Larry M. Wolford D.M.D.

Perez, D. E., L. M. Wolford, E. Schneiderman, R. Movahed, C. Bourland and E. P. Gutierrez (2016). “Does unilateral temporomandibular total joint reconstruction result in contralateral joint pain and dysfunction?” J Oral Maxillofac Surg 74(8): 1539-1547.

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PURPOSE: The purpose of this study was to evaluate patients requiring unilateral total temporomandibular joint (TMJ) reconstruction and the risk for development of postsurgical contralateral TMJ pain and dysfunction over time requiring subsequent contralateral total joint reconstruction. Long-term subjective and objective outcomes of unilateral TMJ reconstruction also were evaluated. MATERIALS AND METHODS: Seventy patients underwent unilateral total joint reconstruction using a patient-fitted total joint prosthesis from a single private practice from 1990 through 2012. The inclusion criteria were 1) unilateral TMJ reconstruction with TMJ Concepts or Techmedica patient-fitted total joint prosthesis; 2) operation performed by 1 surgeon (L.M.W.); 3) minimum 12-month follow-up; and 4) adequate records. There were no specific exclusion criteria. The primary outcome variable was to evaluate the effects of unilateral TMJ reconstruction with a total joint prosthesis on the contralateral TMJ relative to development of pain and dysfunction requiring subsequent contralateral reconstruction with a total joint prosthesis. Secondary outcome variables for all patients included TMJ pain, facial pain, headaches, diet, disability, quality of life, maximum incisal opening (MIO), and lateral excursion movements after unilateral TMJ reconstruction with the patient-fitted total joint prosthesis. Student t test and Wilcoxon test were used for statistical analyses, with a P value less than .01 for statistical significance. RESULTS: Sixty-one of 70 patients (87%) met the inclusion criteria (47 women [77%] and 14 men [23%]; average age, 38 yr; age range, 11 to 69 yr; average follow-up, 44 months; range, 12 to 215 months). Eight of 61 patients (13%) subsequently required contralateral TMJ reconstruction with a total joint prosthesis related to contralateral pain, dysfunction, and arthritis, but all 8 (8 of 27 [29.6%]) had previous contralateral TMJ disc repositioning surgery. For the secondary outcomes, TMJ pain decreased 63%, jaw function improved 61%, facial pain decreased 59%, headaches decreased 57%, diet improved 52%, disability decreased 58.5%, and MIO increased from 31.4 to 38.8 mm (mean change, 7.4 mm). All subjective factors and MIO showed statistically significant improvements at longest follow-up (P < .01). CONCLUSIONS: Patients requiring unilateral TMJ reconstruction with a patient-fitted total joint prosthesis have a strong probability of improving their clinical condition and do not require bilateral reconstruction if the contralateral TMJ is healthy. Patients with previous or concomitant contralateral TMJ surgery (articular disc repositioning) have an approximately 30% chance of requiring a total joint prosthesis in the future.

Wardly, D., L. M. Wolford and V. Veerappan (2016). “Idiopathic intracranial hypertension eliminated by counterclockwise maxillomandibular advancement: A case report.” Cranio: 1-9 [Epub ahead of print].

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INTRODUCTION: Obstructive sleep apnea (OSA) is a secondary cause of intracranial hypertension (IH). Decreased jugular venous drainage has been seen in patients with idiopathic IH. CLINICAL PRESENTATION: A complex case of a 48-year-old female whose idiopathic IH was put into remission after counterclockwise maxillomandibular advancement (CC-MMA), despite persistence of her OSA. CONCLUSION: This case highlights the relationship between OSA and IH and points to the significant morbidity that can result from mild OSA and from what are considered borderline intracranial pressures. This indicates the need for a high index of suspicion for actual underlying pathology that can be surgically corrected when patients manifest symptoms of a somatic syndrome. This is the first report in the medical literature of clinical elimination of IH by CC-MMA. The authors propose that this positive outcome was effected via mandibular advancement producing a decrease in jugular venous resistance, allowing improved absorption of cerebrospinal fluid.

Al-Moraissi, E. A. and L. M. Wolford (2016). “Is counterclockwise rotation of the maxillomandibular complex stable compared with clockwise rotation in the correction of dentofacial deformities? A systematic review and meta-analysis.” J Oral Maxillofac Surg. 2016 Jun 2011 [Epub ahead of print].

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PURPOSE: To compare postsurgical skeletal stability between counterclockwise rotation (CCWR) of the maxillomandibular complex (MMC) and clockwise rotation (CWR) of the MMC for the correction of dentofacial deformities. MATERIALS AND METHODS: To address the study purpose, we designed and implemented a systematic review with meta-analysis based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search strategy was developed, and a search of major databases-PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL)-was conducted to find all pertinent articles published from inception through March 2016. The inclusion criteria were randomized controlled trials, controlled clinical trials, retrospective studies, and case series with the aim of comparing postsurgical stability of CCWR and CWR of the MMC. The analysis was performed using lateral cephalometric analysis of postsurgical mean values and correlation between the surgical and postsurgical changes of the occlusal plane angle and linear changes at A point and B point. A weighted mean difference analysis using a random-effects model with 95% confidence intervals was performed. RESULTS: A total of 133 patients were enrolled from 3 studies (CCWR, n = 83; CWR, n = 50). All included studies were at moderate risk of bias. There was a statistically significant difference between CCWR and CWR of the MMC in the postsurgical changes of the occlusal plane angle (P = .034), but no statistically significant difference was found in the correlation between the surgical and postsurgical changes of the occlusal plane angle in the 2 groups. There was no statistically significant difference between CCWR and CWR of the MMC for stability between assessments immediately after surgery and at longest follow-up relative to the vertical and horizontal positions at A point and B point (P > .05). CONCLUSIONS: CCWR compared with CWR for the correction of dentofacial deformities in the absence of pre-existing temporomandibular joint pathology is skeletally stable relative to the postsurgical changes of the occlusal plane, as well as the vertical and horizontal changes of the maxilla and mandible.

