Težave s čeljustnim sklepom

Odprta artroplastika čeljustnega oziroma temporomandibularnega sklepa (TMS) je kirurški poseg, pri katerem TMS odpremo in ga preoblikujemo. Cilja posega sta dva: izboljšati sklepno gibljivost oziroma zmožnost odpiranja ust in odpraviti ali zmanjšati bolečine v sklepu. Poseg je indiciran pri pacientih, ki zaradi znotrajsklepne patologije ne morejo dovolj dobro odpirati ust in trpijo bolečine, in pri katerih konzervativni ukrepi (omejitve pri prehrani, uporaba razbremenilne grizne opornice, oslabitev žvečnih mišic z injekcijami botulin toksina, vaje in fizioterapija ter artrocenteza oz. izpiranje sklepa) niso dali želenih rezultatov. Treba je poudariti, da se artroplastike resnično lotimo samo takrat, ko ima pacient težave, konzervativni ukrepi pa so izčrpani. Velika večina pacientov se namreč okvarjenemu TMS prilagodi: z omejitvami prehrane, vajami, občasnimi analgetiki in nošnjo razbremenilne opornice, včasih še z botulinsko oslabitvijo žvečnih mišic, se znebijo bolečin. Odpirajo sicer nekoliko omejeno (blag trismus), ampak v vsakodnem življenju jih to prav dosti ne moti. Pri takšnih pacientih artroplastika ni indicirana! Pravzaprav je izmed pacientov z notranjo okvaro TMS (anteriorno dislokacijo artikularnega diska in osteoartritisom) le od 5 do 10 % takšnih, ki imajo hude kronične bolečine in/ali odpirajo manj kot 30 mm, kljub zgoraj opisanim konzervativnim ukrepom in kljub izvajanju vaj za forsirano odpiranje ust. Samo to so pacienti, pri katerih je indicirana artroplastika!

The general rule in treatment of pediatric condyle fractures is that it should be conservative (Andrade et al., 2015; Zhao et al., 2014; Thoren et al., 2001; Nørholt et al., 1993). In children, condyles are still growing and spontaneously remodeling, and it is widely claimed that this bony remodeling capacity is so intense that proper conservative treatment with mouth opening exercises and a soft diet, sometimes combined with orthodontic interventions, are enough to restore normal condylar height, as well as normal function of the TMJ (Andrade et al., 2015; Zhao et al., 2014). But is this always true? Moreover, what about the injured articular disc and its effects on TMJ function (Weinberg et al., 2019; Zhang and He, 2006)?

The claim of an almost limitless remodeling capacity is challenged by young adults who come to our office because of facial asymmetry, and whose history, clinical examination, and imaging (panoramic radiographs and CT/CBCT) clearly reveal that their asymmetry is posttraumatic (Bae and Aronovich, 2018; Thore n et al., 2001). These patients d and even more so their parents d often recall once falling on their chin, that their TMJ hurt for a day or two, but that the pain later went away.

Some of the joints in these patients are tender on examination; others are not. Most exhibit absent or diminished translation upon mouth opening, usually with some clicking or crepitations. The chin is deviated to the side of the affected TMJ, and upon mouth opening the deviation increases (Thoren et al., 2001). Often, the maxilla is tilted and shorter on the injured side. CT scans typically reveal a shortened, hypoplastic, flattened condyle, an asymmetric mandible, and often an asymmetric maxilla.

Clearly, in these cases, the remodeling capacity of the condyles had been exceeded d the fractured condyles had not remodeled well enough. The growth center in the fractured condyle had been damaged, causing hindered growth and subsequent development of facial asymmetry. Could this have been avoided with immediate and proper surgical intervention?

Čeljustni sklep (temporomandibularni sklep - TMS) se lahko, kot vsak drugi sklep, tako hudo okvari, da postane povsem nefunkcionalen. Tako močno okvarjen sklep onemogoča življensko pomembno funkcijo odpiranja ust in žvečenja hrane. V tem primeru ga lahko nadomestimo s totalno endoprotezo (TEP). V preteklosti je bilo zaradi neustrezne izbire materialov za TEP TMS veliko težav in so se te operacije skoraj povsem opustile. Odkar se uporabljajo enaki materiali kot pri TEP za druge sklepe, težav ni.

