Alloplastic Temporomandibular Joint Replacement Research Articles

Temporomandibular joint alloplastic replacement failure

Temporomandibular joint disorders are common, with alloplastic temporomandibular joint replacement (TMJR) being one method of addressing chronic pain and movement limitations that cannot otherwise be managed. Despite this, TMJR has known complications that can lead to failure. We present our experience of managing these cases and review the current evidence on the management and outcomes of alloplastic TMJR failures. Until 2015 our unit regularly used Dundee full metal prostheses, and encountered multiple issues such as infection, heterotopic bone formation, and progression of osteoarthritis beneath the condylar element. We also present our experience with other standard TMJR implants. One common cause of failure we observed is improper placement of a prosthesis due to poor technique, for instance, placement of the fossa implant too close to the ear canal can cause unresolved postoperative pain. There is no consensus on the management of TMJR, but non-surgical measures are preferred initially and surgical intervention is reserved for later stages. Recently our unit has managed numerous failure cases, employing a multidisciplinary approach combined with thorough preoperative planning and postoperative care, which has proven effective in reducing complications and improving outcomes. Based on our experience, we do not recommend the use of Dundee full metal prostheses for TMJR. Appropriate training in the placement of contemporary implants remains crucial. Suboptimal alignment of the implant in some cases does not need surgical intervention, but surgical management is justifiable in cases of persistent symptoms and functional limitations. When placing stock implants or designing a custom-made implant for an adult, we recommend that the posterior edge of the fossa component is at least 3 mm away from the bone of the ear canal.

Influence of preoperative anatomy and functional status on outcomes after total temporomandibular joint replacement with patient-specific endoprostheses: A retrospective cohort study.

Temporomandibular joint (TMJ) replacement may be indicated for various pathological conditions, and the type of condition can affect the surgical procedure and outcomes. The causes of limited range of motion after alloplastic TMJ replacement have not been extensively studied. The present study aimed to evaluate the impact of preoperative jaw anatomy and functional status on the immediate and long-term outcomes of total TMJ replacement using a two-component patient-specific TMJ endoprosthesis. This retrospective study included 31 patients who underwent total TMJ replacement surgery between 2016 and 2020. The main outcome variable was the maximal incisal opening (MIO) after treatment. Secondary outcome variables included MIO improvement and the presence and type of postoperative complications. The primary predictive variable was the preoperative initial MIO. Secondary predictive variables included sex, age, indications for TMJ replacement, preoperative occlusion, condition of the glenoid fossa and/or condyle, shortening of the mandibular ramus, sagittal mandible position, lateral chin deviation, shape of the coronoid process, and type of surgery. The mean preoperative MIO was 13.0 ±8.0 mm, while the mean MIO 1 month after surgery was 20.6 ±5.5 mm, which was not statistically significant. However, at a later follow-up, functional parameters showed a significant improvement (p = 0.003), with a mean MIO of 32.5 ±5.0 mm 3 years after surgery. Statistical analysis indicated that the initial mouth opening is the strongest predictor of long-term functional recovery after TMJ replacement. Postoperative complications occurred in 4 cases (12.9%) following patient-specific endoprosthesis (PSE) placement. The use of PSEs for TMJ replacement has enabled the restoration of anatomical relationships in complex clinical cases and an improvement in mouth opening. The preoperative MIO was the only factor that significantly influenced long-term functional outcomes.

