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Parameters of Care: Clinical Practice Guidelines for Oral and Maxillofacial Surgery (AAOMS ParCare 2012)
TEMPOROMANDIBULAR JOINT SURGERY
Copyright 2012 by the American Association of Oral and Maxillofacial Surgeons. This document may not be copied or reproduced without the express written permission of the American Association of Oral and Maxillofacial Surgeions. All rights reserved. J Oral Maxillofac Surg 70:e204-e231, 2012, Suppl 3 THIS SECTION IS 1 OF 11 CLINICAL SECTIONS INCLUDED IN AAOMS PARCARE 2012, WHICH IS VIEWED AS A LIVING DOCUMENT APPLICABLE TO THE PRACTICE OF ORAL AND MAXILLOFACIAL SURGERY. IT WILL BE UPDATED AT DESIGNATED INTERVALS TO REFLECT NEW INFORMATION CONCERNING THE PRACTICE OF ORAL AND MAXILLOFACIAL SURGERY.
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AAOMS ParCare 2012 Temporomandibular Joint Surgery
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INTRODUCTION
Temporomandibular joint (TMJ) surgery is indicated for the treatment of a wide range of pathologic conditions, including developmental and acquired deformities, internal derangements, arthritis, functional abnormalities, ankylosis, and infection. Parameters of care related to management of tumors of the TMJ are in the Diagnosis and Management of Pathological Conditions chapter, and those for fractures of the mandibular condyle are in the Trauma Surgery chapter. It is recognized that many patients undergoing TMJ surgeries have unique pain control requirements. As such, it may be appropriate to discuss a specic plan for postoperative pain control management. Such therapy might include the surgeon managing the patients pain with narcotic prescriptions for a specied period, followed by referral to a pain control center. Some surgeons may wish to develop a contract with these patients that reviews the planning, timing and other specics of such therapy. The parameters for TMJ surgery are based on the descriptions of pathologic entities and modalities for their treatment that have appeared in peer-reviewed medical literature. This eld has undergone a considerable evolution during the past 15 to 20 years. Basic and clinical research is continuing to increase the potential for successful surgical results.
GENERAL CRITERIA, PARAMETERS, AND CONSIDERATIONS FOR TEMPOROMANDIBULAR JOINT SURGERY

INFORMED CONSENT: All surgery must be preceded by the patients or legal guardians consent, unless an emergent situation dictates otherwise. These circumstances should be documented in the patients record. Informed consent is obtained after the patient or the legal guardian has been informed of the indications for the procedure(s), the goals of treatment, the known benets and risks of the procedure(s), the factors that may affect the risk, the treatment options, and the favorable outcomes. PERIOPERATIVE ANTIBIOTIC THERAPY: In certain circumstances, the use of antimicrobial rinses and systemic antibiotics may be indicated to prevent infections related to surgery. The decision to employ prophylactic perioperative antibiotics is at the discretion of the treating surgeon and should be based on the patients clinical condition as well as other comorbidities which may be present. USE OF IMAGING MODALITIES: Imaging modalities may include panoramic radiograph, periapical and/or occlusal radiographs, maxillary and/or mandibular radiographs, computed tomography, cone beam computed tomography, positron emission tomography, positron emission tomography/computed tomography, and magnetic resonance imaging. In determining studies to be performed for imaging purposes, principles of ALARA (as low as reasonably achievable) should be followed. DOCUMENTATION: The AAOMS ParCare 2012 includes documentation of objective ndings, diagnoses, and patient management interventions. The ultimate judgment regarding the appropriateness of any specic procedure must be made by the individual surgeon in light of the circumstances presented by each patient. Understandably, there may be good clinical reasons to deviate from these parameters. When a surgeon chooses to deviate from an applicable parameter based on the circumstances of a particular patient, he/she is well advised to note in the patients record the reason for the procedure followed. Moreover, it should be understood that adherence to the parameters does not guarantee a favorable outcome. GENERAL THERAPEUTIC GOALS FOR TEMPOROMANDIBULAR JOINT SURGERY: A. Improve function and form B. Limited period of disability C. Improved range of jaw motion and/or function D. Appropriate understanding by patient (family) of treatment options and acceptance of treatment plan E. Appropriate understanding and acceptance by patient (family) of favorable outcomes and known risks and complications GENERAL FACTORS AFFECTING RELATIVE RISK DURING TEMPOROMANDIBULAR JOINT SURGERY: A. Degree of patient and/or family understanding of the origin and natural course of the condition or disorder and therapeutic goals and acceptance of proposed treatment B. Presence of coexisting major systemic disease (eg, disease that increases a patients American Society of Anesthesiologists classication to II, III, or IV as detailed in the Patient Assessment chapter
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C. D. E. F. G. H. I. J. K. L. M. N. O.
Age of patient Presence of concomitant facial pain (eg, dental pain, earache, headache) Presence of parafunctional habit Existing drug or alcohol dependence Issues of secondary gain (eg, pending litigation) Chronic pain disorders (eg, pain in excess of 6 months duration) Presence of malocclusion Presence of deformity or pathology of the TMJ Presence of concomitant skeletal deformity History of previous orthodontics, orthognathic surgery, or TMJ surgery History of sensory or motor nerve abnormality (eg, temporary or permanent) History of infection of surgical site Presence of local or systemic conditions that may interfere with the normal healing process and subsequent tissue homeostasis (eg, previously irradiated tissue, diabetes mellitus, chronic renal disease, liver disease, blood disorder, pregnancy, steroid therapy, contraceptive medication, immunosuppression, malnutrition, Ehlers-Danlos syndrome, bromyalgia) P. Prolonged period of TMJ disuse (eg, ankylosis) Q. History of maxillofacial trauma
GENERAL FAVORABLE THERAPEUTIC OUTCOMES FOR TEMPOROMANDIBULAR JOINT SURGERY: A. Improved masticatory function and facial form B. A level of pain that is of little or no concern to the patient and preferably measured objectively (eg, visual analog scale) C. Improved mandibular function that is compatible with mastication, deglutition, speech, and oral hygiene D. A stable occlusion E. Limited period of disability F. Limit further morbidity G. Patient (family) acceptance of procedure and understanding of outcomes GENERAL KNOWN RISKS AND COMPLICATIONS OF TEMPOROMANDIBULAR JOINT SURGERY: A. Unplanned admission to intensive care unit after elective surgery Comment and Exception: Planned admission should be documented in the patients record before surgery. B. Unplanned intubation for longer than 12 hours after surgery Comment and Exception: Planned intubation longer than 12 hours should be documented in the patients record before surgery. C. Reintubation or tracheostomy after surgery D. Emergency tracheostomy (eg, ankylosis, trismus, unable to maintain airway). E. Use of parenteral drugs and/or uids for longer than 72 hours after elective surgery Comment and Exception: Procedures in which long-term parenteral drugs and/or uids are indicated as part of the original treatment plan should be documented in the patients record. F. Failure to ambulate within 48 hours of elective surgery G. Facial and/or trigeminal nerve dysfunction after surgery (eg, temporary or permanent facial muscle weakness resulting from surgery). The most common resulting problems are an inability to wrinkle the brow, raise the eyebrow, or gain tight closure of the eyelids and numbness (temporary or permanent) of certain areas of the skin in the region of the joint and sometimes in more remote areas of the face and scalp. Comment and Exception: When postoperative nerve dysfunction is common, anticipated decits should be noted in the patients record before surgery (eg, trigeminal nerve dysfunction after sagittal split osteotomies, dysfunction of the temporal branch of facial nerve after TMJ procedures). H. Facial fracture during or after surgery Comment and Exception: A fractured bone that may be a sequela to surgery should be documented in the patients record before surgery. I. Unplanned exploratory procedures associated with surgery J. Dental injury during surgery K. Ocular injury during surgery and postoperative sequelae (eg, corneal abrasion, keratoconjunctivitis, blindness)
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L. Repeat Oral and/or Maxillofacial Surgery Comment and Exception: Staged procedures that are part of the original treatment plan should be documented before the initial procedure. M. Core temperature of greater than 101F 72 hours after elective surgery N. Postsurgical radiograph indicating presence of foreign body Comment and Exception: Foreign bodies (eg, plates, screws, wires, prosthetic replacements) that are anticipated as a normal course of the surgical procedures (eg, total joint replacement) should be noted in the patients record. O. Unplanned transfusion(s) of blood or blood components during or after surgery P. Readmission for complications or incomplete management of problems on previous hospitalization Comments and Exceptions: Complication or incomplete management occurring at another hospital or involving a physician who is not on the medical staff. Readmission for chronic disease (eg, intractable asthma, recurrent congestive heart failure, cancer); service-specic criteria required for this exception. Planned admissions for secondary procedures needed to complete treatment. Q. Development of chronic pain disorder R. Increased and/or persistent pain S. Postoperative development of adhesions, heterotopic bone (reactive bone), or ankylosis within the joint space, which may cause continued jaw dysfunction, decreased range of jaw movement, difculty chewing, and pain requiring further treatment T. Development of TMJ internal derangement U. New or worsened malocclusion V. Imaging evidence of further degenerative joint changes and development of adhesions (scar tissue), joint arthritis (contralateral joint in unilateral cases), or osteomyelitis of the jaw (bone infection) W. Signicant joint noise associated with increased pain and/or dysfunction X. Ear pain and/or dysfunction Y. Development or worsening of a parafunctional habit Z. Abnormal mandibular growth (eg, excessive, restricted) AA. Prolonged period of disability BB. Infection CC. Development of complex regional pain syndrome DD. Foreign body reaction or allergic reaction and rejection of the implant, wear, displacement, breakage, or loosening of alloplastic device components EE. Ear problems, including inammation of the canal, middle or inner ear infections, perforation of the ear drum, temporary or permanent hearing loss, ringing in the ears, or equilibrium problems FF. Postoperative and/or future treatments are not limited to but may include the following: physical therapy, bite splint therapy, restorative or reconstructive dentistry, orthodontia, orthognathic surgery (jaw repositioning surgery), and further reconstructive TMJ surgery GG. Respiratory and/or cardiac arrest HH. Death
SPECIAL CONSIDERATIONS FOR PEDIATRIC TEMPOROMANDIBULAR JOINT SURGERY

