Lee and Hong Maxillofacial Plastic and Reconstructive Surgery (2020) 42:14

[Link]
Maxillofacial Plastic and
Reconstructive Surgery

RESEARCH Open Access

Temporomandibular joint disc plication

with MITEK mini anchors: surgical outcome
of 65 consecutive joint cases using a
minimally invasive approach
Bu-Kyu Lee1,2* and Jun Hee Hong1

Abstract
Background: The purpose of this study is to introduce our modified disc plication technique using MITEK mini
anchors and to evaluate the clinical outcome for patients with internal derangement (ID) of the
temporomandibular joint (TMJ).
Patients and methods: We evaluated 65 joints in 46 patients, comprised 32 women and 14 men, who first visited
the Asan Medical Center from December 2012 to December 2016. The age of the patients ranged from 14 to 79
years, with a mean age of 36.6 years. The patients presented with joint problems including pain, joint noise, and
mouth opening limitation (MOL). Patients who met our inclusion criteria underwent unilateral or bilateral disc
repositioning surgery with our minimally invasive disc plication technique using MITEK mini anchors and No. 2-0
Ethibond® braided polyester sutures. The variables taken into account in this study were the range of maximum
mouth opening (MMO), painful symptoms (evaluated with the visual analog scale, VAS), and the type of noise (click,
popping, crepitus) in the TMJ.
Results: Preoperative examination revealed painful symptoms in 50.7% (n = 35) of the operated joints (n = 69) and
the presence of clicks in 56.5% (n = 39). Postoperative examination revealed that 4.3% (n = 3) of the operated joints
had painful symptoms with lower intensity than that in the preoperative condition. Additionally, 17.4% (n = 12) had
residual noise in the TMJ, among which two were clicking and the other 10 had mild crepitus. The intensity of the
postoperative residual noise was significantly decreased in all cases compared to that in the preoperative condition.
Among patients with MOL below 38 mm (n = 18), the mean MMO was 31.4 mm preoperatively and 44.2 mm at 6
months postoperatively, with a mean increase of 13.8 mm. A barely visible scar at the operation site was noted
during the postoperative observation period, with no significant complications such as facial palsy or permanent
occlusal disharmony.
(Continued on next page)

* Correspondence: [Link]@[Link]
1
Department of Oral and Maxillofacial Surgery, Asan Medical Center, College
of Medicine, University of Ulsan, 05505, Olympic-ro 88, 43-gil, Songpa-gu,
Seoul, Republic of Korea
2
Biomedical Engineering Research Center, Asan Institute for Life Sciences,
Asan Medical Center, College of Medicine, University of Ulsan, 05505,
Olympic-ro 88, 43-gil, Songpa-gu, Seoul, Republic of Korea

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Lee and Hong Maxillofacial Plastic and Reconstructive Surgery (2020) 42:14 Page 2 of 11

(Continued from previous page)

Conclusion: Subjective symptoms in all patients improved following the surgery. TMJ disc plication using MITEK
mini anchors with our minimally invasive approach may be a feasible and effective surgical option for treating TMJ
ID patients who are not responsive to conservative treatment.
Keywords: Temporomandibular joint disorders, Disc displacement, Disc plication, MITEK anchor, TMJ surgery