Antibiotic prophylaxis in alloplastic temporomandibular joint replacement surgery: A multi-national survey of temporomandibular joint surgeons

Temporomandibular disorders include a wide spectrum of extra-articular and intra-articular conditions affecting the temporomandibular joint (TMJ). In salvage cases involving intra-articular end-stage disease, alloplastic temporomandibular joint replacement (TMJR) is a management option which can be utilised to rehabilitate a disabled joint’s function and form. Whilst post-TMJR infection is rare, it is one of the most serious complications. The principles governing TMJR surgery antibiotic prophylaxis have been based on those established in orthopaedic surgery literature. Antibiotic resistance due to antibiotic over-use is a significant concern, therefore antibiotic stewardship has been developed to deal with this world-wide public health concern. The TMJ’s anatomical proximity to the external auditory canal and oral cavity creates the potential for bacterial contamination. The aim of this study was to explore the views of 39 sub-specialist TMJ surgeons across nine nations usual approach to antibiotic prophylaxis and their management of TMJR infection. To accomplish this, an international survey was developed and conducted using Google Forms. The results demonstrated that 97.4% of the respondents employ prophylactic antibiotics at TMJR surgery, 83.8% on discharge. Variability in antibiotic choice with additional antimicrobial perioperative practices were also reported. Opinions on the management of a TMJR infection also varied. This survey establishes there is an agreement on the use of antibiotic prophylaxis, However the variability in choice, timing, course, duration of antibiotic use as well as the management of a postoperative TMJR infection demonstrates the need for further study leading to development of standardised antibiotic prophylaxis and infection management protocols for TMJR surgery.

Hybrid total alloplastic temporomandibular joint replacement prosthesis: a pilot study to evaluate feasibility, functional performance and impact on post-operative quality of life.

The aim of the present study was to investigate the clinical efficiency of hybrid alloplastic temporomandibular joint (TMJ) prosthesis in patients undergoing TMJ total alloplastic joint replacement (TMJR). The prosthesis utilized for this study for TMJR is a hybrid variant with combination of stock prototype design and a partial customization of components. A prospective clinical study was conducted involving five patients with unilateral TMJ ankylosis or end-stage joint disease (ESJD) indicated for and requiring TMJR. The patients underwent resection of the joint or gap arthroplasty followed by TMJR using the hybrid alloplastic TMJ prosthesis. The subjective and objective variables that included the jaw function (JF), inter-incisal opening (IO), diet intake (DI) and quality of life (QoL) were assessed using the psychometric modified Likert scale. The nutritional status of the patients was evaluated using the mid-upper arm circumference (MUAC) as reference. The assessed study variables demonstrated functional and observational improvement in the post-operative follow-up when compared to the pre-operative period. The patients showed an improvement in overall QoL and nutritional status post-operatively. The follow-up period showed subjective and objective improvement in the parameters assessed among the study population. There is a technical and clinical feasibility to utilize the hybrid alloplastic TMJ prosthesis as a reliable alloplastic option for treating patients requiring TMJR, with prudent indications.

The role of alloplastic temporomandibular joint (TMJ) replacement in the management of condylar resorption—a narrative review of the literature

The role of alloplastic temporomandibular joint (TMJ) replacement in the management of condylar resorption—a narrative review of the literature

Arthritic diseases: an indication for alloplastic temporomandibular joint replacement

Arthritic diseases: an indication for alloplastic temporomandibular joint replacement

Indications for alloplastic temporomandibular joint replacement in maxillofacial surgery for benign lesions: a review of the literature and clinical cases

Indications for alloplastic temporomandibular joint replacement in maxillofacial surgery for benign lesions: a review of the literature and clinical cases

Considerations for the Use of Alloplastic Temporomandibular Joint Replacement in Irradiated Patients: Report of an Off-Label Indication.

Custom-made alloplastic temporomandibular joint replacement (ATMJR) is not validated in irradiated patients. However, in specific situations, after previous reconstructive surgical failures, the authors hypothesized the role of a customized ATMJR after radiotherapy. A 65-year-old male patient was referred to Instituto Português da Face-Lisbon, Portugal-after failed attempts of mandibular reconstruction secondary to oral carcinoma resection and partial hemi-mandibulectomy plus radiotherapy of 60 total Grays. Primary reconstruction was performed with fibula free flap. Due to failure, secondary reconstructions were performed with osteosynthesis plate without success. The patient was unable to have adequate mastication and deglutition due to a severe crossbite. The authors treated the patient with an extended customized alloplastic temporomandibular joint replacement (F0M2). With 3 years of follow-up, the patient showed an improvement in masticatory function, mandibular motion, pain levels, and overall quality of life. No complications were observed related to ATMJR. The presented case described how ATMJR, although not a validated option after radiotherapy, can be considered to restore functionality in complex cases with bone and soft tissues problems.

