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Autologous TMJ Disk Replacement
s
AU10G0US1MJ DISK REPIACEMENT
D U R W O O D E. B A C H ,
P E T E R D . W A IT E ,
he hum an tem porom an dibular jo int is a complex structure. The basic anatom y m ay seem simple, but we are still learning about its function and pathological problems. The im portance of the TM J disk in both the pathogenesis and in the prevention of TM J disorders has been controver sial. It is generally thought th a t the articu lar disk functions to tra n sm it forces from the condyle. A ttaching the disk to the condyle allows it to move synchronously w ith the condyle during tra n sla tio n .1 There is a gliding movem ent in the superior jo int space and a rotational m ovem ent in the lower joint space. The disk functions as a mobile, articu lating surface for the condyle. Histologically, the disk is dense ly packed fibrous tissue. It is a biconcave structure, non innervated, avascular, receiving n u trie n ts from th e synovial fluid.2 M any authors have characterized the disk as a shock absorber. The degree to which the disk is actually exposed to compression during m astication and serves as a shock absorber h as not been clearly defined.3 Although the TM J disk m ay be resilient, it is subject to 1504
JADA, Vol. 125, November 1994
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D .D .S ., M .D .; R I O H A R D O . A D A M S , D .D .S .
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Several techniques have been advocated for replacement of displaced or diseased temporomandibular joint disks. Techniques are reviewed and the author’s experience in managing this complex problem is presented.
acute and chronic injury th a t may lead to dislocation, displacem ent, perforation or degeneration. This m ay render the disk non-functional and non-repairable. The abnorm al relationship of the articular disk to the condyle has been commonly referred to as in tern al derangem ent.4 In tern al derangem ent can cause m etaplastic inflam m atory degenerative changes in the disk, the synovial lining and soft tissue attachm ents. Furtherm ore, these changes appear progressive and may resu lt in eventual deterioration of the disk.5 Clinically, th is is often accompanied by pain, restricted m andibular mobility and progressive osseous changes in the joint.6 There is controversy about the m erits of different forms of
surgery for the TM J in tern al derangem ent. Recently, su r geons have reported on the suc cessful m anagem ent of in ternal derangem ents w ith surgical disk repositioning procedures.7'9 Advocates of disk preservation surgery believe th a t this approach restores “norm al” anatom y, physiology and function, and best m aintains norm al joint m echanics.10 There are, however, situations in which the articu lar disk has undergone perfora tion, degenerative or m orpho logical changes to such a degree th a t repair is impossible. In this situation, when accompanied by clinical signs and symptoms of joint pain, painful m andibular function and hypomobility of the jaw , diskectomy becomes the indicated surgical tre a t m ent. Diskectomy, reported in 1909, is one of the oldest su r gical treatm en ts for the TM J.11 A surgical dilem m a arises after diskectomy. Should the disk be replaced or is its re moval therapeutic? If the disk is to be replaced, th en w hat m aterial should be used? There is no consensus to answ er this question. There are, however, m any honest opinions, some of which are supported by scientific study. Review of a rticu lar surface
SPECIALTIES
changes after diskectomy in prim ates showed th a t w ithout disk replacem ent, jo in t archi tecture was m aintained.12 However, in the U nited States, diskectomy w ithout interpositional replacem ent has gen erally been condemned.1314 A pparently, the loss of the cushioning effect of the disk was assum ed to lead to irrevers ible degenerative bone changes of the a rticu lar tissues. P ersis te n t pain w ith lim ited jaw m ovem ents and even ankylosis were expected to occur.16 Some non-hum an prim ate studies16 and other studies17 have corroborated these findings. In hum ans, persisten t crepitus, lim ited opening, ankylosis and a rticu lar surface erosion have been reported after diskectomy.18 Boman reported good early results w ith this surgical procedure; however, la te r changes were