Background However, several oral and maxillofacial surgeons have

Internal derangement of the temporomandibular joint reported that the effectiveness of TMJ disc repositioning
(TMJ ID) is the most common condition that causes is low [14]. In this context, some surgeons preferred
temporomandibular joint disorders (TMDs) [1]. Redu- non-invasive techniques like arthroscopy rather than in-
cible or non-reducible disc displacement of TMJ can re- vasive TMJ repositioning surgery to resolve TMJ ID
sult in noise or crepitus, arthritis, condyle head [15]. However, for patients with refractory limitation of
resorption, jaw deformities, open bite, inflammation, and mouth opening or annoying popping of the disc accom-
joint pain [2]. Although some patients may lack visible panied by intermittent habitual luxation, adequate and
symptoms of TMJ ID, the condition can affect normal comfortable mouth opening can only be achieved
jaw functions such as chewing, swallowing, and phonet- through appropriate surgical methods such as disc repo-
ics in most cases [1]. sitioning surgery via an open TMJ approach [16].
In 1979, McCarty and Farrar introduced a surgical tech- Recently, some surgeons reported that a specific tech-
nique for disc repositioning as a treatment option for TMJ nique using MITEK mini anchors often caused severe
ID, reporting a 94% success rate over a 6-year period [3]. adhesion of the superior joint space, resulting in severe
Other studies have presented variations in the technique, limitation of mouth opening compared to the conven-
with improved symptoms and different follow-up periods tional disc plication technique. The surgeons attributed
[1, 4, 5]. However, despite these reports, many surgeons this outcome to the posterior part of the disc remaining
have indicated that the reposed disc does not last long in open after the junction with the retrodiscal tissue of the
its new position and the high success rate reported in the TMJ was excised. As a result of this preparatory proced-
original study could not be achieved [5]. ure, severe scarring can develop in the dead space [14].
The reported clinical outcomes for TMJ disc reposi- To overcome this technical hurdle, we modified the con-
tioning surgery vary and are often unpredictable [5, 6]. ventional technique by utilizing MITEK mini anchors.
Traditional disc repositioning techniques such as sutur- The aim of this study is to introduce and evaluate our
ing inflamed and often degenerated ligaments result in modified disc repositioning surgery technique using
disc instability and the inevitably wide skin incision re- MITEK mini anchors, which improves the clinical out-
sults in a significant amount of scarring on the face [1]. comes. We also report the clinical data for patients who
Therefore, new surgical techniques have been developed underwent disc repositioning surgery using our modified
for TMJ disc repositioning [1, 7–9]. MITEK mini anchor technique.
Skeletal anchors are used in various surgical proce-
dures to attach soft tissue to soft or hard tissues. They
can also be used in orthopedic, reconstructive, and or- Patients and methods
bital procedures [10, 11]. In the field of TMJ surgery, This was a retrospective study evaluating the treatment
Wolford et al. and other surgeons reported improved records of 65 joints in 46 consecutive patients (32
results by using this anchor system. According to these women and 14 men) who underwent TMJ disc reposi-
authors, the MITEK mini anchor (DePuy Mitek, Rayn- tioning surgery during the period of December 2012 to
ham, MA) showed long-term stability and successful December 2016. This clinical study was approved by the
results in disc repositioning surgery [1, 12]. This anchor Institutional Review Board of Asan Medical Center (IRB
system provides accurate and tight fixation of the disc number: S2018-1771-0001). The age of the patients
to the head of the condyle, harmonizing the disc- ranged from 14 to 79 years, with a mean age of 36.6
condylar relationship when in use and improving the years. The inclusion criteria for the study were as fol-
resistance of the disc to displacement caused by a pull- lows: [17] (1) American Society of Anesthesiology status
out force from the masticatory muscles [13]. Thus, the I patients [18] (i.e., healthy patients) with TMJ disorders
concept of using a bone anchor and artificial ligaments identified based on clinical examination [19] and mag-
for disc stabilization is attractive as it does not depend netic resonance imaging (MRI); (2) no previous surgery
on the structural integrity of soft tissues to maintain involving the TMJ; (3) the presence of pain, joint noise,
postsurgical disc stability [1]. or limited mouth opening [20]; (4) treatment with the
Lee and Hong Maxillofacial Plastic and Reconstructive Surgery (2020) 42:14 Page 3 of 11