Orofacial pains due to TMJ conditions are less common in young children compared with teenagers and adults. Internal derangements are uncommon. TMJ conditions other than congenital deformities (eg, hemifacial microsomia) or acquired anatomical abnormalities (eg, fractures, bony ankylosis, or idiopathic condylar resorption) are very uncommon in children. When painful TMJ conditions do occur, underlying psychopathologic factors are more frequent. Informed consent issues specic to children as discussed in the Patient Assessment chapter are applicable for TMJ surgery. Masticatory muscle hyperactivity in children may present as nighttime grinding or bruxism, and this is common in the deciduous or mixed dentition stages of dental development. Children may complain of headaches, earaches, or jaw stiffness in the morning on awakening. Usually this can be managed with a night guard or biofeedback and appropriate medications, when indicated. Symptomatic clicking generally can be eliminated or diminished with midline hinge axis
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opening exercises to overcome an abnormal opening pattern. The origin of headache in the pediatric patient is primarily related to the sinus, eye, or vascular system. Any operative procedure on the TMJ of a growing child must consider the ultimate effect of the treatment on growth and development of the mandible and face. Management of ankylosis, juvenile rheumatoid arthritis, degenerative joint disease (very rare in children), infectious arthritis, mandibular dislocation, and condylar resorption is similar in children and adults. When reconstructing the TMJ and ramus-condyle unit in children, the Oral and Maxillofacial Surgeon must provide both normal functioning anatomy and an environment in which normal growth may occur. This is true regardless of the underlying condition (eg, tumor, traumatic defect, developmental defect). Therefore, autogenous donor sites with growth potential (eg, costochondral grafts) are recommended. The use of allogenic materials should be carefully considered in children.
MASTICATORY MUSCLE DISORDERS

Masticatory muscle disorders can result in myofascial pain and/or muscle splinting. These disorders are the most common expression of temporomandibular disorders and may occur in combination with joint abnormalities or other pathologic conditions. Management of these disorders is nonsurgical, especially in children. When masticatory muscle disorders occur in combination with joint abnormalities or other pathologic conditions, the management of these disorders must be incorporated into the overall treatment plan. Pretreatment therapeutic goals are determined individually for each patient. I. Indications for Therapy for Masticatory Muscle Disorders May include one or more of the following: A. B. C. D. E. II. Extra-articular pain related to muscles of the head and neck region Earaches, headaches, masticatory or facial myalgias Restricted masticatory function Restricted range of jaw motion Associated TMJ abnormalities or pathology
Specic Therapeutic Goals for Masticatory Muscle Disorders The goal of therapy is to restore form and/or function. However, risk factors and potential complications may preclude complete restoration of form and/or function. A. Presence of a general therapeutic goal, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery B. Improved range of jaw motion and/or function C. Adequate control of pain in muscles of the head and neck region
III.
Specic Factors Affecting Risk for Masticatory Muscle Disorders Severity factors that increase risk and the potential for known complications: A. Presence of a general factor affecting risk, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery B. History of previous maxillofacial trauma
IV.
Indicated Therapeutic Parameters for Masticatory Muscle Disorders Some reduction in symptoms is expected within 3 months. If the symptoms persist or escalate during this period, further assessment of contributing etiologic and risk factors should be considered. A. The pretreatment assessment includes, at a minimum: 1. General history and physical examination, as detailed in the Patient Assessment chapter 2. A focused history and physical examination of the TMJ region to determine if pathology is present 3. An imaging examination, if indicated, based on the history and physical ndings. The examination may include but is not limited to the following: screening panoramic radiography, cephalometric radiography, conventional tomography, arthrography, computed tomography (CT), cone beam computed tomography, radionuclide scanning, and magnetic resonance imaging (MRI). The following procedures for the management of masticatory muscle disorders are not listed in order of preference:
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MASTICATORY MUSCLE DISORDERS (continued)

B. Nonsurgical Management 1. Patient education (eg, stress reduction, dietary recommendations, jaw rest, control of parafunctional jaw habits) 2. Medication (eg, nonsteroidal anti-inammatory drugs [NSAIDs], analgesics, muscle relaxants) 3. Physical medicine (eg, physical therapy, massage, heat, cold, ultrasonography, trigger point injections, neuromuscular blocking agents) 4. Behavioral modication (eg, stress reduction, work modication, counseling, biofeedback, psychotherapy) 5. Orthopedic appliances (eg, splints) 6. Management of dental abnormalities 7. Surgery, other than manipulative treatment therapy, is not indicated for these disorders. 8. Instructions for posttreatment care and follow-up IV. Outcome Assessment Indices for Masticatory Muscle Disorders Indices are used by the specialty to assess aggregate outcomes of care. Outcomes are assessed through clinical evaluation and may include an imaging evaluation. A. Favorable therapeutic outcomes General favorable therapeutic outcomes, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery B. Known risks and complications associated with therapy Presence of a general known risk and/or complication, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery
INTERNAL DERANGEMENT
Surgical intervention for internal derangement is indicated only when nonsurgical therapy has been ineffective and pain and/or dysfunction are moderate to severe. Surgery is not indicated for asymptomatic or minimally symptomatic patients. Surgery also is not indicated for preventive reasons in patients without pain and with satisfactory function. Pretreatment therapeutic goals are determined individually for each patient. I. Indications for Therapy for Internal Derangement May include one or more of the following: A. Moderate-to-severe pain 1. Temporomandibular pain 2. Preauricular pain 3. Referred pain (eg, earaches) 4. Masticatory muscle pain (see Masticatory Muscle Disorders section) B. Dysfunction that is disabling and characterized by any of the following: 1. Restricted range of jaw motion (eg, locking of the joint: acute, chronic, intermittent, persistent) 2. Excessive range of jaw motion (eg, hypermobility; chronic dislocation: acute, chronic, intermittent, persistent) 3. Joint noises (eg, clicking, popping, crepitation) associated with pain 4. Abnormal masticatory function (eg, painful chewing) C. Imaging evidence of internal derangement D. Arthroscopic evidence of internal derangement II. Specic Therapeutic Goals for Internal Derangement The goal of therapy is to restore form and/or function. However, risk factors and potential complications may preclude complete restoration of form and/or function. A. Presence of a general therapeutic goal, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery B. Improved function C. Limited pain in the joint
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INTERNAL DERANGEMENT (continued)