apparently so discouraging th a t the procedure was abandoned.1920 Long-term (30 to 40 years) follow-up evaluations of Boman’s patients, and other diskectomy patients, by Eriksson and W estesson in Sweden, produced interesting resu lts.21 No adverse clinical findings or subjective symptoms were observed. Long-term (30year follow-up) reports by Silver,22 Brown23 and Tolvanen and colleagues20 found favorable surgical results of diskectomy w ithout replacem ent. Tolvanen and his co-workers consider th a t it m ay have been h asty and overly critical to condemn th is procedure.20 Hall and Link reported the results of diskectomy pro cedures on 25 patients. W ith a follow-up period of four to seven years, they concluded th a t this procedure was a good treatm en t 1506
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for pain and dysfunction caused by in tern al derangem ent of the TMJ. B ut they reported deficiencies w ith the outcomes. About 15 to 20 percent of these p atients do not get pain relief. The 35 to 40 percent of patients who have pain relief are unable to chew h a rd or tough foods w ithout tra n sie n t joint discomfort. Consequently, they suggested use of an Figure 1. Auricular cartilage positioned and secured interpositional to the zygomatic arch as disk replacement. m aterial. Hall and Link fu rth er state th a t O ther surgeons believe th a t there are no published d ata replacing a defective or m issing reporting results better th an TM J disk is im portant to diskectomy using any known preventing ankylosis and interpositional (disk degenerative osseous changes replacem ent) m aterials.24 and to m aintain m andibular W ilkes9 reviewed his results m ovem ent.25 The ideal allow ith surgical tre a tm e n t of TM J plastic (synthetic) m aterial has in tern al derangem ents in a not been developed for use in group of 176 p atients w ith an the hum an TMJ. Most experi average follow-up period of 8.1 enced TM J surgeons agree th a t years. He found th a t disk recon a perm anent alloplastic structive procedures, used in interpositional im plant should early stages of internal de be avoided.26 C urrently, there rangem ent, are superior to disk are no long-lasting compatible rem oval operations. He believes m aterials available to w ith stand the w ear of function. th a t reconstructed joints repre sent a more physiological and U sing m aterials like silicone compatible condition. Wilkes sheets for weeks to m onths to fu rth e r states th a t a stable prevent postoperative fibrous condition exists after diskec adhesions or ankylosis is com tomy, b u t the situation is less mon.27 B ut surgeons today are th a n optim al and some m ost likely to consider autog functional disabilities occur. enous m aterial—cartilage,
SPECIALTIES M eyers25 endorses the derm al graft as ideally suited for use in the TM J because it is readily avail able, biologically acceptable, adaptable to functional loading, easy to place surgically and assum es disklike properties w ith tim e. The donor site is usually buttocks, lateral thigh or groin region. Derm al appendages undergo degeneration Figure 2. Post-auricular approach for harvesting after grafting to ear cartilage. th e recipient derm is, fascia or m uscle—when site.28,32 The derm al graft is replacing the disk.26 positioned w ithin the glenoid The TM J can be surgically fossa and secured to th e exposed via a pre-auricular, anterior capsule retrodiskal en daural or post-auricular tissue and collateral ligam ent approach. The resulting scar is attachm ents laterally. inconspicuous and cosmetic. Postoperatively, th e p a tie n t The ideal tissue for use in does not receive m axillom an replacem ent or repair of the dibular fixation and is disk should be available in encouraged to function by sufficient quantity, should have opening and closing gently after low donor site morbidity, m ini 48 to 72 hours. The p atien t m al resorption w ith viable receives a full liquid diet for the incorporation into the joint and first two weeks. An interincisal should w ithstand functional opening greater th a n 35 stresses.24 m illim eters is obtainable in A derm is graft appears to most cases eight weeks after m eet these criteria.28 Dermis as surgery by gradually increasing an interpositional disk replace function w ith jaw -opening m ent graft was advocated by exercises. An alternative Georgiade.29 O thers later re m ethod for range of motion ported clinical success w ith exercise is a commercially derm is as an interpositional obtainable CPM (continuous m aterial in th e hum an TM J.5,3031 passive motion) device. 1508