Razvoj operacij čeljustnih sklepov na Kliniki za maksilofacialno in oralno kirurgijo UKC Ljubljana je intenzivno potekal zadnjih 20 let in še poteka. V prvih letih novega tisočletja smo začeli, najprej le v redkih primerih, nato pa vse bolj redno, kirurško zdraviti ekstraartikularne, oziroma zunajsklepne zlome mandibularnega kondila, t.j. sklepnega odrastka. Do takrat je veljala železobetonska doktrina, da je kirurška oskrba teh zlomov zaradi bližine obraznega živca (n. facialis) preveč rizična. Poleg tega je dejstvo, da se ti zlomi, čeravno v dislociranem položaj, vedno zarastejo, ter da ob zacelitvi v blago napačnem položaju večjih težav ne povzročajo - vsaj kratkoročno. Seveda pa kvaliteta nadaljnje funkcije TMS po napačno zaceljenem zlomu kondila ni primerjljiva z anatomsko reponiranim in čvrsto fiksiranim zlomom, in če je slednje možno doseči brez večjega tveganja, je seveda kirurško zdravljenje teh zlomov še kako upravičeno.

Temporomandibular joint disorder (TMD) is an umbrella term for pain and dysfunction of the temporomandiblar joint (TMJ) and its neighbouring structures, caused by various factors. The prevalence of TMD is 5%; it is more common in women and elderly population (Karlic and Glickman, 2011).

The final stage of the TMD refers to a transformation of the temporomandibular joint to an extent that its function is substantially decreased or even disabled due to disease or injury. In terms of systemic disease, this occurrence is analogous to the endstage renal disease (ESRD), resulting in dialysis and kidney transplantation.

Possible causes for the endstage TMD include congenital disorders, tumors, inflammatory diseases, previous surgical procedures, trauma and ankylosis. The most common causes of TMJ ankylosis are TMJ disc damage and prolonged immobilization of the mandible after an intracapsular trauma. Other etiological factors for TMJ ankylosis are systemic infections, myositis ossificans, osteochondroma, rheumatoid arthritis, systemic lupus erytematosus, radiotherapy (Sporniak-Tutak et al., 2011).

Today, various modes of total TMJ reconstruction are available: use of autogenous bone tissue, distraction osteogenesis and TMJ total prosthesis (TP). The goal of the treatment is to restore the form and structure of the joint, eliminate difficulties, restore function and achieve minimal morbidity and duration of the treatment. In endstage mandibular joint reconstruction, this goal appears to be easily achieved with the use of TMJ TP (Mercuri, 2011a; Machon et al., 2012).

Following National Institute for Health and Care Excellence (NICE) and British Associations of Oral and Maxillofacial Surgeons (BAOMS) guidelines, a total joint replacement of the TMJ is used after other (i.e., conservative, minimally invasive and surgical) methods have been unsuccessful in restoring normal mouth opening and/or eliminating pain (Nice, 2017; Speculand, 2009). In addition to the clinical picture, magnetic resonance imaging (MRI) and computed tomography (CT) have proved to be helpful in deciding whether to operate, as they can indicate a severely damaged or an ankylosing TMJ (Sidebottom, 2009).

Kronična miofascialna bolečina žvečnih mišič je pogosta težava in je lahko posledica nepravilnosti temporomandibularnih sklepov (TMS) ali nefunkcionalnih gibov stomatognatnega sistema, kot npr. pri bruksizmu. Bruksizem je povezan s stresnimi situacijami in z nepravilnostmi spanja. Klinično najpogosteje opažamo palpatorno bolečnost žvečnih mišic in obrabo griznih robov sekalcev ter podočnikov. Pozni zapleti več let trajajočega bruksizma so hipertrofija masetrov, okvara TMS in kronični tenzijski glavobol. Pri 80% bolnikov z začetnimi simptomi je uspešno zdravljenje s pomočjo okluzijske opornice, fizioterapije, analgetikov in psihoterapije. Pri ostalih se je za uspešno metodo zdravljenja izkazalo intramuskularno injiciranje botulin toksina tipa A (BTA).

