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TMJ Reconstruction: Treating TMJ Reconstruction: Treating the Compromised Anatomythe Compromised Anatomy

A SCIENTIFICALLY INFORMATIVE PEER-REVIEWED PUBLICATION · VOLUME 5 · NUMBER 2

FEBRUARY 2006

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Advisory Panel

Stephen Worrall, MD Consultant Surgeon, Hon. Sec. BAOMS

Oral & Maxillofacial Surgeon West Yorkshire, United Kingdom

The TMJournal is the official scientific and informative peer-reviewed publication of the Rocky Mountain TMJ Surgical Conference. Its sole purpose is to furnish objective and scientifically-based information. The TMJournal is committed to “Advancing TMJ Knowledge Worldwide.

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Editorial Board

Patrick Abbey, DMD Private Practice

Oral & Maxillofacial Surgeon Tampa, Florida

Barry Levine, DMD Private Practice Oral & Maxillofacial Surgeon

Tampa, Florida

Ricardo Alexander, DDS St. Luke’s—Roosevelt Hospital

Senior Attending, Division of OMS New York, New York

Albert Lippincott III, BSE Engineering Consulting Services

Bioengineer Consultant Prior Lake, Minnesota

Robert W. Christensen, DDS, FAIMBE Rocky Mountain TMJ Surgical Conference

Executive Director Golden, Colorado

COL Robert Bryan Roach United States Army (Brooke AMC)

Chief, Oral & Maxillofacial Surgery Fort Sam Houston, Texas

James T. Curry, DDS Private Practice

Oral & Maxillofacial Surgeon Highlands Ranch, Colorado

Subrata Saha, PhD Alfred University

Professor of Biomaterials Alfred, New York

Francis Di Placido, DMD Private Practice, Past President AAOMS

Oral & Maxillofacial Surgeon Ft. Myers, Florida

Hermann Sailer, MD, DMD, PhD Private Practice

Professor and Oral & Maxillofacial Surgeon Zurich, Switzerland

Ruben Gutierrez, DDS President—Mexican National OMS Society

Oral & Maxillofacial Surgeon Mexico City, Mexico

Anthony Urbanek, DDS, MD Private Practice

Oral & Maxillofacial Surgeon Franklin, Tennessee

Eugene Keller, DDS, MDS The Mayo Clinic

Director, Department of OMS Rochester, Minnesota

Crayton R. Walker DDS, MD Private Practice

Oral & Maxillofacial Surgeon Salt Lake City, Utah

Jerry V. Dollar, BA, MBA, FACHE Editor-in-Chief

Robert W. Christensen, DDS, FAIMBE Executive Editor

Nancy L. Johnson Managing Editor

Matthew S. Christensen, BS, CCRA Clinical Researcher

Wm Lester Hardrick Surgical Video Journalist

Lynn M. Watwood, Jr., JD President

TMJournal, Volume V, No. 2, February, 2005 Page 1

Temporomandibular Joint Surgery

Alloplastic Reconstruction of the TMJ: Treatment of the Compromised Anatomy

A Surgical Case Report

STEVEN F. WORRALL, MD, FRCS, FDSRCS

Consultant Oral and Maxillofacial Surgeon Honorary Secretary of the British Association of Oral & Maxillofacial Surgeons

ROBERT W. CHRISTENSEN, DDS, FAIMBE

Executive Director, Rocky Mountain TMJ Surgical Conference

Adjunct Professor, Bioengineering, Clemson University

JERRY V. DOLLAR, MBA, FACHE

Executive Secretary, Rocky Mountain TMJ Surgical Conference Editor-in-Chief, The TMJournal

Key Words: Alloplasty, alveolus, atretic ear, branchial arch syndrome, Christensen, cleft lip, compromised anatomy, Condylar Prosthesis, condyle, congenital anomaly, developmental, distraction osteogenesis, Dollar, Fossa-Eminence Prosthesis, glenoid fossa, mandible, mandibular ramus defect, maxilla, maxillary growth retardation, microsomia, syndrome, temporal bone, temporomandibular joint, TMJ, TMJ reconstruction, Worrall, Zygoma.


Abstract

Objective To describe the surgical planning and treatment approach in addressing the oral and maxillofacial needs for one particular patient suffering developmental anomalies of the craniofacial anatomy. A secondary objective is to restore mandibular and maxillary function and esthetics to the young adult patient. The tertiary objective is to educate the surgeon as to alloplastic implant options that may be available to restore function and relieve pain for the patient missing certain anatomical structures from birth. Methods Through the use of advanced medical imaging tools, a thorough understanding of the patient’s prior failed medical treatments, and a meticulous understanding of the benefits of alloplastic reconstruction; the surgeon can mitigate patient symptoms and at the same time increase the probability of a successful outcome. The surgeon can then collaborate with the surgical and implant design team to not only prescribe the surgical correction necessary, but also design and construct the actual TMJ and mandibular implants that will be used for the case, as well as perform mock surgery on a stereolithography anatomical (SLA) model, which will be needed to restore function and esthetics for the patient. The end result is that a Patient-Specific™ (custom) prosthesis can then be manufactured and adapted surgically to the patient’s unique anatomy. Results The early results from this alloplastic reconstructive surgery have brought forth the anticipated results of replacing the congenitally absent TMJ, improving jaw function, reducing joint pain, as well as improving the esthetics. Without this breakthrough surgical development many of these developmental or congenital anatomically deficient patients will not be able to enjoy normal breathing, mastication, jaw function, esthetics, oral and dental health, and the emotional relief which these corrections will allow. Conclusions Many patients who suffer birth-related anatomical deficiencies (such as cleft lip and branchial arch syndrome) never receive the surgical correction necessary. Many have had autogenous reconstruction of missing mandibular and TMJ structures only to relapse into at times a more disfiguring and lasting condition. By simply placing a Christensen Fossa-Eminence Prosthesis and Condylar Prosthesis in a total joint replacement solution, one is more likely to see satisfactory TMJ mobility and reduction in pain, as well as the mechanical replacement of missing anatomical structures; not to mention predictable and lasting improvement. As an additional benefit, the patient also enjoys enhanced esthetics.


