**4. Discussion**

From the results of our search it is reasonable to conclude that there is data to support the efficacy of meniscopexy for the management of temporomandibular joint dysfuction. Studies evaluating various techniques of articular disc repositioning demonstrated a successful outcome in the majority of cases, with little evidence to prove otherwise. However, there are certain limitations present in the literature available:


#### **4.1 Levels of evidence**

According to the *Oxford Centre for Evidence-Based Medicine* 2011 guidelines on levels of evidence in healthcare research [36], the highest levels of evidence consist of systematic reviews of randomised trials *(Level I)* or randomised trials or observational studies with dramatic effect *(Level II)*. The difficulty in conducting randomised, controlled trials prospectively to evaluate outcomes of surgery in this field limit the quality and certainty of conclusions that can be made with regards to effectiveness.

#### **4.2 Follow-up**

Our literature search only yielded 2 articles following up patients for more than 12 months after having received disc repositioning surgery, neither of which was

**113**

*Review of Current Practice for Temporomandibular Joint Meniscopexy Surgery*

conducted prospectively [22, 23]. Concerns exist with regard to long-term outlook of this surgery, specifically incidence of relapse, reoccurrence of symptoms and secondary joint disease [34, 37]. Well-designed, prospective studies of patients receiving meniscopexy with prolonged follow-up are required to address these concerns.

No one surgical technique in the management of advanced TMD seems to predominate, with multiple options described in the literature. Where procedures such as arthrocentesis of the joint space are successful in the management of internal derangement, the role of disc position in the pathology of TMD should be questioned [37]. Ribeiro et al. [38] found articular disc displacement without symptoms to be a common occurrence in the general population (34% of subjects) when conducting an MRI study of 56 asymptomatic volunteers. Other authors [39, 40] have also questioned the role of disc position in TMJ pathology, arguing that pathological changes such as synovitis, osteoarthritis and adhesions to be the causative agents of

However, in instances where there is no response to other treatment, there seems to be benefit in meniscopexy. This suggests there may still be a place for disc mobilisation, with many patients showing immediate improvement in mechanical

Other surgeries performed such as discectomy, joint replacement procedures and various other arthrotomies may also be beneficial in particular circumstances [20]. Since a single procedure has not yet been identified as being preferable in all instances of TMD, the role of the surgeon then becomes to identify the modality

To establish the place of meniscopexy relative to other techniques at the operator's disposal research is required comparing surgical modalities. Despite positive findings no study exists offering a direct comparison between repositioning the disc

A number of different approaches are described to reposition the articular disc, some of which are more technically demanding. No study was found directly comparing the efficacy of different techniques. This is also hard to determine since the efficacy of certain techniques will largely depend on the skill of the operator [13]. For instance, excellent outcomes have been reported with arthroscopic disc repositioning and suturing techniques [32]. However, such results may not be reproducible due to this technically demanding technique, resulting in data that is

Despite the fact that an increasingly greater proportion of TMD is being managed conservatively and minimally invasively, there remains a place for surgical procedures in refractory cases. There is evidence in the literature to suggest meniscopexy is an effective procedure in the management of some instances of TMD, however high-level evidence is lacking. Outcome variables between papers varied, making comparison difficult. In addition, it is apparent that many other techniques are available at a surgeon's disposal, many of which may be more effective than attempts to reposition the disc. Therefore, case selection is vital when deciding to

function potentially leading to better regeneration of the tissues [17].

which will achieve the best outcome on a case-by-case basis.

*DOI: http://dx.doi.org/10.5772/intechopen.93403*

**4.3 Comparison to other techniques**

symptoms, which should be treated separately.

and alternative procedures.

**4.4 Technical limitations**

not universally acceptable [16].

**5. Conclusion**

conducted prospectively [22, 23]. Concerns exist with regard to long-term outlook of this surgery, specifically incidence of relapse, reoccurrence of symptoms and secondary joint disease [34, 37]. Well-designed, prospective studies of patients receiving meniscopexy with prolonged follow-up are required to address these concerns.

### **4.3 Comparison to other techniques**

*Oral and Maxillofacial Surgery*

**4. Discussion**

received meniscopexy.

operators.

