeks 3 and 5. In the PS group, TNF-α increased at 1, 3, and 5 weeks and IL-1β increased significantly after 1 and 3 weeks of stress, and then decreased to normal levels by 5 weeks. Psychological stress increased plasma hormone levels and RT-PCR indicated increased IL-1β and TNF-α expression in the TMJ in a time-dependent manner. These results suggest that cytokine up-regulation was accompanied by stress-induced cartilage degeneration in the mandibular condyle. The proinflammatory cytokines play a potential role in initiating the cartilage destruction that eventually leads to the TMDs.

Effets sur l'articulation temporo-mandibulaire du Twin-Block et d'un appareil myofonctionnel de classe II.

Introduction. Ce projet de recherche consiste en une étude cohorte prospective randomisée visant à évaluer les douleurs ressenties au niveau de l’articulation temporo-mandibulaire (ATM) lors d’une thérapie d’avancement mandibulaire grâce à un appareil fixe, le correcteur de classe II (CC) et d’un appareil amovible, le Twin-Block (TB). Matériels et méthodes. Cette étude comptait 26 patients (11 hommes et 15 femmes), âge moyen de 12ans 10mois (10ans 4mois à 15ans 10mois). Les sujets devaient avoir une malocclusion de classe II et être en croissance, CVM 2 ou 3 (Cervical Vertebral Maturation). Les patients étaient divisés en deux groupes : TB et CC. La douleur était évaluée selon l’axe I de l’examen du RDC/TMD (Research Diagnostic Criteria for Temporomandibular Disorders) à 7 reprises (T0 à T6). De plus, le patient devait remplir un questionnaire, à la maison, sur la douleur ressentie et la médication prise lors des 30 premiers jours. La douleur était évaluée avant l’insertion des appareils (T0), à 1 semaine (T1) post-insertion, 4 semaines plus tard (T2), 8 semaines (T3) où une expansion de 20 tours (environs 5 mm) était débutée, ensuite (T4) (T5) et (T6) chacun à 8 semaines d’intervalles. Les tests statistiques utilisés dans cette étude : le test «Wilcoxon à un échantillon» ainsi que le test «Mann-Whitney à échantillons indépendants ». Résultats et Discussion. La douleur à l’examen clinique est variable mais tend à diminuer avec le temps. Aucune différence, statistiquement significative, ne fut observée entre les 2 groupes en ce qui à trait aux diverses palpations effectuées. Parmi les patients ayant rapporté de la douleur, 40% l’ont ressentie surtout le matin et 63,3% ont dit qu’elle durait de moins d’une heure jusqu’à quelques heures. Conclusion. D’après nos résultats, lors d’une thérapie myofonctionnnelle, il n’y a pas de différence statistiquement significative entre la douleur occasionnée par un Twin-Block et celle produite par un correcteur de classe II fixe au niveau de l’ATM et des muscles du complexe facial.

Effets du port continu de coquilles correctrices Invisalign® sur l’articulation temporo-mandibulaire et les muscles du complexe facial.

INTRODUCTION : L’articulation temporo-mandibulaire (ATM) est un système articulaire excessivement complexe. L'étiologie des désordres temporo-mandibulaires (DTM) est encore incertaine et le lien de cause à effet des traitements orthodontiques en tant que facteur de risque est une question qui a longuement été discutée. Cette étude clinique prospective vise à évaluer les effets à long terme du port continu de coquilles correctrices Invisalign® sur l’ATM et les muscles du complexe facial. MATÉRIELS ET MÉTHODES : L'étude incluait 43 adolescents et adultes âgés entre 13 et 51 ans (25 femmes et 18 hommes). Deux d'entre eux ont été exclus en raison de mauvaise coopération causant l’arrêt du traitement orthodontique. Les effets dans le temps des coquilles sur l'ATM et les muscles du complexe facial ont été évalués en utilisant l’examen du Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). Le nombre de contractions musculaires durant le sommeil a été mesuré objectivement par enregistrements électromyographiques (EMG) et la fréquence de grincement et de serrement des dents à l’éveil a été rapportée subjectivement par les patients à l’aide de questionnaires. Des mesures répétées ont été effectuées aux temps suivants: avant le début du traitement pour les données contrôles (T1), deux semaines (T2), et six mois (T3) après le début du traitement. Les données numériques ont été analysées par l’analyse de variance (ANOVA) en mesures répétées et la méthode de Brunner-Langer, alors que les données nominales ont été évaluées par le test de Cochran-Mantel-Haenszel. Les résultats ont été considérés significatifs si p < 0.05. RÉSULTATS ET DISCUSSION : Le nombre de contractions musculaires par heure (index) durant le sommeil et leur durée moyenne n’ont pas été statistiquement différents entre les trois nuits d’enregistrement EMG (Brunner Langer, p > 0.005). Cependant, 67 % des participants ont rapporté avoir eu du grincement ou du serrement des dents la nuit au T2 et 64 % au T3 comparativement à 39 % au T1, ce qui était une augmentation significative (Cochran-Mantel-Haenszel, p = 0.0112). Quarante-quatre pour cent des patients ont signalé du grincement ou du serrement des dents pendant le jour au T1, tandis qu'un pourcentage nettement plus élevé de 66 % en a rapporté au T2 et 61 % au T3 (Cochran-Mantel-Haenszel, p = 0.0294). Au T1, 12 % des sujets ont indiqué qu'ils se sont réveillés avec une douleur musculaire, comparativement à 29 % au T2, ce qui était une augmentation significative (Cochran-Mantel-Haenszel, p = 0.0347). Au T2, il y avait une réduction significative des mouvements maximaux de la mandibule dans toutes les directions (ANOVA en mesures répétées, p < 0,05). De plus, il y a eu une augmentation significative du nombre de sites douloureux et de l'intensité de la douleur à la palpation de l'ATM et des muscles faciaux avec l'évaluation du RDC/TMD au T2 en comparaison aux T1 et T3 (Brunner Langer, p < 0,05). CONCLUSION : La présente étude n’a révélé aucun effet des coquilles sur l’activité oro-faciale durant le sommeil au fil du temps mesurée objectivement à l’aide des enregistrements EMG, mais une augmentation significative de la fréquence du grincement et du serrement des dents rapportée subjectivement par les patients au moyen des questionnaires aux T2 et T3. Au T2, il y avait une augmentation significative des symptômes de l'ATM et des muscles du complexe oro-facial, mais ces symptômes sont retournés au niveau initial avec le temps.

