Vol 45, No 6 (2017)

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.

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.

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. 

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.

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.

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.