D. Elimination or reduction of noise in the joint III. Specic Factors Affecting Risk for Internal Derangement Severity factors that increase risk and the potential for known complications: A. Presence of a general factor affecting risk, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery B. Presence of alloplast or autograft C. History of previous temporomandibular operative procedures D. History of previous maxillofacial trauma IV. Indicated Therapeutic Parameters for Internal Derangement A. The pretreatment assessment includes, at a minimum: 1. General history and physical examination, as detailed in the Patient Assessment chapter 2. A focused history and physical examination of the TMJ region to determine the presence of indications for care for internal derangement and to identify factors affecting risks 3. An imaging examination, if indicated, based on the history and physical ndings. The examination may include but is not limited to the following: panoramic radiography, cephalometric radiography, conventional tomography, arthrography, CT, cone beam computed tomography, radionuclide scanning, and/or MRI. The following procedures for the management of internal derangement are not listed in order of preference: B. Nonsurgical management 1. Patient education (eg, stress reduction, dietary recommendations, jaw rest) 2. Medication (eg, NSAIDs, analgesics, muscle relaxants) 3. Physical medicine (eg, physical therapy, massage, heat, cold, ultrasonography, trigger point injections) 4. Intracapsular diagnostic and therapeutic injections 5. Behavioral modication (eg, stress reduction, work modication, counseling, biofeedback, psychotherapy) 6. Orthopedic appliances (eg, splints) 7. Management of dental abnormalities 8. Diagnostic records to determine progression of the disease (eg, serial bite registration and models, imaging studies in selected cases) C. Surgical management 1. Examination and observation under anesthesia 2. Manipulation 3. Arthrocentesis 4. Arthroscopic surgery 5. Arthrotomy or arthroplasty a. Disk repair procedures b. Diskectomy without replacement c. Diskectomy with replacement d. Articular surface recontouring (condyle/eminence) 6. Mandibular condylotomy 7. Orthognathic surgery as an adjunct to the management of temporomandibular joint disorders. Correction of skeletal jaw deformities may be indicated before or after denitive joint treatment. D. Posttreatment management 1. Wound care 2. Physical therapy 3. Pain management 4. Diet and oral hygiene management 5. Orthotic appliance 6. Patient reassessment
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INTERNAL DERANGEMENT (continued)

7. Instructions for posttreatment care and follow-up V. Outcome Assessment Indices for Internal Derangement Indices are used by the specialty to assess aggregate outcomes of care. Outcomes are assessed through clinical evaluation and may include an imaging evaluation. A. Favorable therapeutic outcomes 1. General favorable therapeutic outcomes, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery 2. Improved mandibular function 3. Acceptable clinical appearance (eg, absence of motor decits, absence of hypertrophic scar formation, absence of facial asymmetry or deformity) B. Known risks and complications associated with therapy 1. Presence of a general known risk and/or complication, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery 2. Removal of autograft or alloplast 3. Ankylosis 4. Need for additional surgical intervention
DEGENERATIVE JOINT DISEASE

Surgical intervention is indicated only when nonsurgical therapy has been ineffective and pain and/or dysfunction are moderate to severe. Surgery is not indicated for asymptomatic or minimally symptomatic patients. Surgery also is not indicated for preventive reasons in patients without pain and with satisfactory function. Pretreatment therapeutic goals are determined individually for each patient. I. Indications for Therapy for Degenerative Joint Disease May include one or more of the following: A. Moderate-to-severe pain 1. Temporomandibular pain 2. Preauricular pain 3. Referred pain (eg, earaches) 4. Masticatory muscle pain (see Masticatory Muscle Disorders section) B. Dysfunction that is disabling and characterized by any of the following: 1. Restricted range of jaw motion (eg, locking of the joint: acute, chronic, intermittent, persistent) 2. Excessive range of jaw motion (eg, hypermobility; chronic dislocation: acute, chronic, intermittent, and persistent) 3. Joint noises (eg, clicking, popping, crepitation) 4. Abnormal masticatory function (eg, painful chewing) C. Imaging evidence of arthritic condition D. Arthroscopic evidence of arthritic condition E. Failed alloplastic implants F. Failed prior TMJ surgery II. Specic Therapeutic Goals for Degenerative Joint Disease The goal of therapy is to restore form and/or function. However, risk factors and potential complications may preclude complete restoration of form and/or function. A. Presence of a general therapeutic goal, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery B. Improved function C. Improved pain in the joint D. Improved maxillomandibular relationship E. Limited progression of the disease
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DEGENERATIVE JOINT DISEASE (continued)

III. Specic Factors Affecting Risk for Degenerative Joint Disease Severity factors that increase risk and the potential for known complications: A. Presence of a general factor affecting risk, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery B. Presence of an alloplast or autograft C. History of previous maxillofacial trauma D. Degenerative disease affecting other joints E. Prior temporomandibular joint surgery IV. Indicated Therapeutic Parameters for Degenerative Joint Disease A. The pretreatment assessment includes, at a minimum: 1. General history and physical examination, as detailed in the Patient Assessment chapter 2. Focused history and physical examination of the TMJ region to determine the presence of indications for care for degenerative joint disease and to identify factors affecting risks 3. An imaging examination, if indicated, based on the history and physical ndings. The examination may include but is not limited to the following: panoramic radiography, cephalometric radiography, conventional tomography, arthrography, CT, cone beam computed tomography, radionuclide scanning, and/or MRI. The following procedures for the management of degenerative joint disease are not listed in order of preference: B. Nonsurgical management 1. Patient education (eg, stress reduction, dietary recommendations, jaw rest) 2. Medication (eg, NSAIDs, analgesics, muscle relaxants, antiarthritics, steroids) 3. Physical medicine (eg, physical therapy, massage, heat, cold, ultrasonography, trigger point injections) 4. Intracapsular diagnostic and therapeutic injections 5. Behavioral modication (eg, stress reduction, work modication, counseling, biofeedback, psychotherapy) 6. Orthopedic appliances (eg, splints) 7. Management of dental abnormalities 8. Appropriate diagnostic records to determine progression of the disease (eg, serial bite registration and models, imaging studies in selected cases) C. Surgical management 1. Manipulation 2. Arthrocentesis 3. Arthroscopic surgery 4. Arthrotomy or arthroplasty a. Disk repair procedures b. Diskectomy without replacement c. Diskectomy with replacement d. Arthroplasty e. Removal of failed alloplastic implant 5. Condylectomy (partial or total, with or without replacement) 6. Orthognathic surgery (the correction of skeletal jaw deformities may be indicated before or after denitive joint treatment as an adjunct to the management of temporomandibular disorders) 7. Total alloplastic or autogenous joint replacement D. Posttreatment management 1. Wound care 2. Pain management 3. Diet and oral hygiene management 4. Physical therapy 5. Occlusal management
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DEGENERATIVE JOINT DISEASE (continued)

6. Patient reassessment 7. Instructions for posttreatment care and follow-up V. Outcome Assessment Indices for Degenerative Joint Disease Indices are used by the specialty to assess aggregate outcomes of care. Outcomes are assessed through clinical evaluation and may include an imaging evaluation. A. Favorable therapeutic outcomes 1. General favorable therapeutic outcomes, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery 2. Acceptable clinical appearance (eg, absence of motor decits, absence of hypertrophic scar formation, absence of facial asymmetry or deformity) 3. Improved mandibular function (eg, maximum incisal opening, lateral and protrusive excursions) B. Known risks and complications associated with therapy 1. Presence of a general know risk and/or complication, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery 2. Removal of autograft or alloplast 3. Ankylosis
RHEUMATOID ARTHRITIS
Rheumatoid arthritis is one of a constellation of systemic autoimmune diseases that may affect the TMJ. In many cases, these conditions should be managed with the close cooperation of the patients physician and/or rheumatologist. It is important to distinguish whether the condylar resorption is active (progressive) or stable (nonprogressive). In its most severe form, rheumatoid arthritis may result in ankylosis and/or condylar destruction with resultant mandibular retrognathism, anterior skeletal open bite, and painful limitation of function. Surgical intervention for arthritic conditions is indicated only when nonsurgical therapy has been ineffective and pain and/or dysfunction are moderate to severe. Surgery is not indicated for asymptomatic or minimally symptomatic patients. Surgery also is not indicated for preventive reasons in patients without pain and with satisfactory function. Pretreatment therapeutic goals are determined individually for each patient. I. Indications for Therapy for Rheumatoid Arthritis May include one or more of the following: A. Moderate-to-severe pain 1. Temporomandibular pain 2. Preauricular pain 3. Referred pain (eg, earaches) 4. Masticatory muscle pain (see Masticatory Muscle Disorders section) B. Dysfunction that is disabling and characterized by any of the following: 1. Restricted range of jaw motion (eg, locking of the joint: acute, chronic, intermittent, persistent) 2. Excessive range of jaw motion (eg, hypermobility, chronic dislocation: acute, chronic, intermittent, persistent) 3. Joint noises (eg, clicking, popping, crepitation) 4. Abnormal masticatory function (eg, painful chewing, malocclusion) 5. Joint swelling and/or effusion C. Imaging evidence of arthritic process D. Maxillofacial deformity II. Specic Therapeutic Goals for Rheumatoid Arthritis The goal of therapy is to restore form and/or function. However, risk factors and potential complications may preclude complete restoration of form and/or function. A. Presence of a general therapeutic goal, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery B. Limited pain in the joint
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RHEUMATOID ARTHRITIS (continued)