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M arkowitz and colleagues33 reported th eir results w ith free pericranial grafts in 83 joints. The graft is harvested through an incision about 5 centim eters in length, placed in the h air superior and posterior to the auricle. Their prelim inary results were encouraging w ith im provem ent in pain and dys function. The pericranial tissue is tough and resilient. It under goes early revascularization and m etaplastic change sim ilar to cartilage. Furtherm ore, it can be procured easily in large quantity from a donor site in close approxim ation to the recipient site. The donor site scar is inconspicuously hidden in the hairline. Temporalis muscle pericranial pedicled flaps have been advocated for disk replace m ent.3435 A portion of the tem poralis muscle and pericranium is elevated and rotated laterally or anteriorly to the zygomatic arch and posi tioned w ithin the glenoid fossa (Figure 1). Some patients experience persistent tem poral muscle tenderness and tem poral tendinitis. This procedure is principally indicated for TM J reconstruction after ankylosis or significant destructive degeneration. Autogenous cartilage from the external ear has been recommended as an interposi tional m aterial by surgeons.36,37 W hen properly performed, there is no residual deform ity of the ear (Figure 2,3). The cartilage is harvested from the ipsilateral ear w ith the incision placed behind the ear. The conchal bowl is excised, m aintaining perichondrium on the convex surface. Its unique shape allows it to fit the glenoid fossa. Some surgeons37 suture the cartilage
'SPECIALTIES to th e surrounding tissue in th e joint. O thers38'39 prefer to secure th e cartilage to the fossa a t the lateral aspect of the zygomatic arch w ith sutures (Figure 3). A prim ate study by Tucker and others38 docum ented the viability of th e ear cartilage w hen placed interpositionally in th e TM J. In th is anim al study, there was a variable am ount of fibrous connective tissue su r rounding the cartilage grafts, and one anim al developed fibrous adhesions betw een the condyle and the inferior surface of the graft. To prevent adhes ions, surgeons have placed a tem porary silicone sheet be tw een the condyle and cartilage for six to eight weeks (M.R. Tucker, D.D.S., R.G. M errill, M.Sc.D., D.D.S., personal communication, 1991). H all24 states th a t his early results w ith interpositional ear cartilage grafts were disap pointing and th a t he could not recom mend this as a preferred procedure over diskectomy. However, it has been our experience w ith 27 cases of interpositional e ar cartilage grafts over four years, th a t this m aterial has functioned well and is currently our preferred technique for TM J disk replacem ent. We do not use m axillom an dibular fixation postoperatively. We recom mend gradual pro gressive opening exercises to ensure an improved range of m andibular motion. Some su r geons use an occlusal splint to decrease joint loading during th e first few postoperative weeks or m onths. CONCLUSION
We have attem pted to present an overview of the questions 1510
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Figure 3. Temporalis muscle flap rotated down into the jo in t space.
associated w ith disk rem oval in TM J arthrotom y. M any experi enced, wellintentioned surgeons obviously differ in their opinions regarding tre a tm e n t in th is clinical situation. It is, however, likely th a t there are several sim ilar autogenous tissues th a t can be safely and predictably used for this purpose in the TM J. It is also likely th a t the Figure 4. Six-month postoperative view shows choice of tissue minimal cosmetic deformity. m ay be a failure of a TM J surgical m atte r of personal choice, procedure. experience and train in g of the F irst and critically, we m ust individual surgeons. O ther be certain th a t the patien t factors affect the success or