Wolford, L., R. Movahed, M. Teschke, R. Fimmers, D. Havard and E. Schneiderman (2016). “Temporomandibular joint ankylosis can be successfully treated with tmj concepts patient-fitted total joint prosthesis and autogenous fat grafts.” J Oral Maxillofac Surg 74(6): 1215-1227.

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PURPOSE: To measure and identify factors associated with treatment outcomes for patients with temporomandibular joint (TMJ) ankylosis treated with TMJ Concepts patient-fitted total joint prostheses and autogenous fat grafts. PATIENTS AND METHODS: This retrospective cohort study evaluated records of patients with TMJ ankylosis from a single private practice, treated from 1992 to 2011, who met the following inclusion criteria: 1) radiographic evidence of bony ankylosis, 2) limited incisal opening, 3) minimum of 12 months’ follow-up, and 4) treatment with TMJ Concepts (Ventura, CA)/Techmedica (Camarillo, CA) total joint prostheses and fat grafts. For each patient, the number of previous TMJ surgical procedures, as well as the estimated age of ankylosis onset, age at surgery, and length of postoperative follow-up, was recorded. Subjective evaluations were made with Likert-like scales (from 0 to 10) for 1) TMJ pain, 2) headache and facial pain, 3) jaw function, 4) diet, and 5) disability. Objective evaluations included maximal incisal opening and excursion movements. Nonparametric statistics were used for analysis. RESULTS: There were 32 patients (22 female and 10 male patients) with 48 ankylosed TMJs (16 bilateral and 16 unilateral) in this study, with a mean age of 39 years (range, 11 to 68 years), 2 or more previous TMJ surgical procedures in 69%, and a mean follow-up period of 68 months (range, 12 to 168 months). Trauma was the major etiology of TMJ ankylosis, occurring in 17 of 32 patients (53%). The following improvements occurred: The median value for TMJ pain changed from 8.0 preoperatively to 1.5 at longest follow-up; headache, from 8 to 3.5; facial pain, from 8 to 4; jaw function, from 8 to 2.5; diet, from 7 to 3; and disability, from 7 to 1.5. The median incisal opening was 14.5 mm (interquartile range, 6.3 to 20 mm) preoperatively and 35 mm (interquartile range, 30 to 40 mm) at longest follow-up. The median left lateral excursion improved from 0.5 to 2 mm, and the median right lateral excursion improved from 1 to 1.3 mm. All of these improvements were highly significant (P < .001, Wilcoxon tests). Equally favorable outcomes were found in patients with 12 to 48 months of maximal follow-up and patients with more than 48 months of maximal follow-up. CONCLUSIONS: The treatment of TMJ ankylosis with the TMJ Concepts patient-fitted total joint prosthesis in combination with fat grafting around the articulation area of the prosthesis is a viable and predictable method for improving pain levels, function, and quality of life, as well as prevention of reankylosis of the TMJ.

Salash, J. R., R. H. Hossameldin, A. J. Almarza, J. C. Chou, J. P. McCain, L. G. Mercuri, L. M. Wolford and M. S. Detamore (2016). “Potential Indications for Tissue Engineering in Temporomandibular Joint Surgery.” J Oral Maxillofac Surg 74(4): 705-711.

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PURPOSE: Musculoskeletal tissue engineering has advanced to the stage where it has the capability to engineer temporomandibular joint (TMJ) anatomic components. Unfortunately, there is a paucity of literature identifying specific indications for the use of TMJ tissue engineering solutions. The objective of this study was to establish an initial set of indications and contraindications for the use of engineered tissues for replacement of TMJ anatomic components. FINDINGS: There was consensus among the authors that the management of patients requiring TMJ reconstruction as the result of 1) irreparable condylar trauma, 2) developmental or acquired TMJ pathology in skeletally immature patients, 3) hyperplasia, and 4) documented metal hypersensitivities could be indications for bioengineered condyle and ramus TMJ components. There was consensus that Wilkes stage III internal derangement might be an indication for use of a bioengineered TMJ disc or possibly even a disc-like bioengineered “fossa liner.” However, there was some controversy as to whether TMJ arthritic disease (e.g., osteoarthritis) and reconstruction after failed alloplastic devices should be indications. Further research is required to determine whether tissue-engineered TMJ components could be a viable option for such cases. Contraindications for the use of bioengineered TMJ components could include patients with TMJ disorders and multiple failed surgeries, parafunctional oral habits, persistent TMJ infection, TMJ rheumatoid arthritis, and ankylosis unless the underlying pathology can be resolved. CONCLUSIONS: Biomedical engineers must appreciate the specific indications that might warrant TMJ bioengineered structures, so that they avoid developing technologies in search of problems that might not exist for patients and clinicians. Instead, they should focus on identifying and understanding the problems that need resolution and then tailor technologies to address those specific situations. The aforementioned indications and contraindications are designed to serve as a guide to the next generation of tissue engineers in their strategic development of technologies to address specific clinical issues.