End-stage Temporomandibular Joint Disease Research Articles

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.

A 2-Year comparison of quality of life outcomes between Biomet stock and OMX custom temporomandibular joint replacements

PurposeAlloplastic joint replacement is the mainstay treatment for end-stage temporomandibular joint (TMJ) disease. The aim of this study is to evaluate the 2 year quality of life (QoL) outcomes for patients who have undergone alloplastic TMJ total joint replacement with either custom or stock devices. MethodsThis was a retrospective cohort study of patients who had TMJ replacement with either Biomet stock or OMX custom prostheses. All patients were recruited from the patient database of a single surgeon, at a single location. QoL was assessed using a patient completed TMJ Surgery specific QoL (TMJ-S-QoL) questionnaire. Patients answered questions pertaining to pain, diet, speech and aspects related to social and mental health. ResultsA 2 year follow up was completed by 26 Biomet and 40 OMX patients. Survey results demonstrated that 84.6% (N = 22) of Biomet stock and 92.5% (N = 37) of OMX custom prosthesis patients derived significant QoL benefits from their surgery. There was no difference in QoL between the two groups (p > 0.4). ConclusionThis study shows that TMJ total joint replacements provide an improved quality of life for patients with end-stage TMJ disease regardless of whether the prosthesis is stock or individually custom made.

Total Alloplastic Temporomandibular Joint Replacement.

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. 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. 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.

Custom Alloplastic Temporomandibular Joint Reconstruction: Expanding Reconstructive Horizons.

Custom alloplastic temporomandibular joint (TMJ) reconstruction has been well established for the management of end-stage TMJ disease. However, its use in congenital TMJ deformities is limited. Here, the authors present initial outcomes of skeletally mature patients who underwent custom alloplastic TMJ reconstruction and simultaneous orthognathic surgery.A retrospective case series of patients who underwent custom alloplastic TMJ reconstruction concurrent with orthognathic surgery between 2014 and 2019 was completed. Functional, aesthetic and orthodontic outcomes as well as complications were recorded.Seven TMJs in 5 skeletally mature patients (4 female, 1 male, ages 16-30) (2 bilateral, 3 unilateral) were replaced. All but 1 patient had previous attempts at reconstructive surgery with poor results. All cases were prepared using virtual surgical planning and underwent concomitant maxillomandibular orthognathic surgery. All patients demonstrated improved post-operative occlusions. Four of 5 patients achieved >30 millimeters of post-operative MIO. Complications included ear canal perforation and facial nerve dysfunction.There were no infections or other implant-related complications. Mean follow up was 2 years and 15 days. Alloplastic TMJ reconstruction at the time of skeletal maturity for patients with congenital mandibular TMJ defects is an alternative to existing management options. Further long-term prospective outcomes studies are ongoing.

Protocol for fully digital and customized management of concomitant temporomandibular joint replacement and orthognathic surgery

End-stage temporomandibular joint (TMJ) disease is caused by a multitude of pathological processes that impair TMJ anatomy and function. In many cases, end-stage TMJ disease and dentofacial skeletal deformities coexist. The optimal treatment for such conditions is total alloplastic joint replacement and orthognathic surgery. Such procedures have historically been conducted in two separate stages. Furthermore, while technological improvements resulting from the widespread adoption of virtual reality initially led to significant improvements in the field of orthognathic planning, the adoption of virtual design techniques to optimize TMJ reconstruction was a later achievement. Therefore, planning for TMJ replacement and orthognathic surgery did not develop in parallel, leading to various combinations of planning for orthognathic surgery and TMJ replacement with the aim of performing both procedures simultaneously in one stage. Nowadays, improvements in virtual planning and three-dimensional printing have allowed these procedures to be conducted in the same surgical step based on fully digital planning and entirely customized surgery. This paper introduces a fully digital protocol for the treatment of end-stage TMJ disease and associated acquired dentofacial deformities, in which all surgical steps are customized and the whole surgery is performed in succession using automated procedures, thanks to the combined use of virtual surgical planning, surgical guides, custom-designed TMJ prostheses, and patient-fitted osteosynthesis devices.