Case Study - History

Overview:

• 22 year-old female • DOB 15 May 1983

Clinical Problems:

• Left first and second branchial arch syndrome (hemifacial microsomia) • No family history of syndrome or cleft reported in two siblings (brother and

sister)

• Left cleft lip (repaired at age six months)

• Alveolus (repaired at age ten years with alveolar bone graft)

• Atretic left ear with partial hearing loss (partial corrections at ages three years and twelve years). Patient was considered for removal of rudimentary external ear appendages and prosthetic replacement using osseointegrated implants, but not performed.

• Progressive facial asymmetry with short left mandibular ramus and tilting of

occlusal plane due to secondary left maxillary growth retardation.

• Planned for combined orthodontics and orthognathic procedure as a teenager to lengthen left mandible (costochondral graft considered), but patient declined treatment.

• University (law) student who is increasingly aware of facial deformity, pain in

left side of face, and reduced mouth opening.

• Patient underwent distraction of the left mandible in the year 2000

• Referred to Stephen F. Worrall, MD in August 2004 Complaints:

• Reduced interincisal mouth opening (15 mm) • No translation of mandible to the left

• Inability to access dental treatment due to limited mouth opening


• Slight pain on the left side

• Marked pain in right TMJ Findings:

• No left zygomatic arch and glenoid fossa • No left mandibular condyle

• No left coronoid process

• Marked facial asymmetry with deviation to the left

• Significantly reduced mouth opening

• Left buccal crossbite

• Marked tilting of occlusal plane

• Marked pain in the right TMJ with Crepitus (suspect that it is secondary to

overload, as patient has no left TMJ)

• Intolerant of Amitryptiline and Dantrolene as antispasmodics Treatment:

• Therabite® jaw exerciser and daily home physiotherapy

• Right TMJ arthrocentesis Outcome:

• No improvement, with pain still in the right TMJ and limited opening

• Considered for custom left TMJ alloplastic implant to improve opening and function and to reduce the load on the right TMJ

Concerns:

• Aberrant facial nerve – The pre-operative MRI demonstrated the absence of a normal superficial parotid gland. The facial nerve is lying on the mandibular ramus.

• Access to mastoid / skull base for Fossa-Eminence Prosthesis fixation


Figure 1

In the anterior facial photograph of this attractive, developmentally compromised 22-year-old female (Figure 1), we see the malformation of the left side of the face. This process is frequently called hemifacial microsomia, but might also be considered to be unilateral Treacher-Collins Syndrome. The latter disease is characterized by mandibulofacial synostosis, ear and jaw deformities, facial clefts, and external eye region pathology. Treacher-Collins Syndrome has an autosomal and genetic history, which probably rules out this disease in this patient in favor of the more localized, non-inheritable, developmental deformity.

In the lateral photograph of the patient (Figure 2), we see evidence of a surgically corrected lip cleft, which was part of an alveolar cleft in the patient’s left lateral incisor region. The lack of proper anterior mandibular growth and external auditory structure atresia is also evident

Figure 2

In the bone tissue contrast CT scan, axial view, of this patient’s skull (Figure 3, following page), we can see the skeletal-facial deformity present. The marked deformity of the patient’s left zygomatic arch, as well as the internal and external ear appendage is very easily seen.


Figure 3 The 2-D depiction of the patient’s right side of the skull (Figure 4) on the cranio-mandibular CT scan shows normal facial and mandibular growth, with a mild retrusion of the symphysis of the mandible. The temporomandibular joint (TMJ), zygomatic-malar structures, maxilla, orbital rim, nose, and mandible are within normal limits.

Figure 4


Figure 5

In the slightly anterior oblique 2-D view of the patient’s coronal CT scan (Figure 5), we can see more vividly the left side deformity, involving the zygomatic-malar structures and the left mandible.

In the next view (Figure 6), we see the absence of osseous ear structures, the partially developed mastoid, zygoma, mandibular body, ramus, and condyle. We also see a lack of development of the temporomandibular joint. The mandibular dentition is altered, as well as the growth of the mandibular symphysis.

Figure 6


Case Study - Plan

In the stereolithography anatomical (SLA) model view (Figure 7), we begin to see the diagramed areas where the zygomatic, temporal bone, and mandibular prostheses will be constructed by the implant manufacturer (TMJ Implants, Inc., Golden, CO, USA).