SPECIALTIES suffers from in tra-articu lar pathosis, which is the cause of pain and Dr. Adams was chief m andibular resident, Oral and dysfunction. Maxillofacial Surgery, Tripler The general Army Medical d entist should Center, Honolulu. He is now an oral elim inate and maxillofacial dental pain surgeon, Martin and help Army Community Hospital, Fort identify TM J Benning, Ga. 31905. dysfunction. Address reprint requests to Dr. The patien t Adams. and surgeon m ust have realistic expectations as to w hat can be accomplished w ith a particu lar surgical procedure. Knowledge of surgical options by the referring d entist can often assist in tre a tm e n t recom m endations. Finally, p atien t m otivation to postoperative rehabilitation of the joint is extrem ely im portant to th e ultim ate outcome. A program of physical therapy, eith er professionally or personally m anaged, is necessary to re tu rn adequate range of motion, a requisite to good pain-free function. The general d en tist’s participation is necessary to establish the final outcome of norm al occlusion and m asticatory function. ■ This article was prepared as p a rt of the participation of th e specialty organizations in th is section of JADA. Dr. M arkell Kohn, San Diego, is coordinator for th e oral and maxillofacial surgeons. Dr. Bach is colonel, U.S. Army, and chief and director, Residency T raining O ral and Maxillofacial Surgery, and chief, Hospital D entistry, T ripler Army Medical Center, Honolulu. Dr. W aite is associate professor and director, Residency T raining Program , and vice-chairm an, D epartm ent of O ral and Maxillofacial Surgery, School of D entistry,
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U niversity of A labam a a t Birm ingham . 1. DuBrul CE. Sicher and D uBrul’s oral anatom y. St. Louis: Ishiyaku EuroAmerica; 1988. 2. Blackwood H J. C ellular rem odeling in th e articu lar tissue. J D ent Res 1966;45(3) Supplement:480. 3. B row nm an K. Tem porom andibular joint arthrosis and its tre a tm e n t by extirpation of the disk. Acta C hir Scand 1947;95(Supplem ent 118): 19. 4. Dolwick MF. Diagnosis and etiology. In: Helm s CA, K atzberg RW, Dolwick MF, eds. In tern al derangem ents of the tem porom andibular joint. San Francisco: U niversity of California Press; 1983. 5. McCoy JM , Gotcher JE , C hase DC. Histologic grading of TM J tissue in internal derangem ent. J C raniom andibular P ract 1986;4:213-8. 6. Zetz MR, Irby WB. Repair of th e adult tem porom andibular joint m eniscus w ith an autogenous derm al graft. J Oral Maxillofac S urg 1984;42:167-71. 7. M cCarty WL J r., F a rra r W. Surgery for in tern al derangem ents of th e tem porom an dibular joint. J P rosthet D ent 1979;42(2):42. 8. M ercuri LG, Campbell RL, S hanaskin R. In tra-artic u la r m eniscus dysfunction surgery: a prelim inary report. O ral S urg O ral Med O ral Pathol 1982;54:6. 9. Wilkes CH. Surgical tre a tm e n t of in tern al derangem ents of the tem porom andibular joint. Arch Otolaryngol H ead Neck S urg 1991;117(l):64-72. 10. Piper MA. Microscopic disk preservation surgery of the tem porom andibular joint: disorders of the TM J II arthrotom y. O ral Maxillofac S urg Clin N orth Am. Philadelphia: Saunders; 1989:1(2):279. 11. L antz A. D iscitis m andibularis. C entrable C hir 1909;9:289. 12. Block M, K ent J , W alters P. Comparison of 5 diskectomy treatm en ts in prim ates. J O ral Maxillofac S urg 1989;47S:76. 13. H enny FA. The painful tem porom an dibular joint. J O ral S urg 1955;13:341. 14. G uralnic WK, Agan LB, M errill RG. Tem porom andibular joint afflictions. N Engl J Med 1978;299(3): 123-9. 15. Posewillo D. Surgery of th e tem porom andibular joint. In: Zarb GA, Carlsson GE, eds. Tem porom andibular joint function and dysfunction. Copenhagen: M unksgaard; 1979:397-431. 16. Y aillen DM, Shapiro PA, Luschei ES, Feldm an GR. Tem porom andibular joint m eniscectom y—Effects on jo in t structure and m asticatory function in m acaca fascicularis. J Maxillofac Surg 1979;7:255-64. 17. Sprinz R. The role of th e m eniscus in th e healing process following excision of the articu lar surfaces of the m andibular joint in rabbits. J A nat 1963;97:345. 18. Agerber G, S unberg M. Changes in the tem porom andibular joint after surgical treatm en t. O ral S urg O ral Med O ral Pathol 1971;32:865. 19. Boman K. Tem porom andibular joint arthrosis and its treatm en t by extirpation of th e disk. Acta C hir Scand 1947;95:156. 20. Tolvanen M, O ikarinen VJ, Wolf J. A 30-year follow-up study of tem porom an dibular jo in t meniscectomies. Br J O ral Maxillofac S urg 1988;26:311-6. 21. Eriksson L, W estesson PL. Long-term evaluation of meniscectomy of the tem porom andibular joint. J O ral Maxillofac