Alloplastic temporomandibular joint replacement – past, present, and future: “Learn from the past, prepare for the future, live in the present.” Thomas S. Monson

Based on evidence from the orthopaedic, biomedical engineering, and oral and maxillofacial surgical literature, this paper discusses reported successes and failures of past alloplastic temporomandibular joint (TMJ) devices that have led to the development of present total temporomandibular joint replacement (TMJR) devices. The paper concludes with discussion of the ongoing research that will lead to future embodiment (materials, designs, and manufacture) advances in TMJR management of severe and debilitating end-stage TMJ disease, further improving patients’ mandibular function, form, and overall quality of life.

Concomitant Temporomandibular Joint Replacement and Orthognathic Surgery.

The treatment of patients with severe temporomandibular joint (TMJ) disorders and associated skeletal discrepancies presents a complex challenge for oral and maxillofacial surgeons. It is widely recognized that TMDs can impact the stability and outcomes of surgical treatments for dentofacial deformities. Consequently, addressing TMDs prior to or in conjunction with orthodontic or surgical interventions may be necessary to achieve optimal and long-lasting results. Alloplastic temporomandibular joint replacement (TMJR) and orthognathic surgery have emerged as the standard approach due to their predictability, long-term stability and excellent outcomes when addressing end-stage TMJ disease in conjunction with DFDs as it provides a comprehensive solution to address both functional and aesthetic aspects of these patients' conditions. Understanding the appropriate utilization of TMJR in conjunction with orthognathic surgery can lead to improved treatment planning and successful outcomes for patients with complex TMJ disorders and associated dentofacial deformities. This review aims to discuss the indications, preoperative evaluation, staging, sequencing, and surgical considerations involved in utilizing alloplastic TMJ replacement in the presence of dentofacial deformities.

Indications for alloplastic temporomandibular joint replacement in maxillofacial trauma—an analysis of condylar trauma patients with scoping review of the literature

Andreas M. Neff, Niall M. H. McLeod, Jonas P. Jung, Clarissa S. Reichert, Christopher Schmidt

TMJ Ankylosis Following Mandibular Distraction Osteogenesis: Management With Simultaneous Midface External Distraction and Bilateral Temporomandibular Joint Replacement.

Early mandibular distraction osteogenesis (MDO) can decrease upper airway and feeding complications in pediatric patients with micrognathia; however, temporomandibular joint (TMJ) complications like TMJ ankylosis (TMJA) may occur. TMJA can disturb pediatric patients' function and craniofacial growth, resulting in significant physical and psychosocial consequences. Additional surgical procedures may also be required, increasing the burden of care on patients and their families. CMF surgeons must discuss the potential complications of early MDO surgery with families as well as potential solutions should these problems occur. This report presents the case of a 17-year-old male with a severe craniofacial anomaly with features of Treacher-Collins syndrome (TCS) and a surgical history of tracheostomy, cleft palate repair, mandibular reconstruction with harvested costochondral grafts, and MDO with resultant bilateral TMJA and limited mouth opening. The patient Was treated with bilateral custom alloplastic TMJ replacements and simultaneous maxillary DO using a Rigid External Distraction (RED) device.

