BACKGROUND/PURPOSE: The treatment of temporomandibular joint (TMJ) disease is highly variable, from nonsurgical management to salvage procedures like joint replacement. Long-term outcomes data are limited, and there is no consensus for an optimal treatment algorithm. A relatively new and minimally invasive treatment includes fat grafting to the TMJ performed with or without open TMJ reconstruction. We aimed to study the safety, efficacy, and indications for this new approach in patients with TMJ disease.
METHODS/DESCRIPTION: A retrospective chart review was performed on all patients who underwent a nonsalvage procedure under general anesthesia for the relief of TMJ disease by a single surgeon from 2011 through 2019. Patients with minimum 12-month clinical follow-up were included. Patient demographics, diagnosis, pre- and postoperative symptoms, procedure details, complications, and additional interventions for TMJ disease were recorded. Patients were asked to complete a survey elaborating on their symptoms (TMJ pain on 0–10 Likert scale, other symptoms 0–5 scale) before surgery and at their final follow-up. Wilcoxon signed rank test and repeated-measures analysis of covariance were performed to compare pre- and postoperative symptoms (P < 0.05 for significance).
RESULTS: Forty patients were included in the study, 71% female, mean age 34 (range, 10–65) years, mean clinical follow-up 4.3 (range, 1.6–9.0) years. The prevalence of procedures that patients underwent was 90% TMJ fat injection, 90% masticatory Botox injection, 80% Kenalog injection, 36% open TMJ arthroplasty, and 3% concurrent orthognathic surgery. Twenty-six (65%) patients completed the pre- and postoperative surveys. Overall, there was a statistically significant improvement in mean Likert scores at final follow-up versus preoperatively for: trismus (0.46 versus 1.63; P = 0.003), clicking/popping (1.29 versus 3.17; P = 0.001), grinding/clenching (0.29 versus 1.58; P = 0.007), headache (1.27 versus 2.67; P = 0.003), TMJ pain (2.17 versus 6.71; P < 0.001), difficulty eating (1.21 versus 3.50; P = 0.001), difficulty chewing (1.63 versus 4.06; P = 0.001), and muscle soreness (2.12 versus 3.25; P = 0.007) but not for facial asymmetry (0.73 versus 1.21; P = 0.112). Only 3% of patients experienced worsened symptoms at final follow-up. No patients experienced any major or minor complications during the study period. Patients who exhibited preoperative trismus (50%) were more likely to undergo open TMJ surgery compared with those who did not (62% versus 38%; P = 0.206). Preoperative mean Likert scores were otherwise similar for patients who underwent fat/botox injection versus open TMJ surgery. Patients who underwent open TMJ surgery versus a more conservative approach demonstrated similar mean reduction in Likert scores for trismus (1.13 versus 1.23; P = 0.894), headache (1.70 versus 1.08; P = 0.419), muscle soreness (1.34 versus 0.91; P = 0.554), difficulty chewing (2.70 versus 2.62; P = 0.516), difficulty swallowing (2.50 versus 2.08; P = 0.630), grind/clenching (1.00 versus 0.75; P = 0.670), facial asymmetry (0.83 versus 0.13; P = 0.251), and TMJ pain (5.67 versus 3.42; P = 0.064); a significant decrease was only noted for click/popping (2.58 versus 1.16; P = 0.048).
CONCLUSIONS: A combination of TMJ fat grafting, masticatory Botox injection, Kenalog injection, open TMJ arthroplasty, and possible concurrent orthognathic surgery can provide much needed improvement for patients with TMJ disease, while postponing the need for salvage operations like joint replacement. A comprehensive treatment algorithm is presented and discussed.