text: Original ArticlesTotal Joint Replacement After Condylar Destruction Secondary to Long-Standing Dislocation of the Temporomandibular JointSarlabous, Mathilde DMD, FRCDC*; Psutka, David J. DDS, FRCDC†Author Information *Hôpital de l'Enfant Jésus, Québec City †Mount Sinaï Hospital, Toronto, Canada. Address correspondence and reprint requests to Mathilde Sarlabous, DMD, FRCDC, 1066 4e Avenue, G1J 3B2 Québec City, Canada; E-mail: firstname.lastname@example.com Received 18 September, 2019 Accepted 26 December, 2019 DJP occasionally presents continuing education seminars on behalf of Zimmer Biomet. The authors report no conflicts of interest. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 Journal of Craniofacial Surgery: June 2020 - Volume 31 - Issue 4 - p 989-995 doi: 10.1097/SCS.0000000000006317 Open Metrics Abstract Background: To describe the treatment of 2 long-standing chronic dislocation of the temporomandibular joints (TMJs) and 1 chronic recurrent dislocation. Methods: This report describes the treatment of 3 patients; 2 with a long-standing chronic dislocation of the TMJ and 1 with a chronic recurrent dislocation. Duration of dislocation and anatomical considerations make the treatment challenging and controversial. The patients presented in this report all developed destruction of their condyles. They were successfully treated with total joint replacement with alloplastic devices. Results: All the 3 patients underwent successful surgery and recovery. Mandibular function and pain level were significantly improved. Conclusion: Long-standing dislocation of the TMJ is rare. This condition can be successfully treated by resection of the damaged condyles and reconstruction with alloplastic total TMJ replacements. Dislocation of the temporomandibular joint (TMJ) can involve 1 or both condyles and represent 3% of all reported dislocated joints in the body.1 Condylar displacement is most frequently bilateral. The condyles may be displaced anterior, posterior, medial, lateral, or superior to the glenoid fossa but anterior dislocation is the most common.2 Condyles are suddenly displaced anteriorly, beyond the articular eminence. This condition is also referred to as "open lock." Dislocation pathogenesis is multifactorial. Predisposing and triggering factors for condylar dislocation include, but are not limited to: extreme mouth opening (yawning, vomiting, singing), trauma, iatrogenic (dental treatments, laryngoscopy), medications with extra pyramidal effect (dystonia)3–7 (antiemetics like metoclopramide, antipsychotics, propranolol). Joint hypermobility can be seen in diseases with defects in collagen synthesis like Ehlers-Danlos and Marfan's syndrome,8 making dislocation possible. Seizure activity can result in mandibular hyperextension. Variations in anatomy like elongation of the articular eminence9,10 can make the patient more prone to perpetuation of the dislocation. Clinically, dislocation is characterized by the inability to close the mouth after wide opening, associated with an anterior open bite and/or lateral deviation of the mandible if the dislocation is unilateral. Palpation reveals a depression in the preauricular region and sometimes a palpable condyle anterior to the joint.8 Pain can be severe. Dislocation of the temporomandibular joint can be categorized into 3 groups: acute, recurrent, and chronic.11 Acute dislocation is the most common. It can often be reduced by downward and backward manual manipulation of the mandible. Recurrent dislocation is relatively rare. Episodes of dislocation are more frequent and worse enough to suggest treatment. No consensus exists regarding the most effective treatment for recurrent TMJ dislocation. Many surgical treatments have been proposed over the years,11 including eminectomy, lateral pterygoid myotomy, the LeClerc (or Dautrey) procedure, augmentation of the articular eminence with a bone graft. Postoperative scarring probably provides a significant portion of the surgical benefit. Less invasive procedures have also been reported including the injection of autogenous blood or sclerosing agents, arthroscopic scarification of the retrodiscal tissues, and capsule plication. Botox injections in the lateral pterygoid have also been described for treatment of recurrent TMJ dislocation. Long-standing (more than 1 month) chronic dislocation is rare. It is a sequela of an unrecognized acute dislocation. Most surgeons agree that the longer the dislocation persists, the more difficult the reduction of the condyles becomes.12 Progressive fibrosis resulting from this condition prevents the restoration of an appropriate anatomical condylar position. Chronic dislocation can be very challenging to treat and requires invasive surgical intervention to correct the malocclusion and restore both facial form and masticatory function. In this report, 2 patients of chronic TMJ dislocation and 1 patient of chronic recurrent dislocation are described. CLINICAL PRESENTATIONS Patient 1 A healthy 51-year-old man was referred to the main author in December 2013. In December 2012, the patient experienced a seizure episode during which he dislocated his jaw. The condition was initially unrecognized. In February 2013, he presented to an oral and maxillofacial surgeon. Under general anesthesia, the left TMJ was reduced by manipulation but the right side remained dislocated. The patient continued to have difficulty with mouth opening and chewing. He was edentulous but not wearing dentures because of his jaw alignment distortion. The patient was taking Methadone for pain management. Clinical examination revealed a normocephalic male with mild asymmetry and mild deviation of the chin to the left. Palpation of the muscles of mastication did not elicit pain but he had severe pain during palpation of both TMJ. His mouth opening was 25 mm (Fig. 1).FIGURE 1: Preoperative pictures. (A) At rest. (B): During mouth opening, which was limited.Intraoral examination revealed edentulous maxilla and mandible with adequate keratinized mucosa. The panoramic tomography revealed a dislocated right condyle (Fig. 2).FIGURE 2: Panoramic tomography showing the anterior dislocation of the right condyle (arrow).A cone-beam computed tomography (CBCT) showed severe erosive changes with condylar destruction on the right side. The right condyle was positioned anteriorly, articulating with the inferior aspect of the articular eminence (Fig. 3). The left TMJ showed advanced signs of degenerative joint disease (DJD). A diagnosis of long-standing anterior dislocation with fibrous ankylosis on the right side and severe osteoarthritis on the left side was made.FIGURE 3: Cone-beam computed tomography of the condylar heads. (A) Sagittal view of the right side. (B) Sagittal view of the left side. (C) Coronal view of the right side. (D) Coronal view of the left side. Arrows show erosion associated with degenerative joint disease.Given the degree of pain, dysfunction, and advanced destruction of both condyles, bilateral total joint replacement (TJR) with custom fabricated TMJ alloplastic implants was recommended. The TMJ reconstruction using 3-dimensional (3D) CT imaging and computer-assisted design (Medical Modeling, Denver, CO) was used (Fig. 4). Mandibular position correction was also planned at the same time. Using a virtual model of the prosthesis, an alloplastic system composed of a metallic (Cr-Co-Mb) mandible-condylar component and a polyethylene glenoid fossa was custom manufactured for both joints (Zimmer-Biomet, Jacksonville, FL).FIGURE 4: Three-dimensional imaging using computed tomography data shows: (A) preoperative situation, (B) planned resection margins (in red), and (C) custom design of the Zimmer-Biomet prosthetic joints.Custom gunning splints were virtually designed to help stabilize the edentulous mandible during surgery and correct the occlusal alignment (Fig. 5).FIGURE 5: Virtual design of the gunning splints to help stabilize the maxillo-mandibular relationship in this edentulous patient. (A) Splints fitting on stone models. (B) Virtual design of the splints. (C) "Occlusion" fitted in the operating room thanks to the gunning splints.The surgery was carried out in March 2014 under intubated general anesthesia and induced hypotension to minimize blood loss. The mandibular ramus and both condyles were accessed via preauricular and retromandibular incisions. Figure 6 shows the anterior displaced right condyle (Fig. 6A) and the aspect of the specimen after resection (Fig. 6B).FIGURE 6: (A) Operative picture showing the right condyle anteriorly displaced (arrow) and (B) right condyle after resection. Note the advanced degeneration of the condylar head.Postoperative recovery was uneventful. Mild right temporal nerve weakness resolved within a few months. Three years after surgery, the patient was pain free with good function. His mandibular range of motion was 35 mm. Figure 7 shows the prosthetic devices on a cephalogram and Figure 8 shows the 3 years' postoperative clinical pictures.FIGURE 7: Postoperative cephalogram shows the bilateral prosthesis showing a proper position of the prosthetic condyles into their fossa.FIGURE 8: Postoperative pictures. (A) At rest with restored facial symmetry and (B) Showing good mouth opening.Patient 2 A healthy 51-year-old woman was referred in December 2016 to the main author. Her main complaint was a recurrent chronic left TMJ dislocation with persistent severe pain. Her pain was so debilitating that it prevented her from working. Her problems began at the age of 18 following 3rd molar extraction. Regular dislocation of her TMJs began at the age of 32. The CBCT showed an advanced left condylar head degeneration (Fig. 9).FIGURE 9: Cone-beam computed tomography showing the advanced arthritic changes of the left condyle. (A) Frontal view showing loss of joint space left. (B) Sagittal view showing a large osteophyte (arrow).The