Alloplastic total joint replacement in management of temporomandibular joint ankylosis

Evolution of temporomandibular joint reconstruction: from autologous tissue transplantation to alloplastic joint replacement

The reconstruction of the temporomandibular joint presents a multifaceted clinical challenge in the realm of head and neck surgery, underscored by its relatively infrequent occurrence and the lack of comprehensive clinical guidelines. This review aims to elucidate the available approaches for TMJ reconstruction, with a particular emphasis on recent groundbreaking advancements. The current spectrum of TMJ reconstruction integrates diverse surgical techniques, such as costochondral grafting, coronoid process grafting, revascularized fibula transfer, transport distraction osteogenesis, and alloplastic TMJ replacement. Despite the available options, a singular, universally accepted 'gold standard' for reconstructive techniques or materials remains elusive in this field. Our review comprehensively summarizes the current available methods of TMJ reconstruction, focusing on both autologous and alloplastic prostheses. It delves into the differences of each surgical technique and outlines the implications of recent technological advances, such as 3D printing, which hold the promise of enhancing surgical precision and patient outcomes. This evolutionary progress aims not only to improve the immediate results of reconstruction but also to ensure the long-term health and functionality of the TMJ, thereby improving the quality of life for patients with end-stage TMJ disorders.

Indications for the Use of TMJ Prostheses in South America

Since the 1960s, various surgical procedures have been developed to treat the temporomandibular joint (TMJ) disease, including stock or customized prostheses for severe TMJ diseases. Understanding the appropriate indications and timing for joint replacement is crucial for evaluating the prognosis of the treatment. This study sought to identify the indications for joint replacement surgery in three countries in Latin America and to determine characteristics associated with its surgical planning. The study was conducted by interviewing surgeons who performed surgery on patients using customized TMJ prostheses between 2022 and 2024 and who had surgical planning under the same protocol. Only preoperative information related to the indication and complementary procedures related to the customized prosthesis was used, comprising 133 subjects, 41 male subjects (30.82%) and 92 female subjects (69.17%), with significant differences. Degenerative TMJ disease presented the highest indication for replacement with 47 (35.33%) cases, followed by malformations with 26 (19.54%), ankylosis with 22 (16.54%), TMJ deformity by trauma sequelae with 20 (15.03%) and replacement by another joint prosthesis 18 (13.53%). We found a significant correlation between indications and the use of orthognathic surgery in some diseases (P<0.001). In 72.34% of subjects with degenerative disease, orthognathic surgery with bilateral prosthesis was indicated. In subjects with facial malformation, orthognathic surgery with unilateral prosthesis was indicated in 76.92%. We can conclude that female subjects are more common than male subjects in the treatment with TMJ replacement. TMJ prostheses presented the highest indication in degenerative TMJ disease, and they were significantly related to orthognathic surgery.

Utilization of Alloplastic Prostheses in the Extended Reconstruction of the Temporomandibular Joint: A Review of the Literature

Extended temporomandibular joint reconstruction (eTMJR) can be described as a refined approach to conventional temporomandibular joint reconstruction (TMJR) designed to address both the articulating components of the TMJ and associated mandibular segmental defects or defects in the skull base. Extended temporomandibular joint reconstruction (eTMJR) combined with the advancement in VSP not only offers improved functional and esthetic outcomes but also signifies a significant leap forward in the realm of TMJR interventions. In comparison to autogenous grafts, alloplastic pro$stheses exhibit superior outcomes concerning MIO, pain management, and dietary functionality, underscoring their potential as the preferred treatment modality. This review article showcases an in-depth exploration of eTMJR, covering its classifications, indications, contraindications, advantages, disadvantages, complications, virtual surgical planning (VSP), criteria for successful alloplastic devices, and the surgical approach.

Viable Vitreous Grafts of Whole Porcine Menisci for Transplant in the Knee and Temporomandibular Joints

The shortage of suitable donor meniscus grafts from the knee and temporomandibular joint (TMJ) impedes treatments for millions of patients. Vitrification offers a promising solution by transitioning these tissues into a vitreous state at cryogenic temperatures, protecting them from ice crystal damage using high concentrations of cryoprotectant agents (CPAs). However, vitrification's success is hindered for larger tissues (>3 mL) due to challenges in CPA penetration. Dense avascular meniscus tissues require extended CPA exposure for adequate penetration; however, prolonged exposure becomes cytotoxic. Balancing penetration and reducing cell toxicity is required. To overcome this hurdle, a simulation-based optimization approach is developed by combining computational modeling with microcomputed tomography (µCT) imaging to predict 3D CPA distributions within tissues over time accurately. This approach minimizes CPA exposure time, resulting in 85% viability in 4-mL meniscal specimens, 70% in 10-mL whole knee menisci, and 85% in 15-mL whole TMJ menisci (i.e., TMJ disc) post-vitrification, outperforming slow-freezing methods (20%-40%), in a pig model. The extracellular matrix (ECM) structure and biomechanical strength of vitreous tissues remain largely intact. Vitreous meniscus grafts demonstrate clinical-level viability (≥70%), closely resembling the material properties of native tissues, with long-term availability for transplantation. The enhanced vitrification technology opens new possibilities for other avascular grafts.

Assessment of Long-Term Effects and Patient Satisfaction following TMJ Disc Replacement Surgery

Objectives

The purpose of this research is to evaluate patient satisfaction and long-term consequences after temporomandibular joint (TMJ) disc replacement surgery in a tertiary care environment.