Figure 7

Figure 8 In the left-side view of the SLA model (Figure 8), prepared from the patient’s CT scan, we can see an earlier diagrammed depiction of where the margin of the proposed Co-Cr-Mo prostheses will eventually be placed. Eventually, we will be presented with some minor design variations, as planned by Dr. Worrall and Dr. Christensen.

In the left lateral view of the patient’s SLA model (Figure 9), we are presented with an excellent depiction, of the actual zygomatic, temporal, and mandibular prostheses, constructed in wax, being prepared for metal casting.

Figure 9


At this stage, the patient can see an actual hand-held model with the joint prostheses. This provides clarity in establishing a patient acceptance of the proposed surgical treatments and thus develops a meaningful patient informed consent environment. Please note that the distal portion of the temporal-zygomatic prosthesis extends to thicker cranial bone over the diminished mastoid bone region. In the photograph of the metal prostheses (Figure10), the reader can see the actual screw hole placement, with the indicated screw lengths highlighted in brackets, for the Patient-Specific™ Fossa-Eminence Prosthesis (FEP), and the indicated bone depth through the Condylar Prosthesis (CP) without brackets. Suggested screw lengths for the CP appear between the brackets.

Figure 10 This protocol aids the surgeon immeasurably during implant surgery. It is interesting to observe in this case that the actual Fossa-Eminence Prosthesis is not resting on bone, but rather is held in place by the anterior and distal retaining portion of the implant.


Figure 11

The articular surface of the free-standing fossa portion of the FEP (Figure 11) shows the shiny articulation surface, with marginal lipping to capture and articulate against the Condylar Prosthesis head’s surface. The implant shown is the actual cast and finished Co-Cr-Mo prosthesis that was implanted in this patient.

As illustrated in the photograph (Figure 12) of the cast metal hemi-mandibular prosthesis (also referred to as the CP), we see the shape of the implant, with its attaching screw holes and ramal and condylar components. The articular head is finely polished, while the other surfaces are left in a velvet-like, or matte, finish.

Figure 12

Case Study - Surgery

Procedure:

• Standard towel and drape, plus skin preparation with Betadine • Nasal intubation, plus micro bore nasogastric tube for post-operative feeding


• Combined parotidectomy and coronal flap skin incisions

• Main trunk of facial nerve identified on mandibular ramus with no intervening parotid tissue present

• The facial nerve was dissected out, and the marginal mandibular, buccal, and

zygomatic branches were identified and preserved

• The coronal flap was elevated and the body of the zygoma was exposed anteriorly and the mastoid bone exposed posteriorly

• The patient was placed in temporary maxillo-mandibular fixation, using

orthodontic brackets and elastics

• The custom Fossa-Eminence Prosthesis was inserted with a very accurate fit

• The facial nerve branches were tagged and mobilized. A vertical incision was made through soft tissue onto the mandible between the branches in order to expose the mandible

• The rudimentary condyle stump and coronoid process were removed with a

saw

• The Condylar Prosthesis was inserted. There was a tight fit below the main trunk of the facial nerve, but a good position was achieved.

• The occlusion and opening were checked. The result was a 35-40 mm

opening with free translation

• Two vacuum drains were placed. Closing was in layers. A pressure head bandage was applied for 48 hours

• A Therabite® jaw exerciser started to mobilize the joint after 48 hours

Figure 13

The left lateral view of the patient’s surgically prepared head during the initial stages of anesthesia (Figure 13), we see that the eyelids have been taped shut. This was performed after the earlier placement of an appropriate ophthalmic ointment by the anesthesiologist. The skin incision has been marked, depicting a continuous bicoronal, pre-auricular, submandibular approach. The draping will give adequate ability to visualize the surgical field and the motor function where nerve identification and stimulation becomes necessary. This is especially critical when performing surgery on a developmentally or genetically compromised patient with unexpected anatomical features.


After a measured amount of Marcaine 0.5% with Epinephrine 1:200,000 is injected into the surgical area for hemostasis; the actual skin incision and skin flap are developed for a parotidectomy surgery (Figure 14). This flap can either be sewn forward to the face or the 2-0 silk or nylon sutures can be retained in a Kelly or mosquito hemostat. This process will then allow the assisting surgeon to mobilize the flap when required for nerve stimulation.

Figure 14 In this dissection (Figure 15), the goal is to begin to locate the main structure of the patient’s facial nerve, somewhere distal to its exiting the temporal bone at the stylo-mastoid foramen. A moderate distance after it leaves the temporal bone, the nerve divides into two main divisions; the temporofacial and cervicofacial. These two divisions generally lie in the isthmus of the parotid gland, so the nerve actually runs within the “parotid sandwich.” These two nerve divisions break into a fanlike plexus at the anterior aspect of the parotid gland and supply the motor function to the anterior facial region.

Figure 15


Figure 16

The facial dissection is carried to the level of the parotid isthmus, which in this patient was not present due to the absence of the superficial lobe of the parotid gland (Figure 16). It is at this point that the facial nerve trunk and cervico-mandibular branches are visible. It is also noteworthy to observe that the facial nerve branches lay on the masseter muscle.

In the following photograph (Figure 17), we can see the superior and inferior divisions of the facial nerve. By accomplishing a parotidectomy type of incision and dissection, we are permitted a proper visualization of the nerve tissues during the entire alloplastic reconstruction of the zygoma, temporal bone, and mandible. This is important in cases such as this one, where there is a rather grave alteration in osseous and soft tissue structures and anatomy.