patient also complained about severe right TMJ pain, secondary to severe osteoarthritis. Bilateral TMJ total joint reconstruction with custom prostheses was proposed to the patient. She underwent surgery in April 2017. The patient's normal occlusion was maintained. The right and left condyles and coronoid processes were removed through preauricular and retromandibular approaches. Figure 10 shows the left TMJ specimen after resection. Figure 11 shows the adaptation of the custom left TMJ prosthesis on the native mandible and glenoid fossa. The postoperative recovery was uneventful. Figure 12 shows the postoperative radiographs taken 1 week after surgery.FIGURE 10: Left temporomandibular joint specimen: articular disc (arrow head), condylar head (large arrow), and coronoid process (thin arrow).FIGURE 11: Left temporomandibular joint custom prosthesis. (A) Footplate adapted the mandibular ramus. (B) Left prosthetic condyle articulates with the condylar fossa.FIGURE 12: Postoperative radiographs. (A) Panoramic tomography. (B) Posterior-anterior radiograph. (C) Lateral cephalogram.After 2 years of follow-up, she is pain free and has good function with an interincisal opening of 35 mm. Patient 3 This 61-year-old woman was referred in March 2017 by an ENT surgeon for bilateral chronic TMJ dislocation of 7 months duration. This was the first episode and the patient could not recall the trigger event leading to the dislocation. She had an attempt at manual reduction under sedation in January 2017 with no success. She reported severe pain and difficulty with function. Medical comorbidities included schizophrenia. Figures 13 and 14 show the preoperative clinical photographs taken during the first consultation. Figure 15 is a 3D reconstruction of both dislocated TMJs.FIGURE 13: Preoperative pictures: (A) facial view at rest (note the anterior open bite), (B) showing mouth opening, (C) profile view.FIGURE 14: Intraoral pictures: (A) frontal view showing the open bite, (B) lateral view.FIGURE 15: Three-dimensional reconstruction of the right (A) and left (B) temporomandibular joint.Given the severe degeneration in both condyles, TJR with custom prostheses and simultaneous correction of the occlusion was recommended. Six months prior to surgery, teeth 24 and 47 were extracted to facilitate occlusal alignment. Orthodontics was not possible for this patient. Reconstruction was facilitated by virtual surgical planning (Fig. 16).FIGURE 16: Three-dimensional imaging using computed tomography data shows (A) pre-operative situation, (B) planned resection margins (in red) and corrected occlusion, and (C) custom design of the Zimmer-Biomet prosthetic joints.The patient underwent surgery in May 2018. The right and left condyles and coronoid processes were removed through preauricular and retromandibular approaches. Her postoperative recovery was uneventful. Figure 17 shows the postoperative pictures taken 3 months after surgery. The patient's pain had completely resolved, and she was chewing a full diet. A mild left marginal mandibular nerve neuropraxia is resolving.FIGURE 17: Postoperative pictures 3 months after surgery. (A) At rest. (B) During mouth opening. (C-D) Restored occlusion.DISCUSSION Different treatment modalities can be considered for management of recurrent TMJ dislocation. The injection of sclerosing agents (alcohol, ethacridine, sodium psylliate, morrhuate sodium, sodium tetradecyl sulfate) in the superior joint has a low success rate and should not be considered a safe treatment.2 The rationale for injecting these agents is founded on causing intracapsular fibrosis and thus limiting jaw movement. The ability to control the extent of fibrosis is not predictable thus risking undesirable fibrous ankylosis. Autogenous blood injection has been reported.13–17 Fibrosis formation in the superior joint space is again the goal though the mechanism of action is still unclear.18 The volume of blood used ranges between 2 and 4 mL in the superior joint space and 1 and 1.5 mL in the pericapsular structures, repeated twice a week for 3 weeks.19 A head bandage to restrict mandibular movements for 3 to 4 weeks has been proposed. Patients with autologous blood injected around the pericapsular tissues and into the superior joint space had less recurrence of dislocation than those with injection into the superior space alone.10 A systematic review published in 201520 report successful results but there remain concerns about the potential for articular degeneration, fibrosis, and ankylosis. Botulinum toxin A (Botox) has been injected in the lateral pterygoid muscle to prevent recurrent dislocation. It acts by temporarily weakening of skeletal muscle by blocking the Ca2+-mediated release of acetylcholine from the nerve endings of the neuromuscular junction. Repeated injections are usually necessary. Botox is particularly useful when recurrent dislocation is due to neurogenic disorders with tardive dyskinesia and dystonia.21,22 Local diffusion can lead to adverse affects like transient dysphagia, nasal speech, nasal regurgitation, and dysarthria.8 Botox is contraindicated in diseases affecting neuromuscular transmission like myasthenia gravis and in pregnant and lactating women. Eminectomy is the most commonly performed surgery for recurrent dislocation.23 The rationale for surgery is to "clear the path" for the dislocated condyle to easily return into the glenoid fossa, rather than being blocked anteriorly by the eminence. This technique has satisfactory results and surgeons empirically consider eminectomy to be the gold standard for treatment of recurrent dislocation. Pneumatization of the zygomatic arch and eminence should be recognized before surgery to avoid intraoperative perforation of the basal skull. Arthroscopic eminoplasty has also been described.24 It has been proposed that the success of eminectomy is secondary to the resultant scar formation that ultimately "blocks the path" of the condyle, preventing it from leaving the joint socket.25 Arthroscopic retrodiscal tissue scarification and disc plication26,27 has a reported high success rate. It is a minimally invasive procedure. The senior author favors this procedure when the TMJ is otherwise not degenerated. Zygomatic arch down fracture (Leclerc or Dautrey procedure) is a well-known surgical technique for treatment of recurrent dislocation.28,29 A greenstick fracture is performed at the zygomaticotemporal suture. The major risk is a complete arch fracture. This procedure should be avoided in elderly patients where osteoporosis may increase the propensity to adverse fracture. Metallic obstacles like miniplating of the articular eminence30–33 have been used successfully in selected patients but hardware fracture appeared as a relatively frequent complication (25%)34 as well as subsequent resorption of the condylar head.10 Increasing the articular eminence height with hydroxyapatite (HAP), silicon, or autogenous bone (iliac or calvarial bone graft) has been suggested. However, displacement of HAP and silicon implant has been reported as well as immune reactions to the implant material. Iliac crest bone grafts have been reported to be prone to rapid resorption. Calvarial harvest can have serious complications (dural tears, arachnoidal bleeding, scalp infections).2 Muscle surgery has also been described for treatment of recurrent dislocation. Lateral pterygoid myotomy and shortening of the temporalis tendon have been used but have not been proved very efficient.35 Long-standing dislocation causes muscle spasm, and articular degeneration, ankylosis, and pericapsular fibrosis making reduction difficult. If the anatomy is preserved, conservative treatment is a reasonable first step with closed reduction under general anesthesia. If this technique is not effective, minimally invasive surgical procedures like traction with a bone hook over the sigmoid notch or to the lower border with wires can be considered.7 Conservative management by placing posterior acrylic bite blocks and application of elastic traction to reduce the dislocation has been used.36 A multitude of surgical treatments has been reported for the treatment of long-standing dislocation of the TMJ which has failed conservative reduction: myotomy, condylotomy, condylectomy, menisectomy, eminectomy.9,37,38 Managing the occlusion without operating the TMJ when anatomy and joint function are preserved has been reported. The inverted L-shaped ramus osteotomy, vertical ramus osteotomy, and sagittal split osteotomy have been described.10,13 There is also a report of midline mandibulotomy.39 Long-standing dislocation can lead to ankylosis (patient 1). Long-term adverse loading secondary to aberrant joint biomechanics can induce progressive articular degeneration (patient 2). The TJR has been described for treatment of ankylosis after traumatic dislocation of the condyle in the middle intracranial fossa.40,41 The TJR for long-standing dislocation is minimally reported.9 In the case of concomitant DJD, the results were favorable. CONCLUSION Optimal treatment of condylar dislocation requires early reduction to avoid late complications. The goals of reduction are to re-establish a functional occlusion and anatomy and to reduce pain. Recurrent and long-standing dislocation often requires surgical management. Significant intra-articular adhesions and fibrosis can make closed reduction impossible. This report presents 3 patients, 2 of the rare condition of chronic long-standing TMJ dislocation and 1 of long-standing chronic recurrent dislocation. All the 3 patients had concomitant severe DJD. The use of custom alloplastic total TMJ prostheses facilitated reconstruction of the TMJs with simultaneous correction of the occlusion. All the 3 patients have had very favorable results both in terms of pain control and improved function. There has been no further dislocation in these patients.REFERENCES 