Alloplastic Temporomandibular Joint Reconstruction for Patients With Juvenile Idiopathic Arthritis

The purpose of this study was to assess the efficacy of alloplastic temporomandibular joint (TMJ) total joint replacement (TJR) in patients with juvenile idiopathic arthritis (JIA). All patients with a formal diagnosis of JIA requiring a TMJ patient-specific TJR between 2010 and 2018 at The University of Texas-Health at San Antonio were retrospectively analyzed. To be included, patients must have had a formal diagnosis of JIA, complete records, and TMJ reconstruction with the TMJ Concepts patient-specific total joint prosthesis (TMJ Concepts, Ventura, CA). Clinical data acquisition was required at a minimum of 12months after surgery (longest follow-up [LFU]).Subjective and objective analyses were performed using a 10-point visual analog scale at the preoperative and LFU time points.Surgical data at the perioperative and LFU time points were recorded for comparison. Twenty patients with JIA met the inclusion criteria. The mean visual analog scale measurements for facial pain, TMJ pain, jaw function, diet, and disability were all significantly reduced at LFU. The maximal interincisal opening with pain was increased from 33.5mm preoperatively to 44mm at LFU, and the mean maximal interincisal opening without pain was increased from 31.1mm preoperatively to 43mm at LFU.None of the patients had complications from their TMJ TJR. Alloplastic TMJ reconstruction is a safe and efficacious treatment option for the surgical management of end-stage TMJ disease in JIA patients.

Accuracy of orthopantomograms in the assessment of implant position following alloplastic temporomandibular joint replacement.

The aim of this study was to determine the accuracy of orthopantomograms (OPGs) when assessing post-operative temporomandibular joint (TMJ) implant position, compared with cone beam computerized tomography (CBCT). A retrospective analysis was undertaken on six adult patients who were implanted with a custom TMJ prosthesis due to end-stage TMJ disease. Post-operative CBCT was compared with post-operative OPGs. Overall magnification of each OPG was calculated and used to linearly rescale each image. Implant position was assessed by measuring the gonion angle and the distance between each surgical screw and the mandibular gonion (SG length). Mean magnification for OPGs was 24.2%. There were no significant differences (p > 0.05) in the gonion angle on OPGs compared with CBCT images. There was a mean decrease in SG lengths of 0.02mm on OPGs, corresponding to error level of 5.31%. The 95% limits of agreement between OPGs and CBCT images for SG lengths were 1.65mm and - 1.73mm. This study presents a clinically applicable and accurate first-line radiographic screening tool to assess TMJ implant position. When combined with clinical assessment, OPGs can help reduce the need for further imaging and radiation exposure post-operatively.

Abstract: Customized Alloplastic Temporomandibular Joint Reconstruction: Expanding the Reconstructive “Net”

PURPOSE: Customized alloplastic temporomandibular joint (TMJ) reconstruction has been well established for refractory ankyloses and arthroses,1 trauma and end-stage TMJ disease in adult patients. However, its use in congenital absence or deficiency of the TMJ in younger patients is not well defined.2,3 The goal of this study was to present outcomes of patients with congenital mandibular defects who underwent customized alloplastic TMJ reconstruction simultaneous with orthognathic surgery. METHODS: A retrospective case series of patients who underwent customized alloplastic TMJ reconstruction concurrent with virtual surgical planning-guided orthognathic surgery (2014–2017) was completed. Anatomic, functional, and complication outcomes were documented. RESULTS: Five TMJs in 4 patients (1 bilateral, 3 unilateral) were reconstructed. Causes of TMJ absence included Goldenhar Syndrome (2), idiopathic bilateral condylar resorption (1), and post-oncologic in a patient with Gorlin Syndrome (1). The two patients with Goldenhar Syndrome had previous attempts at reconstructive surgery with poor results (distraction, bone grafting, alloplastic implants). All patients were skeletally mature at the time of surgery, had virtual surgical planning and had concomitant maxillomandibular orthognathic surgery at the time of TMJ reconstruction. All patients had improved post-operative occlusal results. Three of 4 patients had >30 millimeters post-operative maximal incisal opening. Complications included revision of implant position (1), ear canal perforation (1), and frontal branch of facial nerve injury requiring secondary brow lift (1). There were no infections or other implant-related complications. Mean follow up was 1.32 years (range, 0.46–2.74 years). CONCLUSION: We present a growing series of patients with congenital mandibular defects who underwent successful custom alloplastic TMJ reconstruction with pre-operative virtual surgical planning. Such reconstruction at the time of skeletal maturity for patients with congenital mandibular TMJ defects may present an alternative to existing treatment options, such as mandibular distraction, bone grafting, and prosthesis completed during skeletal immaturity.2,4,5

