finding in the preoperative, early

postoperative and one year

postoperative. Of the study population
Abstract
the 78.5% have an advanced TMJ
The object of this study was to evaluate
dysfunction in stages III and IV to Wilkes
the condilar disk plication (discopexy)
classification. There was significant
with resorbable mini anchor in advanced
reduction of pain and TMJ sounds and
stages of temporomandibular joint
improvement in mandibular function. Was
dysfunction according to Wilkes
observed an stability in the position of the
classification in 65 patients with 122 TMJ
articular disk in MR imaging
with anterior disk displacement without
postoperative en 93.8% of the patient.
reduction, with indication for surgical disk
We can conclude that the application of
reposition, this procedure was executed
the articular disk with resorbable mini
with resorbable mini anchor (Mitek
anchor is a highly effective technique in
resorbable Depuy Synthes). In this study
the management of the TMJ disorders in
were evaluated the pain according visual
advanced stages according to Wilkes.
analogue scale, mouth opening range
and the eccentric mandibular
Keywords: disc-repositioning, internal
movements, the presence of TMJ
derangement, absorbable mini anchors,
sounds, trigger points, and MR imaging
discopexy.

Cirujana Oral y Maxilofacial Hospial

Universitario La Samaritana, Bogotá Introduction
(Colombia), Docente Universidad
Nacional de Colombia Internal disorders are defined as any
interference that prevents the functional
Cirujana Oral y Maxilofacial,
joint movement such as the adhesions
Universidad Nacional de Colombia
and accessions of the disk, subluxations,
Cirujana Oral y Maxilofacial,
and dislocations of the condyle complex
Universidad Nacional de Colombia
disk. 1 They have also been defined as a STAGE CLINIC IMAGE

disorder in the normal anatomic

I (early) Clicking without pain, Disk slightly forward,
relationship between the disk and the
there is no restriction normal bone contour
condyle, which interferes with the of movements
temporomandibular joint movement,
causing pain, clicking, and limitation of II (early / Click occasionally Disk displaced slightly
mouth opening or block. 2 Although this intermedia painful, intermittent forward, early deformity
term includes all types of intracapsular te) blockages, of the disk, normal
interference that prevent the movements headaches bone contour.
of the ATM, this term has been used as a
synonym for the displacement of the III Frequent pain, Previous displacement

disk.1,3 (intermedi tenderness in the of the condyle,

ate) joints, headache, moderate to marked

Theoretically the disk can move in locks, restricted thickening of the disk,
movements, chewing normal bone contour.
different degrees, and in any direction. In
pain.
a normal ATM the disk is positioned on
the condylar head with the posterior band IV(interme Chronic pain, Previous displacement
at 12 (above the condyle), the diate/late) headaches, of the disk, marked
intermediate zone positioned at 1 restriction of thickening of the disk,
(superoanterior to the condyle).1 movements. abnormal bone contour.

It is estimated that from 12 to 87% of the V(late) Variable pain, Previous displacement
American population has presented any crepitation. of the disk, with
signs of temporomandibular dysfunction. perforation or
The previous and / or medial abnormalities of the
displacement of the articular disk is the disk. Degenerative

most common cause of this dysfunction. bone changes.

The etiology of the internal disorders is

multifactorial; it can be explained by the
macrotrauma, microtrauma, occlusal
factors, osteoarthritis and psychological
factors. 4
In 1989 Clyde H. Wilkes established a
staging classification in search of internal
disorders, correlating the clinical and
radiographic signs with surgical findings.
This classification consists of 5 stages
that goes from a slight previous
displacement of the asymptomatic disk
until degenerative arthritic changes with
severe symptoms 3. See table 1. 5
Table 1. Classification of the ATM
Internal Disorders Regarding the Clinical,
Radiological and Surgical Findings.
Wilkes 1989
The treatments of the temporomandibular
disorders part of the conservative
treatment to invasive treatment. The non-
surgical treatment represents the initial
management. Among the strategies of
the conservative treatment is a soft diet,
modifications of behavior (reduction of
stress levels, physical therapy, increased
sleep times), muscle relaxants, NSAIDS,
occlusal splints, moist heat, blocks trigger
6,
point, botox injections, among others.
7
Continuing with the scale of treatment,
surgical treatment is indicating when the
patient has pain or dysfunction that alter
the quality of life, ineffective non-surgical position the articular disk and maintain
treatment, when the ATM is the source of harmony with the condyle. But it was not
pain and realization of arthroscopy is until 1978 when Wilkes using
required for diagnosis. See figure 1. arthrography describes the anatomy,
shape and function of the ATM, that the