1. Shorey CW, Campbell JH. Dislocation of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000; 89:662–668. Cited Here | View Full Text | PubMed | CrossRef 2. Martins WD, Ribas M, de O, et al. Recurrent dislocation of the temporomandibular joint: a literature review and two case reports treated with eminectomy. Cranio J Craniomandib Pract 2014; 32:110–117. Cited Here 3. Solomon S, Gupta S, Jesudasan J. Temporomandibular dislocation due to aripiprazole induced dystonia. Br J Clin Pharmacol 2010; 70:914–915. Cited Here | View Full Text | PubMed | CrossRef 4. Zakariaei Z, Taslimi S, Tabatabaiefar MA, et al. Bilateral dislocation of temporomandibular joint induced by haloperidol following suicide attempt: a case report. Acta Med Iran 2012; 50:213–215. Cited Here | PubMed 5. Kodama M, Fujiwara M. Risperidone-induced dislocation of the temporomandibular joint. J Clin Psychiatry 2012; 73:176. Cited Here | PubMed | CrossRef 6. Aghabiklooei A, Elahi H, Mostafazadeh B. Temporomandibular joint dislocation due to acute propranolol intoxication. Int Med Case Rep J 2010; 3:59–61. Cited Here 7. Luyk NH, Larsen PE. The diagnosis and treatment of the dislocated mandible. Am J Emerg Med 1989; 7:329–335. Cited Here | PubMed | CrossRef 8. Shakya S, Ongole R, Sumanth KN, et al. Chronic bilateral dislocation of temporomandibular joint. Kathmandu Univ Med J (KUMJ) 2010; 8:251–256. Cited Here | PubMed 9. Baur DA, Jannuzzi JR, Mercan U, et al. Treatment of long term anterior dislocation of the TMJ. Int J Oral Maxillofac Surg 2013; 42:1030–1033. Cited Here | PubMed | CrossRef 10. Akinbami BO. Evaluation of the mechanism and principles of management of temporomandibular joint dislocation. Systematic review of literature and a proposed new classification of temporomandibular joint dislocation. Head Face Med 2011; 7:10. Cited Here 11. Matthews NS. Springer International Publishing, Dislocation of the Temporomandibular Joint: A Guide to Diagnosis and Management. New York, NY: 2018. Cited Here 12. Huang I-Y, Chen C-M, Kao Y-H, et al. Management of long-standing mandibular dislocation. Int J Oral Maxillofac Surg 2011; 40:810–814. Cited Here | PubMed | CrossRef 13. Coser R, da Silveira H, Medeiros P, et al. Autologous blood injection for the treatment of recurrent mandibular dislocation. Int J Oral Maxillofac Surg 2015; 44:1034–1037. Cited Here | PubMed | CrossRef 14. Hegab AF. Treatment of chronic recurrent dislocation of the temporomandibular joint with injection of autologous blood alone, intermaxillary fixation alone, or both together: a prospective, randomised, controlled clinical trial. Br J Oral Maxillofac Surg 2013; 51:813–817. Cited Here | PubMed | CrossRef 15. Machon V, Abramowicz S, Paska J, et al. Autologous blood injection for the treatment of chronic recurrent temporomandibular joint dislocation. J Oral Maxillofac Surg Off J Am Assoc Oral Maxillofac Surg 2009; 67:114–119. Cited Here 16. Bayoumi AM, Al-Sebaei MO, Mohamed KM, et al. Arthrocentesis followed by intra-articular autologous blood injection for the treatment of recurrent temporomandibular joint dislocation. Int J Oral Maxillofac Surg 2014; 43:1224–1228. Cited Here | PubMed | CrossRef 17. Daif ET. Autologous blood injection as a new treatment modality for chronic recurrent temporomandibular joint dislocation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010; 109:31–36. Cited Here | View Full Text | PubMed | CrossRef 18. Candirli C, Yüce S, Cavus UY, et al. Autologous blood injection to the temporomandibular joint: magnetic resonance imaging findings. Imaging Sci Dent 2012; 42:13–18. Cited Here 19. Sharma NK, Singh AK, Pandey A, et al. Temporomandibular joint dislocation. Natl J Maxillofac Surg 2015; 6:16–20. Cited Here 20. Varedi P, Bohluli B. Autologous blood injection for treatment of chronic recurrent TMJ dislocation: is it successful? Is it safe enough? A systematic review. Oral Maxillofac Surg 2015; 19:243–252. Cited Here | PubMed 21. Vázquez Bouso O, Forteza González G, Mommsen J, et al. Neurogenic temporomandibular joint dislocation treated with botulinum toxin: report of 4 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010; 109:e33–e37. Cited Here | View Full Text | PubMed | CrossRef 22. Fu K-Y, Chen H-M, Sun Z-P, et al. Long-term efficacy of botulinum toxin type A for the treatment of habitual dislocation of the temporomandibular joint. Br J Oral Maxillofac Surg 2010; 48:281–284. Cited Here | PubMed | CrossRef 23. Vasconcelos BC, Porto GG, Neto JP, et al. Treatment of chronic mandibular dislocations by eminectomy: follow-up of 10 cases and literature review. Med Oral Patol Oral Cirugia Bucal 2009; 14:e593–e596. Cited Here 24. Segami N, Kaneyama K, Tsurusako S, et al. Arthroscopic eminoplasty for habitual dislocation of the temporomandibular joint: preliminary study. J Craniomaxillofac Surg 1999; 27:390–397. Cited Here | PubMed | CrossRef 25. Undt G. Temporomandibular joint eminectomy for recurrent dislocation. Atlas Oral Maxillofac Surg Clin North Am 2011; 19:189–206. Cited Here | PubMed | CrossRef 26. Torres DE, McCain JP. Arthroscopic electrothermal capsulorrhaphy for the treatment of recurrent temporomandibular joint dislocation. Int J Oral Maxillofac Surg 2012; 41:681–689. Cited Here | PubMed | CrossRef 27. Ybema A, De Bont LGM, Spijkervet FKL. Arthroscopic cauterization of retrodiscal tissue as a successful minimal invasive therapy in habitual temporomandibular joint luxation. Int J Oral Maxillofac Surg 2013; 42:376–379. Cited Here | PubMed | CrossRef 28. Gadre KS, Kaul D, Ramanojam S, et al. Dautrey's procedure in treatment of recurrent dislocation of the mandible. J Oral Maxillofac Surg 2010; 68:2021–2024. Cited Here | PubMed | CrossRef 29. da Costa Ribeiro R, dos santos BJ, Provenzano N, et al. Dautrey's procedure: an alternative for the treatment of recurrent mandibular dislocation in patients with pneumatization of the articular eminence. Int J Oral Maxillofac Surg 2014; 43:465–469. Cited Here | PubMed | CrossRef 30. Vasconcelos BC, Porto GG, Lima FTB. Treatment of chronic mandibular dislocations using miniplates: follow-up of 8 cases and literature review. Int J Oral Maxillofac Surg 2009; 38:933–936. Cited Here | PubMed | CrossRef 31. Shibata T, Yamashita T, Nakajima N, et al. Treatment of habitual temporomandibular joint dislocation with miniplate eminoplasty: a report of nine cases. J Oral Rehabil 2002; 29:890–894. Cited Here | View Full Text | PubMed | CrossRef 32. Cavalcanti JR, Vasconcelos BC, Porto GG, et al. Treatment of chronic mandibular dislocations using a new miniplate. Int J Oral Maxillofac Surg 2011; 40:1424–1427. Cited Here | PubMed | CrossRef 33. Kahveci R, Simsek ME, Akin S, et al. Treatment of recurrent temporomandibular joint dislocation. J Maxillofac Oral Surg 2013; 12:379–381. Cited Here | PubMed | CrossRef 34. de Almeida VL, Vitorino N, de S, et al. Stability of treatments for recurrent temporomandibular joint luxation: a systematic review. Int J Oral Maxillofac Surg 2016; 45:304–307. Cited Here | PubMed | CrossRef 35. Sindet-Pedersen S. Intraoral myotomy of the lateral pterygoid muscle for treatment of recurrent dislocation of the mandibular condyle. J Oral Maxillofac Surg 1988; 46:445–449. Cited Here | PubMed | CrossRef 36. Pradhan L, Jaisani MR, Sagtani A, et al. Conservative management of chronic TMJ dislocation: an old technique revived. J Maxillofac Oral Surg 2015; 14: (Suppl 1): 267–270. Cited Here | PubMed | CrossRef 37. Marqués-Mateo M, Puche-Torres M, Iglesias-Gimilio M-E. Temporomandibular chronic dislocation: the long-standing condition. Med Oral Patol Oral Cirugia Bucal 2016; 21:e776–e783. Cited Here 38. Klüppel L-E, Olate S, Serena-Gomez E, et al. Efficacy of eminectomy in the treatment of prolonged mandibular dislocation. Med Oral Patol Oral Cirugia Bucal 2010; 15:e891–e894. Cited Here 39. Lee S-H, Son S-I, Park J-H, et al. Reduction of prolonged bilateral temporomandibular joint dislocation by midline mandibulotomy. Int J Oral Maxillofac Surg 2006; 35:1054–1056. Cited Here | PubMed | CrossRef 40. Rikhotso ER, Bobat MA. Total alloplastic joint reconstruction in a patient with temporomandibular joint ankylosis following condylar dislocation into the middle cranial fossa. J Oral Maxillofac Surg 2016; 74:2378.e1–2378.e5. Cited Here | CrossRef 41. Zamorano GM, Nuñez LF, Alvarez LA, et al. Temporomandibular joint ankylosis after condylar dislocation into the middle cranial fossa: a case report. Rev Stomatol Chir Maxillo-Faciale Chir Orale 2016; 117:351–356. Cited Here Keywords:Custom total joint replacement; long-standing dislocation; temporomandibular joint © 2020 by Mutaz B. Habal, MD.View full article text


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Given the current climate, many authorities are placing restrictions on restaurant openings. We are continuously updating the availability of our partners to reflect these measures. Learn how to support your local restaurants.
Porters Restaurant & Bar in Singapore is a cool spot with a lively atmosphere and a seriously impressive food offering. This funky space prides itself on serving delicious European cuisine, including succulent steaks, Portobello mushrooms with a truffle chantilly cream, and a Wagyu cheeseburger to die for. This carefully designed, chich restaurant is located on Marina Boulevard at The Sail in the Marina Bay and is only a short walk from the Downtown Underground station. Perfect for treating yourself and your friends to a delicious, refined dining experience, it doesn't get much better than Porters Restaurant & Bar in Marina Bay. Popular for very good reason, this Singapore restaurant most definitely deserves a reservation.
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Food sounds delicious?
Get a table before they're gone
The food is nothing special but a bit pricey. The service was ok.
good atmosphere for a quiet lunch. food was nothing special. slightly pricey.