Methods

500 patients who had TMJ disc replacement surgery at a tertiary care facility between 2010 and 2015 were the subject of a retrospective investigation. Pre-operative clinical features, demographic information, and intraoperative information were gathered. Standardized measurements were used to evaluate functional results, pain levels, and patient-reported outcomes. Descriptive statistics, paired t-tests, and significance set at P < 0.05 were all used in the statistical analysis.

Results

There were notable improvements in functional outcomes, with a mean increase in lateral excursion from 8.7 mm to 12.6 mm (P < 0.001) and maximal incisal opening from 30.5 mm to 40.2 mm (P < 0.001). The pain level was found to have greatly diminished, as evidenced by the VAS scores falling from 7.8 to 3.2 (P < 0.001). The Jaw Function Limitation Scale scores (42.6 to 21.8, P < 0.001) and patient-reported outcome measures scores (58.3 to 76.5, P < 0.001) exhibited significant increases in patient-reported outcomes.

Conclusion

In conclusion, tertiary care TMJ disc replacement surgery shows positive long-term outcomes, such as enhanced jaw function, less discomfort, and high patient satisfaction. This research supports the ongoing use of TMJ disc replacement surgery as a potential therapy for refractory TMJ disease, although noting its limitations.

Temporomandibular joint re-ankylosis: a case report and literature review

Re-ankylosis is a common postoperative complication of temporomandibular joint (TMJ) ankylosis surgery. Various surgical options to prevent reankylosis, both with and without interpositional material, have been discussed in the literature. However, no standardized protocol has been suggested for management or prevention of TMJ ankylosis. This paper discusses the probable causes behind TMJ re-ankylosis and presents a case of unilateral TMJ re-ankylosis, which was managed by gap arthroplasty using an autologous abdominal dermal fat graft as an interpositional material and closely monitored for signs of relapse. Autologous fat graft acted as an effective barrier between the glenoid fossa and mandibular condyle, thus preventing dead space, hematoma and heterotrophic bone formation. A brief review of the literature and update on TMJ re-ankylosis are also presented.

Management of bilateral temporomandibular joint ankylosis using bilateral custom alloplastic temporomandibular joint prosthesis and genioplasty: A case report

INTRODUCTION AND IMPORTANCE

Temporomandibular joint (TMJ) ankylosis can be effectively managed through the utilization of autogenous grafts or alloplastic TMJ prostheses. Alloplastic TMJ prostheses are available in two forms: stock or custom. Custom alloplastic TMJ prostheses represent an emerging treatment modality for TMJ ankylosis.

PRESENTATION OF THE CASE

A 47-year-old female patient presented with a 30-year history of complete inability to open her mouth, chew, speak, and be on a liquid diet. Bilateral TMJ ankylosis and a nine mm right-sided chin deviation were noted. A bilateral osteoarthectomy was performed, followed by reconstruction of the TMJ using a custom alloplastic TMJ prosthesis via an extended preauricular and submandibular approach. The abdominal fat pad was utilized for interposition to prevent recurrence. Genioplasty was carried out through a vestibular approach, shifting the chin nine mm to the left. Postoperatively, the patient achieved a 30 mm mouth opening, and correction of facial asymmetry resulting from chin deviation was observed.

CLINICAL DISCUSSION

Treatment options for TMJ ankylosis include autogenous grafts and alloplastic materials. Autografts have limitations such as prolonged surgery, resorption, undergrowth/overgrowth, donor site morbidity, and graft fracture. Stock alloplastic TMJ prostheses may not suit all patients due to anatomical variations. Thus, custom alloplastic TMJ prostheses have emerged as the preferred treatment modality for adult TMJ ankylosis.

CONCLUSION

Custom alloplastic TMJ prostheses are considered an optimal treatment modality for reconstructing the TMJ in adult patients with TMJ ankylosis.

Total temporomandibular joint replacement in recurrent temporomandibular joint ankylosis: a case report

Total temporomandibular joint replacement (TMJR) is a surgical procedure in which end-stage temporomandibular joint disorders are replaced with an alloplastic prosthesis between the mandible and the base of the skull when autogenous grafts are inadvisable. These alloplastic prostheses may be available as stock or custom-made prostheses consisting of the mandibular condyle and glenoid fossa components. Although the first total temporomandibular joint prosthesis was used in the 1960s, we present the case of a 20-year-old female patient, probably the first case of total temporomandibular joint arthroplasty in Nepal, performed at Dhulikhel Hospital in Kavrepalanchok. The patient underwent bilateral TMJR with a custom joint prosthesis for recurrent TMJ ankylosis. Postoperatively, the patient noticed significant improvements in mouth opening, chewing ability, facial esthetics and, most importantly, her self-esteem and confidence.

Total Alloplastic Temporomandibular Joint Replacement

Purpose

End-stage temporomandibular joint (TMJ) disease are not uncommon and affects quality of life. Multiple surgical procedures have been mentioned in literature for management of TMJ disease which ranges from conservative management to aggressive resection of involved joint and replacement with alloplastic total joint prosthesis. The purpose of the present paper was to provide an overview of the role of alloplastic total joint prosthesis in TMJ replacement.

Methods and results

Alloplastic total joint prosthesis is nowadays considered as a standard of care in the adult patients who require TMJ replacement. The requirement of alloplastic total prosthesis has increased in present era with the improvement in design and material of implants, surgical skills and reported victorious outcome along with improved quality of life after its use. It provides restoration of form and functions, improvement in quality of life, reduction in pain and maintenance of ramal height. Additionally, in TMJ ankylosis it reduces chances of re-ankylosis and allows facial asymmetry correction. Currently, enough evidence is however not available for replacement in skeletally immature patient.

Conclusion

The authors conclude that the total joint replacement is a standard procedure for end-stage TMJ disease. Every maxillofacial surgeon should be well-acquainted with TMJ replacement.