C. Improved maxillomandibular function D. Corrected or improved associated maxillofacial relationship E. Limited progression of the disease III. Specic Factors Affecting Risk for Rheumatoid Arthritis Severity factors that increase risk and the potential for known complications: A. Presence of a general factor affecting risk, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery B. Active process of resorption C. Ankylosis D. Presence of alloplast or autograft E. Rheumatoid disease affecting other joints IV. Indicated Therapeutic Parameters for Rheumatoid Arthritis A. The pretreatment assessment includes, at a minimum: 1. General history and physical examination, as detailed in the Patient Assessment chapter 2. Focused history and physical examination of the TMJ region to determine the presence of indications for care for rheumatoid arthritis and to identify factors affecting risks 3. Appropriate laboratory studies to conrm the diagnosis of rheumatoid arthritis (eg, antinuclear antibody, sedimentation rate, rheumatoid factor) 4. An imaging examination, if indicated, based on the history and physical ndings. The examination may include but is not limited to the following: panoramic radiography, cephalometric radiography, conventional tomography, arthrography, CT, cone beam computed tomography, radionuclide scanning, and/or MRI. 5. Appropriate diagnostic records to determine progression of the disease (eg, serial bite registration and models, imaging studies, laboratory studies) The following procedures for the management of rheumatoid arthritis are not listed in order of preference: B. Nonsurgical management 1. Patient education (eg, stress reduction, dietary recommendations, jaw rest) 2. Medication (eg, NSAIDs, analgesics, muscle relaxants, antiarthritics, steroids) 3. Physical medicine (eg, physical therapy, massage, heat, cold, ultrasonography, trigger point injections) 4. Intracapsular diagnostic and therapeutic injections 5. Behavioral modication (eg, stress reduction, work modication, counseling, biofeedback, psychotherapy) 6. Orthopedic appliances (eg, splints) 7. Management of dental abnormalities 8. Appropriate diagnostic records to determine progression of the disease (eg, serial bite registration and models, imaging studies in selected cases) C. Surgical management The activity of the systemic disease must be considered prior to surgical management of the TMJ. 1. Active (progressive) TMJ disease a. Arthrocentesis b. Arthroscopic surgery c. Biopsy d. Arthroplasty e. Total alloplastic or autogenous graft joint replacement 2. Stable (nonprogressive) TMJ disease a. Arthrocentesis b. Arthroscopic surgery c. Biopsy d. Arthroplasty e. Orthognathic surgery f. Total alloplastic or autogenous graft joint replacement
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RHEUMATOID ARTHRITIS (continued)

D. 1. 2. 3. 4. 5. 6. 7. 8. V. Posttreatment management Wound care Pain management Diet and oral hygiene management Physical therapy Ongoing rheumatologic management Occlusal management Patient reassessment Instructions for posttreatment care and follow-up
Outcome Assessment Indices for Rheumatoid Arthritis Indices are used by the specialty to assess aggregate outcomes of care. Outcomes are assessed through clinical evaluation and may include an imaging evaluation. A. Favorable therapeutic outcomes 1. General favorable therapeutic outcomes, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery 2. Acceptable clinical appearance (eg, absence of motor decits, absence of hypertrophic scar formation, absence of facial asymmetry or deformity) 3. Improved mandibular function (eg, maximum incisal opening, lateral and protrusive excursions) B. Known risks and complications associated with therapy 1. Presence of a general known risk and/or complication, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery 2. Removal of autograft or alloplast 3. Ankylosis
INFECTIOUS ARTHRITIS
The management of infectious arthritis depends on whether the condition is acute or chronic and primary or secondary. Treatment objectives are directed toward the elimination of causes. Surgical intervention for infectious arthritis is indicated only when nonsurgical therapy has been ineffective and pain and/or dysfunction are moderate to severe. Pretreatment therapeutic goals are determined individually for each patient. I. Indications for Therapy for Infectious Arthritis May include one or more of the following: A. Evidence of localized or systemic infection B. Moderate-to-severe pain 1. Temporomandibular pain 2. Preauricular pain 3. Referred pain (eg, earaches) 4. Masticatory muscle pain (see Masticatory Muscle Disorders section) C. Dysfunction that is disabling and characterized by any of the following: 1. Restricted range of jaw motion (eg, hypomobility: acute, chronic, intermittent, persistent) 2. Joint noises (eg, crepitation) 3. Abnormal masticatory function (eg, painful chewing, malocclusion) 4. Swelling, erythema, suppuration, and/or joint effusion D. Imaging evidence of infectious process, failed prosthesis, or foreign body E. Maxillofacial deformity II. Specic Therapeutic Goals for Infectious Arthritis The goal of therapy is to restore form and/or function. However, risk factors and potential complications may preclude complete restoration of form and/or function. A. Presence of a general therapeutic goal, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery
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INFECTIOUS ARTHRITIS (continued)

B. C. D. E. F. G. H. III. Elimination of infection Removal of any foreign body Alleviation or reduction in pain in the joint Elimination or reduction in noise in the joint Limited progression of disease Corrected malocclusion Corrected or improved associated maxillofacial deformity
Specic Factors Affecting Risk for Infectious Arthritis Severity factors that increase risk and the potential for known complications: A. Presence of a general factor affecting risk, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery B. Virulence of microorganisms C. Compromised host defenses D. Presence of alloplast or autograft E. Extent of infection
IV.
Indicated Therapeutic Parameters for Infectious Arthritis The source of the infection (eg, extension of an otologic infection), systemic manifestations of the infection (eg, septicemia), presence of systemic disease (eg, diabetes mellitus), and host response (eg, human immunodeciency virus infection, immunosuppression) all must be considered before surgical management of the infected TMJ. A. The pretreatment assessment includes, at a minimum: 1. General history and physical examination, as detailed in the Patient Assessment chapter 2. Focused history and physical examination of the TMJ region to determine the presence of indications for care for infectious arthritis and to identify factors affecting risks 3. Appropriate laboratory studies to conrm the diagnosis of infectious arthritis (eg, white blood cell count by serum or aspiration, Gram stain, bacterial culture, and sensitivity) 4. An imaging examination, if indicated, based on the history and physical ndings. The examination may include but is not limited to the following: panoramic radiography, cephalometric radiography, conventional tomography, arthrography, CT, cone beam computed tomography, radionuclide scanning, and/or MRI. The following procedures for the management of infectious arthritis are not listed in order of preference: B. Nonsurgical management 1. Patient education (eg, dietary recommendations, jaw rest) 2. Antibiotic therapy 3. Pain management 4. Physical therapy 5. Supportive therapy (eg, hydration, antipyretics) C. Surgical management 1. Acute infection a. Aspiration and/or arthrocentesis b. Incision and drainage with culture and sensitivity studies c. Identication and elimination of etiology d. Arthroscopic surgery e. Removal of implant or foreign body 2. Chronic infection a. Aspiration and/or arthrocentesis b. Incision and drainage with culture and sensitivity studies c. Identication and elimination of etiology d. Arthroscopic surgery e. Biopsy f. Arthroplasty
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INFECTIOUS ARTHRITIS (continued)