Figure 1. Scale treatment of the surgical repositioning of the disk comes

temporomandibular disorders. to a surgical technique accepted. The

repositioning of the disk can be done
along with other surgical procedures such
as arthroplasty and eminectomy. It has
been reported rates of therapeutic
success in combination with the
arthroplasty ranging from 77 al 100%.
Among the objectives of the disk
repositioning surgery include the

The American Association of Oral and elimination of pain, mechanical

interference and stopping the progression
Maxillofacial Surgeons described in
of the disk degeneration and
1984 the objectives of surgical
osteoarthritis.9
treatment: 1. No pain or not
significant, 2. Opening greater than or The clinical results of the disk

equal to 35mm, 3. Lateral excursion repositioning surgery have been variable

and often unpredictable, with faults
and protrusion greater than or equal
related to the long-term stability, being
to 6mm ,4. Normal diet with the
necessary the use of a method for the
exception of hard foods, 5. No
stabilization of the disk. By observing this
significant radiological changes, 6.
problem Wolford and collaborators,
Absence of complications.8
developed a surgical technique using
bone anchor for the stabilization of the
The surgical treatment for the articular disk. 10
Although the mini-
management of the articular disk anchors are available in different sizes,
displacement is the meniscopexy. The the mini anchor Mitek is the most
replenishment of the disk was first applicable for the ATM articular disk. The
described by Annadale in 1887. In 1918 mini anchor is cylindrical, with a diameter
Behan described his technique to of 1.8 and a length of 5.0 mm. The
anchor body is composed of a titanium Figure 2. Absorbable mini anchors.
alloy (90% titanium, 6% aluminum, 4%
vanadium), while its arches are
composed of nickel titanium (nitinol),
using super elastic properties. An eyelet
in the posterior aspect of the anchor
allows the placement of sutures that
function as artificial ligament.9, 10 Although
the results obtained with the use of these
metal anchors are good, subsequent
research report multiple complications
such as loosening, migration, integration
Materials and method
of metal implant within the joint, difficulty
to a reoperation if necessary, chondral
This retrospective study evaluated 65
damage and artifacts in the image control
11 patients (122 joints) to which were held
such as MRI. Because of these
discopexy with mini absorbable anchor
complications have arisen resorbable
by modified endaural approach
devices as an alternative (see figure 2),
performed by the same surgeon (see
and have recently been used in
figure 3). The inclusion criteria were: 1.
orthopedics more often than metal
12 Over 18 years of age; 2. Evidenced
anchors. . The main advantages of
displacement of the articular disk in NMR
these past anchors is its absorption in
(see figure 4); 3. Not having prior articular
time, theoretically minimizing or
surgery; 4. Not present bone disease,
preventing migration problems or
(neoplasms, inflammatory disorders,
interference with surgeries of revision or
ankylosis).
reoperation. However, perhaps its
greatest advantage is that they are Figure 3. Absorbable mini anchors
radiolucent, reducing or eliminating placement at most lateral, superior and
artifacts in MRI, allowing a better posterior aspect of mandibular condyle
interpretation of the image. Besides its via modified endaural approach
effectiveness in creating a safe repair
tendon-bone it has been comparable to
13, 14
metal anchors.
 according to visual analogue scale (0: no
pain; 1-3: mild pain; 4-7 moderate pain;
8-10: severe pain), 2) oral opening range
measured in millimeters, 3) range of
eccentric mandibular movement
measurements in millimeters, 4)
presence of joint noises, 5) pain on
palpation of the mastication muscles, 6)
MRI findings. The first three variables are
Figure 4. Anterior displacement of the
inclusive as they are part of the treatment
articular disk
objectives set out by the American
Association of Oral and Maxillofacial
Surgeons in 1984. Data were collected
by a single evaluator, initially 5 clinical
histories were evaluated, and these same
histories were later reappraised to 8 and
15 days, in order to examine the quality
of data. Once collected the information
was tabulated and analyzed using the
Excel 2007 program.

Results

The information was collected from The average age of this study was 40,11
medical records that were performed in years (range 18-70). A total of 122
the preoperative period (T1), in the meniscopexys were performed in 65
immediate postoperative period (T2) and patients, of which 57 (87.7%) underwent
a year (T3) in a data collection replacement of the articular disk
instrument, which was previously bilaterally, 8 patients (12.3%) unilateral, 3
validated in appearance and content. the right side and 5 on the left. See
Patients are evaluated in the consultation graphic 1.
of maxillofacial surgery specialized in
temporomandibular joint, which has
implemented a questionnaire that asks
about the following variables: 1) pain
 Graphic 1. Distribution of cases Measured Pain in Visual Analog Scale
According Intervened Side (VAS)
The mean postoperative pain was 7 (SD
2), in the immediate postoperative period
was 2 (SD 1), and in the postoperative
period a year 1(SD 1). A total of 28
patients (42.8%) presented severe
preoperative pain and 37 (57,1%)
moderate pain. No patient presented
severe pain in the immediate
postoperative period or the year 14
(21,4%) presented moderate pain in the
immediate postoperative period and 7
(10,71%) in the postoperative period a
year. See graphic 3.
Of the 65 patients evaluated 30 (46.15%)
presented Wilkes stage III, 21 (32.30%) Graphic 3. Comparison of pain in T1, T2,
stage IV, 14 (21.53%) stage II. See and T3 measured in Visual Analogue
Graphic 2 Scale (VAS)