MITEK mini anchor; and (5) post-operative follow-up Surgical procedures

period of more than 6 months. A meticulous surgical intervention is needed to obtain
In our protocol, the indications for TMJ disc reposi- predictable results. All patients received the surgery with
tioning surgery were as follows: (1) painful anterior disc the same procedures (Figs. 2, 3, 4, 5, 6, 7, 8, and 9). All
displacement with reduction that did not respond to patients underwent surgery under general anesthesia
nonsurgical and minimally invasive procedures, (2) an- with nasotracheal intubation, and sterile surgical prepar-
terior disc displacement without reduction with persist- ation and draping were performed in a routine manner
ent pain and limited mouth opening that did not for all patients. With digital traction of the preauricular
respond to nonsurgical and minimally invasive proce- region, a short endaural incision line was drawn with a
dures, (3) severe TMJ sounds (ex. popping) with inter- sterilized marking pen. Unilateral or bilateral preauricu-
mittent locking of the disc, (4) patient request for lar sites were injected with 2.0 ml of lidocaine (2% with
surgery after conservative treatment, (4) no serious sys- 1:100,000 epinephrine) in a subcutaneous plane. Using a
temic disease such as diabetes mellitus or rheumatoid No. 15 scalpel, incisions were made along the surgical
arthritis, (5) no serious mental health condition, and (6) design line. Dissection was performed with sharp dissec-
no previous TMJ surgery. tion scissors and a Bovie electrocautery from the tragal
cartilage down and forward approximately 15 to 20 mm
through the subcutaneous tissue. The first assistant was
MITEK mini anchor frequently instructed to pull the mandible anteriorly and
MITEK anchors were first developed for orthopedic sur- to push backward posteriorly. Afterward, the surgeon
gery such as shoulder cuff repair, medial and lateral col- placed his point finger on the surgical area and deter-
lateral ligament repair, bicep tendon reattachment, and mined the position of the mandibular condylar head and
other muscle, ligament, and tendon repair surgery [11, the articular eminence based on the tactile sensation.
21]. The MITEK mini anchor is a suitable size for TMJ This step of the procedure enabled the surgeon to ap-
disc stabilization, and successful utilization of the anchor proach the joint space safely even with a small incision.
for TMJ disc repositioning has been reported by Wol- Blunt dissection was performed with mosquito forceps
ford et al [1, 22]. The anchor consists of a titanium alloy in the direction of the superficial temporal fascia and
shaft with a 2-0 Ethibond® braided polyester suture below the fat tissue to avoid damage to the facial nerves.
threaded through its eyelet and wings. The shaft is made The superficial temporal fascia was dissected with mos-
of 90% titanium metal alloy, 6% aluminum, and 4% van- quito forceps and separated using Bovie electrocautery.
adium. The two retention wings are made of nickel and Using Senn-Miller retractors, the first assistant entered
titanium. The composition and structure of the MITEK the dissected plane and retracted the forceps in an anter-
mini anchor are known to contribute significantly to the ior and inferior direction. The second plane was elevated
osseointegration of the anchors in the condyle, proper and dissected in the same fashion, arriving at the tem-
positioning of the TMJ disc, and long-term stability of poral fascia at this level to reveal the TMJ capsule. One
the surgery [13, 23]. The general scheme of disc plica- milliliter of lidocaine (2% with 1:100,000 epinephrine)
tion using MITEK mini anchor was illustrated in Fig. 1. was injected into the superior joint space to hydraulically

Fig. 1 Schema of position of MITEK mini anchor (a) and placement of two No. 2-0 polyester sutures at posterior segment of TMJ disc sutured to
mini anchor placed on most lateral superior and posterior aspect of mandibular condyle (b). Med, medial aspect of mandibular condyle; Lat,
lateral aspect of condyle
Lee and Hong Maxillofacial Plastic and Reconstructive Surgery (2020) 42:14 Page 4 of 11

