In 2004, total alloplastic temporomandibular joint (TMJ) replacement began in the Czech Republic and Slovakia. This paper presents initial subjective and objective data compiled between 2005 and 2009 from those cases. Data were collected from 27 patients (38 joints) reconstructed with the Biomet-Lorenz stock and custom TMJ prostheses during a mean follow-up period of 24 months. The variables of pain and mouth opening were evaluated pre- and postoperatively. Patients classified pain on a scale of 0–5 (none – unbearable). The extent of opening was investigated by a physician (the distance between the points of the incisors on the upper and lower jaw was measured). The most common indication for replacement was ankylosis. There was an improvement in pain score in 15 patients. 4 patients reported worsening of pain and 8 patients did not complain of pre- or postoperative pain. Mandibular opening increased from a mean of 17.7 mm preoperatively to a mean of 29.1 mm postoperatively. There were complications related to the surgery, but no significant complications related to the devices. Total alloplastic TMJ replacement appears to be a safe and effective method of reconstruction in the patients in this initial study.
Total alloplastic temporomandibular joint (TMJ) replacement is a mechanical salvage solution for severe and debilitating biological joint disease. The goal of this surgery is the restoration of mandibular function and form. Indications for total alloplastic TMJ reconstruction are: ankylosis; inflammatory arthritic disease; pathology resulting in loss of posterior mandibular vertical dimension; multiple failed open TMJ surgeries; failed autogenous tissue TMJ reconstruction; and failed prior TMJ alloplastic replacements.The TMJ complex can be reconstructed using autogenous tissue or alloplastic devices. Recent literature demonstrates that for the above indications, alloplastic reconstruction provides more stable long-term results. The use of alloplastic devices eliminates the need for a second operated donor site and the potential for associated complications (e.g. pneumothorax, infection). It significantly reduces operating time and exposure to anaesthesia and allows immediate postoperative physical therapy. Relative contraindications to alloplastic TMJ replacement are: an immature facial skeleton; a compromising systemic disease (e.g. uncontrolled diabetes); psychoses; and uncontrolled para-functional mandibular habits.
The objective of this paper is to present the initial results of the use of total alloplastic TMJ replacement pooled from the cooperative efforts of the surgeons in Prague (Czech Republic) and Bratislava (Slovakia) between the implantation of the first device in 2004 and 2009.
Materials and methods
Between 2004 and 2009, 38 total alloplastic Biomet-Lorenz (Biomet Microfixation, Jacksonville, FL, USA) TMJ devices were implanted in 27 patients (16 unilateral, 11 bilateral). Stock devices were utilized in 34 cases. Custom Biomet-Lorenz devices, designed and manufactured from CT generated stereolithic models (Medical Modeling, Golden, CO, USA), were used in 4 cases (for planning orthognathic surgery and TMJ replacement in patients with congenital anomalies). The data set consists of 21 females (mean age 42.6 years), and 6 males (mean age 35.4 years).
Ankylosis was the diagnosis in 10 patients (15 joints); degenerative joint disease in 7 patients (11 joints); high inflammatory arthritis (rheumatoid disease) in 2 patient (3 joint); post-condylectomy (condylectomy as a surgical method for temporomandibular disorders) in 1 patient (1 joint); and congenital anomalies in 4 patients (condylar hypoplasia, 4 joints).
Pre-surgically, intra-operatively and 1 week postoperatively, antibiotics, penicillin or lincomycin, were administered intravenously. Steroids were also given for 3 days intravenously. In all cases, standard pre-auricular and retro-mandibular surgical approaches were used.
In all cases, the surgical procedure was the same. After inducing general anaesthesia, the first step was to introduce intermaxillary fixation screws (Biomet, W Lorenz, 2 mm in diameter and 7, 9 and 11 mm long). 5 screws were always introduced into the upper and lower jaw (the first molar region, premolar region and the region between the incisors).
The next step was to expose the condyle and zygomatic arch region (preauricular approach) and the mandibular ramus (retroangular approach). Both approaches were joined by tunnelling along the lateral surface of the mandibular ramus, followed by resection of the condylar process and coronoid process. The patient was placed in rigid intermaxillary fixation. The surface of the fossa and mandibular ramus were shaped to accept the components of the device using a bone bur. Subsequently the prosthesis components were fitted; the fossa (fixed with some screw to the zygomatic arch) and the condylar component (fixed to the mandibular ramus). The final step was to release the intermaxillary fixation, test the function of the prosthesis, irrigate and close the wounds. An autogenous fat graft was placed around the articulating components of the prosthesis in all cases of ankylosis to deter the formation of heterotopic bone.
Postoperative physical therapy was started on the second postoperative day, consisting of spontaneous mouth opening exercises for 2 weeks, progressing to finger pressure opening continued for 2 weeks and finally tongue blade exercises with masticatory muscle massage. Patients were followed at intervals of 2 weeks, 1, 3, 6 and 12 months postoperatively and yearly thereafter.
Patients reported their preoperative and postoperative pain scores on a scale of 0–5 (0 no pain; 5 worst pain imaginable). Maximum interincisal opening was measured and recorded in mm (preoperative and postoperative). X-rays were taken before surgery, then 2 weeks and 6, 12 and 24 months after surgery. CT imaging was only indicated in cases with postsurgical complications. The data was analysed by Wilcoxon signed ranks test.
The results are shown in Tables 1–3 . 38 joint replacements were carried out in 27 patients (16 patients underwent unilateral replacement, 11 underwent bilateral TMJ replacement).
|Men||28||R + L||A||8||27||0||0||Stock|
|Men||21||R + L||A||9||29||0||0||Stock|
|Female||18||R + L||A||4||27||0||0||Stock|
|Female||33||R + L||A||18||29||5||2||Stock|
|Female||36||R + L||A||5||25||3||3||Stock|
|Female||49||R + L||A||8||25||2||1||Stock|
|Men||21||R + L||A||20||28||0||0||Stock|
|Men||33||R + L||OA||30||37||4||0||Stock|
|Female||28||R + L||OA||15||25||3||3||Stock|
|Female||35||R + L||OA||32||38||5||2||Stock|
|Female||29||R + L||OA||25||23||4||5||Stock|
|Ankylosis||12 patients (19 TMJs)|
|Significant degenerative changes||8 patients (12 TMJs)|
|Congenital jaw anomalies related to condylar hypoplasia and aplasia||4 patients (4 TMJs)|
|Condylar resorption as a result of rheumatoid disease||2 patients (2 TMJs)|
|Condition after condylectomy||1 patient (1 TMJ)|