Background Mounting evidence suggests that central nervous system amplification, similar to that seen in fibromyalgia (FM), contributes to pain experience in a subset of patients with temporomandibular disorders (TMD). Methods In this prospective observational study, patients with TMD completed the 2011 FM survey questionnaire, a surrogate measure of “centralized” pain. The influence of centralized pain on TMD pain, dysfunction, and disability was assessed dichotomously by determining the incidence of FM-positive cases in the sample and by using FM survey scores as a continuous measure of “fibromyalgia-ness” (FMness). Results The patients meeting criteria for FM diagnosis (17 of 89) had significantly more disease burden on numerous measures. FMness was positively associated with pain at rest, negative mood, tenderness to palpation, perceived jaw functional limitation, and pain-related disability, and it was negatively associated with comfortable pain-free jaw opening. The impact of FMness on perceived jaw functional limitation and disability was mediated by levels of spontaneous, ongoing pain in the orofacial region. Importantly, this pattern of findings was still present even in those not meeting the criteria for FM diagnosis. Conclusion Together, these results imply that higher FMness increases TMD patient burden by amplifying spontaneous pain and further hampering painless jaw function, even in patients who do not meet criteria for FM diagnosis. These results are highly relevant for the clinical management of TMD, since they imply that targeting the CNS in the treatment of TMD patients with evidence of pain centralization may help ameliorate both pain and jaw dysfunction.

Purpose of review Options for segmental mandibular reconstruction in patients poorly suited to undergo fibula free flap (FFF). Recent findings Although FFF is the current ‘gold standard’ for segmental mandibular reconstruction, other reconstructive options must be considered when FFF is contraindicated or disfavoured and/or patient frailty precludes a lengthy anaesthetic. In addition to various nonvascularized and soft tissue only reconstructions, excellent osseous free flap alternatives for functional segmental mandibular reconstruction may be employed. The subscapular system free flaps (SSSFF) may be ideal in frail and/or elderly patients, as SSSFF allows for early mobility and does not alter gait. In extensive and/or symphyseal defects, functional mandibular reconstruction in lieu of a free flap is extremely limited. Pedicled segmental mandibular reconstructions remain reasonable options, but limited contemporary literature highlights unpredictable bone graft perfusion and poor long-term functional outcomes. Summary There are several excellent free flap alternatives to FFF in segmental mandibular reconstruction, assuming adequate cervical recipient vessels are present. On the basis of the current literature, the optimal mandibular reconstruction for the medically frail, elderly and/or patients with extreme vessel-depleted necks is limited and debatable. In qualifying (i.e. limited, lateral) defects, soft tissue only reconstructions should be strongly considered when osseous free flaps are unavailable.

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