Food was ok only and relatively pricey. Unlikely will return.

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Common among young children, thumb sucking can help be an effective way for young children to self-soothe. However, as children age, it can become an embarrassing habit that can be harmful to their oral health.
Studies suggest that 70 to 90% of children take part in some form of finger sucking or pacifier use in their lifetime.1 Usually, it's a harmless habit that kids grow out of on their own between the ages of two and four years old. However, when children continue to thumb suck as they get older, issues with tooth alignment and bite can arise.2
All infants are born with the need to suck—in fact, some infants even start thumb sucking while still in the womb.3 Thumb sucking is a natural reflex that can make children feel secure, soothed and safe.4
Is thumb sucking bad?
For young children, thumb sucking is usually nothing to worry about. Thumb sucking is a perfectly normal habit, one that children usually grow out of on their own.5 As long as the habit stops early, it usually doesn't have any negative long-term side effects. Thumb sucking is especially harmless if your child only does it now or then, such as during a stressful event or at bedtime.
Thumb sucking can damage your child's teeth
Thumb sucking can damage teeth, but it doesn't always. If the habit stops early enough, dental problems are usually avoided or self-corrected, as they only occur in the primary teeth.6 However, if your child continues to thumb suck after the age of four when permanent teeth are developing and preparing to erupt, more serious dental problems can arise.7
Damage to teeth from thumb sucking can include:8
- Problems with tooth alignment
- Overbite
- Open bite
- Crossbite
- Changes in the roof of the mouth
The effect of thumb sucking on teeth depends on a variety of factors, including the intensity, frequency, and duration of thumb sucking. For example, children who occasionally rest their thumbs passively in their mouths are much less likely to have serious bite or alignment issues than children who vigorously suck their thumbs.9
If your child is four years old or younger, thumb sucking shouldn't be much cause for concern. But if your child is older, it might be a good idea to try and help them curb the habit. In either case, your dentist can offer advice on whether your child's thumb sucking is causing any dental problems, what to look out for and how to help your child stop thumb sucking.
How to help your child stop thumb sucking
Curbing your kid's thumb sucking habit can be beneficial for both your child's physical and social well being. While different techniques work for different children, here are a few ways you can try to help your child break the thumb sucking habit:10
- Positive reinforcement - Praise your child when you notice them not thumb sucking.
- Notice triggers - Children tend to suck their thumbs when feeling insecure or uncomfortable. Correcting the cause of their anxiety can solve the problem at its source.
- Ask for input - If your child is old enough, involve them in choosing how to stop.
- Involve your dentist - At your child's next dental checkup, have your dentist offer them encouragement and explain what could happen to their teeth if they do not stop thumb sucking.
- Cover it up - Consider bandaging your child's thumb or putting a sock over their hand at night to remind your child of the habit.
If none of these methods work, talk to your child's dentist or pediatrician. Depending on the severity of the condition, they might prescribe a bitter medication to coat your child's thumb or the use of a mouth appliance.
While thumb sucking can damage your child's teeth, it's usually a harmless habit. Talk to your dentist if you're concerned. Otherwise, focus on keeping your little one healthy and promoting good oral hygiene habits.
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Brought to you by The Guardian Life Insurance Company of America (Guardian), New York, NY. Material discussed is meant for general illustration and/or informational purposes only and it is not to be construed as tax, legal, investment or medical advice. This is not dental care advice and should not be substituted for regular consultation with your dentist. If you have any concerns about your dental health, please contact your dentist's office.


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Cook at Home or Outsource? Follow the Data!July 6, 2020
When you run a small business, like a personal chef company, it can be helpful to keep track of trends–both to keep you in the know about the industry and consumers and to give you some new ways to think about what you do and what your clients want or need.
SmartBrief published a piece on July 2, 2020 by Laurie Demeritt, the CEO of The Hartman Group, which does market research. The Hartman Group just released The Hartman Group/FMI U.S. Grocery Shopper Trends COVID-19 Tracker report representing mid-May. Here's some of what they found:
- In planning meals, focus often goes to minimizing trips and waste through smart use of perishables.
- Over one-third (36%) feel they are now eating healthier. Younger consumers especially have adjusted how they eat, with more emphasis on maintaining a healthy body while at home.
- Older consumers aim to safeguard their health via prudent consumption, minimizing trips and waste.
- During the timeframe of the report during the lockdown, 41% of consumers said they were cooking more of their meals, 27% said they were "planning more meals in advance, and 20% said they were trying more new dishes.
- Consumers are reevaluating the very necessity of shopping trips and turning to larger, less frequent trips and alternative modes of sourcing perceived to be safer, such as online and click and collect.
- Consumers are reevaluating the very necessity of shopping trips and turning to larger, less frequent trips and alternative modes of sourcing perceived to be safer, such as online and click and collect.
- Looking farther ahead, new routines that focus on preparation for the unknown are likely to have lasting impacts.
So, no surprise, the pandemic has deeply impacted consumers' lives when it comes to food and cooking. But what about those who are finding being in the kitchen less joyful? This same report noted that 23% of shoppers said their priority when cooking is to spend as little time as possible doing it and 33% said they seek "something interesting" to eat when they cook at home, which apparently indicates some fatigue with cooking.
And here's where it gets even more fascinating for you: More than half–57%–of households outsource cooking to food service and dine out at least one a week with 21% doing it three or more times.
Is there anyone more "food service" than a personal chef? For these shoppers, the decision between cooking at home–seen as being more healthy than eating out–considers three things: cost, time and effort, and taste and cravings.
These little data bites should make you stop and think about the possibilities for your personal chef business. They can guide you on how to market yourself to potential clients or sell yourself again to clients who may have drifted away around March when the world started shutting down. And, they can also give you some inspiration for a new way to conduct your business or add services to it for now, during the pandemic, and once it eventually comes to an end.
It could mean not just preparing meals for clients but sending the message that their exhaustion in preparing their own meals–and perhaps the same old things–can come to an end with an exciting menu you create for them.
For those still anxious (including you) about preparing meals in clients' homes, it could mean renting time in a commercial kitchen, perhaps a restaurant kitchen that's reduced hours and could use some income, and then delivery the meals to them. Sometimes the old way doesn't work all the time.
And then there are those people who you could help by putting together a weekly menu of recipes and sourced ingredients. You could do your own version of a Blue Apron and create a video cookalong to help with technique.
Look above at what you've learned about consumers. They don't like making grocery store trips. They want to eat healthier. They want to prepare meals in advance. They want to try new dishes. How can you not look at this data and project your own business onto it! This is an opportunity a serious personal chef should take advantage of!
How is your personal chef business evolving during the pandemic? What are you learning about consumers during this time?
Not an APPCA member? Now's the perfect time to join! Go to personalchef.com to learn about all the benefits that come with membership.
And if you are a member and have a special talent or point of view to share on this blog, let us know so we can feature you!
It's been a few months since the country locked down. That means we've had some time to rethink how we go about serving clients–and if we're serving clients.
Brian Kasten of the Supper Solution in Vermont and an APPCA member explains, "When I saw this coming I secured a commercial kitchen that was unused and have done a temporary transition for those clients I have that are immune compromised. One day a week I work out of this kitchen to cover those clients and I am the only one allowed in… Plus I spend two hours re-sanitizing before any equipment is moved in. And then afterwards."
Kathy Dederich of Chef, Please! in Arkansas and also an APPCA member recounts, "We have a man here who was in the process of opening a restaurant…his plans are on hold, but he's cooking in a church kitchen for the community. The church pays for the food, but they accept donations. In a twist of fate, the American Legion hall decided to sell their building and, rather than build out the initial space he had selected, he's hoping to take over the hall…which is a much nicer facility. Talk about serendipity!"
On June 3, 2020, Eater published a story about how New York's fine dining chefs have done a 180 and have been starting entrepreneurial home businesses. Alejandra Nicolon, laid off as a pastry chef from Eleven Madison Park, is now making bagels with her husband Andre Lev Pavlik, formerly sou chef at Tom Colicchio's FiDi restaurant Temple Court. Daniel Burns, from closed, Michelin-starred restaurant Luksus, is making meals. Kate Telfeyan, formerly the chef de cuisine at Mission Chinese Food is not only making dishes like cumin-spiced lamb and kimchi stew, but she's delivering them herself by bike.
As a personal chef, you probably find this sounds familiar and perhaps not quite kosher.
"We developed the personal chef concept almost 30 years ago specifically to provide a legitimate alternative career path for professional culinary workers who found it difficult or impossible to work in traditional commercial kitchen situations yet chose to support their families using their culinary skill and expertise," explains APPCA founder and executive director Candy Wallace. "We worked with state and city governments to develop a template to assist chefs and cooks in setting up and operating legitimate, successful businesses as personal and private chefs which meant operating within the safety and licensing requirements of their particular municipalities so the industry could grow and contribute to the benefit of clients who required or desired the service and the financial stability of the chef owner/operator."
Candy points out that food preparation in residential kitchens being delivered to client's homes or businesses is illegal in all 50 states in the U.S. Operating with a municipal or State business license, specific local Food Sanitation certification and Specific General Liability Insurance coverage is also required.
So, if you're not already a personal chef and certified, please, she says, pay attention to these important requirements before you proceed.
