Evaluation of Alloplastic Reconstruction of Temporomandibular Joint Using Artificial Condyles

INTRODUCTION
Disturbances in temporomandibular joint functions
either due to acute or chronic problems is a
disabling condition that causes disturbances in
mastication, digestion, speech, cosmetics, social
communications and psychological stability [1].
It can also cause disturbance in craniofacial
growth in young patients and acute compromise
of airway due to shortening of posterior facial
height followed by retrogenthia which negatively
reflected on the width of the airway [1-4].
1
The indications for reconstruction of the Temporomandibular
Joint (TMJ) include ankylosis,
severe osteoarthritis, rheumatoid arthropathy, neoplastic
disease, posttraumatic dysfunction, and
congenital disease [5].
The aims of reconstruction include the restoration
of mandibular function and form, decreased
patient disability and suffering, and the prevention
of disease progression [6].
Various procedures for the treatment of temporomandibular
joint functional disturbances have
been described in the literature. These include gap
arthroplasty, interpositional gap arthroplasty, with
or without joint reconstruction using autogenous
grafts or alloplastic materials [7].
Alloplastic prosthesis have been used in treatment
of degenerative conditions and other functional
problems of temporomandibular joint either
due to, tumors, trauma, infections or iatrogenic [8].
A number of alloplastic materials and systems
have been developed for use in reconstruction of
the TMJ. Alloplastic joints are said to allow a
closer reproduction of the normal anatomy of the
joint (with restoration of vertical dimension),
avoidance of donor site morbidity, and reduction
in operation time and reduction in the chance of
recurrent ankylosis. All these factors allow immediate
physiotherapy and rehabilitation with consequent
increased benefit to the patient [9].
PATIENTS AND METHODS
Part of this study was one in Plastic Department,
Faculty of Medicine, Menoufia University Hospital.
It was done in the period from July 2009 to February
2018. All eighteen patients were treated surgically
by replacing the lost or affected condyle or
condyles either unilateral or bilateral using alloplastic
artificial condyles with or without using
reconstruction plate.
When mandibular body resection needed, autogenous
bone graft was used to compensate for
mandibular body resection in 2 patients.
All patients were subjected to history taking,
clinical examination, and laboratory investigations
and radiological in form panoramic X-ray cephalometric
studies and three dimensional CT scan.
Eight patients suffered from mandibular tumors
in form of ameloblastoma with wide destruction
of mandible extending in two cases to mandibular
body, in which we did mandibular body resection
and reconstructed with split bundle rib graft in
addition to alloplastic artificial condyle and reconstruction
plate.
Six cases suffered from trauma due to road
traffic accidents; two cases artificial condyles were
initially fixed directly on the ramus to compensate
for the fragmented destroyed condyle using mini
escrows 9mm. In the remaining four cases surgery
was done after long peroid from the time of trauma.
Two cases had iatrogenic temporomandibular
dysfunction due to disc removal as a treatment of
internal derangment, followed by limited mouth
opening and chronic pain, ankylosis occurred,
condylectomy done, reankylosis again, finally
treated with alloplastic artificial condyles.
Two cases with well formed bony ankylosis
with several operations as gap arthroplasty, interpositional
gap arthroplasty and costochondral grafts
with resorption reankylosis and finally treated with
alloplastic artificial condyles also in these cases
we need concomitant bimaxillary orthognathic
surgery to correct accompanying skeletal problems
due to longstanding ankylosis.
Surgical technique:
The operation was done under general anesthesia
with nasotacheal intubation, armored tube was
fixed using silk stich zero to the septum to avoid
slippage during surgery and pre-operative antibiotics
were given and continued for 10 days after
surgery.
Periauricular incision is used in cases which
needed condylar replacement only and submandibular
incision is done in cases we need to reconstruct
mandibular body in addition, in one case we used
periauricular incision with retro mandibular incision
in continuity. C-arm was used to predict the exact
position of condyles in cases in which we used
submandibular incision alone, the length of condyle
needed was determined after adjustment of occlusion
and securing the occlusion by IMF during
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fixation of artificial condyles, in cases we need to
put split bundle rib graft was fixed to reconstruction
plate 2.7 or 2.3mm by screws, suction drain was
inserted and removed after ten days, compression
bandage was left for first 72 hours. Patients with
longstanding ankylosis were subjected to program
of physiotherapy in form of insertion of gradually
increased tongue blades between anterior teeth for
gradual slow muscle elongation to alleviate pain
and to encourage normal mouth opening and painless
mastication, all patients were followed-up for
a period ranged from one to eight years.
RESULTS
The study was carried out on eighteen patients;
fourteen were females (77%), and four were males
(23%), age of patients ranged from eighteen years
to fifty two years with mean range (20.8). The
etiology of the complaint was after tumor resection
in 8 cases, post traumatic in 6 cases, iatrogenic in
2 cases and after ankylosis in 2 cases. Patient's
data were shown in (Table 1).
Table (1): Patients' data.
Characteristics (N=18)
Patient data
Sex:
Male
Female
Comorbidities:
Smoking
DM
Age (y.):
Mean
Median
Range
Etiology:
Post tumor excision
Post traumatic
Iatrogenic
Post ankylosis
Site:
Unilateral
Bilateral
No.
4
14
42
%
23
77
23
11.5
20.8
35
18-52
8622
14
4
Fourteen cases (77%) had unilateral alloplastic
condylar reconstruction and four cases (23%) had
bilateral alloplastic condylar reconstruction.
Regarding to post-operative complication; two
patients (11%) out of eighteen had limited infection
due to infected hematoma treated with broad spectrum
antibiotics and developed chronic sinus. One
case (5.5%) only developed slippage of the alloplastic
condyle. All patients had deviation to the
artificial condyle side in unilateral cases on maximum
mouth opening. Post-operative complication
data were shown in (Table 2).