Fig. 2 Anterior digital traction for initial surgical markings with methylene blue. a Modified short endaural approach marked with methylene blue
when digital traction is released b showing how the incision is hidden

displace the disc inferiorly. The lateral capsule was in- head of the condyle. The mini anchor was inserted on
cised horizontally with a No. 15 scalpel. Dissection of the most posterior aspect of the mandibular condyle.
the superior joint space was performed with a periosteal The position of the anchor varied slightly for each case,
elevator, enabling entrance into the superior joint space. but was generally 5 to 10 mm below the superior aspect
Disc liberation enabled posterior movement and reposi- of the condyle. TMJ disc plication was achieved using
tioning of the TMJ disc. It was often necessary to free two No. 2-0 Ethibond® braided polyester sutures placed
the disc anteriorly when the ligament adhered to the an- on the posterior part of the disc. After the discs were
terior band of the disc to the anterior slope of the articu- repositioned with sutures, the condyle was manipulated
lar eminence. The medial attachments sometimes had to in various directions to confirm the disc and condylar
be released as well. Using a MITEK drill bit (2.1 mm in unit could move harmoniously and the disc was well-
diameter), a hole was made laterally in the posterior secured in its new, optimal position. We usually coagu-
lated the retrodiscal tissue and the posterior bilaminar
area. To better secure the reposed disc, additional

Fig. 4 Horizontal incision of capsular ligament after the confirmation

Fig. 3 Intra-articular injection of lidocaine (2% with 1:100,000 of condylar position. This layer is tagged with two 5-0 white Vicryls
epinephrine) to facilitate further dissection of capsular ligament for ease of layer-by-layer suture afterwards
Lee and Hong Maxillofacial Plastic and Reconstructive Surgery (2020) 42:14 Page 5 of 11

Fig. 5 Displaced disc is detached from fibrous adhesion and rotated

posterolaterally to achieve the correct condyle-disc-fossa relation

sutures were added to the posterolateral margin of the

Fig. 7 MITEK mini anchor placement at most lateral, superior, and
disc and internal capsule of the TMJ, as with the con-
posterior aspect of mandibular condyle
ventional method. Afterward, the surgical site was irri-
gated with normal saline and the lateral capsule was
sutured back together. No. 5-0 Vicryl sutures (Ethicon, surgical drain was inserted in the joint space. The skin
Somerville, NJ) were used to reposition the surgical was reapproximated and sutured with single interrupted
planes. Adequate and accurate repositioning and sutur- No. 6-0 nylon sutures. Postoperative care was routinely
ing of the joint capsule were performed, and an anti- performed according to our protocol. Briefly, intermaxil-
adhesive agent based on hyaluronic acid (HA) (Guardix®, lary fixation (IMF) was applied for 2 days after surgery,
Hanmi Pharma., Seoul, Korea) was applied to the joint and early mouth opening exercises were initiated from 3
space to avoid adhesion within the space. Afterward, the days after surgery. A soft diet was recommended for a
overlying layers were meticulously closed for proper tis- month before the patient was allowed to gradually re-
sue healing as well as postoperative TMJ function. No sume a normal diet. Wearing a prefabricated
stabilization splint as soon as possible after the operation
was advised, and occlusion in the patient was checked
during each follow-up visit. Patients were instructed to
continue the above conservative treatment practices
throughout their life time.

Evaluation criteria and statisticsok

All patients were operated on by the same surgeon (BK
Lee), and all clinical evaluations were independently per-
formed by three examiners. We applied the following
evaluation criteria: (1) subjective TMJ pain using the vis-
ual analog scale (VAS) (0 = no pain, 10 = worst pain),
(2) objective evaluation of: maximal mouth opening
(MMO) measured as the distance between the upper
Fig. 6 a, b Initial bone perforation for MITEK mini anchor implant and lower central incisal edges, and (3) TMJ noises dur-
placement located at most lateral, superior, and posterior aspect of
ing repeated opening of the jaw. In addition, the general
mandibular condyle
success rate of our TMJ disc repositioning surgery
Lee and Hong Maxillofacial Plastic and Reconstructive Surgery (2020) 42:14 Page 6 of 11