A new three-dimensional, print-on-demand temporomandibular prosthetic total joint replacement system: Preliminary outcomes

PurposeThe aim of this study is to present the preliminary clinical data on the OMX Temporomandibular Joint (TMJ) Prosthetic total joint replacement system. Materials and MethodsA prospective, cohort, clinical study was undertaken of consecutive adult patients with Category 5 end-stage joint disease who were implanted with the OMX TMJ prosthesis between May 2015 and April 2017. A total of 50 devices were implanted in 38 patients, with 12 patients receiving bilateral prosthetic joints. There were 31 females and 7 males in this cohort, who ranged in age from 20 to 66 years, with a mean of 43.8 years (±14.0 years). Ten of the 50 prosthetic joints (20%) were fully customized, while the remaining were patient matched using virtual planning software. ResultsBased on a mean follow-up period of 15.3 months (range 12–24 months) following the TMJ total joint replacement, preliminary results suggest the OMX TMJ prosthesis has made a positive impact on clinical outcomes, with a mean 74.4% reduction in joint pain levels and significant improvements (p < 0.05) in jaw function as measured by the visual analogue scales for mouth opening (30.8%), diet (77.1%), and function (59.2%). No device failures were reported during the study period. ConclusionThis study suggests that the print-on-demand OMX TMJ prosthesis, designed for rapid delivery of both patient-matched and fully customize devices, represents a safe, reliable and versatile implantable joint replacement system for the treatment of category 5 end-stage TMJ disease.

A Retrospective Study of Patient Outcomes Following Temporomandibular Joint Replacement with Total Joint Prosthesis at Massachusetts General Hospital

Disorders of the temporomandibular joint (TMJ) occur frequently with a prevalence of between 15% and 18%. Total joint replacement (TJR) surgery is reserved for patients with end-stage TMJ disease with an original diagnosis of congenital abnormality, growth disorder, infection, fracture, tumor, arthritis, ankylosis, dislocation, internal derangement, and other conditions that have not responded to prior non-surgical or surgical treatments.

Temporomandibular joint reconstruction with stock and custom-made devices: Indications and results of a 14-year experience

Temporomandibular joint (TMJ) reconstruction with alloplastic implants is a reliable, safe and effective treatment option for selected debilitating pathologies of the TMJ. This study retrospectively analyzes our 14-year experience in total alloplastic reconstruction of the TMJ using stock and custom Biomet prostheses. Indications, results and rationale for the choice of stock and custom-made devices are discussed. Patients were enrolled in the study who underwent single-stage alloplastic total joint replacement from January 2000 to October 2014. The subjective and objective variables were as follows: TMJ pain, diet, jaw function, maximum interincisal opening (MIO), quality of life and occlusion. The minimum follow-up was 12 months. A total of 38 patients (55 joints) met the inclusion criteria and were enrolled in the study. Of the patients, 25 underwent Biomet total joint reconstruction system with stock prosthesis, 12 patients underwent total joint reconstruction system with custom made (patient matched) prosthesis, and 1 patient underwent bilateral total joint reconstruction using stock system on one side and custom system on the other side. The following adverse events and complications were recorded: bleeding, 2 cases; malocclusion, 1 case; postoperative infection with prosthesis removal, 1 case; heterotopic bone formation, 1 case; and contralateral TMJ overload in unilateral cases, 1 case. The occlusion was habitual unchanged in 29 of 38 cases. In 1 patient occlusion worsened with less stable functional contact. The patient refused postoperative orthodontic treatment. In 8 patients, a concomitant orthognatic procedure was planned in order to improve the occlusion. In all these patients, the occlusion improved. Quality of life and MIO relevantly improved in all cases. This study supports the use of total joint reconstruction for end-stage TMJ disease. Both stock and custom implants allow consistent results, but there are precise indications for the use of custom implants.