Figure 17


At this point the surgical dissection moves more superiorly (Figure 18), involving such structures as the posterior facial vein lying just posterior to the mandibular ramus. This vein then becomes the superficial temporal vein, with adjacent arterial vessels. The masseter muscle, joint capsule, and temporo-muscle fascia are all visible during this approach.

Figure 18

A vast amount of exposure is required to place the highly customized Fossa-Eminence Prosthesis (Figure 19). The prosthesis attaches to the anterior zygomatic-malar region and replaces the missing zygoma, missing glenoid fossa, and missing articular eminence of the temporal bone. It also attached posteriorly to the slightly thicker temporal bone over the mastoid bone region.

Figure 19


The implant was designed with the screw holes involving the temporal bone cranial region; such that 8mm to 10mm screw lengths could be placed, just inferior to entering the middle cranial fossa. Whereas, in the anterior attachment area, along the zygoma; four 8mm screws would be sufficient to retain the free standing FEP during expected jaw motion pressures. These would be expected from the FEP’s contact with the CP

Again, we see the placement of the upper joint prosthesis (the FEP) with visualization of the facial nerve divisions inferiorly (Figure 20). The involved more superficial arteries and veins have either been electrocauterized or grasped and tied.

Figure 20 It is important that ample irrigation of all wound surfaces occur during the surgery. The irrigating solution must contain a proper antibiotic within its composition.

Figure 21

We receive a better perspective of the need to expose the developmentally altered and deficient mandible lying medial to the parotid gland, masseter muscle, facial nerve, and external maxillary artery (Figure 21). The anterior facial vein has been identified, grasped, severed, and tied. To attempt to place these types of prostheses, in the absence of this type of incision and dissection, would lead to more serious complications, if not outright failure.


We see the necessary exposure of the more medially placed ramus, body, and condyle of the mandible (Figure 22). The two divisions of the facial nerve have been meticulously dissected by Dr. Worrall and his surgical team. This then makes room for the alloplastic mandibular reconstruction prosthesis. It is noteworthy to observe that this degree of mandibular expansion does not require the use of pre-surgical tissue expansion.

Figure 22 The two prostheses are easily visualized with the superior division of the facial nerve lying right over the ramal section of the condyle-mandibular implant (Figure 23). The inferior division of the facial nerve is seen paralleling the inferior surface of the implant in the body position.

Figure 23


This prosthesis was designed and manufactured to furnish some new shape to the angle of the mandible. It was necessary to cantilever three of the screw attachments to gain added retention to the more proximal segment, where forces are the greatest. Again, we are able to see the Condylar Prosthesis with its spherical polished head resting properly in the highly polished articulating cup of the suspended Fossa-Eminence Prosthesis (Figure 24). By designing these prostheses as a well-engineered, properly placed, biocompatible, durable, and one-stage procedure; we have allowed this patient the greatest chance for proper jaw mobility and function. In addition, the patient benefits from minimal surgery, improved esthetics, and quite possibly a lessened incidence of post-surgical nerve injury or infection.

Figure 24 We can not over emphasize the need for cooperation and understanding of all of the pre-surgical patient and anatomical concerns to be dealt with in this type of major developmental or genetic craniofacial reconstructive surgery. It is imperative that the surgical specialists involved consider a fresh new look at the necessary goals and possibilities for hopefully restoring form, function, esthetics, and pain-free motion to such a patient, with minimal risks and with maximum attainment of the goals in as simplified a fashion as possible.


Case Study - Conclusion

Figure 25

Figure 26

The panoramic radiograph of the patient’s maxilla and mandible (Figure 25), taken shortly after implant surgery, shows the proper location and articulation of the Fossa-Eminence and Condylar Prostheses. Note the placement of screw holes in the Condylar Prosthesis was in hope of avoiding the mandibular branch of the trigeminal nerve. Also observe that the prostheses have improved the contour of the mandible. In the P-A cranial view radiograph (Figure 26), we see the mandibular implant properly aligned and secured to the body and ramus of the left mandible, with the spherical condylar head residing in the cup-shaped Fossa-Eminence Prosthesis.


It is very important in planning this type of alloplastic reconstructive procedure that individuals with design and engineering experience review and actually plan the design and screw hole configuration for the device. Even more important is that the person(s) who delineate these very important design functions also have ample surgical experience. With Dr. Christensen helping to design each phase of these devices, and also helping by conveying some surgical consultation to Dr. Worrall, the best of both worlds is achieved for the patient. This then allows for successful collaboration with the attending surgeon. The patient, during the closing moments of surgery, and still nasally intubated, is able to have her jaw opened easily, fully, and symmetrically (Figure 27). The measured MIO is approximately 30mm, which is a very ample opening at this stage.

Figure 27 In the first post-operative week, the patient can be seen evidencing that facial nerve function is nearly fully intact (Figure 28). She is nearly free of pain and swelling, and should be well on her way to a full recovery.