"In our current reality of the Covid-19 virus, cooking for clients in your home or their home at this time is dangerous from a potential virus transfer standpoint but also from a legal vulnerability standpoint. If any of your clients or their extended family members become sick, you are a big target," Candy emphasizes. "If you have no liability insurance coverage, you are cooked. If the health department or city administration departments in your city or state choose to pursue you, they will, and you will find yourself in a morass of red tape that will prevent your being able to open another business.
"Please think before you act."
Candy suggests that instead you locate a licensed commercial kitchen and deliver safely and legally from it. Protect yourselves by being aware of local requirements and cover your bases.
What have you been doing with your business since the lockdown? Have you discovered some useful workarounds to serve clients?
Not an APPCA member? Now's the perfect time to join! Go to personalchef.com to learn about all the benefits that come with membership.
And if you are a member and have a special talent or point of view to share on this blog, let us know so we can feature you!
Community CookingApril 27, 2020
Don't you love the revealing moments people share about themselves that make you admire them all the more? I saw a post APPCA member April Lee shared on Facebook a couple of weeks ago that made me rush out a note to her asking if I could use it as the basis of a post here. Not only did April, owner of Tastefully Yours in the DC-Baltimore area, agree, but she shared even more information for me to put together here for you. I'd like to think of it as the inspiration we all need to do what we can in our communities during this pandemic. So, this is from April:
During this pandemic when it's become extremely dangerous for older people to go out, I've been boxing up meals and delivering them to the senior citizens I know who can benefit from some well-made, nutritious meals. While I and many here are professional personal chefs, anyone can set aside an extra portion or two to offer to others. I have friends who are nurses and first responders. They also need ready-to-eat meals. So, consider reaching out to people you know (this is important as you cannot cook out of your home for strangers because of liability issues and health department regulations). But cooking for friends or acquaintances is fine and very much appreciated now. Just please be extra vigilant in following food safety guidelines when cooking, cooling and storing food. And maintain social distancing.
I wear a mask and gloves always when going out. I call the person to let them know when I'm coming. I call/text again once I arrive (just to make sure they are at home) and then leave the boxed meals in a bag at their front door. I will not leave food if they cannot bring it inside their home as I wave from inside my car.
I've been giving free meals to low-income senior citizens and families in my county every week since February of 2017. Because I work out of a leased commercial kitchen, I am able to do this. I would NOT encourage personal chefs who don't have a commercial kitchen to even try this because it is in violation of all sorts of codes and regulations. Even if you're giving the food away, you can't cook out of your own residential kitchen. It's been a good project for me, a way to use up extra ingredients and not waste anything. Many of my clients found out what I was doing and pay me a little extra to help offset my expenses for the groceries and containers for my "guests" (versus my paying clients). People like the idea of helping their community in a very direct way.
My suggestion for others to set aside portions of their home-cooked meals is because there is such a great need right now for ready-to-eat meals. Senior citizens, especially those who are elder orphans, are particularly vulnerable now because they don't have family members checking in on them. And, as I said, first responders, nurses, doctors, hospital staff workers (think about all the minimum wage workers who are doing all the janitorial and housekeeping work in these hospitals), all need to eat after working days and shifts on end.
Again, I don't want to give the impression that people can start providing meals to strangers. They absolutely cannot. HOWEVER, they can set aside a couple of portions of the dinners they are making for friends and acquaintances they know who could benefit from a tasty, nutritious, well-prepared meal. Many of the moms and dads who are still out there working because they must, would appreciate having dinner delivered for their families. Parents who are home with their young children now because daycare and schools are closed are struggling to balance getting their work done, taking care of the kids, helping them with online classes, and tending to household chores. You'd be amazed at just what a batch of freshly made chocolate chip cookies can do for a friend or acquaintance who's overworked, over stressed, and sleep deprived. There are so many ways we can help and, now is the time for us to share our bounty and our talents with those in need. Not everyone knows a first responder, but everyone knows someone (probably many someones) who are pushed to their max right now. A prepared dinner is manna from heaven for these pandemic weary folks.
What kinds of service are you providing your community or your extended family these days? Send us your story!
Not an APPCA member? Now's the perfect time to join! Go to personalchef.com to learn about all the benefits that come with membership.
And if you are a member and have a special talent or point of view to share on this blog, let us know so we can feature you!
Launch a Newsletter for Clients and ProspectsApril 20, 2020
How's everything going? Are you still able to work with clients or have some cancelled for the shelter-at-home duration?
If you're using this time to make changes in your business, how about staying in your clients' line of vision–and the vision of potential clients–by sending out a weekly newsletter?
The newsletter could be as simple as a weekly note via email that checks in on your clients, lets them know what's going on with you (yeah, you're not all that busy either but perhaps you're noodling around with new recipes, working in your garden, starting a cookbook…), shares links to health or food news, and perhaps offers a recipe or two. Just design it so that the content is broken up into easily consumable pieces, bold type where useful, along with bullet points and links.
But that same content could also be part of a more designed, formal e-newsletter, using Constant Contact, Benchmark, CampaignMonitor, MailChimp, or some other platform. Depending on your distribution, these could be free to use or modestly priced.
Each offers templates that allow you to pretty easily create a design. You can set up a format that offers a box for any news you want to promote, such as a guest post for this blog, a new Facebook group you've launched, volunteer/community work you're doing, or a new cooking demo you've released on YouTube. You could have another that offers a recipe with a photo. If you have a niche service, like cooking for athletes or expectant moms, you could have a section with relevant health news and links to stories with the details. And, of course, you should have a permanent section that describes who you are, where you are, the services you provide, and how to contact you, etc. Fill it with great photos, but keep enough white space in the design so it doesn't feel claustrophobic.
When I was still writing my blog, San Diego Foodstuff, I prepared and sent out a weekly e-newsletter using MailChimp to both promote it and my other work as a food writer. I ran an excerpt from the new post on the top left, food community news on the top right (a cookbook author coming to town, classes people I knew were teaching, food events, etc.), and below that a photo and description of my latest story for the San Diego Union-Tribune's food section with a link to the story. If I had won an award, that was placed on the lower left above the block that had information for how to get in touch with me and then a description of my work. And, of course, I included any advertising I had and a photo of my dogs–because why not? (Also create an easy way for people to unsubscribe because realistically not everyone on your subscription list will want to receive it.)
You should also include any social media links you have: Facebook, Twitter, Instagram, Pinterest.
Why so much information? Because you're marketing yourself at a time when you need to keep your clients engaged and plant seeds in the minds of potential new ones. Because you may be looking for new opportunities under your personal chef umbrella to teach classes, cater events, write food articles, or be on local television.
You may think, well, I have a half dozen clients. I'm doing fine. Why should I bother writing a weekly newsletter? Well, how about broadening the possibilities and sending it to local news producers, local newspaper editors, or influencers who could help you find new clients or other food-related gigs? If you're on social media, you can even announce you're launching a newsletter, describe the type of content you're planning and encourage people to sign up for it.
These are weird and challenging times. If you and yours are healthy and you can carve out some time, why not design and start sending out a collateral via email that can help you rebound once the world reopens? If you're concerned about your business, this is another tool in your toolbox to help it come back. And if you're one of the lucky ones who is still busy, congratulations. But you know you should always be thinking ahead. A weekly newsletter can help you stay at top of mind with those with whom you already have a relationship and launch new relationships with those you want to impress with your skills.
How do you promote your business? Have you been writing a newsletter to clients?
Not an APPCA member? Now's the perfect time to join! Go to personalchef.com to learn about all the benefits that come with membership.
And if you are a member and have a special talent or point of view to share on this blog, let us know so we can feature you!
Starting a ChefDemicApril 13, 2020
Last week APPCA member and friend Christine Robinson wrote a Facebook post that articulated what so many of us are feeling these days–boredom with the routine at home, irritability with the constraints, and yet a total understanding that it was all necessary. So, I asked Christine who, with her partner Dennis Nosko, operates A Fresh Endeavor Personal Chef Service in Boston, Massachusetts, if she'd like a different challenge, guest writing a post for her fellow personal chefs. I'm so glad she embraced this because what she wrote below is so meaningful!
I had heard from a lifelong friend sometime in mid January that she was concerned about this virus popping up in China and had I heard. I researched the rumblings and decided that it would be a good idea to just prepare a little bit (anyone knows my least little bit is over the top) because we all know when you prepare and over plan, nothing happens.
Needless to say, here we are. We have been in business for 20 years and have seen downturns, trends, situations, busy times, lean times, but everything always balanced out. This, this is one for the history books as we navigate the biggest challenge our world has faced in recent history.
When everything started hitting we made sure to let clients know how vigilant we were and that we understood their fears. We have had about five clients hang on for the duration, all people who stay at home under most circumstances, have some special needs, and have spacious enough homes that we can practice safe distancing and bring in as few items as possible. Cleaning frantically has become the norm and taking our temperatures and announcing numbers has become second nature. We keep in touch with other clients who have taken this time off to email, trade some recipes and just check in with no mention of business concerns, rather human concerns. We love our people and want to see everyone on the other side.
Right now is the time for our best ideas to be put forth, to brainstorm, to get creative.
I started a Facebook page almost a month ago called ChefDemic—we are just over 250 members. We became concerned with people's abilities to cook from what they had available in their freezers and pantries, and also wanted to address food waste and using what you have on hand. Our intent is to amp up on demo videos (our son bought us a tripod to use for videos) and to move over to a YouTube platform and continue this. The sense of community on the page is very strong and we have regular posts from members showing off their own creations. When we have not been available to offer advice in a timely manner, 10 odd people will address a member's concern. Much more than the food advice, is the distraction, the humor, and the support for our members has built a wonderful, creative group.