An evaluation of clinical outcome of total alloplastic temporomandibular joint replacement and costochondral graft in temporomandibular joint ankylosis cases – A retrospective study

Background: The temporomandibular joint (TMJ) ankylosis management incorporates various modalities. Total alloplastic temporomandibular joint replacement (TJR) has opened a new avenue in TMJ reconstruction. Costochondral grafts (CCGs) are the gold standard treatment option. Aim: This study was designed to compare the clinical outcome between total alloplastic TJR and CCG in TMJ ankylosis cases. Materials and Methods: The retrospective data of patients were collected between 2017 and 2020. A total of 12 TJR cases and 8 cases of CCG were included in the study. Maximum mouth opening was recorded in mm and pain score/diet score was recorded on a Visual Analog Score system where 0 was no pain/normal diet and 10 was worse pain/liquid diet. The data were statistically analyzed using the “two-sample t-test (Welch's t-test).” Results: The mean interincisal opening in the TJR group was 32.67 (±2.19) and in the CCG group was 33.71 (±4.77). The pain reduction score was better in the TJR group with 0.5 (±0.90) and the diet score was better in the CCG group with 0.714 (±0.95). Conclusion: The stock TJR devices have a predictable outcome with a good pain reduction score and an acceptable diet score; however, the autogenous CCG is still better in terms of maximum mouth opening. Although failed CCG cases can be taken up for further correction with the TJR.

Concomitant Microvascular Aided Extended Temporo-Mandibular Joint Replacement (ME-TJR) and Stock Temporo-Mandibular Joint Replacement (MS-TJR) During Mandibular Reconstruction.

Disarticulation is indicated when pathologic process involves the condyle or when a body/ramus lesion extends into condylar process. The goal of reconstruction is to reinstate joint mechanism for function and also to restore facial symmetry. Retrospective evaluation of functional and aesthetic outcomes in patients with disarticulation defects of mandible treated with concomitant alloplastic temporomandibular joint replacement and microvascular free flap reconstruction. Nine patients (8 benign pathologies and 1 secondary reconstruction for malignant neoplasm), who underwent mandibular resection with condylar disarticulation and reconstruction with Free microvascular flap and Alloplastic total joint replacement between 2015 and 2022 were included in the study. A modified functional intra-oral Glasgow scale(FIGS)2 was used for quality of life (QOL) scoring. Speech, mastication, swallowing, VAS pain score, mouth-opening, occlusion, facial symmetry and overall patient satisfaction were assessed. 8 patients with benign pathology reported excellent outcome with a QOL score of 13-15 in terms of speech, chewing and swallowing. Pre-operative occlusion of native mandible was maintained in all dentulous patients. VAS score of 0-1 was reported. Mouth opening was adequate in all patients. 2 patients reported mild ipsilateral deviation of mandible. Mild facial asymmetry was reported by 2 patients with an overall satisfaction of 8-9. There were no significant intra/post-operative complications in patients with benign pathology. Failure of stock joint was observed in secondary reconstruction for malignant neoplasm. Microvascular free flap aided stock or custom alloplastic replacement of temporomandibular joint (MS-TJR, ME-TJR) restores function and aesthetics following mandibular resection with disarticulation of condyle.

Stresses, friction, and wear on different materials and design for temporomandibular joint total joint replacement (TMJ TJR)

The purpose of the present study was to evaluate the coefficient of friction, wear volume, surface damage, and contacting stresses regarding different materials and condyle design for alloplastic temporomandibular joint total joint replacement (TMJ TJR). Spherical- and anatomical-shape condyle specimens were prepared from CoCrMo or Ti6Al4V alloys which were assessed against ultra-highly molecular weight polyethylene (UHMWPE) square specimens. On the wear assessment, reciprocating sliding pin-on-plate wear tests were performed considering usual TMJ TJR motion on 30 N normal loading, 1 Hz sliding frequency, and 4-mm linear stroke length for 60 min. Wear tests were performed in Ringer’s solution at 37o C to mimic the surrounding environment. The coefficient of friction and wear volume were recorded for the two condyle design and materials’ pairs. The von Mises stresses and displacement were calculated using a 3D finite element model (FEM) simulation built on tetrahedral linear elements, performed relatively to the condyle-to-UHMWPE central axis. On anatomical TMJ TJR condyle, von Mises stresses were lower when compared to standard TMJ TJR condyle. Wear tests showed a low wear volume of UHMWPE against Ti6Al4V although the volume loss recorded for UHMWPE was lower on the anatomical-shape condyle than that for the spherical design. Scanning electron microscopy revealed plastic deformation on the UHMWPE resulting in ploughing and materials’ degradation after wear testing. Thus, an anatomical TMJ TJR condyle design revealed lower stress distribution and wear volume when compared to a standard TMJ TJR condyle that could improve the long-term mechanical integrity of TMJ TJR over cyclic loading.