S urg 1985;43:263. 22. Silver CM. Long-term resu lts of meniscectom y of th e tem porom andibular joint. J C raniom andibular P ra ct 1984;3:47. 23. Brown WA. In tern al derangem ent of th e tem porom andibular joint: Review of 214 patients following meniscectomy. Can J Surg 1980;23:30. 24. H all DH, Link J J . Diskectomy alone and w ith ea r cartilage interposition grafts in joint reconstruction. In: D isorders of the TM J II arthrotom y. O ral S urg O ral Med Oral Pathol 1989;1(2):329. 25. M eyer RA. Autogenous derm al g rafts in reconstruction of tem porom andibular joint. In: D isorders of th e TM J II arthrotom y. Oral Surg O ral Med O ral Pathol 1989; 1(2):351-6. 26. M errill RG. Preface: D isorders of the TM J II: arthrotom y. O ral S urg O ral Med O ral Pathol 1989;1(2):16. 27. T ucker MR, B urkes E J. Tem porary silastic im plantation following diskectomy in the p rim ate tem porom andibular joint. J Oral Maxillofac S urg 1989;47:1290-5. 28. S tew art HM, H ann JR , DeTomasi DC, Neville BW, DeChamplain RW. Histologic studies of derm al grafts following im plantation for tem porom andibular joint meniscal p erfo ratio n s prelim inary study. Oral Surg Oral Med Oral Pathol 1986;62:481-5. 29. Georgiade N. The surgical correction of tem porom andibular jo in t dysfunction by m eans of autogenous derm al grafts. P last Reconstr S urg 1962;30:68. 30. Topazian RG. Comparison of gap and interpositional arthroplasty in th e treatm en t of tem porom andibular jo in t ankylosis. J O ral Surg 1966;24:405. 31. M eyer R. The autogenous derm al graft in tem porom andibular joint disc surgery. J Oral Maxillofac S urg 1988;46:948. 32. Thompson N. The subcutaneous derm is graft: a clinical and histological study in m an. P last R econstr Surg 1960;26:1. 33. M arkowitz NR, P atterson T, C aputa L. A tw o-stage procedure for tem porom andibular joint disc replacem ent using tem poralis pericranial grafts: A prelim inary report. J O ral Maxillofac Surg 1991;49:476-81. 34. Feiberg SE, L arsen PE. The use of a pedicled tem poralis m uscle—pericranial flap for replacem ent of the TM J disc: prelim inary report. J O ral Maxillofac S urg 1989;47:142-6. 35. A lbert TW, M errill RG Tem poralis myofascial flap for reconstruction of th e tem porom andibular joint. In: D isorders of th e TM J II: arthrotom y. O ral Maxillofac S urg Clin N orth Am. P hiladelphia:Saunders; 1989:l(2):341-9. 36. W istsenburg B, F reihofer HPM. Replacem ent of the pathological tem porom an dibular articu lar disc using autogenous cartilage of th e external ear. In t J O ral Surg 1984;13:401. 37. M atukas VJ, L achner J . The use of autologous auricular cartilage for tem porom andibular joint disc replacem ent: a prelim inary report. J Oral Maxillofac Surg 1984;13:401. 38. T ucker MR, Kennedy MC, Jacorvay JR. Autogenous auricular cartilage im plantation following diskectomy in the prim ate tem porom andibular joint. J O ral Maxillofac Surg 1990;48:38-44.
AU10G0US1MJ DISK REPIACEMENT
D U R W O O D E. B A C H ,
P E T E R D . W A IT E ,
he hum an tem porom an dibular jo int is a complex structure. The basic anatom y m ay seem simple, but we are still learning about its function and pathological problems. The im portance of the TM J disk in both the pathogenesis and in the prevention of TM J disorders has been controver sial. It is generally thought th a t the articu lar disk functions to tra n sm it forces from the condyle. A ttaching the disk to the condyle allows it to move synchronously w ith the condyle during tra n sla tio n .1 There is a gliding movem ent in the superior jo int space and a rotational m ovem ent in the lower joint space. The disk functions as a mobile, articu lating surface for the condyle. Histologically, the disk is dense ly packed fibrous tissue. It is a biconcave structure, non innervated, avascular, receiving n u trie n ts from th e synovial fluid.2 M any authors have characterized the disk as a shock absorber. The degree to which the disk is actually exposed to compression during m astication and serves as a shock absorber h as not been clearly defined.3 Although the TM J disk m ay be resilient, it is subject to 1504
JADA, Vol. 125, November 1994
A
B
S
D .D .S ., M .D .; R I O H A R D O . A D A M S , D .D .S .
