Table 11.
Controversial recommendations. Legend: Grade: grade of recommendation A (strong recommendation)/B (recommendation)/0 (recommendation open); LoE: level of evidence; K1: Initial Consensus Phase OMFS; and K2: Interdisciplinary Consensus.
| Item (Final Version) | LoE | Grade | Criteria | Comment/Discussion | Adaptation |
|---|---|---|---|---|---|
| 1. Three-dimensional imaging (CT/CBCT) shall be applied for further diagnosis and treatment planning or to rule out differential diagnosis. | 4/k++ | A | Criterion 1: K1.1 Approved by majority (57%) K2.1 Approved by majority (66%) |
Not adapted due to missing comments/discussion and insufficient evidence | |
| 2. Three-dimensional imaging (CT/CBCT) is the current standard for imaging and documenting the extent of disease and ruling out other differential diagnoses at initial presentation, thus it should be used to document initial presentation and disease progression. | 4/k++ | B | Criterion 2: K2.1 Consensus (83%) → Adaptation of text |
After consultation with the competent scientific association on questions concerning imaging and request for expert assessment modification of text in accordance with the state of art | Modification of text |
| 3. For specific questions regarding bony structures, CT or CBCT should be used as a diagnostic tool. | 4/k++ | B | Criterion 2: K1.1 Consensus (86%) → Adaptation of text |
The examination using cbct was assessed as equivalent to the examination using CT, and therefore supplemented in a text adaptation | Modification of text |
| 4. An MRI scan can provide important additional information for the choice of surgical treatment and for clarification of differential diagnoses, especially for evaluation of soft tissue, especially the disc. | 4/k+ | 0 | Criterion 1: K1.1 Approved by majority (57%) |
Not adapted due to missing comments/discussion and insufficient evidence | |
| 5. In order to exclude or further verify an autoimmune or rheumatic disease as the cause, primarily contrast-enhanced MR diagnostics of the temporomandibular joint should be performed, serological diagnosis only if the result is unclear. | 4/k+ | B | Criterion 1: K1.1 Not approved by majority (43%) |
According to the current German S3 guideline “Inflammatory diseases of the temporomandibular joint—Juvenile idiopathic arthritis and rheumatoid arthritis of the temporomandibular joint”, contrast-enhanced MR diagnostics of the temporomandibular joint are primarily indicated to verify juvenile idiopathic arthritis or rheumatoid arthritis of the temporomandibular joint. | Based on the high level of evidence available (S3 guideline) and subsequent discussion, the initially dissenting guideline group members later agreed with the majority opinion |
| 6. If it is not possible to sufficiently control the symptoms of active condylar resorption (pain, functional limitations) by conservative measures, condylectomy with subsequent reconstruction may be indicated, e.g., from rib cartilage (CCG), or comparable autologous procedures, or use of microsurgical grafts, or total alloplastic joint replacement (cf. S3 Guideline No. 007/106 “Total alloplastic temporomandibular joint replacement”, status 04/2020), if necessary in combination with orthognathic surgery. | 4/k+ | 0 | Criterion 1 and 2: K1.1 Approved by majority (71%) → Adaptation of text |
Option to perform reconstruction after condylectomy with microsurgical grafts was added | Modification of text |
| 7. Arthroplastic procedures, e.g., for disc repositioning, condylar shave or similar, should generally be performed as a two-stage procedure, if required in combination with orthognathic surgery. The arthroplasty procedure should be performed first, followed by orthognathic surgery. | EC | B | Criterion 1: K1.3 Not approved by majority (43%) |
Not adaptated due to missing comments/discussion and insuffi-cient evidence | |
| 8. If adequate conservative and surgical interventions with autologous reconstruction prove unsuccessful, or after multiple operations performed in the region, the indication for arthroplasty with total alloplastic joint replacement should be considered, if symptoms are sufficiently severe. | 4/k+ | B | Criterion 1: K1.1 Not approved by majority (43%) |
The previous recommendation contradicts the recommendation of the current S3 guideline “Total Alloplastic Jaw Joint Replacement”, rendering the previous recommendation obsolete | Based on the high level of evidence available (S3 guideline) and subsequent discussion, the initially dissenting guideline members agreed with the new recommendation |
| 9. Reconstructive procedures performed as part of more complex reconstructive procedures, e.g., using alloplastic (TEP) or autologous procedures (e.g., CCG) to replace the temporomandibular joint, should be performed in a single-stage procedure, if a combination with orthognathic surgical realignment is required. | EC | B | Criterion 1: K1.3 Not approved by majority (43%) |
Not adaptated due to missing comments/discussion and insuffi-cient evidence |