Graphic 2. Distribution of Cases

Regarding Wilkes Stage

Oral opening and lateral movements

The 39.3% of the patients had limitation
on oral opening between 26-30mm,
21.4% between 31-35mm, noting
improvement in the postoperative period
a year, since the 46.4% of patients have
a range of oral opening between 36-
40mm. The average of the oral opening
in T1 was 27mm, T2 was 30mm and T3
of 36mm. In regard to the mandibular
eccentric movements, most of the patient
presented a range of Left and Right
laterality between 3-5mm, (T1) 60.7%,
(T2) 67.9%, (T3) 89, 3%. See Graphic 4.
Graphic 4. Comparison of the average
Preoperative Oral Opening, immediate
post-operative per year
Trigger points
In the preoperative evaluation 35.7% of
the patients presented trigger points, and
in the postoperative period per year
42.9%, noting an increase in the
presence of these.
Articular noises
A total of 72,3% had preoperative noises
and only 12,3% had noises in the
postoperative period per year.
NMRI
All patients had articular disk
displacement without reduction: 87.7%
bilateral, 7.7% left, 4,6% right. In the
imaging control postoperative per year it
shows that only 4 patients (6,2%) had
disk displacement; two without reduction
and two with reduction. In the others it
evidenced proper position of disk.
Discussion
The anterior displacement of the articular
disk is the alteration of the structural
relationship of the condyle relationship
disk where the disk remains displaced
and does not return to its normal position.
Clinically the patient presents limited oral
opening, pain on jaw movements, and in
addition there may be presence of
articular noises. 6,10
Temporomandibular disorders occur
more often in women than in men in a
proportion female male between 4:1 and
6:1.6 In this study, only one patient was
male gender, confirming once again the
high prevalence of the TMJ articular
pathology in the female gender.
A large number of factors may of the disk comes to make an accepted
predispose or cause displacement of the surgical technique. In 1979 McCarty and
articular disk, including trauma, Farrar described the surgical relocation
parafunctional habits, malocclusion, local and plication of the disk of the TMJ for
1
or systemic disease. Disk may be the correction of internal disorders of the
displaced by the rupture, tear or TMJ. Subsequently Wolford and
degeneration of the ligaments. Any of collaborators, developed a surgical
these conditions can lead to the loss of technique using bone anchor for the
the integrity of the ligaments that allow stabilization of the articular disk.9, 10
and at the same time restrict the
movement of the articular disk, what This study evaluated 65 patients in total
makes these ligaments are not suitable to 122 joints that had disk displacement
give stability to the disk. Likewise, the without reduction, with indication of the
retrodiscal tissue does not present the articular disk replacement, which were
features that are required for such performed with mini resorbable anchor.
stability. The functional load of the joint (Mitek resorbable ® Depuy Synthes). The
followed by an attempt to repair the etarias characteristics with respect to the
ligament or retrodiscal tissue can clinical presentation of articular
subsequently cause failure or the dysfunction are slightly different to what
procedure and disk displacement with has been reported in the literature; our
15
continuous joint degeneration. It is for patients are in a wide range of age
this reason that the concept of using a between 18 y 70, with an average of 40,
bone anchor to stabilize the disk is 11, being slightly higher than the study of
striking, since it does not depend on the Wolford10 where the average age was
structural integrity of the soft tissues.10 32.6 years, with a range between 14 to
57 years, and Carlos Ruiz 16 study where
Disk replenishment was first described in the average was 33.5 years, with a range
1887 by Annadale. In 1918 Behan between 19 to 53 years.
described his technique to reposition the
articular disk and maintain harmony with All patients were classified according to
the condyle. But it was not until 1978 their articular dysfunction stage for which
when Wilkes using arthrography we use the classification of Wilkes 1989;
describes anatomy, shape and function which correlates the clinic and
of the ATM, that the surgical repositioning
radiographic signs with the surgical
findings. This consists of 5 stages that similar to our study where a total of 28
goes from a slight anterior displacement patients (42.8%) had severe preoperative
of the asymptomatic disk until pain, and no patient presented severe
degenerative arthritic changes with pain in the immediate postoperative
severe symptoms. 5. In this study the period or a year, 14 (21,4%) had
majority of patients (78,5%) had moderate pain in the immediate
advanced articular dysfunction, in stage postoperative period and 7 (10,71%) in
III (46,15%) and IV (32.30%) of Wilkes. the postoperative period per year. The