Fig. 8 a, b Location of TMJ disc plication with No. 2-0 polyester suture to MITEK mini anchor

technique using the MITEK mini anchor in this study regarded as a success when the patient fulfilled all three
was assessed according to the following criteria: (1) pain conditions at 6 months after the operation. Paired t tests
with VAS less than 1 at MMO or when chewing, (2) no were used for statistical analysis of the data in this study.
or little TMJ noise with no discomfort in daily life, (3)
MMO greater than 38 mm, and (4) no serious or per- Results
manent complications after surgery. The operation was Sixty-five joints in 46 patients underwent unilateral or
bilateral TMJ disc repositioning surgery with MITEK
mini anchors. The following joint pathologies were diag-
nosed with MRI: ADDwoR, ADDwoR in association with
joint effusion in 32 patients, ADDwR, ADDwR in associ-
ation with joint effusion in 12 patients, and normal disc
position in two patients who suffered from clinical
symptoms like chronic pain and popping that were not
resolved with conservative treatment.
Preoperative examination revealed painful symptoms
in 50.7% (n = 35) of the evaluated joints (n = 69), with a
mean VAS score of 4.85. Postoperative examination re-
vealed that painful symptoms remained in 4.3% of joints
(n = 3), with an average VAS score of 0.78, representing
a 91.4% success rate in eliminating pain (Figs. 10 and 11).
The presence of clicks in the TMJ was observed in 56.5%
(n = 39) of joints postoperatively. Additionally, 17.4% (n =
12) of joints had residual noise on digital palpation in the
TMJ, but only two joints made a clear clicking sound
(Fig. 12), representing a 94.9% success rate with elim-
inating clicking. The clicking sounds in the other 10
TMJs were crepitus-like, with very little noise. In all
12 joints with residual noise, the intensity of the
noise was significantly decreased compared to the
preoperative condition. Interestingly, two out of the
10 crepitus-like residual noises were newly developed
after the operation. The preoperative diagnosis for
these two joints was anterior disc displacement with-
out reduction with severe mouth opening limitation
Fig. 9 Final flap repositioning and placement of 8 No. 6-0 nylon
(MOL). Therefore, the newly developed noise resulted
single interrupted sutures
from increased movement of the condyle after the
Lee and Hong Maxillofacial Plastic and Reconstructive Surgery (2020) 42:14 Page 7 of 11

Fig. 10 Evaluation of preoperative (Pre op.) and postoperative (Post op.) TMJ pain

operation. Further, as observed in many cases, due to visits by 3 years after the operation. Cosmetically, the
degeneration, TMJ discs that require surgical correc- result was satisfactory because no visible scar was left
tion are likely to be already deformed and hardened at the operation site. Additionally, no significant com-
compared to normal healthy discs. Therefore, the fric- plications such as facial nerve palsy or serious per-
tion between the reposed disc and the articular fossa manent occlusal disharmony were noted during the
may be high, which may cause crepitus-like noise in postoperative observation period. As a result, the gen-
the TMJ even without disc displacement from the eral success rate of our TMJ disc repositioning sur-
condylar head. In patients with MOL less than 38 mm gery using MITEK mini anchors in this study was
(n = 18), the mean MMO was 31.4 mm preoperatively 91.0% (42/46) at 6 months after surgery.
and 44.2 mm at 6 months postoperatively (Fig. 13),
with a mean increase of 13.8 mm. The MMO for pa- Discussion
tients who continued to visit our clinic for more than Sufficient mouth opening, pain relief, functional stability,
6 months after surgery showed further increases over and long-term maintenance of the position of the disc
time until their last visit (2.2 mm in average). Six are the main objectives of TMJ disc repositioning sur-
months after the operation, the number of patients gery [24]. Though disc repositioning surgery is often ne-
with consistent follow-up decreased with time. Only cessary to achieve these objectives, many surgeons are
50% of patients (n = 23) continued their follow-up against the surgery because it can lead to the aggravation