There is still much debate about the best mode of treatment of fractures of the mandibular condylar process, although in the past decade the number of proponents of surgical treatment has been steadily increasing (Zide and Kent, 1983; Dahlström et al., 1989; Takenoshita et al., 1990; Konstantinović and Dimitrijević, 1992; Hayward and Scott, 1993; Eckelt and Rasse, 1995; Brandt and Haug, 2003; Vesnaver et al., 2005). In this Journal, the majority of papers in the last 5-year period (2006e2011) have discussed and favoured surgical treatment of condylar fractures (Eckelt et al., 2006; Biglioli and Colletti, 2008; Parascandolo et al., 2010; Meyer et al., 2008; Eckelt, 2006; Schneider et al., 2007) over conservative treatment (Zacharides et al., 2006).

At the Department of Maxillofacial and Oral Surgery of the University Medical Centre Ljubljana, Slovenia, as well as at other institutions worldwide, conservative treatment used to be the gold standard. In 2000, following reports and techniques described in the literature, we started treating our first patients surgically (Eckelt and Rasse, 1995; Ellis and Zide, 1995a, 1995b; Anastassov et al., 1997; Choi and Yoo, 1999). As the preliminary results were good, our doctrine was changed in 2002, and these fractures started to be treated surgically: the fracture was approached through a periauricular or retromandibular incision, reduced under direct vision, and internally fixated with miniplates and screws, which led to good results and a shorter rehabilitation period (Vesnaver et al., 2005).

After performing routine surgical treatment of mandibular condyle fractures for several years, a retrospective study was performed to compare longterm results of surgical and conservative treatment, as well as to determine the safety and efficiency of surgical treatment, as objectively as possible.

Na Kliničnem oddelku za maksilofacialno in oralno kirurgijo smo leta 2002 spremenili doktrino zdravljenja zlomov sklepnega oz. kondilarnega odrastka mandibule. Zlome kondilarnega odrastka, ki so od vseh zlomov mandibule najpogostejši (15–30 %), smo do tega leta praviloma zdravili konzervativno. Bolnikom smo na zgornji in spodnji zobni lok navezali posebne opornice (kambe), nato pa zobe spravili v pravilen stik (okluzijo) in jih v tem položaju imobilizirali s pomočjo žičnih ligatur – t. i. intermaksilarna fiksacija (IMF). Po 10- do 14-dnevni imobilizaciji smo IMF odstranili in bolniki so pričeli razgibavati temporomandibularni (TM) sklep s pomočjo vaj za odpiranje ust.

Leta 2002 smo začeli zunajsklepne (ekstrartikularne), dislocirane zlome kondilarnega odrastka mandibule praviloma oskrbovati kirurško z odprto repozicijo in interno fiksacijo odlomkov z mini ploščicami in vijaki. Pri posegu smo kostna odlomka reponirali v anatomski položaj in ju učvrstili s pomočjo ploščic in vijakov. Za pristop do sklepa smo uporabljali kozmetsko ugoden kožni rez, enak rezu pri t. i. faceliftu, ki se zelo lepo skrije v gube okoli ušes in postane praktično neviden, ko brazgotina po nekaj mesecih pobledi. Rezultati kirurškega zdravljenja so bili zelo dobri, bolniki pa zelo zadovoljni. Še vedno pa smo konzervativno oskrbovali znotrajsklepne (intraartikularne) zlome glavice kondilarnega odrastka mandibule, saj leži glavica kondilarnega odrastka v celoti znotraj sklepne ovojnice. Konzervativno zdravljenje teh zlomov je še danes doktrina na večini evropskih institucij.

Po opravljenem tečaju o kirurškem zdravljenju zlomov kondilarnega odrastka mandibule v Strasbourgu aprila 2004, ki ga je vodil prof. Michael Rasse iz Innsbrucka, eden pionirjev kirurške oskrbe poškodb kondilarnega odrastka in TM sklepa, pa smo začeli na naši ustanovi kirurško zdraviti tudi te, dokaj zapletene zlome.