This has also spurred talk of online cooking class parties or instruction.
We are taking this time at home to rest our minds, deal with our own health, get out and walk, and allow ourselves to fear the uncertainties, while taking some time to regroup mentally. Menus for clients are being revamped, we are cooking for ourselves, concentrating on balanced meals rooted in foods that boost immunity. I have managed to maintain a 20-pound weight loss I started on shortly after my surgery at the end of October and so has Dennis. Documenting this journey could be another direction we explore.
As far as the future, our plans are to focus on the very cornerstone of the personal chef industry, something we all know, to sense and execute customized food in the safety of the client's home with attention to quality personally managed for them. I see a trend of gatherings being more special and possibly more frequent as we are all learning to celebrate the little things, as no one wants to miss out on any moment with loved ones ever again. I envision a time when the RSVP lists are going to be packed with 'YES! We will be theres," and fewer, "Can't make its." While that may take time, we are willing to rework our model to fit the client needs.
Be well and be safe. You are our people and we love you, too.
How are you coping with sheltering at home. How are you thinking about adjusting your business for the future?
Not an APPCA member? Now's the perfect time to join! Go to personalchef.com to learn about all the benefits that come with membership.
And if you are a member and have a special talent or point of view to share on this blog, let us know so we can feature you!
What Brings You Joy as a Personal Chef?April 6, 2020
As everyone's all too well aware, we're caught up in pretty anxious times right now, thanks to the coronavirus outbreak. Your clients are so lucky to have you help them through it with delicious and nutritious meals. We also hope those of you who for various reasons aren't engaged with your clients right now are taking care of yourselves, sheltering at home, and working on new strategies for re-opening your business.
Back in the day, APPCA's executive director Candy Wallace created this career path to give chefs an alternative to working a restaurant line–to be able to follow their own joy when it comes to working in a kitchen. Being a personal chef enables professionals to create the kind of business that works for them and their lives–to make food that inspires them, to help others, charge fees they deem appropriate for their services, and create their own hours. Some also elect to take on additional, related opportunities, like catering, teaching, and writing, under their personal chef umbrella.
When everything comes together, we find that chefs are creating a life for themselves that brings them joy. It may be the independence of directing their own business. It may come from their clients in the form of appreciation. It may be pride in what they're accomplishing creatively. Or it's the grace of knowing they are helping others.
We're often in conversation about how to do things better–be more efficient, get more clients, update menus. But can we take a moment and share what brings you joy as a personal chef? We don't talk about that nearly enough and we surely need it now. We asked participants in our Facebook group and business page what about being a personal chef brings them joy. Here's what they had to say. Sound familiar?
Jennifer M. Grawburg: "When someone really thanks me for bringing joy to their lives whether it's a memorable birthday or just easing the everyday grind by providing dinners each week. I'm truly thankful for amazing clients."
Christina Hamilton Snow: "The smile on the face of a client that with my help, lost 90 lbs and is no longer pre diabetic."
Christine H. Robinson: "When a tiny child who hates everything likes something I make…."
Natasha Layne: "When we create tasty and healthy dishes it does something to not only our spirit but to the spirit of the person we're cooking for. I love taking some degree of stress away from a busy family or a person who's worked a long hard day."
Debbie J. Elder: "The chance to meet new people from all over. I focus on private dinner parties for visitors to the city."
Erin Tripp: "The freedom to work by myself, when I can… and receiving accolades at the end of the night, isn't so bad either!
Jim Huff: "Just this week I was stuck at a client's home waiting for a towing service (stupid chef trick I locked my keys in the car) my client, who I haven't seen in two months as he started new job, felt so bad for me he offered to heat up some "delicious food" and join him for dinner! Of course he was referring to what I had cooked for him that day!
Judy Harvey: "My senior clients that look forward to the food, but more so of me sharing 4 hours with them."
Shelbie Hafter Wassel: "When a client, two weeks ago gave me a bottle of wine from his collection… retails at $325. Gulp!"
Evangeline Kochanek: "Seeing clients become healthier and feel better
Julie Handwerker Cicero: "When my client tells me I got her eat vegetables!"
Not an APPCA member? Now's the perfect time to join! Go to personalchef.com to learn about all the benefits that come with membership.
And if you are a member and have a special talent to share on this blog, let us know so we can feature you!
Lights! Camera! Online Cooking Class!March 30, 2020
So, what week of the coronavirus shut down are we in? I'm losing track. How about you? What I do know is that many of us have lost work and are trying to hold things together–both financially and emotionally. So, here's a suggestion: put your talent to work in a different way and hold online cooking classes.
Already I'm hearing about APPCA members trying this out. In fact, member Shelbie Hafter Wassel shot me a message inviting me to take a look at her new video on Facebook, which she later uploaded to YouTube, shot by her husband Jerry. Here she offers a couple of recipes for making fish. Check it out!
So, here's what I'm thinking. You have clients. You have recipes. You may have limited access to groceries but no doubt you have a fridge and freezer packed with food. Why not learn to use a new technology while you have some down time, engage your current clients, social media promote the heck of your video classes to get new ones when this crisis ends–and maybe even make some money while you're at it?
Money? You can earn money making a video? Well, there are at least half a dozen platforms that could enable you to earn some money holding online cooking classes. Let's discuss.
Skype: You probably are already familiar with Skype. So, why not use it for an interactive online cooking class? You can charge a fee and share recipes for the class ahead of time so your participants can follow along. Maybe you teach a knife skills class with recipes based on various skills you teach. Or perhaps you create a meal kit for clients and include this interactive online class to teach them how to use it?
Google Hangouts Chat: You can do the same thing on Google Hangouts Meet as with Skype. Take a look at this invite from San Diego chef Jason Roehm, who regularly teaches via this platform. The class is live, followed by recipes. He charges $25 for a two-hour class and sells the tickets via a link to Eventbrite.
Patreon: Here's how this website describes itself: "Patreon powers membership businesses for creators by giving them the tools they need to acquire, manage, and energize their paying patrons. With a subscription-style payment model, fans pay their favorite creators a monthly amount of their choice in exchange for exclusive access, extra content, or a closer look into their creative journey."
As The Street describes it, "Patreon is a crowdfunding platform that enables fans (or patrons) to pay and support artists for their work. For producers of videos, webcomics, music, podcasts and more, Patreon is a way to earn extra money on what might otherwise be free content, and allows fans to contribute to their favorite artist's platform."
The site allows creators to set up monthly, subscription-style payment tiers. Creators can also charge an upfront payment instead–and that remains permanent. Your "patrons" can join by creating an account and pledging money to you, with subscription options sorted by different payment tiers or per-post options for content. According to their site, Patreon takes 5% of the amount paid to creators in fees. Creators keep some 90% of their revenues, with an additional 5% going to transaction fees.
Vēmos: Vēmos allows creators to host interactive classes that enable participate to engage with you. You can sell tickets to attend your virtual class to earn income from your home. Vēmos uses Stripe Connect. This allows ticket sales to be deposited directly into your account as soon as sales role in. They don't charge a monthly subscription fee. Instead, a 10 percent fee is added to the consumer buying the ticket, with a maximum fee of $9.95 per ticket. You select the price point for each ticket for the class. Vēmos has a step-by-step guide for starting an event.
Zoom: I hate to say it, but if you haven't heard of Zoom in the last few weeks you've been living under a rock (and probably safer there). Zoom has become the default platform for video conferencing for the coronavirus shelter at home worker. But why not make it work for you for earning some money with virtual cooking classes? It's free. It's easy to sign up. Perhaps use Eventbrite to sell tickets and then you can round up your students at the time you teach the class.
Now you may not make a ton of money doing this, but every little bit can help. Plus, you learn a new tool and can flex your muscles working on a new angle to promote yourself and your business.
Have you started doing video cooking classes? What's your experience been like?
Not an APPCA member? Now's the perfect time to join! Go to personalchef.com to learn about all the benefits that come with membership.
And if you are a member and have a special talent to share on this blog, let us know so we can feature you!
Steps You Can TakeMarch 23, 2020
In the coming weeks, Candy and I will be working to developing suggestions for ways in which you can keep yourselves whole during this coronavirus shutdown. We know many of you are worried about how to make ends meet. Here's what Candy had to say this week:
First things first. I suggest that APPCA members file for a Small Business relief loan immediately. Here's how to get the information. Contact all of your monthly financial obligations including cellphone carriers, internet providers, all utilities, car loan holders, landlords/mortgage lenders, and student loan lenders, for example, to see what kind of disaster relief they are offering.
On our Facebook group page, member Holly Verbeck shared her experience with contacting every business she has bills with:
"DROP your personal and business expenses QUICKLY!
I'm adjusting NOW to the fact business/income will be down for 90 days or so.
I just got off the phone with every company I pay a bill to.
– Verizon 'suspended' my account for 30 days (=ZERO due this month w/ no changes to my service!!)
– NY Times dropped my paper subscription by HALF for one YEAR!
– my utility company dropped my bill by 20% for one YEAR!
– Sirius XM dropped my bill by 30% for one YEAR!
The list goes on…
I'm dropping all my expenses and haven't reduced services!
This makes it a helluva lot easier to pay the mortgage!
Call…call now…call everyone, chef. Ask them what they can do to help reduce your payments while your business is impacted! And SHARE your results with other chefs!!"