Figure 28


Shown in the anterior facial view (Figure 29), during the immediate post-operative period, we see that the patient has a minor weakness of the left upper eyelid during closure of the eye. Any such weakness, of minor degree, is usually transient and due to tissue stretching, and not a permanent nerve injury or impairment. The facial nerve function was fully restored in this patient within a 2-week post operative period. The improved, but not quite perfect, facial symmetry is noted, which is very much appreciated by the patient.

Figure 29 Within the first few weeks after this reconstructive surgery all motor nerve function returned to normal and the operated side pain went to zero. The un-operated contra-lateral (right) temporomandibular joint has experienced a slight degree of pain and might eventually have to undergo hemiarthroplasty with insertion of a Christensen Fossa-Eminence Prosthesis if internal derangement becomes an issue. This will be confirmed through the use of an MRI of the right TMJ. Her MIO has increased to 35mm over the past few weeks. Consideration is always given to the visible deformity of the external ear, in case a surgical reconstruction is deemed advisable. Special attention is paid to the size and shape of the helix, anti-helix, tragus, and lobule. In this instance, with the patient being a mature female with adequate cranial hair, little notice will occur as to any residual surgical wound, scar, or ear deformity. In the left lateral view of the patient (Figure 30, next page), in the immediate post-operative period, we see the cosmetic result of proper incision lines and post-surgical facial form. This is the direct result of meticulous planning and advanced surgical technique in the proper handling


of these complicated and challenging instances of cranio-mandibular alloplastic reconstructive surgeries.

Figure 30

Discussion and Conclusion

Alloplastic reconstruction of temporomandibular joints can range from the relatively simple to the extremely complex. The latter part of the range can be seen in patients who have associated, and frequently connected, cranio-facial deformities, whether they be developmental, trauma-induced or the result of congenital anomalies. For the patient who has TMJ pathology as simple as internal derangement (Wilkes Classification Stage I-V), it may well only require the placement of the Christensen Fossa-Eminence Prosthesis as a hemiarthroplasty. This procedure will suffice and will give the patient many years of comfort and function. Historically, some of these patients never required additional surgical treatment, even after some 40 plus years. Additionally, the use of the hemiarthroplasty with the Christensen TMJ Prosthesis for earlier joint pathology has a great record; compared to all of the autogenous TMJ repairs which involve such things as dermis, conchal cartilage, dura, and pig pericardium. All of these materials have large and repeatable failure rates.


For those patients with normal anatomic structures in the TMJ region, but showing evidence of degenerative joint disease, congenital anomalies, traumatic injury, AVN, tumor, or local infections, and where there is an alteration of the natural condyle; total TMJ alloplastic reconstruction may be indicated. Frequently, this can be accomplished using the “stock” (pre-manufactured) TMJ Implants, Inc. Total Joint Reconstruction System. If bone quality or quantity has been compromised, then the surgeon and implant designer need to agree upon the proper design of the implant(s), as well as related screw positions and quantities. This then becomes a “custom” (Patient-Specific) solution for the patient, which is designed and constructed from a CT-based SLA model. In the more severe and complicated, altered or deformed, cranio-facial-mandibular defects; much pre-operative study is required. The degree and complexity of the problem, the timing of the onset of the problem and the proper staging of the plastic and reconstructive surgery is paramount. Any possible alternative plans need to be identified and recorded; then a full disclosure to the patient of each stage of the procedure, as well as realistic goals to be attained, must be fully communicated. This process involves recording, witnesses, and signatures from the patient and witnesses in front of the healthcare professional charged with accomplishing the surgical task. The patient, or guardian, may elect to repair a cleft lip early, wait on orthodontic treatment, or even waive a surgical reconstruction surgery. This may often be for very sound reasons. Insurance coverage and out-of-pocket expenses, esthetic considerations, convenience such as in cases of ankylosis, or severe pain are all legitimate reasons for delaying or expediting treatment options in such a case.

Other Challenging Cases – A Brief Survey

Hemiarthroplasty In the patient shown below, we see the use of the Christensen Fossa-Eminence Prosthesis as an alloplastic hemiarthroplasty (Figure 31). Occasionally, a Fossa-Eminence Sizer will be required (Figure 32) if some alteration of the fossa or articular eminence bone is required at surgery.

Figure 31 Figure 32


Severe Developmental Deformity – Multiply Operated Patient The situation depicted in the following case shows us the facial and CT evidence (Figure 33 and 34) of an on-going, severely disfiguring fibrous dysplasia which involves the greater part of this 35 year-old female’s skull, face, and mandible. Earlier attempts at maintaining airway and oral opening, by resecting and grafting the symphysis of the mandible, did little to relieve the problem. A very serious consultation between the patient, neurosurgeon, cranial-base surgeon, OMS, and otolaryngologist is essential.

Figure 33 Figure 34

TMJ Ankylosis and Deficient Bone Growth – Adolescent Patient

Figure 35 Figure 36 This particular case study (Figures 35 and 36) was described in Volume IV, Number 10 issue of The TMJournal (October 2005). This same technology of unilateral or bilateral TMJ hemiarthroplasty, combined with Distraction Osteogenesis makes for a near-perfect surgical treatment in these patients. It can be used in infant, adolescent, or adult patients where sleep apnea is a serious problem.


