Vol 45, No 6 (2017)

Cover Page

Full Issue


Combined Joint-Jaw-Occlusion therapy: a new theory and our protocol

Yang C., He D., Chen M., Zhang S., Qiu Y., Zhang X., Ma Z., Xie Q., Shen P., Hu Y.


Temporomandibular joint (TMJ) internal derangements, or TMJ disc displacement, is a commonly seen disease among adults, as well as children. It interacts with facial deformities and occlusion etiologically and pathologically, and the treatment often involves adjustment of occlusion as well. The aim of this article is to review relevant references and to introduce our combined methods of disc repositioning, occlusal therapy, orthodontics, and sometimes orthognathics, as the new Joint-Jaw-Occlusion (JJO) protocol, supported by sample case illustrations before the intervention and at follow-up. We analyze short- and long-term results of implementation JJO protocol in patients with various types of TMJ internal derangements and temporomandibular disc displacement. In our experience, the proposed protocol is a highly effective procedure, both functionally and cosmetically, and can help to avoid osteotomies.

Almanac of Clinical Medicine. 2017;45(6):440-459
pages 440-459 views

Temporomandibular joint disc repositioning with arthroscopy: part III – detailed introduction of the technique

Yang C., Zheng J., Liu X.


Disc displacement is one of the most common conditions affecting the temporomandibular joint (TMJ). In our previous publications we described the basic technical elements of the anterior disc repositioning surgery with arthroscopy and the success rates immediately after surgery. However, the surgical procedure is very complicated and difficult to study, and the technique has not been introduced in details in the previous papers. The present article presents the detailed introduction of the arthroscopic surgery to demonstrate the safe and successful performance of this procedure. It describes preparation for the surgery, the instruments and materials used, the puncture procedure with the choice of the puncture points, the technique of anterior release of the disc, stepwise disc suturing, and discusses some key points to avoid potential pitfalls and mistakes during the surgery. All steps of the technique are comprehensively illustrated by original photographs and diagrams and the intervention results are supported by magnetic resonance imaging scans. Since 2015, the arthroscopic procedure of this type has been performed by the study authors in 760 joints with a short-term success rate of up to 99.08%.

Almanac of Clinical Medicine. 2017;45(6):460-465
pages 460-465 views

Temporomandibular joint disc repositioning by modified anchorage surgery

Yang C., He D., Zhang X., Bai G., Liu X.


The appropriate position and morphologic preservation of the disc are critical to prevent excess remodeling and degenerative changes within the temporomandibular joint. The paper reviews the history of surgical approaches to disc displacement and presents a modified technique of temporomandibular joint disc reposition developed by the authors. Seven key points are highlighted that are essential for the success of the proposed arthroscopic intervention. The anterior release should be complete, with avoidance of any damage to the masseteric nerve and vessels. Expansion of the upper joint space to ensure appropriate placement of the incision should be performed with the straight ramus retractor used to distract the mandible and injecting saline, which helps prevent cutting of the disc or cartilage when entering the fossa. The disc should be repositioned without any tension. Two mattress sutures (one medial and one lateral) should be placed at the border of the disc and the posterior band. The disc is fixed with one bone anchor which is sufficient for its further stability. The position of the disc should be overcorrected to avoid relapse. Autogenous fat grafting in the anterior release region is vital to lessen scarring and thus to improve long term outcomes. All steps of the proposed technique are discussed with comparison with previous approaches. Factors influencing a relapse and measures to prevent it are reviewed in detail.

Almanac of Clinical Medicine. 2017;45(6):466-470
pages 466-470 views

Evaluation of arthroscopic disc repositioning: a prospective study

Yang C., Hu Y.