Patient-centered quality of life measures after alloplastic temporomandibular joint replacement surgery

The purpose of this study was to evaluate patient-reported outcome measures of quality of life (QoL) for patients with end-stage temporomandibular joint (TMJ) disease who have undergone TMJ prosthetic replacement. The records of 36 patients who had undergone alloplastic total joint replacement procedures were analyzed. Patients were treated using either TMJ Concepts or Biomet/Lorenz prosthetics. Patients were asked to complete a 12-item TMJ-S-QoL survey, which encompassed questions pertaining to pain, speech, chewing function, and various aspects of social life and mental health. The questions were answered on a 5-point scale. Data were analyzed using the Wilcoxon signed-rank test. Among the 36 patients (six male and 30 female), 18 responded to the survey. Markers of QoL after surgery were compared to the preoperative period. Significant improvements were reported for pain (94.4% of patients), chewing (83.3% of patients), speech (55.6% of patients), anxiety (72.2% of patients), activity (66.7% of patients), recreation (61.1% of patients), and mood (66.7% of patients) (all P<0.05). TMJ prosthetic replacement significantly enhanced QoL among patients suffering from chronic pain, limited range of motion, anxiety, impaired speech, and chewing due to end-stage TMJ disease in this sample of surgical patients.

Evaluation of total alloplastic temporo-mandibular joint replacement with two different types of prostheses: A three-year prospective study

BackgroundTemporo-Mandibular Joint (TMJ) replacement has been used clinically for years. The objective of this study was to evaluate outcomes achieved in patients with two different categories of TMJ prostheses.Material and MethodsAll patients who had a TMJ replacement (TMJR) implanted during the study period from 2006 through 2012 were included in this 3-year prospective study. All procedures were performed using the Biomet Microfixation TMJ Replacement System, and all involved replacing both the skull base component (glenoid fossa) and the mandibular condyle.ResultsFifty-seven patients (38 females and 19 males), involving 75 TMJs with severe disease requiring reconstruction (39 unilateral, 18 bilateral) were operated on consecutively, and 68 stock prostheses and 7 custom-made prostheses were implanted. The mean age at surgery was 52.6±11.5 years in the stock group and 51.8±11.7 years in the custom-made group. In the stock group, after three years of TMJR, results showed a reduction in pain intensity from 6.4±1.4 to 1.6±1.2 (p<0.001), and an improvement in jaw opening from 2.7±0.9 cm to 4.2±0.7 cm (p<0.001). In the custom-made group, after three years of TMJR, results showed a reduction in pain intensity from 6.0±1.6 to 2.2±0.4 (p<0.001), and an improvement in jaw opening from 1.5±0.5 cm to 4.3±0.6 cm (p<0.001). No statistically significant differences between two groups were detected.ConclusionsThe results of this three-year prospective study support the surgical placement of TMJ prostheses (stock prosthetic, and custom-made systems), and show that the approach is efficacious and safe, reduces pain, and improves maximum mouth opening movement, with few complications. As such, TMJR represents a viable technique and a stable long-term solution for cranio-mandibular reconstruction in patients with irreversible end-stage TMJ disease. Comparing stock and custom-made groups, no statistically significant differences were detected with respect to pain intensity reduction and maximum mouth opening improvement. Key words:Temporo-mandibular joint, temporo-mandibular joint replacement, prosthesis, biomaterials, biomedical engineering, computer-aided design and manufacturing.

Comparison of the outcomes of three surgical treatments for end-stage temporomandibular joint disease

The aim of this study was to determine whether there are any differences between condylectomy, rib grafts, and prosthetic joints (Biomet TMJ stock prosthesis) with regard to outcomes for patients with end-stage temporomandibular joint (TMJ) disease. Fifty-six of a total 127 patients who presented with category 5 end-stage TMJ disease over 3 years (2010–2013) agreed to participate in this retrospective, comparative, cohort study. Patients were divided into four groups: preoperative (n=16), condylectomy (n=8), rib graft (n=16), and prosthetic joint (n=16). They were assessed for major postoperative complications (i.e., return to theatre) and maximum range of mandibular motion, and all completed a specific quality of life (QOL) questionnaire. Whilst the condylectomy group demonstrated the best mandibular range of motion (P<0.01), rib graft patients were more likely to experience complications (43.8%) necessitating a return to theatre. The prosthesis group recorded the best mean aggregate QOL score, but the difference compared to the rib graft and condylectomy groups was not statistically significant. The results of this study suggest that for dentate patients, prosthetic joints are highly dependable with no returns to theatre and favourable QOL outcomes. For edentulous patients, condylectomies alone also appear to work well. Future TMJ prosthetic designs should focus on improving mandibular range of motion, as the current stock prosthesis allows only a restricted range, no better than that achieved with rib graft (P>0.05) and far less than that achieved with condylectomy (P<0.01).