Is Heterotopic Ossification Removal From Alloplastic Temporomandibular Joint Prosthesis Using Er,Cr:YSGG Laser Superior to Conventional Methods?

Heterotopic ossification (HO) formed over the major components and fixation screw heads of an alloplastic temporomandibular joint replacement (TMJR) prosthesis can result in decreased quality of life, limited function, prosthesis failure, and hinder prosthesis revision, replacement, or removal. This study simulated HO removal from the major components and fixation screw heads of alloplastic TMJR prostheses using an erbium, chromium-doped yttrium, scandium, gallium, and garnet (Er,Cr:YSGG) laser and compared the results to conventional methods of HO removal. The surface morphology and chemical structure of the exposed components were analyzed. The investigators hypothesize that HO removal with an Er,Cr:YSGG laser causes less damage to TMJR prosthesis components compared to conventional HO removal methods. This multiple test descriptive analysis simulated HO removal from TMJR prostheses mounted to stereolithic models. Simulated HO removal was completed using a novel Er,Cr:YSGG laser method and conventional methods which utilized a fissure carbide bur in a high-speed rotary instrument, a standard osteotome, and an ultrasonic aspirator. Surfaces exposed on the TMJR prostheses were analyzed for morphological or chemical change using scanning electron microscopy, energy dispersive X-ray spectroscopy, and Raman spectroscopy. The Er,Cr:YSGG laser did not adversely affect the titanium screws or titanium components of the TMJR prostheses, while conventional methods of HO removal did. HO removal using the Er,Cr:YSGG laser and conventional methods both inflicted surface damage to the fossa ultrahigh molecular weight polyethylene component of the TMJR prostheses. Damage inflicted to titanium alloy or commercially pure titanium components of TMJR prostheses by conventional HO removal methods can be avoided by instead removing HO with an Er,Cr:YSGG laser. However, long exposure of the Er,Cr:YSGG laser to ultrahigh molecular weight polyethylene surfaces should be avoided. Additional research to expand on applications to other procedures and in other surgical fields is encouraged.

Is Heterotopic Ossification Removal from Alloplastic Temporomandibular Joint Prosthesis Using Er,Cr:YSGG Laser Superior to Conventional Methods?

Heterotopic ossification (HO) formed over the major components and fixation screw heads of an alloplastic temporomandibular joint replacement (TMJR) prosthesis can result in decreased quality of life, limited function, prosthesis failure, and hinder prosthesis revision, replacement, or removal. This study simulated HO removal from the major components and fixation screw heads of alloplastic TMJR prostheses using conventional methods versus HO ablation with an erbium, chromium-doped yttrium, scandium, gallium and garnet (Er,Cr:YSGG) laser.

Heterotopic ossification after alloplastic temporomandibular joint replacement: a case cohort study