Aim: To evaluate clinical outcomes and success rates of our arthroscopic disc repositioning and suturing technique in patients with internal derangements of the temporomandibular joint (TMJ). Materials and methods: This was a prospective study in selected patients who met certain criteria. At baseline, we collected the information on their age, gender, disease duration, and the operated TMJ. Preoperative and postoperative variables included joint pain, joint clicking, maximal inter-incisal opening, mandibular protrusion, and lateral movements. Postoperative assessments were also performed, including magnetic resonance imaging (MRI) scans, assessment of numbness, scar, diet, and quality of life. All patients were assessed preoperatively and at 1, 3, 6, 12 months after the arthroscopic surgery. An independent t-test was used to assess the quantitative data and chi-square test was applied to the binary data. Results: The study was completed in 224 joints from 179 patients. Their mean age was 21.35 ± 8.71 years. Joint pain and quality of life improved significantly at 1 month of the follow-up, and almost vanished at 3 months of the follow-up. Frequency of joint clicking was significantly lower at 1 month of the follow-up, but increased significantly at 3 months of the follow-up. Numbness was significantly reduced at 12 months after surgery. Dietary and scar improvements were obvious at 3 months after surgery. Jaw movements were significantly improved at 12 months after the surgery. The success rate of the disc position evaluated by MRI decreased slightly from 99.6% to 97.8% at 1 month and 12 months of the follow-up. Conclusion: Our arthroscopic disc repositioning technique is an effective surgical method not only to improve the joint functioning, but also to correct the disc displacement for a relatively long time. It can be regarded as an appealing technique for the treatment of TMJ internal derangements.

Almanac of Clinical Medicine. 2017;45(6):471-477
pages 471-477 views

Assessment of occlusal appliance in repositioning of the temporomandibular joint anterior disc displacement with reduction: a 3 to 36 months follow-up

Yang C., Shen P.


Rationale: Occlusal appliance is one of methods for temporomandibular joint anterior disc displacement with reduction (ADDWR). However, most studies have focused on the symptom reliefs rather than the disc-condyle positional relationship. Aim: To evaluate the success rate and the prognosis of occlusal appliances in repositioning of the disc in temporomandibular joint ADDWR. Materials and methods: One hundred and forty four (144) patients (210 joints) diagnosed with temporomandibular joint ADDWR based on magnetic resonance imaging (MRI) were consecutively included in our study. For all joints it was confirmed by MRI that the disc could be recaptured in a mandible anterior position. Occlusal appliances, including anterior repositioning appliance, twinblock or Herbst, were worn to keep the mandible in this position. MRI scanning was carried out before, 6 months later, at the end of treatment and at the follow-up visit. Logistic regression was used to analyze the risk factors for success. Cox regression model was applied to estimate the prospective risk of failure. Results: Among the occlusal appliances used, there were 100 anterior repositioning appliances, 23 twin-blocks, and 21 Herbst, with mean treatment duration of 9.5 ± 2.6 months. One hundred and seventy seven (177) joints (84.3%) were successfully repositioned at the end of splint treatment, according to MRI. Logistic regression showed that the appliance types were significantly associated with the success rate. At 2 years of regular follow-up, in almost 53% of the cases the disc-condyle relationship was normal. Gender, age, treatment duration and orthodontics were identified in the final Cox regression model with hazard ratios of 1.375, 1.141, 0.396 and 0.364 respectively. Conclusion: Occlusal appliance is one of the useful methods to recapture the disc in patients with temporomandibular joint ADDWR. However, the patient selection should be rigorous. 

Almanac of Clinical Medicine. 2017;45(6):478-485
pages 478-485 views

Temporomandibular joint's reconstruction after segmental mandibulectomy in patients with primary and secondary tumors of the mandible

Kropotov M.A., Sobolevskiy V.A., Dikov Y.Y., Yakovleva L.P., Lysov A.A.