1. 2. 3. 4. 5. 6. 7. 8. V. g. Alloplastic joint replacement D. Posttreatment management Ongoing medical management of infection Wound care Pain management Diet and oral hygiene management Physical therapy Reassessment of infectious process Instructions for posttreatment care and follow-up Management of residual deformity after elimination of infectious process (eg, orthognathic surgery, joint reconstruction)
Outcome Assessment Indices for Infectious Arthritis Indices are used by the specialty to assess aggregate outcomes of care. Outcomes are assessed through clinical evaluation and may include an imaging evaluation. A. Favorable therapeutic outcomes 1. General favorable therapeutic outcomes, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery 2. Elimination of infection 3. Limited period of disability 4. Acceptable clinical appearance (eg, absence of motor decits, absence of hypertrophic scar formation, absence of facial asymmetry or deformity) 5. Improved mandibular function (eg, maximum incisal opening, lateral and protrusive excursions) B. Known risks and complications associated with surgery 1. Presence of a general known risk and/or complication, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery 2. Need to remove an autograft or alloplast 3. Ankylosis 4. Progression of infection (eg, osteomyelitis, sepsis, deep space infection) 5. Adherent unacceptable scar formation
MANDIBULAR DISLOCATION: RECURRENT OR PERSISTENT

Mandibular dislocation can be acute, recurrent, or persistent. All of these refer to the dislocation of the intact nonfractured condyle. Acute dislocation describes blockage of the condyle by the eminence that prevents its return to the glenoid fossa, thus causing inability to close the mouth. Recurrent dislocation describes multiple episodes of dislocation during a specic period. Persistent dislocation describes a long-term blockage of the condyle by the eminence and may be associated with irreversible intracapsular pathology. This section addresses the therapy for recurrent or persistent dislocation. Acute dislocation is addressed in the Trauma Surgery chapter. I. Indications for Therapy for Mandibular Dislocation: Recurrent or Persistent May include one or more of the following: A. Moderate-to-severe pain 1. Temporomandibular pain 2. Preauricular pain 3. Masticatory muscle pain (see Masticatory Muscle Disorders section) B. Dysfunction that is disabling and characterized by any of the following: 1. Restricted range of jaw motion 2. Excessive range of jaw motion in patients who relocate after the dislocation 3. Joint noises (eg, clicking, popping, crepitation) 4. Abnormal masticatory function (eg, painful chewing, malocclusion) 5. Displaced autograft or alloplastic implant C. Imaging evidence of dislocation and/or displaced autograft or alloplastic implant
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MANDIBULAR DISLOCATION: RECURRENT OR PERSISTENT (continued)

II. Specic Therapeutic Goals for Mandibular Dislocation: Recurrent or Persistent The goal of therapy is to restore form and/or function. However, risk factors and potential complications may preclude complete restoration of form and/or function. A. Presence of a general therapeutic goal, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery B. Correction and prevention of dislocation C. Limited pain in the joint D. Elimination or reduction of noise in the joint III. Specic Factors Affecting Risk for Mandibular Dislocation: Recurrent or Persistent Severity factors that increase risk and the potential for known complications: A. Presence of a general factor affecting risk, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery B. Status and/or degree of abnormal condylar and/or articular eminence growth and development C. Presence of autograft and/or alloplastic implant D. Therapeutic use of medications causing extrapyramidal reactions IV. Indicated Therapeutic Parameters for Mandibular Dislocation: Recurrent or Persistent A. The pretreatment assessment includes, at a minimum: 1. General history and physical examination, as detailed in the Patient Assessment chapter 2. Focused history and physical examination of the TMJ region to determine the presence of indications for care of mandibular dislocation and to identify factors affecting risks 3. An imaging examination, based on the history and physical ndings, may include but is not limited to the following: panoramic radiography, cephalometric radiography, conventional tomography, arthrography, CT, cone beam computed tomography, radionuclide scanning, and/or MRI. The following procedures for the management of mandibular dislocation are not listed in order of preference: B. Nonsurgical management 1. Patient education (eg, dietary recommendations, jaw rest, decreased range of motion) 2. Discontinuation of use of medications causing extrapyramidal reactions 3. Medication (eg, drugs used to manage tremors, NSAIDs, analgesics, muscle relaxants, steroids) 4. Physical medicine (eg, physical therapy, massage, heat, cold, ultrasonography) 5. Intracapsular diagnostic and therapeutic injections 6. Behavioral modication (eg, counseling, biofeedback, psychotherapy) C. Surgical management 1. Manipulation and relocation of the condyle 2. Application of maxillomandibular xation 3. Arthroscopic surgery 4. Arthrotomy or arthroplasty a. Disk repair procedures b. Diskectomy without replacement c. Diskectomy with replacement d. Articular surface recontouring (condyle/eminence) e. Removal of displaced autograft or alloplastic implant 5. Autogenous graft to limit condylar movement 6. Temporalis muscle scarication 7. Inferomedial fracture of zygomatic arch 8. Orthognathic surgery (eg, modied condylotomy) 9. Autogenous or alloplastic joint replacement 10. Neuromuscular blocking agents D. Posttreatment management 1. Wound care 2. Pain management
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MANDIBULAR DISLOCATION: RECURRENT OR PERSISTENT (continued)

3. 4. 5. 6. 7. IV. Diet and oral hygiene management Physical therapy Occlusal management Patient reassessment Instructions for posttreatment care and follow-up
Outcome Assessment Indices for Mandibular Dislocation: Recurrent or Persistent Indices are used by the specialty to assess aggregate outcomes of care. Outcomes are assessed through clinical evaluation and may include an imaging evaluation. A. Favorable therapeutic outcomes 1. General favorable therapeutic outcomes, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery 2. Absence of recurrent or persistent mandibular dislocation B. Known risks and complications associated with therapy 1. Presence of a general known risk and/or complication, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery 2. Need to remove an autograft or alloplast 3. Continued dislocation
ANKYLOSIS AND RESTRICTED JAW MOTION

Intra-articular and extra-articular processes may restrict jaw motion severely. Ankylosis of the TMJ is an intra-articular process characterized by brous, bro-osseous, or osseous obliteration of the joint space. Extracapsular causes of restricted jaw motion (pseudoankylosis) include but are not limited to coronoid-zygomatic fusion, coronoid hypertrophy, and muscular brosis. Surgical intervention for ankylosis is indicated only when nonsurgical therapy has been ineffective and pain and/or dysfunction are moderate to severe. Pretreatment therapeutic goals are determined individually for each patient. I. Indications for Therapy for Ankylosis and Restricted Jaw Motion May include one or more of the following: A. Severely restricted jaw motion accompanied by one or more of the following: 1. Inadequate masticatory function 2. Abnormal speech (eg, constrained) 3. Inability to undergo dental and/or medical care (eg, dental preventive and/or restorative, oral or pharyngeal surgery, endoscopy) 4. Compromised anesthetic management (eg, intubation) 5. Inhibited facial growth 6. Imaging evidence of osseous or soft tissue abnormality 7. Clinical and/or imaging evidence of restriction or obstruction unrelated to the TMJ (eg, coronoidzygomatic fusion, coronoid hypertrophy) II. Specic Therapeutic Goals for Ankylosis and Restricted Jaw Motion The goal of therapy is to restore form and/or function. However, risk factors and potential complications may preclude complete restoration of form and/or function. A. Presence of a general therapeutic goal, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery B. Release of ankylosis C. Access for dental and/or medical care D. Improved speech E. Improved masticatory function F. Relief or reduction of pain
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ANKYLOSIS AND RESTRICTED JAW MOTION (continued)