Fig. 11 Evaluation of preoperative (Pre op.) and postoperative (Post op.) pain degree (VAS)
Lee and Hong Maxillofacial Plastic and Reconstructive Surgery (2020) 42:14 Page 8 of 11

Fig. 12 Evaluation of preoperative (Pre op.) and postoperative (Post op.) TMJ noise

of TMJ symptoms, relapse of the disc, and potential side tearing, herniation, stretching, or degeneration of the
effects such as facial nerve damage and scars [25]. How- ligaments that normally support the disc in position
ever, many efforts to overcome these hurdles have been [1]. Therefore, management of predisposing factors is
made by some surgeons with technological advance- indispensable for the success of surgery and long-
ments and better understanding of the pathophysiology term stability [26].
of TMDs. Thus, more comprehensive approaches before The disc plication of TMJ using MITEK mini anchor
and after disc plication surgery have been established. is one of newly developed techniques but has been still
Basic principles of TMJ treatment should be applied be- improving to enhance its clinical outcome. Basically,
fore and after any surgical intervention, and all predis- proper diagnosis and meticulous surgery with minimal
posing factors should be controlled with conservative trauma are essential. In this sense, in this MITEK anchor
treatment like self-administered physical therapy to relax technique, determination of the position and condition
masticatory muscles and other self-care behavior like of the TMJ disc was critical to plan the surgical scheme
avoiding bad habits including clenching and chewing prior to the operation. To date, the interpretation of
habits. These conservative management practices should MRI is essential for determining the disc position,
be observed throughout the patient’s life after surgery amount of joint effusion, and bone abnormalities [27].
because various factors that contribute to disc displace- To ensure accurate diagnosis of TMJ disorders, the com-
ment remain even after surgery. Factors that can predis- bination of MRI findings with clinical examination is
pose or cause TMJ disc displacement and dysfunction critical [28]. The MITEK technique cannot be applied to
include trauma, parafunctional habits, gender, malocclu- all types of displaced TMJ discs. Because the anchor can
sion, hormones, and systemic or local disease/pathology only be inserted in a limited direction on the lateral or
[1]. Discs can become displaced because of rupture, posterior surface of the condylar head, lateral or

Fig. 13 Evaluation of preoperative (Pre op.) and postoperative (Post op.) average MMO in trismus patients (n = 18)
Lee and Hong Maxillofacial Plastic and Reconstructive Surgery (2020) 42:14 Page 9 of 11