Background: Auto and allografts are used for segmental resection of the mandible with its exarticulation and simultaneous reconstruction. Endoprosthetic replacement of temporomandibular joint (TMJ) may bring good functional results. However, some complications, such as fracture of the fixing part of the endoprosthesis, migration of its head into the middle cranial fossa and prosthesis eruption, can occur in the long-term. The use of revascularized bone autografts allow for replacement of the mandibular defect and to restore TMJ function. Aim: To evaluate functional, aesthetic and oncological results after segmental resection of the mandible with its exarticulation and simultaneous reconstruction with allografts and revascularized bone autografts. Materials and methods: Thirty patients were enrolled into the study, 22 of them being with primary mandibular tumors and 8 with oral cancers originating from mucosa, with advanced involvement of the mandible. Segmental mandibulectomy with simultaneous reconstruction was performed in all patients, with 9 of them having the allograft and endoprosthesis of the articular head and 21 patients having revascularized bone or combined grafts. If only a defect of the mandibular ramus and articular head was to be replaced, we used an iliac free flap (n = 5), whereas for replacement of a defect of the mandibular ramus, body and articular head a fibular free flap was implanted (n = 16). Results: The use of allografts was associated with 4 (44.4%) complication events, such as plate fracture (n = 2) at 2 and 6 years and eruption of the plate. When revascularized grafts were used, complete necrosis was seen in 1 (4.7%) case. The iliac graft was formed with the size of the ramus defect (most often, up to the mandibular angle), and the articular head was formed from the distal part. At least one osteotomy was performed in the fibular graft at the angle, and the articular head was formed in the distal part. Twenty (66.7%) patients are currently disease-free. Six (33.3%) patients died of relapse at 1 to 5 years, and 4 (13.3%) patients died with lung metastases of osteogenic sarcoma of the mandible. Conclusion: Allotransplantation after segmental resection of the mandible gives good functional results, although with a high rate of late complications (44.4%). In patients with limited defects of the mandibular ramus and head, revascularized iliac grafts can be used. In those with large defects, the method of choice is a fibular graft. It is possible to make the articular head of the distal end of the graft with its subsequent adaptation to the functional load.

Almanac of Clinical Medicine. 2017;45(6):486-494
pages 486-494 views

Temporomandibular disorder in chronic migraine

Latysheva N.V., Filatova E.G., Platonova A.S.


Rationale: For many years, temporomandibular disorder (TMD) has been studied primarily by dentists and maxillofacial surgeons. However, new data is emerging that TMD is comorbid with various types of headache; however this association has not been studied in detail. Aim: To analyze TMD prevalence and clinical structure in patients with migraine. Materials and methods: We assessed 84 patients with chronic migraine (CM) and 42 patients with episodic migraine (EM). TMD was diagnosed according to the Diagnostic Criteria for Temporomandibular Disorders: Clinical Protocol and Assessment Instruments 2014. We also performed subgroup analysis for low-frequency EM (less than 4 headache days per month, LFEM) vs. high-frequency EM and CM (over 10 headache days per month, HFEM + CM). Results: In both groups, myofascial pain was the most prevalent form of TMD. The prevalence of TMD was higher in CM as compared to EM (52.4% vs. 28.6%, correspondingly, р = 0.02). Even more evident differences were observed between LFEM and HFEM + CM (18.2% vs. 51.6%, correspondingly, р < 0.009). The difference was significant for painrelated TMD only. The prevalence of bruxism was comparable across LFEM and HFEM + CM (18% vs. 30.5%, correspondingly, р = 0.3) and significantly lower than TMD prevalence in HFEM + CM (30.5% vs. 51.6%, correspondingly, p = 0.005). The anxiety level in patients with and without TMD was also comparable (8.1 ± 4.1 vs. 8.3 ± 4.7, correspondingly, р = 0.8). Conclusion: CM patients have a high prevalence of pain-related TMD (52.4%). The prevalence of TMD in LFEM is comparable to that in the general population. The presence of bruxism or anxiety cannot be associated with a high TMD prevalence in our patients. In CM, pain in the masticatory muscles may be caused by anti-nociceptive dysfunction, mirroring central sensitization and disrupted descending modulation of pain.