The Severely Ankylosed TM Joints

Figure 37

This case illustrates an example of Treacher-Collins Syndrome, as depicted in the 2-D CT scan reconstruction (Figure 37). We see the use of the Patient Specific™ TMJ alloplastic arthroplasty (Figure 38) with actual prostheses mounted on a Stereolithography Anatomical (SLA) model of the patient’s anatomy. This patient deformity was fully discussed in Volume IV, Number 2 issue of The TMJournal (February 2005).

Figure 38 Arthroplasty in the Totally Reconstructed Mandible In the CT scan shown below (Figure 39), we see the Tibial graft reconstruction of a mandible which had nearly been totally resected in a young female patient, for tumor reasons. The remaining left normal condyle was sitting in the temporal space, forward of the left temporal bone articular eminence.

Figure 39


This case will require accomplishing a left TMJ hemiarthroplasty using the Christensen Fossa-Eminence Prosthesis, with an added anterior stop. The right side will require a 13 mm resection of the proximal end of the right tibial bone, then construction of the right total TM joint, as shown below (Figure 40). This prosthesis will feature an added lateral and posterior stop, built into the Fossa-Eminence Prosthesis, to avoid muscular forces dislodging the Condylar head from the FEP.

Figure 40

Total Mandibular Replacement Including Bilateral TMJ’s This 12 year-old young lady was missing the greater part of her mandible, both auditory structures, some periorbital, zygomatic, and temporal bone regions, and also had a large facial cleft. The diagnosis at the time of treatment was determined to be Bilateral Goldenhar Syndrome. In the photo below (Figure 41) we see the patient prior to surgery. The subsequent photo shows initial placement of her alloplastic mandible (Figure 42). The staging of her surgery was important and certainly the full disclosure of risks versus benefits, as well as realistic outcome goals, was mandatory. Again, the study, training, diligence, experience, and commitment of the surgical team was paramount.

Figure 41

Figure 42


Challenging Cases in General These types of cases should be accomplished and supervised by those healthcare professionals who have shown superior ability to accomplish the complex procedures required. They must be ready to bring forth a successful and realistic conclusion that will hopefully satisfy the patient, the family, and those who provide care. There is no doubt that these challenging surgical patients allow a great opportunity for innovation and surgical accomplishment. It will be seized by those surgeons and implant designers who are prepared and who have the vision and confidence to address the specific need. Such was the instance in this particular case. The patient, family, and authors of this article are most pleased with the early results reported for this young female patient.

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AAOMS Parameters of Care for Oral and Maxillofacial Surgery, A Guide for Practice, Monitoring, and Evaluation (AAOMS Parameters of Care – 95) Temporomandibular Joint Surgery; JOMS, September 1995, (Vol. 53) No. 9, Supplement 5. Alexander R. Total Temporomandibular Joint Replacement. Who? What? When? Where? NYSDJ, December 1999, pp 28-32. Alexander R. Temporomandibular Joint (TMJ) Replacement: An Update on Methods. Private Hospital Healthcare Europe; Theatre & Surgery, 2002, pp T35-37. Amstutz HC, Sparling EA. Innovations in Total Hip Replacement for the 21st Century. Res & Staff Phys, August 1999; 45 (8): pp 33-46. Anderson G, Russell R, Christensen R, Gerard D, Hudson J, Chase DC. Thirty Year Follow-up of Patients with Alloplastic TMJ Prostheses. Presented at AADR/IADR 1993 Meeting. Britton C, Christensen RW, Curry JT. Use of the Christensen TMJ Fossa-Eminence Prosthesis™ System: A Retrospective Clinical Study. Surgical Technology International X, 2002, pp 273-281. Campbell P, Shen F, McKellop H. Biologic and Tribologic Considerations of Alternative Bearing Surfaces. Joint Replacement Institute and J. Vernon Luck Orthopaedic Research Center Hospital, Clinc Orthop, January 2004 No. 418. Chase DC, Hudson JW, Gerard DA, Russell R, Chambers K, Curry JR, Latta JE, Christensen RW. The Christensen Prosthesis: A Retrospective Clinical Study. Oral Surg Oral Med Oral Pathol, 1995; 80: pp 273-8. Chase D, Robinson A, Christensen R, Russell R, Gerard D. Mechanical Evaluation of Alloplastic TMJ Prostheses. Presented at AADR/IADR 1993 Meeting. Christensen RW. Chronic Unilateral Dislocation of the Mandibular Joint Treated Surgically by a High Condylectomy. Oral Surg Oral Med Oral Pathol, January 1960 (Vol. 13) No. 1, pp 12-22. Christensen RW. Arthroplastic Implantation of the Temporomandibular Joint (Chapter 29) Oral Implantology Vol. II No. 2, Cranin N (ed.), 1970.