**4.1 Levels of evidence**

Rajkumar et al. conducted MRI assessment at 6 months for 10 patients managed with meniscopexy with orthodontic mini-screws, finding stable positioning of the disc and lack of progression of arthritic changes of the condyle on evaluation [24]. Zhou et al. when using MRI scans to follow up patients post-operatively found 4.7% of patients relapsed with anterior disc displacement. Of the 149 patients, 5 relapsed after 1 year and 2 after 2 years [25]. However, further studies investigating the longterm follow up of all cases is required to accurately ascertain incidence of relapse. Other outcomes such as reduction in joint noises, increase in diet consistency, muscle pain and joint loading signs were also looked at in a few isolated studies as a means to assess the success of surgery. However, there were not enough studies

From the results of our search it is reasonable to conclude that there is data to support the efficacy of meniscopexy for the management of temporomandibular joint dysfuction. Studies evaluating various techniques of articular disc repositioning demonstrated a successful outcome in the majority of cases, with little evidence to prove otherwise. However, there are certain limitations present in the literature available:

• There is limited evidence looking at long-term follow up of patients who have

• No study currently compares the efficacy of meniscopexy directly relative to other surgical techniques available (*e.g.* arthroscopy/arthrocentesis or total joint replacement) to establish its superiority in similar groups of patients.

• There is a lack of consistency in outcome variables evaluated and method in which these were determined, as well as surgical techniques used between papers. Some studies did not describe technique used. Therefore, it is difficult

• Many of the procedures described are sensitive techniques, and therefore results may not necessarily be reproducible across centres or among different

According to the *Oxford Centre for Evidence-Based Medicine* 2011 guidelines on levels of evidence in healthcare research [36], the highest levels of evidence consist of systematic reviews of randomised trials *(Level I)* or randomised trials or observational studies with dramatic effect *(Level II)*. The difficulty in conducting randomised, controlled trials prospectively to evaluate outcomes of surgery in this field limit the quality and certainty of conclusions that can be made with regards to effectiveness.

Our literature search only yielded 2 articles following up patients for more than 12 months after having received disc repositioning surgery, neither of which was

• There is a lack of high-level evidence to evaluate outcomes.

to compare and collate the results of various studies.

available to effectively use these to determine outcomes.

**112**

**4.2 Follow-up**

No one surgical technique in the management of advanced TMD seems to predominate, with multiple options described in the literature. Where procedures such as arthrocentesis of the joint space are successful in the management of internal derangement, the role of disc position in the pathology of TMD should be questioned [37]. Ribeiro et al. [38] found articular disc displacement without symptoms to be a common occurrence in the general population (34% of subjects) when conducting an MRI study of 56 asymptomatic volunteers. Other authors [39, 40] have also questioned the role of disc position in TMJ pathology, arguing that pathological changes such as synovitis, osteoarthritis and adhesions to be the causative agents of symptoms, which should be treated separately.

However, in instances where there is no response to other treatment, there seems to be benefit in meniscopexy. This suggests there may still be a place for disc mobilisation, with many patients showing immediate improvement in mechanical function potentially leading to better regeneration of the tissues [17].

Other surgeries performed such as discectomy, joint replacement procedures and various other arthrotomies may also be beneficial in particular circumstances [20]. Since a single procedure has not yet been identified as being preferable in all instances of TMD, the role of the surgeon then becomes to identify the modality which will achieve the best outcome on a case-by-case basis.

To establish the place of meniscopexy relative to other techniques at the operator's disposal research is required comparing surgical modalities. Despite positive findings no study exists offering a direct comparison between repositioning the disc and alternative procedures.

### **4.4 Technical limitations**

A number of different approaches are described to reposition the articular disc, some of which are more technically demanding. No study was found directly comparing the efficacy of different techniques. This is also hard to determine since the efficacy of certain techniques will largely depend on the skill of the operator [13]. For instance, excellent outcomes have been reported with arthroscopic disc repositioning and suturing techniques [32]. However, such results may not be reproducible due to this technically demanding technique, resulting in data that is not universally acceptable [16].