Almanac of Clinical Medicine. 2017;45(6):495-501
pages 495-501 views

Osteoplasty of the maxilla in patients with unilateral cleft lip and palate by a mandibular bone graft with the use of 3D computer modeling

Ivanov A.L., Reshetnyak E.I., Starikova N.V., Nadtochiy A.G.


Rationale: Maxillary defects in patients with unilateral cleft lip and palate are very heterogeneous. The existing methods to assess the results of osteoplasty are suboptimal. The ways to measure the volume of a defect are not truly three-dimensional; instead, they are based on the sum of the sizes of maxillary defect measured in the sections done across the alveolar process. This is a more or less precise approximation and its calculation may be time-consuming. Aim: To evaluate efficacy of osteoplasty with a mandible bone autograft in children with cleft lip and palate and to determine the optimal pre-requisites for satisfactory treatment results. Materials and methods: We examined and treated 30 patients with unilateral cleft lip and palate and maxillary defects, aged from 7 to 17 (mean age 11.2 ± 3.5 years). The following types of abnormalities were found: incomplete cleft lip, alveolar process and palate; complete cleft lip, alveolar process and palate; complete cleft lip, alveolar process and palate with partial ossification of the posterior hard palate related to previous surgeries. In all patients, the surgical intervention consisted of maxillary osteoplasty with a combination graft consisting of the cortical plate from the mandible body, shaped to the existing defect, an autologous bone chips taken from the mandible ramus, and a Bio-Oss xenograft. The patients were divided into 4 groups, depending on their age, diagnosis, defect size, and postoperative complications. Three-dimensional modeling to determine the volume of the defect was performed as follows: a geometrical model of the mandible defect was obtained based on the mirror copy of the contralateral healthy part; the volume of the defect was computed as the difference between the baseline and the mirror model. The results of the osteoplasty were assessed by Bergland and Chelsea scales, as well as by our own scales. Results: The defect volumes were in the range of 0.46 to 2.9 cm3 (mean, 1.32 ± 0.54 cm3). According to Bergland and Chelsea scales, good results of osteoplasty were obtained in 83% (25 / 30) of the cases. The regenerated bone thickness was good in 94% (28 / 30) of the patients. The edge of the foramen piriformis was well shaped in 90% (27 / 30) of them. After surgery, the volumes of the defects in the patients with incomplete cleft lip, palate and alveolar process were significantly smaller than those in the patients with complete cleft and partial ossification of the posterior hard palate (on average, by 0.8 cm3, p = 0.0071). In all cases, where cortical mandible grafts were taken, it was possible to obtain cortical blocks of the needed size, starting from the age of 7, without any risk of damage to the immature permanent teeth. Graft formation from the mandible body was not associated with any local complications in any patient. Conclusion: Our method of 3D modeling to determine the volume of mandible defects is a truly 3D approach, which allows for a highly accurate quantitative assessment of the defects. The use of the combination grafts from the mandible body and the Bio-Oss xenografts for osteoplasty helps to replace the maxillary defect irrespective of the patient's age and the defect volume. Cortical grafts can be taken from the mandible starting from the age of 7 without any risk of damage to the immature permanent teeth. Irrespective of the clinical situation, the osteoplasty results are influenced predominantly by adherence to the surgical technique and to post-operative recommendations.

Almanac of Clinical Medicine. 2017;45(6):502-510
pages 502-510 views

Comparative analysis of the results of surgery for juvenile nasopharyngeal angiofibroma with the use of 3D reconstructions of computed tomography angiography

Grachev N.S., Vorozhtsov I.N., Krasnov A.S.