III. Specic Factors Affecting Risk for Ankylosis and Restricted Jaw Motion Severity factors that increase risk and the potential for known complications: A. Presence of a general factor affecting risk, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery B. Type of ankylosis (eg, brous or bony) C. Etiology of the ankylosis (eg, traumatic or inammatory) D. Extent and duration of ankylosis E. Degree of preexisting muscular atrophy F. Ankylosis in a growing child G. Previous placement of alloplastic joint IV. Indicated Therapeutic Parameters for Ankylosis and Restricted Jaw Motion A. The pretreatment assessment includes, at a minimum: 1. General history and physical examination, as detailed in the Patient Assessment chapter 2. Focused history and physical examination of the TMJ region to determine the presence of indications for care of ankylosis and restricted jaw motion and to identify factors affecting risks 3. An imaging examination, based on the history and physical ndings. The examination may include but is not limited to the following: panoramic radiography, cephalometric radiography, conventional tomography, CT, 3-dimensional CT, cone beam computed tomography, radionuclide scanning, and/or MRI. The following procedures for the management of ankylosis and restricted jaw motion are not listed in order of preference: B. Nonsurgical management (usually not helpful in bony ankylosis) 1. Medication (eg, NSAIDs, analgesics, muscle relaxants, antiarthritics, steroids) 2. Physical therapy 3. Management of dental abnormalities C. Surgical management 1. Brisement (forceful manipulation of jaw under general anesthesia) 2. Arthroplasty 3. Condylectomy, partial or total and with or without replacement 4. Gap arthroplasty with autogenous or alloplastic replacement (eg with autogenous fat grafting) 5. Coronoidectomy or coronoidotomy 6. Osteotomy of zygoma or zygomatic arch 7. Myotomy 8. Scar revision (eg, intraoral and/or extraoral) 9. Orthognathic surgery for residual maxillofacial deformity (see the Surgical Correction of Maxillofacial Skeletal Deformities chapter) 10. Excision of heterotopic bone or gap arthroplasty with reconstruction of the ramus-condyle unit by distraction osteogenesis D. Posttreatment management 1. Wound care 2. Physical therapy 3. Pain management 4. Diet and oral hygiene management 5. Occlusal management 6. Appropriate diagnostic records to determine progression of the disease (eg, serial bite registration and models, imaging studies in select cases) 7. Patient reassessment 8. Instructions for posttreatment care and follow-up Outcome Assessment Indices for Ankylosis and Restricted Jaw Motion Indices are used by the specialty to assess aggregate outcomes of care. Outcomes are assessed through clinical evaluation and may include an imaging evaluation.
V.
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ANKYLOSIS AND RESTRICTED JAW MOTION (continued)

A. Favorable therapeutic outcomes 1. General favorable therapeutic outcomes, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery 2. In a growing child, continued symmetric growth of the mandible in proper relationship to the midface 3. Acceptable clinical appearance (eg, absence of motor decits, absence of hypertrophic scar formation, absence of facial asymmetry or deformity) 4. Improved mandibular function (eg, maximum incisal opening, lateral and protrusive excursions) B. Known risks and complications associated with therapy 1. Presence of a general known risk and/or complication, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery 2. Need to remove an autograft or alloplast 3. Recurrence of ankylosis
CONDYLAR HYPERPLASIA OR HYPOPLASIA

Abnormal condylar size or conguration characterizes condylar hyperplasia or hypoplasia, which may be associated with abnormal mandibular and/or maxillary growth or changing skeletal relationships. Surgical intervention for condylar hyperplasia or hypoplasia is indicated when nonsurgical therapy has been ineffective and/or considered inappropriate and pain, dysfunction, or deformity is moderate to severe. Pretreatment therapeutic goals are determined individually for each patient. The clinical and imaging characteristics of the condylar abnormality may mimic those of a neoplasm or other pathologic process, necessitating further evaluation. I. Indications for Therapy for Condylar Hyperplasia or Hypoplasia May include one or more of the following: A. Moderate-to-severe pain 1. Temporomandibular pain 2. Preauricular pain 3. Referred pain (eg, earache) 4. Masticatory muscle pain (see Masticatory Muscle Disorders section) B. Dysfunction that is disabling and characterized by any of the following: 1. Restricted range of jaw motion (eg, hypomobility: acute, chronic, intermittent, persistent) 2. Excessive range of jaw motion (eg, hypermobility: acute, chronic, intermittent, persistent) 3. Joint noises (eg, clicking, popping, crepitation) 4. Abnormal masticatory function (eg, painful chewing, malocclusion) C. Imaging evidence of condylar hyperplasia or hypoplasia D. Maxillofacial deformity E. Continued abnormal growth II. Specic Therapeutic Goals for Condylar Hyperplasia or Hypoplasia The goal of therapy is to restore form and/or function. However, risk factors and potential complications may preclude complete restoration of form and/or function. A. Presence of a general therapeutic goal, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery B. Limited pain in the joint C. Elimination or reduction of noise in the joint D. Limited progression of the disease E. Corrected malocclusion F. Corrected or improved associated maxillofacial deformity III. Specic Factors Affecting Risk for Condylar Hyperplasia or Hypoplasia Severity factors that increase risk and the potential for known complication:
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CONDYLAR HYPERPLASIA OR HYPOPLASIA (continued)

A. Presence of a general factor affecting risk, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery B. Status and/or degree of abnormal condylar growth IV. Indicated Therapeutic Parameters for Condylar Hyperplasia or Hypoplasia A. The pretreatment assessment includes, at a minimum: 1. General history and physical examination, as detailed in the Patient Assessment chapter 2. Regional history and physical examination to determine the presence of indications for care for condylar hyperplasia or hypoplasia and to identify factors affecting risks 3. An imaging examination, if indicated, based on the history and physical ndings. The examination may include but is not limited to the following: panoramic radiography, cephalometric radiography, conventional tomography, arthrography, CT, cone beam computed tomography, radionuclide scanning, and/or MRI. 4. Appropriate diagnostic records to determine progression of the disease (eg, serial bite registration and models, imaging studies in selected cases) The following procedures for the management of condylar hyperplasia or hypoplasia are not listed in order of preference: B. Surgical management 1. Incisional or excisional biopsy 2. Partial or total condylectomy 3. Arthroplasty 4. Partial or total joint reconstruction (eg, autogenous graft, allogeneic graft, alloplastic implant) 5. Osseous reduction or augmentation 6. Soft tissue reduction or augmentation 7. Orthognathic surgery (see the Surgical Correction of Maxillofacial Skeletal Deformities chapter) C. Posttreatment management 1. Wound care 2. Pain management 3. Diet and oral hygiene management 4. Physical therapy 5. Occlusal management 6. Patient reassessment 7. Instructions for posttreatment care and follow-up Outcome Assessment Indices for Condylar Hyperplasia or Hypoplasia Indices are used by the specialty to assess aggregate outcomes of care. Outcomes are assessed through clinical evaluation and may include an imaging evaluation. A. Favorable therapeutic outcomes 1. General favorable therapeutic outcomes, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery 2. Acceptable clinical appearance B. Known risks and complications associated with therapy 1. Presence of a general known risk and/or complication, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery 2. Removal of autograft or alloplast 3. Infection 4. Continued growth 5. Continued asymmetry
V.
GOUTY ARTHRITIS
Gouty arthritis (arthritis, hyperuricemia) is a metabolic disease that may affect the TMJ. The disease may be primary or secondary to another disease and/or medication that causes an increase in serum uric acid. In acute gouty arthritis,
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GOUTY ARTHRITIS (continued)

urate crystals can be precipitated in the synovial uid of the TMJ, causing a severely painful inammation. This condition should be treated with the close cooperation of the physician managing the overall systemic disease. Gout occurs in less than 0.5% of the population and is more common in males than in females. The disease, when present, usually occurs in people older than 40 years. Although the large toe is the joint most commonly involved, the TMJ can also be affected. A synovial uid analysis demonstrating urate crystals is necessary to conrm the diagnosis. Symptoms include severe TMJ pain, swelling, erythema, joint noise, and restricted mandibular mobility. Surgical intervention for arthritic conditions is indicated only when nonsurgical therapy has been ineffective and pain and/or dysfunction are moderate to severe. Surgery is not indicated for asymptomatic or minimally symptomatic patients. Surgery also is not indicated for preventive reasons in patients without pain and with satisfactory function. Pretreatment therapeutic goals are determined individually for each patient. I. Indications for Therapy for Gouty Arthritis May include one or more of the following: A. Moderate-to-severe pain 1. Temporomandibular joint pain 2. Preauricular pain 3. Referred pain (eg, earaches) 4. Masticatory muscle pain (see Masticatory Muscle Disorders section) B. Dysfunction that is disabling and characterized by any of the following: 1. Restricted range of jaw motion (eg, locking of the joint: acute, chronic, intermittent, persistent) 2. Joint noises (eg, clicking, popping, crepitation) 3. Abnormal masticatory function (eg, painful chewing, malocclusion) 4. Joint swelling and/or effusion 5. Erythema of skin over the TMJ region C. Imaging evidence of arthritic process D. Maxillofacial deformity II. Specic Therapeutic Goals for Gouty Arthritis The goal of therapy is to restore form and/or function. However, risk factors and potential complications may preclude complete restoration of form and/or function. A. Presence of a general therapeutic goal, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery B. Limited pain in the joint gouty arthritis C. Decreased systemic uric acid level D. Improved function E. Elimination or reduction in noise in the joint F. Limited progression of the disease G. Corrected or improved associated maxillofacial deformity III. Specic Factors Affecting Risk for Gouty Arthritis Severity factors that increase risk and the potential for known complications: A. Presence of a general factor affecting risk, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery B. Active process of condylar cortical erosions, bone spurs, and exostoses C. Presence of alloplast or autograft D. Gouty arthritis affecting other joints III. Indicated Therapeutic Parameters for Gouty Arthritis A. The pretreatment assessment includes, at a minimum: 1. General history and physical examination, as detailed in the Patient Assessment chapter 2. Focused history and physical examination of the TMJ region to determine the presence of indications for care for gouty arthritis and to identify factors affecting risks
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GOUTY ARTHRITIS (continued)