Treatment of mandibular condyle fractures is still a matter of controversy, with surgical treatment slowly gaining ground over conservative treatment as the preferred option. However, intra-articular (diacapitular) condyle fractures are still treated conservatively at many institutions, including those that treat extraarticular fractures (ie, condylar neck and subcondylar fractures) surgically.

At the Department of Maxillofacial and Oral Surgery, University Medical Centre Ljubljana, in Ljubljana, Slovenia, treatment of all condylar fractures until 2002 was, as a rule, conservative. Patients were treated with a 2-week period of maxillomandibular fixation and subsequent physiotherapy. In 2002 the doctrine was changed, and the predominant mode of treatment for extra-articular condylar fractures became open reduction with internal fixation via miniplates and screws. A transparotid facelift approach was used in most cases, as it achieves good exposure of the fractured condyle and heals with a barely perceptible scar. The results of treatment were very good, with the patients being very satisfied. Treatment of intra-articular fractures of the condylar head, however, remained conservative.

After completion of a course on surgical treatment of condylar fractures in Strasbourg, France, in April 2004, intra-articular fractures began to be treated operatively in our department. The results of the first 3 years are presented in this article.

Artroskopija je minimalno invaziven poseg, pri katerem s posebnim endoskopom oziroma artroskopom pogledamo v sam sklep, kar močno izboljša diagnostiko sklepnih okvar, saj lahko pod kontrolo očesa natančno in v živo pregledamo sklep od znotraj. Po opravljeni diagnostični artroskopiji pa lahko v isti seji s posebnimi instrumenti v sklepu izvršimo še različne artroskopske posege.

Artroskopska kirurgija je sicer standardno orodje ortopedov in travmatologov, še posebej v kolenskem sklepu. Prvo artroskopijo kolena je Takagi opravil že leta 1918, sistematično pa se je začela razvijati v drugi polovici 60-ih in v 70-ih letih prejšnjega stoletja. Prvo artroskopijo čeljustnega sklepa je opravil Ohnishi leta 1975, v Evropi pa Holmlund leta 1984.

Few facial fracture treatments have been the subject of so much disagreement as that of the fractured mandibular condyle. Debates have been continuing for six decades with no general consensus as yet (Takenoshita et al., 1990; Konstantinović and Dimitrijević, 1992; Hayward and Scott, 1993; Smets et al., 2003). Advocates of conservative treatment consider the risks and morbidity of the surgical procedure too great to justify the procedure. They claim that the application of intermaxillary fixation (IMF) for approximately3weeksandmouthopeningexercises afterwards achieve good results (Takenoshita et al., 1990; Konstantinović and Dimitrijević, 1992). Advocates of surgical treatment, on the other hand, argue that only precise open reduction and internal miniplate fixation can prevent unwanted long-term effects – shortening of the ramus, facial asymmetry, arthrosis of the temporomandibular joint (TMJ) and impaired masticatory and articular function. Rehabilitation is quicker with surgical treatment, enabling theTMJandmusclesofmasticationtofunction normally faster (Anastassov et al., 1997; Choi and Yoo, 1999; Devlin et al., 2002).

The reasons behind this long-standing discussion are many, but probably the most important one is the complicated surgical procedure, as injury to branches of the facial nerve has to be avoided. The facial nerve exits the cranial base through the stylomastoid foramen, travels anteriorly towards the posterior rim of the mandibular ramus and then passes over its lateral aspect where it branches into several rami (Ellis and Zide, 1995a and b; Anastassov et al., 1997). The nerve branches have to be identified, dissected and retracted out of the surgical field. The fact that the facial nerve and its branches are within the parotid gland makes this procedure even more demanding. After the fracture site is exposed, reduction can be another serious problem, especially in medially displaced fracture dislocations, where the joint capsule is torn and the lateral pterygoid muscle exerts unopposed traction on the condylar head, displacingitmediallyoutoftheglenoidfossa.