Rationale: The relapse rates after surgery for juvenile nasopharyngeal and/or skull base angiofibroma is in the range of 23 to 27.5%, which is mostly related to diagnostic issues. Aim: To perform a comparative analysis of the results of surgical treatment for juvenile nasopharyngeal and skull base angiofibroma based on our technique of 3D reconstructions of computed tomography angiograms in patients with primary tumors and with relapses. Materials and methods: We analyzed retrospectively the data from 32 patients with juvenile nasopharyngeal and skull base angiofibroma who had been diagnosed and treated from 2013 to 2017 (42 surgeries). Multislice computed tomography (MSCT) angiography with 3D reconstruction was used for the planning of surgical approaches. At days 3 to 7 after the surgery, in 31 patients with stages II, IIIa and IIIb (according to U. Fisch classification modified by R. Andrews, 1989), we looked for residual tumor tissues by MSCT with standard analysis and with 3D MSCT angiography reconstructions, comparing them with their corresponding baseline images. The patients were divided into two groups: group 1, 17 patients with primary tumors (median age 13.5 years), group 2, 14 patients who had been previously operated (median age 14 years). Both groups were comparable in their clinical and demographic characteristics, as well as in the tumor staging (p > 0.05). Results: The relapse rates were 22.58% (7 / 31 patients), being 11.76% (2 / 17) in the group 1 and 35.71% (5 / 14) in the group 2 (p > 0.05). In each group, the maximal difference in the resected tumor volume was found in stage II patients, with more radical resection in the patients with primary tumors (p < 0.05). Contrast-enhanced MSCT showed residual tumor masses in 19 patients (8, with primary tumors and 11, with relapses). From those, 10 patients (3 with primary tumors and 7 who had underwent surgery earlier) required second surgeries (4 patients were curatively operated, and 2 patients relapsed within 1 year). All other patients continue their follow-up monitoring. By the time the paper was submitted, the duration of their follow up was from 3 months to 3 years; no relapses were identified. The data obtained by 3D reconstructions of MSCT angiography correlated with summary reports from the Department of Diagnostic Radiology in 100% of cases. During follow-up, we had few cases of diagnostic discrepancies between the assessment reports by territorial radiologists and the conclusions obtained by our method, although these discrepancies were not statistically significant. Conclusion: 3D images obtained after the reconstruction make it possible to evaluate the tumor spread in relation to anatomical structures (for primary tumors), as well as the results of surgical treatment. Curative potential of surgical treatment for juvenile nasopharyngeal and skull base angiofibroma is lower with higher tumor stages.

Almanac of Clinical Medicine. 2017;45(6):511-517
pages 511-517 views


Experience of head and neck free flap reconstruction in children

Grachev N.S., Tereshchuk S.V., Babaskina N.V., Vorozhtsov I.N.


From 2015 to 2017, 14 surgical intervention for benign and malignant tumors of mandibular and maxillary regions, soft tissues in the temporal areas and extra organ soft tissue tumors of the head have been performed in the Department of Oncology and Pediatric Surgery of Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology (Moscow). Simultaneous or delayed reconstructions were performed with a bone-muscle flap taken from the crista iliaca, with a fibular flap or a soft tissue radial flap. In all cases, the anastomoses were well-fixed and the flaps viable. The paper presents a clinical case of a 6-year old girl with a central gigantic cell granuloma of the mandibular body. The tumor was resected with a simultaneous reconstruction with a free fibular flap based on stereolythographic resection templates. By the time this paper was written, the duration of the follow-up exceeded 1.5 years. There is no relapse, the free flap is well-fixed and functional, and the child is socially adapted. Based on the radical resection of the primary tumor, preserved innervations of the chin soft tissues, full facial mimics and rapid social adaptation of the child, as well as functional preservation of the jaw and the possibility of oral nutrition, together with the possibility of prosthodontics in the post-operative period, we consider this treatment approach to be optimal for this case. The use of free flaps was highly optimal in all other cases as well, due to their advantages, such as highly radical resection, good functional and esthetic results, rapid social adaptation of children. We believe that wider indications for reconstruction with free flaps are very promising in pediatric practice. 

Almanac of Clinical Medicine. 2017;45(6):518-524
pages 518-524 views

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