posterior displacement of the disc is not as effective as correlation with the study by Mehra and Wolford [1],
medial or anterior disc displacement. where the authors reported a 91% postoperative success
As one of our important technical modifications, we rate, with improvements in pain, articular sounds, and
cauterized the redundant retrodiscal tissue with electro- mouth opening range. In addition, Fernandez Sanromán
cautery instead of cutting away the area as in the trad- et al. [31] reported subjective TMJ pain improvement,
itional MITEK procedure. This modification could avoid with an increase in the mouth opening range on postop-
a huge retrodiscal dead space which may cause severe erative assessment. However, they reported persistent ar-
scar formation or adhesion of the joint space. Another ticular sounds in eight of the 12 patients included in
unique feature of our modified method is that drainage their study, which is a higher incidence rate for postop-
is not inserted into the joints after surgery, but a com- erative articular sounds than in our study. Interestingly,
mercial HA is injected into the superior joint cavity fol- habitual subluxation cases in this study showed excellent
lowing capsular suture. This method can reduce the results during our observation period. Generally, habit-
patient's discomfort when the drain is removed. It also ual subluxation is caused by an imbalance of the disc
has the advantage of not only alleviating inflammation in and condylar head position due to laxation of the liga-
the joints due to the pharmacological action of the HA, ments. In this sense, tightening the disc position and
but also preventing adhesion of the joints. condylar head can restore balanced symbiotic movement
In all cases, we used the modified short endaural ap- in complex condylar movement of the mandible. Add-
proach [29], which left a nearly invisible scar and pro- itionally, open TMJ surgery may lessen mandibular hy-
vided enough space to place the MITEK anchors and permobility, which is another benefit for managing
reposition the disc. Esthetically, invisibility of the post- subluxation.
operative scar is essential for young female patients. As In this study, unfortunately, post-operative MRI
the proportion of female patients that undergo disc dis- could not be performed for all patients because some
placement of the TMJ is quite large, this approach has a of the patients refused to undergo MRI due to the
certain benefit over the conventional surgical design for high cost and the reduced discomfort in their TMJs.
facial esthetics. In addition, radiologic artifact of MITEK anchor in
As our study showed, MITEK mini anchors were MRI could interfere the clear interpretation of the op-
placed to facilitate repositioning of the joint disc over erated condyle in MRI (Fig. 14). Therefore, for most
the condylar head, thus facilitating the physiologic patients, post-operative disc positions were evaluated
movement and function of the joint structures. Our by digital palpation and the path of mouth opening.
study results coincide with findings reported by other Nonetheless, this method was effective for diagnosing
authors in terms of the mean age versus the clinical disc displacement [14].
manifestations of dysfunctional TMJs. Our patients’ ages Considering the noise, there were two cases of re-
ranged between 15 and 69 years, with a mean age of currence in this study. These patients did not follow
34.6 years, correlating with the study by Mehra and Wol- our post-operative instructions properly and overused
ford [1] where the mean age of patients was 32.6 years, their TMJ. In particular, they were also under a lot of
with a range between 14 and 57 years. Our study popula- stress from their surrounding social environments. As
tion also coincides with that in the study by Sato et al is well known, chronic stress acts as a major con-
[30], where the age range for patients who underwent tributor to tense masticatory muscles, leading to the
surgery was between 16 and 45 years, with a mean age of inflammation of muscles and ligaments and causing
29.2 years, and to that of Anderson et al. [7], with a or exacerbating jaw joint disorders. Therefore, for pa-
mean age of 28.1 years and a range between 14 and 48 tients with excessive stress other than the jaw joint, it
years. Similarly, the distribution of gender in this study is advisable to suspend or defer disc plication surgery
had a ratio of 1:1.7 (18 men vs 32 women), coinciding until their stress lessens to achieve good surgical
with the 1:1.8 male to female ratio reported in the litera- results.
ture, confirming the greater prevalence of TMJ disorders Temporary occlusal discrepancy after disc plication
in female patients [1, 30, 31]. surgery is relatively common, but these changes
On the other hand, this study highlights important dif- normalize spontaneously over time without additional
ferences in symptoms before and after the procedure— treatment like occlusal equilibration or orthodontic
postoperative absence of pain in 91.4% of patients, mean treatment.
improvement in mouth opening by 13.8 mm in trismus
patients, and absence of clicks in 92.9% of individuals Conclusion
evaluated, which correspond to other studies using We conclude that our modification technique using
MITEK mini anchors in the TMJ. Analyzing the pres- MITEK mini anchors represent an alternative with great
ence of postoperative articular sounds, we found a utility for procedures such as discopexy of the TMJ,
Lee and Hong Maxillofacial Plastic and Reconstructive Surgery (2020) 42:14 Page 10 of 11

Fig. 14 a, b Pre- and postoperative (1 year) MRI of a female patient who underwent left joint disc plication surgery. The disc position is marked
with an arrow

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Consent for publication
findings. Maxillofac Plast Reconstr Surg 37:17
All authors read and approved the final manuscript.
16. Sharma A, Paeng JY, Yamada T, Kwon TG (2016) Simultaneous gap
arthroplasty and intraoral distraction and secondary contouring surgery for
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Received: 3 April 2020 Accepted: 15 April 2020 internal derangement of the temporomandibular joint. Br J Oral Maxillofac
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