average preoperative pain was 7 in the
Different clinical studies have reported scale of VAS observing a great decrease
favorable results of the plication of the in the postoperative period with an
disk in terms of a decrease in pain and average of 1.
improvement of the mandibular function
in 80 to 94% of patients. Dolwick and Ruiz and Marroquín in its study published
Nitzan evaluated 152 patients who were in 2011 evaluated 50 patients, a total of
made a replacement of the articular disc 100 articulations, which they reported an
between 1984 and 1988 finding an average of preoperative oral opening of
improvement of 85% in 90% of patients. 23.5mm compared with postoperative
However, 5.3% reported no improvement average which was 38,3mm, noting an
and 4.5% reported worsening after improvement of 14.8mm.16 In the present
surgery. Also observed that the majority study the average preoperative oral
of patients who reported improvement opening was 27mm and the
after surgery continued to express pain, postoperative per year of 36mm, with an
articular noises, decrease in the range of improvement of 9mm. Specifically, 39.3%
mandibular movements but in smaller of patients present limitations for oral
17
proportion tan prior to the surgery. The opening between 26-30mm, 21.4%
study of Mehra and Wolford10 evaluated between 31-35mm, noting an
105 patients for a total of 180 joints, in improvement in the postoperative period
which there was a great improvement of the year, since the 46.4% of the
with regard to pain, since in preoperative patients present a range of oral opening
55% of patients had severe pain and between 36-40mm. Another similar
20.8% moderate pain, in the late aspect between the two studies is the
postoperative only 3.8% had severe pain presence of articular noises as in Ruiz
and 8.5% moderate pain, this being article and collaborators in the
preoperatively period 76% of patients However it persisted with VAS 4 pain,
presented noises and in the limitation for oral opening and imaging
postoperative period only 10% showed evidence of displacement of the disk
them. In our work a total of 47 patients without reduction, so a year of the
(72,3%) had preoperative noises and surgery was performed again bilateral
only 8 (12,3%) had noises in the meniscopexy. The patient continued in
preoperative period per year. controls where improvement in pain
symptoms (VAS 1) and oral opening of
However in terms of the presence of 40mm is evident. The other patient that
trigger points this articles differs from required a second surgical management
others because it was observed a slight had also received initial management
increase in the postoperative period, with bilateral meniscopexy. In the
since 35.7% had preoperative trigger postoperative period of 8 months
points 42.9% in the postoperative period presented oral opening of 40mm,
per year. however persisted with severe pain (VAS
8) in right TMJ and presence of trigger
In terms of follow-up imaging with MRI, it points. In the MRI does not showed
was noted that two patients had disk displacement of the articular disk and it
displacement without reduction and two was therefore decided to perform right
with reduction in the postoperative TMJ arthroscopy and arthrocentesis. In
period, similar to what is evaluated in the the postoperative control after two
study of Fernández Sanromán and months of arthroscopy and arthrocentesis
collaborators in which evaluated 12 presented VAS 1, oral opening of 42mm
patients who were performed and absence of trigger points.
meniscopexy with Mitek, observed in
NMR of postoperative control of 6 months These results allow us to conclude that
that of 12 operated patients, 10 had the replacement of the articular disk with
normal disk position and two presented mini resorbable anchors in an effective
anterior displacement of the disk with technique that presents very good results
reduction in the other two cases. in terms of the decrease of pain and the
restoration of the mandibular function,
In this study, two patients had to be being reflected in the improvement in the
reoperated, one of them who had quality of life of patients. Without a doubt
performed bilateral meniscopexy. the absorbable anchors provide the
advantage of allowing a suitable imaging
control to be radiolucent, decreasing or
removed the artifacts in the NMR, thus
facilitating the interpretation of the image.
So far has not found published studies
that evaluated the effectiveness of the
meniscopexy with resorbable anchors,
what gives to this study a great
importance. However due to the lack of
publications in the literature with this type
of anchors, it was not possible to
compare with similar studies, so he used
those reported with metal anchors to
make this comparison. We also consider
that it is necessary to continue the study
to have a longer follow-up time to assess
the effectiveness and stability of the
meniscopexy with resorbable anchors in
the long term.
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