Christensen RW. Letter to the Editor of JOMS. In response to: Wolford L, et. al. Comparison of Two Temporomandibular Joint Total Prosthesis Systems. JOMS 2003; 61: pp 685-690. Christensen RW, Alexander R, Curry JT, Christensen MS, Dollar, JV. Hemi and Total TMJ Reconstruction Using the Christensen Prostheses. Surgical Tech International XII, 2004. Christensen RW. Surgical Correction of Complete Bilateral Ankylosis of the Mandible. Oral Surg Oral Med Oral Pathol, December 1955 (Vol. 8) No 12: pp 1235-1244. Christensen RW. Surgical Treatment of Mandibular Ankylosis. Use of a Cast Vitallium Glenoid Fossa. Dental Radiology and Photography, 1964 (Vol. 37) No. 1. Christensen RW. The Correction of Mandibular Ankylosis by Arthroplasty and Insertion of a Cast Vitallium Glenoid Fossa Prosthesis: A New Technique. A Preliminary Report of Three Cases. AM J Orthopedics, January 1963; 5: pp 16-24. Christensen, RW. The Temporomandibular Joint Prosthesis Eleven Years Later. J Oral Implantology, 1971 (Vol. II) No. 2: pp 34-8. Christensen RW, Alexander R, Christensen MS, Covey CJ, Curry JT, Masters TE. Hemi and Total TMJ Reconstruction Using the Christensen TMJ Prostheses: A Retrospective and Prospective Evaluation. TMJ Implants, Inc., Label 2-037, April 2003. Collins CP, Collins PC, Christensen RW. An Alloplastic Alternative to Autogenous Material in Temporomandibular Joint Surgery. Critical Reviews in Biomedical Engineering, 1998, 5: pp 403-4. Collins CP, Wilson KJ, Collins PC. Lateral Pterygoid Myotomy with Reattachment to the Condylar Neck: An Adjunct to Restore Function After Total Joint Reconstruction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, June 2003 95(6): pp 672-3. Curry JT. TMJ Replacement in a Case of Failed Prosthesis and Severe Giant Cell Reaction. Private Hospital Healthcare Europe; Theatre & Surgery, 2003, pp T9-10. Curry JT. The Effects of Hemiarthroplasty Utilizing a Metal Fossa Prosthesis on the Mandibular Condyle: A Retrospective Review. TMJournal, 2001 (Vol. 1) Issue 1: pp 6-12. Curry J, Latta J. An Evaluation of Christensen TMJ Prostheses in 58 Consecutive Patients. Presented at AADR/IADR 1993 Meeting. Garabadian C, May BM, Saha S. Reducing Condylar Compression in Clenching Patients. TMJournal, 2001 (Vol. 1) Issue 1: pp 15-19.

Garrett WR, Abbey PA, Christensen R. Temporomandibular Joint Reconstruction with a Custom Total Temporomandibular Joint Prosthesis: Use in the Multiply Operated Patient. Surg Tech Intl VI, 1997. Garrett WR, Abbey PA. Protocol for the Treatment of Heterotopic Bone Formation in the Temporomandibular Joint. Surgical Technology International VIII,1999. Hensher R. TM Joint Hemi-Arthroplasty. TMJournal, 2002 (Volume 2) Issue 1: pp 10-13. Jungles, BS. Total Joint Reconstruction Utilizing the Christensen Prosthesis: A Preliminary Report. Poster 14: AAOMS Annual Meeting, 1990. Kummoona R. Functional Rehabilitation of Ankylosed Temporomandibular Joints. Oral Surg October 1978; 46 (4): pp 495-505. Lippincott III AL, Chase DC, Christensen RW. Alternative Total TMJ Arthroplasty: Metal-On-Metal for Longevity in Implant Survivorship and Patient Satisfaction. Surgical Technology International VII, 1998.


Lippincott III AL, Dowling JM, Medley JB, Christensen RW. Temporomandibular Joint Arthroplasty—Using Metal-on-Metal and Acrylic-on-Metal Configurations: Wear in Laboratory Tests and Retrievals. Surgical Technology International VIII,1999. Masters TE. Anatomical Modeling: An Imaging Technologist’s Perspective. TMJournal, 2002 (Vol. 2) Issue 1: pp 38-39. May B, Saha S. Animal Models for TMJ Studies: A Review of the Literature. TMJournal, 2001 (Vol. 1) Issue 1: pp 20-27. McKay E, Russell R, Christensen R, Curry J, Latta J, Gerard D, Hudson J, Chase D. Placement of a Christensen Fossa-Eminence Prosthesis in the Absence of the Meniscus. Presented at AADR/IADR 1993 Meeting. McKellop H. TMJ v. Orthopaedic Device / Materials Comparison. The Joint Replacement Institute at Orthopaedic Hospital Internal Paper. Los Angeles, 1999: pp 1-2. McLeod NMH, Saeed NR, Hensher R. Internal Derangement of the Temporomandibular Joint Treated by Discectomy and Hemi-Arthroplasty with a Christensen Fossa-Eminence Prosthesis. British Journal of Oral and Maxillofacial Surgery, 2001 39: pp 63-66. Park J, Keller EE, Reid KI. Surgical Management of Advanced Degenerative Arthritis of Temporomandibular Joint With Metal Fossa-Eminence Hemijoint Replacement Prosthesis: An 8-Year Retrospective Pilot Study. JOMS. February 2004 62: pp 320-8. Robbins JL. Rehabilitation after Temporomandibular Joint Surgery: A Review of the Literature and Guidelines for Practice. TMJournal, 2002 (Vol. 2) Issue 1: pp 39-41. Russell R, Christensen R, Curry J, Latta J, Gerard D, Robinson A, Hudson J, Chase D. Total TMJ Reconstruction With Alloplastic Prosthesis. Presented at AADR/IADR 1993 Meeting. Saeed NR, McLeod NMH, Hensher R. Temporomandibular Joint Replacement in Rheumatoid-Induced Disease. British Journal of Oral and Maxillofacial Surgery, 2001 39: pp 71-75. Speculand B, Hensher R. Powell D. Total Prosthetic Replacement of the TMJ: Experience with Two Systems 1988-1997. British Journal of Oral & Maxillofacial Surgery, 2000 38: pp 360-369. Stack BC, Gregory E, Gjerde G, Hanssen JI, Leivseth G. Modified Meiniscoplasty for Treatment of Chronic Disc Displacement without Reduction: 60 Patients; 117 Joints. TMJournal, 2002 (Volume 2) Issue 1: pp 23-32. Tawfillis A, Chappell ET, Farhood VW. Alloplastic Reconstruction of Temporal Bone and Glenoid Fossa Defect. JOMS, 2002 60: pp 1079-1082. TMJ Implants, Inc. Christensen TMJ Prosthesis System: The Product of Choice. Private Hospital Healthcare Europe; Theatre & Surgery, 2003, pp T 54. Woodbury SC, Stanton DC, Quinn PD, Beanland DR, Foote JW. Options for Immediate Reconstruction of the Traumatized Temporomandibular Joint. The Journal of Cranio-Maxillofacial Trauma, 1998 4(2): pp 22-29. Van Loon J, De Bont L, Boering G. Evaluation of Temporomandibular Joint Prostheses: Review of the Literature from 1946 to 1994 and Implications for Future Prosthesis Designs. J Oral Maxillofac Surg, 1995 53: pp 984-96. Xia JJ, Gateno J, Teichgraeber JF. Three-Dimensional Computer-Aided Surgical Simulation for Maxillofacial Surgery. Atlas Oral Maxillofacial Surg Clin N Am, 2005 13: pp 25-39. Christensen RW, Walker CR, Dollar JV. New Hope for Treacher-Collins Syndrome: A Surgical Case Report. Surgical Technology XIV, 2005.