3. Appropriate laboratory studies to conrm the diagnosis of gouty arthritis (eg, identication of uric acid crystals in the synovial uid, serum uric acid level, and, in acute cases, leukocytosis and an elevated sedimentation rate) 4. An imaging examination, if indicated, based on the history and physical ndings. The examination may include but is not limited to the following: panoramic radiography, cephalometric radiography, conventional tomography, arthrography, CT, cone beam computed tomography, radionuclide scanning, and/or MRI. 5. Appropriate diagnostic records to determine progression of the disease (eg, laboratory studies, synovial aspirate analysis, imagining studies in selected cases) The following procedures for the management of gouty arthritis are not listed in order of preference: B. Nonsurgical management 1. Medication (eg, colchicine, indomethacin, NSAIDs, analgesics) 2. Physical medicine (eg, physical therapy, cold) 3. Intracapsular diagnostic synovial uid aspiration 4. Medical management (eg, steroid injections, evaluation of medications that can increase uric acid) 5. Orthopedic appliances (eg, splints) C. Surgical management 1. Synovial uid aspiration 2. Arthrocentesis 3. Arthroscopic surgery 4. Biopsy 5. Arthroplasty 6. Partial or total joint reconstruction (eg, autogenous graft, allogeneic graft, alloplastic implant) E. Posttreatment management 1. Wound care 2. Pain management 3. Diet and oral hygiene management 4. Physical therapy 5. Laboratory studies 6. Occlusal management 7. Patient reassessment 8. Instructions for posttreatment care and follow-up IV. Outcome Assessment Indices for Gouty Arthritis Indices are used by the specialty to assess aggregate outcomes of care. Outcomes are assessed through clinical evaluation and may include an imaging evaluation. A. Favorable therapeutic outcomes 1. General favorable therapeutic outcomes, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery 2. Acceptable clinical appearance (eg, absence of motor decits, absence of hypertrophic scar formation, absence of facial asymmetry or deformity) 3. Improved mandibular function (eg, maximum incisal opening, lateral and protrusive excursions) B. Known risks and complications associated with therapy 1. Presence of a general known risk and/or complication, as listed in the section entitled General Criteria, Parameters, and Considerations for Temporomandibular Joint Surgery 2. Removal of autograft or alloplast 3. Ankylosis
SELECTED REFERENCES TEMPOROMANDIBULAR JOINT SURGERY

This list of selected references is intended only to acknowledge some of the sources of information drawn on in the preparation of this document. Citation of the reference material is not meant to imply endorsement of any statement contained in the reference material. The list is not an exhaustive compilation of information on the topic. Readers should consult other sources to obtain a complete bibliography.
AAOMS ParCare 2012 Temporomandibular Joint Surgery SPECIAL CONSIDERATIONS FOR PEDIATRIC TEMPOROMANDIBULAR JOINT SURGERY
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Accessed June 6, 2011. 5. Barr T, Carmichael NM, Sandor GK: Juvenile idiopathic arthritis: a chronic pediatric musculoskeletal condition with signicant orofacial manifestations. J Can Dent Assoc 74:813, 2008 6. Behnia H, Motamedia MH, Tehranchi A: Use of activation appliances in pediatric patients treated with costochondral grafts for temporomandibular joint ankylosis: analysis of 13 cases. J Oral Maxillofac Surg 55:1408, 1997 7. Bodner L, Miller UJ: Temporomandibular joint dysfunction in children: evaluation of treatment. Int J Pediatr Otolaryngol 44:133, 1998 8. Cahill AM, Baskin KM, Kaye RD, et al: CT-guided percutaneous steroid injection for management of inammatory arthropathy of the temporomandibular joint in children. AJR Am J Roentgenol 188:182, 2007 9. Canter HI, Kayikcioglu A, Saglam-Aydinatay B, et al: Mandibular reconstruction in Goldenhar syndrome using temporalis muscle osteofascial ap. J Craniofac Surg 19:165, 2008 10. Deleyiannis FW, Vecchione L, Martin B, et al: Open reduction and internal xation of dislocated condylar fractures in children: long-term clinical and radiologic outcomes. Ann Plast Surg 57:495, 2006 11. Gupta RK, Jadhav V, Gupta A, et al: Congenital alveolar fusion. J Pediatr Surg 43:1421, 2008 12. Kaban LB, Bouchard C, Troulis MJ: A protocol for management of temporomandibular joint ankylosis in children. J Oral Maxillofac Surg 67:1966, 2009 13. Kaban LB, Treves ST: Skeletal scintigraphy for assessment of mandibular growth and asymmetry. In Treves ST, ed.: Pediatric Nuclear Medicine. New York, NY, Springer-Verlag, 1985 14. Katzberg RW, Tallents RH, Hayakawa K, et al: Internal derangements of the temporomandibular joint: ndings in the pediatric age group. Radiology 154:125, 1985 15. Krieborg S, Bakke M, Kirkeby S, et al: Facial growth and oral function in a case of juvenile rheumatoid arthritis during an 8-year period. Eur J Orthod 12:119, 1990 16. Krishnan B: Autogenous auricular cartilage graft in temporomandibular joint ankylosisan evaluation. Oral Maxillofac Surg 12:189, 2008 17. Kuseler A, Pedersen TK, Gelineck J, et al: A 2 year followup study of enhanced magnetic resonance imaging and clinical examination of the temporomandibular joint in children with juvenile idiopathic arthritis. J Rheumatol 32:162, 2005 18. Kuseler A, Pederson TK, Herlin T, et al: Contrast enhanced magnetic resonance imaging as a method to diagnose early inammatory changes in the temporomandibular joint in children with juvenile chronic arthritis. J Rheumatol 25:1406, 1998 19. Lifschultz BD, Kenny JP, Sturgis CD, et al: Fatal intracranial hemorrhage following oral surgical procedures. J Forensic Sci 40:131, 1995 20. Lopez EN, Dogliotti PL: Treatment of temporomandibular joint ankylosis in children: is it necessary to perform mandibular distraction simultaneously? J Craniofac Surg 15:879, 2004 21. Mandall NA, Gray R, OBrien KD, et al: Juvenile idiopathic arthritis (JIA): a screening study to measure class II skeletal pattern, TMJ PDS and use of systemic corticosteroids. J Orthod 37:6, 2010 22. Medra AM: Follow up of mandibular costochondral grafts after release of ankylosis of the temporomandibular joints. Br J Oral Maxillofac Surg 43:118, 2005 23. Mehrotra D, Dhasmanaa S, Kumar S: Management of temporomandibular ankylosis with temporal fascia inter-positional arthroplasty and distraction osteogenesis: report of 30 cases. J Long Term Eff Med Implants 19:139, 2009 24. Mercuri LG, Swift JQ: Considerations for the use of alloplastic temporomandibular joint replacement in the growing patient. J Oral Maxillofac Surg 67:1979, 2009 25. Miller UJ, Bodner L: Temporomandibular joint dysfunction in children. Int J Pediatr Otorhinlaryngol 38:215, 1997 26. Montazem AH, Anastassov G: Management of condylar fractures. Atlas Oral Maxillofac Surg Clin North Am 17:55, 2009 27. Muller L, Kellenberger CJ, Cannizzaro E, et al: Early diagnosis of temporomandibular joint involvement in juvenile idiopathic arthritis: a pilot study comparing clinical examination and ultrasound to magnetic resonance imaging. Rheumatology (Oxford) 48:680, 2009 28. Obwegeser HL, Obwegeser JA: New clinical-based evidence for the existence of 2 growth regulators in mandibular condyles: hemimandibular elongation in hemifacial microsomia mandible. J Craniofac Surg 21:1595, 2010 29. Okeson JP, ODonnell JP: Standards for temporomandibular evaluation in the pediatric patient. Pediatr Dent 11:329, 1989 30. Pedersen TK, Kuseler A, Gelineck J, et al: A prospective study of magnetic resonance and radiographic imaging in relation to symptoms and clinical ndings of the temporomandibular joint in children with juvenile idiopathic arthritis. J Rheumatol 35:1668, 2008 31. Posnick JC, Goldstein JA: Surgical management of temporomandibular joint ankylosis in the pediatric population. Plast Reconstr Surg 91:791, 1993 32. Rao K, Kumar S, Kumar V, et al: The role of simultaneous gap arthroplasty and distraction osteogenesis in the management of temporomandibular deformity in children. J Craniomaxillofac Surg 32:38, 2004 33. Sayan NB, Karasu HA, Uyanik LO, et al: Two-stage treatment of TMJ ankylosis by early surgical approach and distraction osteogenesis. J Craniofac Surg 18:212, 2007 34. Steinberg B, Nelson US, Feinberg SE, et al: Incidence of maxillofacial involvement in arthrogryposis multiplex congenita. J Oral Maxillofac Surg 54:156, 1996 35. Subramanian B, Agrawal K, Panda K: Congenital fusion of the jaws: a management protocol. Int J Oral Maxillofac Surg 39:925, 2010 36. Tallents RH, Catania J, Sommers E: Temporomandibular joint ndings in pediatric populations and young adults: a critical review. Angle Orthod 61:7, 1991 37. Twilt M, Mobers SM, Arends LR, et al: Temporomandibular involvement in juvenile idiopathic arthritis. J Rheumatol 31:1418, 2004 38. Weiss PF, Arabshahi B, Johnson A, et al: High prevalence of temporomandibular joint arthritis at disease onset in children with juvenile idiopathic arthritis, as detected by magnetic resonance imaging but not by ultrasound. Arthritis Rheum 58:1189, 2008 39. Yu H, Shen G, Zhang S, et al: Gap arthroplasty combined with distraction osteogenesis in the treatment of unilateral ankylosis of the temporomandibular joint and micrognathia. Br J Oral Maxillofac Surg 47:200, 2009
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MASTICATORY MUSCLE DISORDERS