Then, how best can we serve our current client base and/or secure new income stream sources? With all the restaurant closings chefs all over the country and restaurants have converted to production cooking and either pick up or delivery from licensed commercial kitchens.
However, your client base relies upon and appreciates the personal commitment and custom designed programs designed by and provided by their personal chef. Members with access to commercial space can convert to 100 percent delivery to avoid exposure for their clients and for themselves. Come up with promotions you can afford to do to spark more interest. Perhaps an extra dish with meals? A discount on a future catering gig?
Adding on or providing separate services like shopping for clients, if feasible in your city, could provide income.
The biggest challenge for personal chefs right now is securing product. You may find that your usual local markets are out of your usual items because of the panic run by customers. While this is likely temporary–officials stress there is no shortage of food–it can be inconvenient right now. Here are some options:
- I found that shopping for produce with the closure of the farmers markets in our area was a challenge (although in San Diego the Little Italy Mercato just announced a limited market with stringent entrance rules). I turned to Chefs Garden, which delivers fresh-picked, customer-selected amazing produce via FedEx in a cooled shipping carton.
- Check in with local farms to learn if they are creating CSAs to sell their produce. If you haven't heard of them, CSA stands for community supported agriculture. Many farms have subscription CSAs. You sign up and then pick up or have delivered a box of the farm's produce weekly or every other week. Farms that usually sell directly to restaurants are now instead opting to sell directly to customers. So find out if this is an option in your locale.
- Contact farms directly or go to their Facebook page to learn if they are holding temporary farm stands.
- If your city has a restaurant warehouse, a Costco Business Center, or wholesale markets–not just for produce but also seafood and other proteins–find out if you can buy from them.
- I've seen on Facebook offers from people who participate in community gardens make offers to the general public to share produce. Check this out.
If you have encountered other options, please share them with us below! Or contact Caron at firstname.lastname@example.com so she can share them.
What changes are you making to your business to adapt? What could you use help with?
Not an APPCA member? Now's the perfect time to join! Go to personalchef.com to learn about all the benefits that come with membership.
And if you are a member and have a special talent to share on this blog, let us know so we can feature you!
We Can Do This!March 16, 2020
How're you doing? Coping with the chaos? Our chef members are the rocks of their communities. In times of disruption there may be nothing more important than to have focus, a strategy, pragmatism, and, yes, optimism. Every state and locale is experiencing this coronavirus pandemic differently so far but what we have in common is to critical mandate to protect ourselves and our society by following CDC guidelines and keeping up with federal, state, and local direction.
APPCA's founder and executive director Candy Wallace has been through tumultuous periods before–from recessions to 9/11 to other pandemics. Naturally, she has a great perspective on what we're going through now and advice for member chefs.
I have been struggling with this situation, like you, for weeks, watching it evolve so that I could offer realistic recommendations and suggestions to support our personal chef members.
This is even more challenging than the financial challenges of 2008 with the gravity of a global pandemic. Safety from contagion is paramount. Peace of mind, professional leadership, and stability are vital to prevent panic. Personal chef clients hire us because they need/want our assistance and guidance, so how can we continue to be useful in the present situation?
Let's address first what we are dealing with: A fear of food source instability that's causing panic buying, fear of exposure, and a lack of comprehensive information and/or direction from our government to name a few. Let's not forget anxiety and the collapse of our way of life when it comes to employment, healthcare, education, sports/entertainment outlets, and organized face-to-face religious support and worship.
Let's be honest. We are in a state of chaos where the parameters change with the fluidity of liquid mercury so the ability to adapt service for clients while remaining safe is the quandary.
What do we know with certainty at this point? Not much. But this is no time to panic. We're smart; we're resourceful. And we're among the luckiest of our citizens. So, let's make use of it. How? Think of this period as a time to prepare, do your best to help clients and your families, and plan for the future–because this will resolve and life as we knew it will resume.
I have no doubt that when the chaos settles and the fear factor is reduced, personal chefs are going to be a big part of the recovery process and an enormous asset for a population that wants to get well and maintain a healthy lifestyle. So stay in touch with your current and past clients, offer services that don't put you in any jeopardy, and be a resource of advice and tips on being safe in their home kitchens in an epidemic and they will rely on you in the future.
What do I advise?
- Wait. Watch. Pay attention. Rest. Exercise. Eat well. Keep safe. Remain calm.
- Prepare to react quickly when we have real and reliable information.
- Use this opportunity to update your recipe files and develop new healthy recipes.
- Help current clients by updating them on ways to stay safe and offer support through communication and information.
- Use social media to communicate your presence and commitment to the well-being of your clients and your community. Post current information impacting resources that impact your specific area so they will turn to you as a reliable source of information and support.
- Stay in touch with your professional colleagues to glean and share information, suggestions and support.
- Stay in touch with us–we have our forums and Facebook page and group that are all great resources for sharing information and comparing notes.
Let's face it, our world is changing. We are in what I refer to as a breakdown across the board of Epic Proportions, and yes, I intentionally capitalized those last two words. We must be part of the equally Epic BREAKTHROUGH that is on the other side of this dreadful current reality.
In order to survive as professional personal chefs and rebuild our businesses and industry we must choose to be part of the change, be able to adapt and address the realities that are in the process of revealing themselves, and act quickly implementing a new service model when we have enough real information to determine direction.
In the next week stay safe, rest, reflect and recharge your batteries. And be sure to let us know what you need from us and keep us posted on what's happening in your community!
Are you still able to work with clients? What kinds of challenges are you facing and how are you resolving them?
Not an APPCA member? Now's the perfect time to join! Go to personalchef.com to learn about all the benefits that come with membership.
And if you are a member and have a special talent to share on this blog, let us know so we can feature you!
In a Culinary Rut?March 2, 2020
Winter doldrums, menu malaise… It's easy to get into a cooking rut. But it's just as easy to get out of one, too. Especially with spring around the corner. Produce seems prettier and more inviting that basic root veggies. There's color outside and more color in the markets.
I asked our Facebook page followers what they do when they're feeling the need for some inspiration for new dishes, techniques, and menus. What is their inspiration? And I got a variety of options to share with you:
- "I watch Fast Forward cooking shows," responded Cherylanne Farley. "The Kitchn always has good ideas techniques."
- "The Barnes and Noble bargain cookbook area," is member Carol Borchardt's inspiration. "Pinterest. Old magazines because everything that is old can be made new again."
- "Tasting Table, Plate magazine or Pinterest are my go to's," said Jennifer M. Grawburg.
- "Pinterest," is Suzy D. Brown's source of inspiration.
Media, of course, is a great source for food-related ideas. Social media is awash in food images and video. And you should certainly subscribe to daily newsletters that arrive in your email's inbox from Epicurious, Serious Eats, Tasting Table, Well Done, Cooking Light, the Kitchn, ProChef SmartBrief, and MyRecipes–just to name some of the most obvious. So are the vast array of cooking shows on PBS, Netflix, Hulu, and YouTube.
But sometimes you need to get your head out of your computer or device and get out. A recent PBS series that puts out there just how inspirational a hometown can be is chef Marcus Samuelsson's "No Passport Required." His second season just concluded but you can find the episodes on demand or the PBS website. Lucky you if you're from Boston or LA, Philadelphia or Seattle or Houston. Most cities have enclaves of different ethnic groups and watching No Passport Required should give you the itch to explore your city's Armenian neighborhood, or Filipino or Nigerian or Italian.
Yes, I recognize the irony of suggesting a TV show to get outside. So get outside. You may think you've hit all the hot spots of your town but there may be other towns nearby to explore.
I asked a chef I know in San Diego what she does when she's looking for inspiration. She goes on food tours of the city–in San Diego or wherever she happens to be. They take her to markets, restaurants, food stalls, and street vendors. There she can try new flavors, ask questions, and develop ideas for new dishes. I've done this myself in San Diego, Los Angeles's Koreatown, San Francisco, Paris, Quebec City, Vancouver, and Montreal. It can explode your mind and lead to an exciting new approach to your menu.
If you're not in an area where organized food tours are available, how about gathering up a few friends and day trip somewhere close by? Take a bus or train or carpool to a nearby city for a day of markets and food from another culture? Bring a notebook, take photos, and ask lots of questions of chefs and shoppers? See something you don't recognize in a bin? Ask someone making a selection about how to use it and how to pick the best quality.
And, if you can't leave town and you have several different kinds of markets in your town or city, turn that into a day trip and enjoy your region's diverse offerings. Mark Dietz told us on Facebook he swears by markets as inspiration.
What if your inspiration needs to come from a very specific practitioner? Let's say you're interested in taking on cooking for clients with a specific dietary need. Sure, you can turn to the Internet and Pinterest, etc. But how about reaching out to professionals–dietitians or nutritionists, for instance–who can give you some ways you can incorporate specific foods into dishes? Maybe you can have a cook date to learn techniques?
It all comes down to how eager you are to come up with novel resources that ignite that spark of change. Just getting a fresh perspective from another chef or an aisle of gorgeous spring vegetables may send you racing back to your kitchen, eager to develop a new recipe or two for clients.
What's your inspiration when you are in a culinary rut?
Not an APPCA member? Now's the perfect time to join! Go to personalchef.com to learn about all the benefits that come with membership.
And if you are a member and have a special talent to share on this blog, let us know so we can feature you!


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Mini Golf Zone
Located at Zone Laser Tag Albury and fun for all ages!
Whatever the weather, you can enjoy 9 holes of black light mini golf at Mini Golf Zone. Located behind Zone Laser Tag Albury and fun for the whole family and casual guest play.