Publisher and Distributor of Publisher and Distributor of The TMJournalThe TMJournal

Rocky Mountain TMJRocky Mountain TMJ Surgical ConferenceSurgical Conference

Golden, Colorado USAGolden, Colorado USA

Jerry V. Dollar, BA., MBA, FACHE Executive Secretary Rocky Mountain TMJ Surgical Conference Golden, Colorado USA [email protected] www.tmjournal.com (V) +1 303.277.1338 (F) +1 303.277.1421

For Additional Information, Contact:For Additional Information, Contact:

The Rocky Mountain TMJ Surgical Conference is Dedicated to The Rocky Mountain TMJ Surgical Conference is Dedicated to Advancing Knowledge in the Treatment of TMJ DisordersAdvancing Knowledge in the Treatment of TMJ Disorders

Would you like to see the Rocky Mountain TMJ Would you like to see the Rocky Mountain TMJ Surgical Conference conducted in your locale?Surgical Conference conducted in your locale?

Annual sessions are held in Golden, Colorado every January, however the Surgical Conference can come to you too! In the past 12 years we have conducted sessions in England, the Canary Islands, and all over the United States. We would be very pleased to discuss your specific needs.

RMTMJSC to Lecture and Assist RMTMJSC to Lecture and Assist Surgically in Three Spanish CitiesSurgically in Three Spanish Cities

In mid-February 2006, Robert W. Christensen, DDS, FAIMBE (Executive Director) and Jerry V. Dollar, MBA, FACHE (Executive Secretary) will represent the RMTMJSC in a series of lectures and surgeries to be conducted in Spain. Hosted by the Spanish OMS Association, three different venues will be available for the conferences. Madrid, Barcelona, and Seville are the scheduled locales for the educational effort.

The Spanish OMS community has been quick to adopt the advantages of alloplastic TMJ reconstruction and quite a number of these surgeries have already been performed in Spain. Attendees

are not only expected from the Spanish OMS Association, but also from different European cities. The RMTMJSC wishes to acknowledge the efforts of Juan Manuel Leguineche (TARMA Industrias Electromedicas, SA) and Florencio Monje, MD, PhD (Spanish OMS Association) in bringing this unique educational opportunity together. In the future, the RMTMJSC plans to conduct similar events in other countries as well.

First TMJWebLEARN First TMJWebLEARN Virtual ConferencesVirtual Conferences

Beginning in late March of this year, the RMTMJSC will have the capability to broadcast live lectures and seminars to any point in the world through its web site www.tmjournal.com. This will greatly enhance the ability to teach large numbers of surgeons with minimal cost. Your RMTMJSC is committed to sharing knowledge with all interested healthcare professionals at no cost. The first two conferences are scheduled for: March 27th - Dental School OMS Program Brasilia, Brazil April 4th - Mexican Dental Society Mexico City, Mexico If your university, association, society, or residency program would like to receive a virtual conference, please e-mail: [email protected] Include TMJWebLEARN in the subject line.

17301 West Colfax Avenue (V) +1 (303) 277-1338 Suite 135 (F) +1 (303) 277-1421 Golden, CO 80401 USA (E) [email protected]

Different? Yes!Different? Yes!

Better? Definitely!Better? Definitely!

A SCIENTIFICALLY INFORMATIVE PEER-REVIEWED PUBLICATION ...tarma.es/documentos/06_08_21_994.pdf ·...

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