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CATEGORY LINICAL

Category 5 – TMJ End-Stage Degenerative Joint Disease Category 5 refers to end-stage joint disease where none of the joint components can be salvaged due to catastrophic changes in all joint structures including both the disc and condylar head. e most common disorder depicted in this category is osteoarthritis, but may also include benign neoplasia, brous and bony ankylosis, and autoimmune disorders such as rheumatoid and psoriatic arthritis. Developmental TMJ disorders such as idiopathic condylysis or condylar resorption are also included in this category which describes catastrophic changes to the joint (Fig. 4). erefore, the TMJ is best resected and reconstructed with autogenous tissues such as rib grafts or alloplastic TMJ prosthetic total joint replacements.

is restricted because of the mechanical obstruction caused by the displaced disc. Surgical repositioning of the disc to its normal physiological position, either arthroscopically or by open surgery called arthrotomy, is usually e ective in the management of recalcitrant cases that fail to respond to conservative TMD measures. In this category, there are severe structural changes such as tear, structural deformity, or perforation of the disc (Fig. 3) that is often displaced. e condylar head may also demonstrate early degenerative changes. is category also includes chronic TMJ dislocation where the joint cannot be physically reduced due to extensive scarring and requires surgical intervention. Essentially, the disc has degenerated to a point where it cannot be salvaged and will need to be surgically removed in a procedure referred to as TMJ discectomy. e resultant joint cavity may remain empty, however, most surgeons elect to use autogenous tissue such as abdominal fat to ll up the joint space. While the underlying condylar head may be mildly degenerate, it is left largely intact with only minor surgical intervention such as debridement and scraping of loose cartilage. Category 4 – TMJ Disc Degeneration +/- Early Condylar changes

compared 2 . By using a practical surgical TMJ classi cation as a guide to diagnosis [Table 1], future studies can more reliably determine which surgical interventions are successful. To better understand the role of surgery in TMD, we need to look no further than our Orthopaedic colleagues to see that joint surgeries (i.e. arthroscopy, arthroplasty and joint replacements) are the most common surgical procedures undertaken globally. With the aid of radiological images showing the structural integrity of the TMJ, clinicians can clearly see that it makes no sense to try and salvage tissue components such as perforated or severely deformed discs (i.e. Category 4) that are best excised. Equally, it makes no sense to salvage a severely arthritic condyle (i.e. Category 5) when a condylectomy, with or without reconstruction, is the only realistic option. Lastly, dental practitioners who practice in the TMD space should keep in mind that when the TMJ is structurally compromised by disease or derangement, conservative measures can only o er so much. Patients with proven joint pathology as depicted in Table 1 should ultimately be given the option of surgery if conservative TMD measures fail to o er su cient relief. u temporomandibular joint disorders: A surgeon’s perspective. Aust Dent J. 2018;63 Suppl 1:S79-S90. doi: 10.1111/adj.12593.PMID: 29574810 2 Dimitroulis G. A new surgical classi cation for temporomandibular joint disorders. Int J Oral Maxillofac Surg. 2013;42:218-22. doi: 10.1016/j. ijom.2012.11.004. temporomandibular joint: a critical review of the literature. Part 2. Int J Oral Maxillofac Surg. 2005;34:231-7. doi: 10.1016/j.ijom.2004.06.006. PMID: 15741028 4 Guarda-Nardini L, De Almeida AM, Manfredini D. Arthrocentesis of the Temporomandibular Joint: Systematic Review and Clinical Implications of Research Findings. J Oral Facial Pain Headache. 2021;35:17-29. doi: 10.11607/ ofph.2606.PMID: 3373012 3 Dimitroulis G. e role of surgery in the management of disorders of the References 1 Dimitroulis G. Management of

Figure 4 Coronal CT scans showing a normal condyle (left) compared with a Category 5 TMJ (right), demonstrating erosive and degenerative changes in the condylar head.

Discussion: e controversies related to TMJ surgery are largely the result of treatments that have been promoted without reference to a radiological diagnosis 3 . Studies related to TMJ arthrocentesis e ectiveness, for example, are di cult to evaluate because most of the patients had no MRI scans to prove the degree of joint pathology 4 . To address these critical issues, the TMJ surgical classi cation described in this article is particularly focused on the radiological diagnosis of the TMJ itself so that the e ectiveness of the various treatment options can be more easily

Figure 3 Surgical specimen showing a perforated disc from a Category 4 TMJ.

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