Table of Contents:
The basis for this medical dissertation were four expired S1 clinical practice guidelines of the Association of the Scientific Medical Societies in Germany (AWMF), namely on temporomandibular joint dislocation, ankylosis and temporomandibular joint hypomobility, idiopathic condylar resorption and condylar hypo- and hyperplasia. The high relevance of these disorders results from a group of predominantly younger patients (under the age of 30) who are experiencing a severe restriction in quality of life due to functional, aesthetic and psychosocial effects of the disorders. The practice guidelines of the AWMF provide systematically developed aids for decision making, as well as information for medical staff and patients, based on the latest scientific knowledge and clinical expertise.
The aim of this dissertation was to update the S1 guidelines, based on a literature research, with a subsequent vote on the developed drafts within an organized consensus process. In doing so, another aim was to upgrade the guidelines to class S3. Furthermore, the consensus process of each guideline was critically analyzed to identify controversial recommendations and topics without unanimous consensus regarding treatment of a particular disorder.
The methodology involved a systematic online literature review for each guideline. The literature was summarized in tables, and a grade was determined for each source. Following this, the guideline draft was constructed, comprising the actual recommendations. The Delphi method was chosen as the consensus process. This involved submitting the guideline draft in written form to a select group of experts of the German Society of Mouth, Jaw, and Facial Surgeons (DGMKG). The experienced surgeons in this internal group were able to vote for a level for each recommendation and propose literature-based modifications to the draft. The results were summarized anonymously, and proposed modifications were made. The updated draft was then sent to the group members for another round of votes. This procedure was continued until for each recommendation the highest consensus possible had been reached or the recommendation had been reworded to a neutral statement. After completion of the internal consensus rounds, the same procedure was followed with representatives of external medical associations. For each guideline the methodology was set out in a report. Following the approval by the boards of all participating associations, the long and short versions of the updated and upgraded S3 guidelines were published online, along with the report. One guideline was published in the German Medical Association’s official international bilingual science journal ‘Deutsches Ärzteblatt International’.
The post-analysis of the consensus process involved a detailed analysis of the votes. By doing this, key data was identified for each guideline, including for example the number of required consensus rounds. In a second step, criteria were drawn up to define controversial recommendations.
The first part of the results section comprises long and short versions of the updated and upgraded S3 guidelines, and the associated report. The second part of the results is the post-analysis, which enabled a comparison between the consensus rounds for the different guidelines. In addition, controversial recommendations were identified, for which the course of the votes was outlined in detail, and the core issue articulated.
The discussion section in the beginning focused on issues concerning the methodology. Emphasis was given to the fact that anonymization used in the Delphi method was applied inconsistently. Another limitation of the dissertation is the weak body of evidence for the disorders concerned. Finally, all recommendations that had been defined as controversial were discussed, along with further relevant topics, regarding the current literature. The main topic for each guideline could thereby be established, which may be of particular interest to further studies. The topics are the minimal-invasive therapeutic procedures for recurrent temporomandibular joint dislocations, the use of alloplastic temporomandibular joint prostheses in patients with temporomandibular joint ankylosis, the role of orthognathic surgery in the development of idiopathic condylar resorption, and the establishment of a diagnostic ‘gold standard’ to evaluate the activity of condylar hyperplasia.