Egypt, J. Plast. Reconstr. Surg., January 2020 3
All patients were seen 72 hours after surgery,
compression bandage is removed, wound is
checked, patient is assured that all pre-operative
complaints are gone and they suffered only from
wound pain, panoramic X-ray was done also to
check artificial condyles, also dental occlusion is
checked for any aberration, and patients were
checked every 4 weeks after that for the next six
months. The post-operative results were evaluated
as regards the subjective improvement of patients'
complaints and integrity of reconstruction and
condyle position in the glenoid fossa.
Table (2): Post-operative complications data.
Post-operative complications data Characteristics
N=18
Hematoma
Wound infection
Chronic sinus
Slippage of the condyle
Wound dehiscence
Duration of hospital stay (in days)
No.
2
2
2
1
0
%
11
11
11
5.5
0
3
Fig. (1C): Post-operative 3D CT. Fig. (1D): Late post-operative photo of the patient.
Case demonstration:
Patient 1: A 23 years female patient, committed
suicide with multiple body bony fractures and
comminuted fracture left condyle, artificial condyle
was fixed to the remaining part of ramus after
excision of comminuted condyle after adjustment
of occlusion by IMF, Fig. (1).
Patient 2: A50 years male patient with longstanding
ameloblastoma extending from the right
condyle to the ipsilateral first molar, resection was
done to all affected bone through wide submandibular
incision and reconstruction was done using
artificial condyle with reconstruction plate and
split bundle rib graft to replace the resected mandibular
body, infection occurred in the tenth day
due to presence of hematoma, Fig. (2).
Patient 3: A 30 years female patient was complaining
of pain in TMJ due to chronic internal
derangement was treated by bilateral discectomy
followed by TMJ ankylosis, patient was also treated
with gap arthroplasty, interpositional gap arthroplasty,
and finally with bilateral alloplastic condylar
reconstruction, Fig. (3).
Fig. (1A): Pre-operative 3D CT. Fig. (1B): Pre-operative coronal CT cut.
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Fig. (2A): The artificial condyle used for the patient. Fig. (2B): Autogenously bone graft was used to compensate
for mandibular body resection.
Fig. (2C): Intraoperative photo showing the incision and
reconstruction plate.
Fig. (2D): Intraoperative photo by C-arm.
Fig. (2E): Post-operative panorama X-ray. Fig. (2F): Late post-operative photo of the patient.
Egypt, J. Plast. Reconstr. Surg., January 2020 5
DISCUSSION
Different types of operations for the management
of TMJ ankylosis have been described in
literature including; gap arthroplasty, interpositional
gap arthroplasty and joint reconstruction [10].
There is no agreed treatment described, and
results have often be variable and less than satisfactory,
gap arthroplasty including condylectomy
is a simple method with a short operating time,
whoever, the disadvantages are many, including
the creation of pseudo articulation, a short ramus,
failure to remove all the bone pathology, increased
risk of re ankylosis, and lack of functional restoration
of the joint [10]. In addition, complications
include the development of an open bite in bilateral
cases, premature occlusion on the affected side,
open bite on the contrary side in unilateral caser
and suboptimal post-operative range of motion for
these reasons, GA has largely been abandoned for
the treatment of TMJ ankylosis [11].
The interpositional gap arthroplasty IPG, autogenous
or alloplastic materiales are placed at the
osteotomy site to prevent recurrent ankylosis, the
various autogenous materials that can be used as
interpositional material include a TMF, fascia lata,
auricular cartilage, dermis and full thickness flap.
The temporalis muscle is the most widely used
among the interpositional materials due to dependable
blood supply, proximity to the temporal joint,
good functional results, minimum risk of facial
paralysis, successful clinical results and minimal
complications.
The various autogenous materials that can be
used for reconstruction of the joint are costochondral
graft, rib graft, second and fourth metatarsal
bones, sternoclavicular joint, ulnar head, clavicular
bone, fibula and iliac bone. Advantages of costchondral
rib grafts include biological compatibility,
workability; the growth potential of CCG makes
it the ideal choice in children, while its advantages
Fig. (3A): Pre-operative photo show limited mouth opening.
Fig. (3B): Intraoperative photo showing artificial condyle in
place.
Fig. (3C): Post-operative panorama showing bilateral artificial
condyle.
Fig. (3D): Post-operative photo showing the improvement of
mouth opening.
include; fracture, re ankylosis, increased operating
time, additional donor site morbidity and potential
overgrowth of the graft and suboptimal postoperative
range of motion [9].
To avoid these problems, a number of alloplastic
materials have been developed of TMJ reconstruction.
Allopplastic joints or condyles allow restoration
of posterior facial height, no additional site
morbidity, short operative time and mostly no
recurrence of ankylosis, however there are disadvantages
of alloplastic condyles include increased
risk of infection. Slippage wear or failure of material,
high cost and no future growth so it is not
suitable for growing children [12].
We have presented our experience of the use
of single stage technique for the replacement of
the damaged TMJ with alloplastic artificial condyle
with or without reconstruction plate, there was a
considerable follow-up time, despite the presence
of infection in two cases we did not have any
serious complications. Most of the patients tolerated
the alloplastic condyle with minimal mouth deviation
to the reconstructed side in unilateral cases,
only we had one case that she developed slippage
of prosthesis posteriorly in one side due to lack of
patient compliance and also there was some dental
ocular interference, treated with some teeth grinding
physiotherapy, patient restored normal range of
movement and pain disappeared in spite of persistent
slippage of artificial condyle. A single stage
procedure is beneficial to the patient and to the
community as it is cost-effective alternative to two
stages technique. Other single stage techniques
that have been described require the use of expensive
surgical navigation equipment's.