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237. Chase DC, Hudson JW, Gerard DA, et al: The Christensen prosthesis. A retrospective clinical study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 80:273, 1995 238. Feinberg SE, Larsen PE: The use of a pedicled temporalis muscle-pericranial ap for replacement of the TMJ disc: a preliminary report. J Oral Maxillofac Surg 47:42, 1989 239. Israel HA, Syrop SB: The important role of motion in the rehabilitation of patients with mandibular hypomobility: a review of the literature. Cranio 15:74, 1997 240. Kearnes GJ, Perrott DH, Kaban LB: A protocol for the management of failed alloplastic temporomandibular joint disc implants. J Oral Maxillofac Surg 53:1240, 1995 241. Laskin DM: Diagnosis of pathology of the temporomandibular joint. Clinical and imaging perspectives. Radiol Clin North Am 31:135, 1993 242. Macintosh RB: Current spectrum of costochondral and dermal grafting. In Bell WH, ed.: Modern Practice in Orthognathic and Reconstructive Surgery. Philadelphia, PA, WB Saunders Co, 1992 243. Matsuura, H et al: Effect of partial immobilization on reconstruction of ankylosis of the temporomandibular joint with an autogenous costochondral graft: an experimental study in sheep. Br J Oral Maxillofac Surg 39:196, 2001 244. Mercuri LG: Alloplastic temporomandibular joint reconstruction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 85:6, 1998 245. Mercuri LG: Microbial biolms: a potential source of alloplastic device failure. J Oral Maxillofac Surg 64:1303, 2006 246. Mercuri LG: TMJ reconstruction. In Fonseca RJ, Turvey TA, Marcaini RD: Oral and Maxillofacial Surgery. Philadelphia, PA, Elsevier/ Saunders, 2008
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Parameters of Care: Clinical Practice Guidelines for Oral and Maxillofacial Surgery (AAOMS ParCare 2012)

TEMPOROMANDIBULAR JOINT SURGERY

AAOMS ParCare 2012 Temporomandibular Joint Surgery

GENERAL CRITERIA, PARAMETERS, AND CONSIDERATIONS FOR TEMPOROMANDIBULAR JOINT SURGERY

AAOMS ParCare 2012 Temporomandibular Joint Surgery

AAOMS ParCare 2012 Temporomandibular Joint Surgery

SPECIAL CONSIDERATIONS FOR PEDIATRIC TEMPOROMANDIBULAR JOINT SURGERY

AAOMS ParCare 2012 Temporomandibular Joint Surgery

MASTICATORY MUSCLE DISORDERS

AAOMS ParCare 2012 Temporomandibular Joint Surgery

MASTICATORY MUSCLE DISORDERS (continued)

AAOMS ParCare 2012 Temporomandibular Joint Surgery

INTERNAL DERANGEMENT (continued)

AAOMS ParCare 2012 Temporomandibular Joint Surgery

INTERNAL DERANGEMENT (continued)

DEGENERATIVE JOINT DISEASE

AAOMS ParCare 2012 Temporomandibular Joint Surgery

DEGENERATIVE JOINT DISEASE (continued)

AAOMS ParCare 2012 Temporomandibular Joint Surgery

DEGENERATIVE JOINT DISEASE (continued)

AAOMS ParCare 2012 Temporomandibular Joint Surgery

RHEUMATOID ARTHRITIS (continued)

AAOMS ParCare 2012 Temporomandibular Joint Surgery

RHEUMATOID ARTHRITIS (continued)

AAOMS ParCare 2012 Temporomandibular Joint Surgery

INFECTIOUS ARTHRITIS (continued)

AAOMS ParCare 2012 Temporomandibular Joint Surgery

INFECTIOUS ARTHRITIS (continued)

MANDIBULAR DISLOCATION: RECURRENT OR PERSISTENT

AAOMS ParCare 2012 Temporomandibular Joint Surgery

MANDIBULAR DISLOCATION: RECURRENT OR PERSISTENT (continued)

AAOMS ParCare 2012 Temporomandibular Joint Surgery

MANDIBULAR DISLOCATION: RECURRENT OR PERSISTENT (continued)

ANKYLOSIS AND RESTRICTED JAW MOTION

AAOMS ParCare 2012 Temporomandibular Joint Surgery

ANKYLOSIS AND RESTRICTED JAW MOTION (continued)

AAOMS ParCare 2012 Temporomandibular Joint Surgery

ANKYLOSIS AND RESTRICTED JAW MOTION (continued)

CONDYLAR HYPERPLASIA OR HYPOPLASIA

AAOMS ParCare 2012 Temporomandibular Joint Surgery

CONDYLAR HYPERPLASIA OR HYPOPLASIA (continued)

AAOMS ParCare 2012 Temporomandibular Joint Surgery

GOUTY ARTHRITIS (continued)

AAOMS ParCare 2012 Temporomandibular Joint Surgery

GOUTY ARTHRITIS (continued)

SELECTED REFERENCES TEMPOROMANDIBULAR JOINT SURGERY

AAOMS ParCare 2012 Temporomandibular Joint Surgery

MASTICATORY MUSCLE DISORDERS

AAOMS ParCare 2012 Temporomandibular Joint Surgery

AAOMS ParCare 2012 Temporomandibular Joint Surgery

AAOMS ParCare 2012 Temporomandibular Joint Surgery

DEGENERATIVE JOINT DISEASE

AAOMS ParCare 2012 Temporomandibular Joint Surgery

MANDIBULAR DISLOCATION: RECURRENT OR PERSISTENT

ANKYLOSIS AND RESTRICTED JAW MOTION

AAOMS ParCare 2012 Temporomandibular Joint Surgery

CONDYLAR HYPERPLASIA OR HYPOPLASIA

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