Influence of the lateral pterygoid muscle on the growth of the mandibular condilar cartilage

At the end of the last century, a model to explain clinical observations related to the mandibular growth was developed. According to it, the lateral pterigoid muscle (LPM) was one of the main modulators of the differentiation of mesenquimal cells inside the condyle to condroblasts or osteoblasts, and therefore of the growth of the mandibular condilar cartilage (CCM). The main components of the model were the humoral and the mechanical. Nowadays, the humoral would include growth factors such as IGF-I, FGF-2 and VEGF, which seem to be involved in mandibular growth. Since skeletal muscle can secrete these growth factors, there is a possibility that LPM modulates the growth of CCM by a paracrine or endocrine mechanism. The mechanical component derived from the observations that both the blood flow inside the temporomandibular joint (ATM) and the action of the retrodiscal pad on the growth of the CCM, depend, in part, on the contractile activity of the LPM. Despite the fact that there are some results suggesting  hat LPM is activated under conditions of mandibular protrusion, there is no full agreement on whether this can stimulate the growth of CCM. In this review, the contributions and limitations of the works related to mandibular growth are discussed and a model which integrates the available information to explain the role of the LPM in the growth of the CCM is proposed.

Consistência interna e reprodutibilidade da versão em português do critério de diagnóstico na pesquisa para desordens temporomandibulares (RDC/TMD - Eixo II)

OBJETIVO: Estudar a confiabilidade, da versão em português, do questionário para o diagnóstico psicológico e psicossocial dos indivíduos com desordens temporomandibulares (RDC/TMD). MÉTODOS: Foram entrevistados 109 indivíduos, de ambos sexos, que demandaram atendimento junto à Clínica de Fisioterapia do Centro Universitário de Araraquara, de janeiro a julho de 2006. Os questionários foram aplicados por um único examinador. Após duas semanas, o mesmo foi reaplicado em 36 indivíduos. Para avaliação da consistência interna do método, utilizou-se o Coeficiente Alfa de Cronbach; para análise da reprodutibilidade intra-examinador, o Coeficiente de Correlação Intraclasse (ro) e a estatística Kappa (kapa), respectivamente às variáveis de natureza quantitativa e qualitativa. RESULTADOS: A consistência interna para as dimensões intensidade da dor crônica e incapacidade; limitação da função mandibular; sintomas físicos não-específicos, incluindo os itens de dor; sintomas físicos não-específicos, excluindo os itens de dor e depressão foi de 0,8479, 0,8971, 0,8673, 0,8080 e 0,9270 respectivamente, atestando ao método excelente validade interna. Obteve-se excelente concordância intra-examinador para as questões referentes ao tempo de presença da dor e sua gradação, e boa para a questão referente à dor presente. Os menores valores de kapa relacionaram-se aos itens de sintomas físicos e depressão. A percepção de estalos ou rangidos pelos indivíduos apresentou concordância regular bem como a questão referente à procura de profissional para tratamento da dor. As demais questões apresentaram reprodutibilidade boa e ótima, sendo que a maioria dessas apresentou nível máximo de concordância. CONCLUSÃO: A versão adaptada para o português mostrou-se confiável para detecção das alterações psicológicas e psicossociais associadas às desordens temporomandibulares.