Check our fantastic 45 metre long and 3.6 metre high Marvel Hero artwork across three large walls, it truly is wonderful to stop and admire as you play. Take a selfie moment too.
Arcade games
The mini golf section has a popular variety of video arcade game play with some redemption and prize machines. Many more redemption and prize machines in the laser tag foyer.
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Allow approx. 20 minutes to play the course. This does depend on the individuals' skill level and the group ize, time my be longer
Score cards are available


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The MoGo is a responsive mouse and tracks well. The MoGo Mouse BT is perfectly symmetrical, so left-handers should find it as easy to use as right handers. This freedom makes the mouse easier to use and ideal for such intense activities as computer gaming as well as fine detail work such as photo editing. OnePlus 6T first take review: It even features a "kickstand" to elevate the mouse during use, improving ergonomics.
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Enter new zip code to refresh estimated delivery time. However, its performance was erratic at times, and during these periods it nogo frustrating to use. Once it's charged, an LED glows green on the outside lip, meaning you're ready to connect.
OnePlus 6T first take review: Wireless Bluetooth Interface The wireless Bluetooth interface allows you to use your mouse without having to worry about the cord getting caught or tangled. The MoGo Mouse BT addresses these issues by communicating with your notebook via Bluetooth and residing and charging up in your system's PC Card slot when it's not in use. See any errors on this page?
Read in comfort at the pool or beach. You may unsubscribe from these newsletters at any time. Google Pixel XL 8.
MoGo Mouse BT | TechRadar
LG V40 ThinQ review: Newton Peripherals MG specs. My Profile Log Out.
Optical Tracking Miuse dpi optical tracking technology gives you the ultimate in control when using your mouse. Be the first to review this item. It looks pretty sharp when you eject it from the PCMCIA card slot to kick off a presentation, and because of its diminutive size, it hardly takes up any space in your laptop bag.
However, it's easy to break nouse pairing by pressing the same Connect button mpgo to create one, after which you can go through the pairing process again with another notebook.
MoGo even has a Bluetooth adapter styled to look in keeping with the mouse. Newton Peripherals MG overview. For this mouse you will need a PowerBook. Connecting to your notebook is straightforward: If you take your laptop everywhere with you and have a Bluetooth connection, then this mouse could make a great travelling companion for your Mac.
Great price, innovative technology, and responsive performance.
Mofo will be able to make fine adjustments with the optical precision that you just won't find in a ball mouse. Migo has an operating range of up to 30 feet, giving you extreme versatility in how you use the mouse. The flat form does take a bit of getting used to, but we had no real complaints about its performance. The MoGo Mouse BT is perfectly symmetrical, so left-handers should find it as easy to use as right handers.
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However, a mouse is yet another item to carry in your bag, and that there's often an inconvenient wired connection to the computer. The mouse works with both PCs and Macs; we tested it on our regular notebook, a Fujitsu Siemens model with Bluetooth built in. Apple iPhone 7 Plus 9.
Full-featured smartphone built for Android tinkerers. The mouse needs a full charge before you can pair it to the Bluetooth receiver in your PowerBook. Newton Peripherals MG reviews.
PC and Macintosh Compatible The mouse is fully compatible with both Bluetooth-enabled Windows PCs and Nouse computers, allowing you to go wireless on whichever platform you use.
Apple Mac mini review:


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The Sun says you've got a talent which you can pursue. A God- given gift which will draw your fate and allow you to achieve all the three, fame or notoriety, or some or fulfillment. You also ought to pursue your hobbies, read, exercise, and /or learn a new skill. Do anything that can make you happy and increase your life. Live every day without hunting or searching to get a romantic partner. Will come to you when you stop looking, what you want.
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For your man's, let us be honest about our height. You're just five foot six, and if she's anticipating a six- footer, this will be a issue. Particularly if she decides to wear three inch heels inch frame. She's going to tower over you, and the bald spot you been concealing is red from your embarrassment, and going to be front and centre.
It may be hard to look your partner in the eye and tell her or him your desire to describe in detail or to have sexual intercourse while tied to the bedpost exactly where you wish to be aroused and how. However, having these conversations empower your spouse to please you and can definitely add excitement to your sex life.
But how about just a little nepotism? " Hello! I am Nick's sister Julie. Nick's sort of shy so I will tell you a little bit about him. " Hi! I am Nick's sister, here on behalf of the overbearing, meddling family.
It may be helpful to write a description of the guy. What could he do in his typical week? What is his career coaching? Is he? Is he more of a poet? Do you want him to be even more or active and sarcastic of a supporter of points of view. Is he decisive? Does he love the outdoors? Is he committed to your vision of living and fitness? Jot down a few quick notes and prop that page before you as you are working on your essay drafts. Just take a deep breath. Relax. Consider the tone you'd use in speech. You do not have to force anything. Write as the person speaking to the person that you truly want to be with.
You see hinting that his lack of tenderness, affection and affirmation doesn't really disturb you, only makes you remain in denial and your love tank sitting on" E" ( vacant) ! Instead of denying that his ways just aren't working for you, sit down and be honest. After you've done that, give him ideas concerning how you want to be loved examples on.
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Deal- Breaker- The next most important factor for finding an perfect mate of your aims. All these have to do with belief or a individual's circumstance that makes them undateable for you. Similar to flag that is yellow or a red flag but is more goal.
You increase your power to be grounded in your life and daily tasks. After the chaser is pursuing, it seems like you are avoiding your life and feelings and emotions are guided towards your Twin Flame rather your thought. When the chaser completely surrenders, you feel powerful and strong to concentrate on what things in your own life without caring about what your Twin Flame is doing.
How can we manage this event that is important? How can we lessen the impact and how do we ensure that we've done everything possible to reasonably anticipate a positive outcome? Let's begin in the start, shall we? I can not say enough the value of honesty. When we build a house of cards, that we could anticipate that abode to come crashing down to us, it is. One of the pieces of this puzzle is your primary profile photograph. You might have been honest enough to use a image of yourself, however you dishonestly used one taken.
Major TIP- Online Dating Rules- Own It! The times of wasting loads of money and time searching for your ideal match are becoming less and less, as internet dating becomes more and more mainstream. This is obviously good news, but that your match might be a few clicks away, the rules of engagement have changed. The New Dating Challenge First off, the multitude of opportunities and possible matches can lead to some challenges you definitely have to be aware of ifyou're to successfully find your match. Notice if your online dating attempts have been hindered by any of the following challenges.
Allow yourself some time to get to know a man, especially when he is one of those ones with a kind and compassionate high heel hookers. Remember there are tons of men out there.
- They are open to the idea of meeting. Remember try to not be too pushy about meeting dating can be dangerous so a smart woman will take her time and try to be sure that she is keeping himself safe. But if you say assembly up and she seems to keep blowing it off then the chances are she is not really interested.
Now, exercise for a break- up recovery plan backfired for the strangest reason: everytime I looked in the mirror at myself, and felt amazing after that piece of exercise, I missed my ex! I believed that noone was here to appreciate me as a woman. Share my brand new even- more- beautiful self and I wanted to reach out to him. It had been an overpowering rush of endorphins and I associated it all together with him, and kept hoping for when we'd get back together.
If you are you can set a reminder in your phone. Send a birthday card on her birthday. Wish her achievement if she has examinations or is currently going to get an interview. Basically, show her she is vital and that you care. This will make her appreciate you more and she is likely to forget about all the other guys who could be wooing her.
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@MISC{Legge86psychophysicsof, author = {Gordon E. Legge and Gary S. Rubin}, title = {Psychophysics of Reading IV. WAVELENGTH EFFECTS IN NORMAL AND LOW VISION }, year = {1986}}
Does the color of text influence its legibility? There are reasons why it may do so for specific groups of low-vision observers. We used psychophysical methods to measure the effects of wavelength on the reading performance of four normal observers, two dichromats, and 25 low-vision observers. Reading rates were measured for text scanned across the face of a television (TV) monitor. We compared performance under four luminance-matched conditions in which sets of neutral-density and Wratten color filters were placed in front of the TV screen-blue (λmax = 430 nm), green (λmax = 550 nm), red (λmax = 650 nm), and gray. Under photopic conditions, the reading rates of normal subjects were independent of wavelength, with the exception of characters near the acuity limit. At lower luminances, wavelength effects could be explained by the shift from photopic to scotopic vision. It was hypothesized that light scatter or absorption in eyes with cloudy ocular media would result in depressed performance in the blue. Only one of seven subjects demonstrated this effect, which we traced to wavelength-specific absorption. Observers with advanced photoreceptor disorders tended to read blue text faster than red text. This could not be explained on the basis of photopic spectral sensitivities alone. Finally, the presence of central or peripheral field loss was not predictive of wavelength-specific effects in reading. On the whole, wavelength only occasionally plays a significant role in reading. When it does, performance tends to be depressed either in the red or the blue and to be nearly optimal for green or gray.
wavelength effect normal low vision
low-vision observer
psychophysical method
normal observer
reading performance
depressed performance
peripheral field loss
acuity limit
wavelength effect
luminance-matched condition
tv screen-blue
text influence
reading rate
photopic spectral sensitivity
photopic condition
significant role
normal subject
light scatter
specific group
blue text
wavelength-specific absorption
wavelength-specific effect
advanced photoreceptor disorder
red text
cloudy ocular medium
wratten color filter
performance tends
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