BackgroundHeterotopic ossification (HO) is one of the serious complications leading to the failure of alloplastic temporomandibular joint replacement (TJR). However, there was few research on its exact incidence and occurrence. Severe HO might result in pain and limited mouth opening after surgery. Therefore, it is necessary to clarify its clinical and imaging manifestations. The purpose of this study was to study the occurrence and classify HO after the alloplastic TJR.MethodPatients who underwent standard TJR (Zimmer Biomet stock prostheses or Chinese stock prostheses) with fat graft and at least 1-year-follow-up were included. HO was classified into 4 types according to postoperative computed tomography (CT) scans. Type and occurrence in different TMJ disease were compared. Joint space within 1 week after operation was measured and compared between HO and non-HO TJRs. Maximum incisal opening (MIO), pain, and quality of life (QoL) were recorded and their relevance with HO was analyzed statistically.Result81cases with 101 joints were included in the study. The mean follow-up time was 22.9 months (12 ~ 56 months). Among the 48 joints, 27 (56.3%) were type I (bone islands); 16 (33.3%) were type II (bone spurs from the mandibular ramus); 3 (6.3%) were type III (bone spurs from the fossa); and 2 (4.2%) were type IV (bone spurs from both the mandibular ramus and fossa). In HO patients, joint space in type IV was smaller than the other 3 types. Pain scores in HO were significantly greater than non-HO patients before and after operations (p < 0.05). 1 patient in Type IV HO developed ankylosis and had prosthesis revision which accounted for 2.1% in HO patients and 1.0% in all TJR patients.ConclusionHO after alloplastic TJR with fat graft was not severe except for type IV, which was easy to cause ankylosis. Preserving sufficient TJR space was important for ankylosis prevention.

Extended Total Temporomandibular Joint Replacement - A Feasible Option for Functional and Aesthetic Reconstruction of Mandibular Defects Involving the Temporomandibular Joint.

Study design: Retrospective case series. Objective: Alloplastic temporomandibular joint replacement has been established as a standard technique for end- stage temporomandibular (TMJ) pathologies. Joint replacement when there are extensive mandibular defects remains a challenging clinical problem. Custom-made extended temporomandibular joint replacement is a feasible option but there is limited information about this emerging technique. Methods: Included were all patients undergoing extended TMJ-replacements (TMJe), all operatrions were carried out by the senior author. Surgical technique was either single stage or two stage protocol. Surgical details and pitfalls and outcome of more than 2 years follow-up with reference to thirteen including twelve patients were recorded. Results: The most common diagnosis was ameloblastoma of the mandibular ramus. Single stage or two stagge regime were carried out depending on resection requirements and involvement of teeth. Improved mouth opening of more than 30mm was achieved in 10 of 12 patients. One patient with previous TMJ replacement reported temporary weakness of the facial nerve, which resolved after 10 months. Conclusions: The authors suggest a simplified anatomically based single-stage or two-stage regime, with both regimes achieved excellent anatomic reconstruction, facial appearance and function with low surgical morbidity. Custom-made extended temporomandibular joint protheses appear an advanced and reliable solution for reconstruction of combined complex mandibular defects including the temporomandibular joint. If surgical clearance of the pathology can be achieved, a single-stage regime is favoured.

A novel 3D-printed, patient-specific alloplastic temporomandibular joint replacement allowing enthesis reconstruction: A finite element analysis

This study aims to evaluate the mechanical performance of a unique, state-of-the-art, patient-specific alloplastic total replacement system for the temporomandibular joint that allows for enthesis reconstruction developed by CADskills BV (Ghent, Belgium), and its influence on the remaining adjacent healthy tissue, by looking into the magnitude and location of the stresses and micromotions. Because the reattachment of the lateral pterygoid muscle is unique, having never before been used in temporomandibular joint prostheses, the loading patterns and performance may be completely different from existing devices and their analyses. Therefore, multiple finite element models were created to compare existing devices, prosthetic models of the CADskills device, and healthy situations. These were used to investigate the influence of such patient-specific prostheses through the evaluation of micromotion, loading on the opposite joint, strain on the healthy bone and condyle, and stress shielding.The results showed that the temporomandibular joint prostheses were subject to stress considerably below their yield strength, except for the polyethylene of the fossa component, which might undergo abrasion under extreme muscular loads (larger than loads occurring during the activities of daily living). Additionally, the implant was shown to have little influence on stresses in the bone compared to a healthy model. Furthermore, the dynamic model shows how the load upon and stresses in the healthy joint increase when maximum muscle activation takes place with the mouth open.