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Chapter 4122symptoms are disguised either because of the depth of the implant in the tissues or because the pain has been ascribed to another cause.(42) Given the huge impact on outcome, it seems at least advisable to select a titanium prosthesis, which currently are only available in the custom(ized) version (3D-printed titanium). The prevalence of Ti allergy is not known but is estimated to be very low, and a patch test with titanium salt or the actual titanium alloy is recommended.(43) Surgical techniques do not easily lend themselves to scrutiny via randomized clinical trials.(44) Observational cohort studies and comparisons with historical controls may take decades when the indications are so limited as for TMJ TJR. On the other hand, surgeons are quickly convinced of techniques that are more promising from a physiological point of view. To switch back from a customized TMJ to a stock prosthesis may seem like switching from open reduction and (semi)rigid osteosynthesis to closed reduction and intermaxillary fixation in CMF trauma repair. Luckily, in Europe, the costs for some animal-tested customized TMJ TJRs have become similar to those of FDA-approved systems.ConclusionThis meta-analysis evaluated the MMO and VAS scores for pain and diet to provide pooled estimates for both patient-fitted and stock TMJ-TJR systems. While no significant differences were found between the implant systems, the provided data do not consider pathology severity, which can heavily influence post-operative outcomes and is prone to bias of pooled data. By means of a prospective randomized trial, this bias could be overcome, yet this forces the use of a certain implant system even if not deemed suited by the performing surgeon, posing an important ethical dilemma. There is need for a detailed diagnostic evaluation tool to better describe the degree of joint degeneration, as well as pre-operative testing for allergies to the implant components to prevent the need for explantation Nikolas de Meurechy NW.indd 122 05-06-2024 10:14