T
R
A
C
T
Several techniques have been advocated for replacement of displaced or diseased temporomandibular joint disks. Techniques are reviewed and the author’s experience in managing this complex problem is presented.
acute and chronic injury th a t may lead to dislocation, displacem ent, perforation or degeneration. This m ay render the disk non-functional and non-repairable. The abnorm al relationship of the articular disk to the condyle has been commonly referred to as in tern al derangem ent.4 In tern al derangem ent can cause m etaplastic inflam m atory degenerative changes in the disk, the synovial lining and soft tissue attachm ents. Furtherm ore, these changes appear progressive and may resu lt in eventual deterioration of the disk.5 Clinically, th is is often accompanied by pain, restricted m andibular mobility and progressive osseous changes in the joint.6 There is controversy about the m erits of different forms of
surgery for the TM J in tern al derangem ent. Recently, su r geons have reported on the suc cessful m anagem ent of in ternal derangem ents w ith surgical disk repositioning procedures.7'9 Advocates of disk preservation surgery believe th a t this approach restores “norm al” anatom y, physiology and function, and best m aintains norm al joint m echanics.10 There are, however, situations in which the articu lar disk has undergone perfora tion, degenerative or m orpho logical changes to such a degree th a t repair is impossible. In this situation, when accompanied by clinical signs and symptoms of joint pain, painful m andibular function and hypomobility of the jaw , diskectomy becomes the indicated surgical tre a t m ent. Diskectomy, reported in 1909, is one of the oldest su r gical treatm en ts for the TM J.11 A surgical dilem m a arises after diskectomy. Should the disk be replaced or is its re moval therapeutic? If the disk is to be replaced, th en w hat m aterial should be used? There is no consensus to answ er this question. There are, however, m any honest opinions, some of which are supported by scientific study. Review of a rticu lar surface
SPECIALTIES
changes after diskectomy in prim ates showed th a t w ithout disk replacem ent, jo in t archi tecture was m aintained.12 However, in the U nited States, diskectomy w ithout interpositional replacem ent has gen erally been condemned.1314 A pparently, the loss of the cushioning effect of the disk was assum ed to lead to irrevers ible degenerative bone changes of the a rticu lar tissues. P ersis te n t pain w ith lim ited jaw m ovem ents and even ankylosis were expected to occur.16 Some non-hum an prim ate studies16 and other studies17 have corroborated these findings. In hum ans, persisten t crepitus, lim ited opening, ankylosis and a rticu lar surface erosion have been reported after diskectomy.18 Boman reported good early results w ith this surgical procedure; however, la te r changes were apparently so discouraging th a t the procedure was abandoned.1920 Long-term (30 to 40 years) follow-up evaluations of Boman’s patients, and other diskectomy patients, by Eriksson and W estesson in Sweden, produced interesting resu lts.21 No adverse clinical findings or subjective symptoms were observed. Long-term (30year follow-up) reports by Silver,22 Brown23 and Tolvanen and colleagues20 found favorable surgical results of diskectomy w ithout replacem ent. Tolvanen and his co-workers consider th a t it m ay have been h asty and overly critical to condemn th is procedure.20 Hall and Link reported the results of diskectomy pro cedures on 25 patients. W ith a follow-up period of four to seven years, they concluded th a t this procedure was a good treatm en t 1506
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for pain and dysfunction caused by in tern al derangem ent of the TMJ. B ut they reported deficiencies w ith the outcomes. About 15 to 20 percent of these p atients do not get pain relief. The 35 to 40 percent of patients who have pain relief are unable to chew h a rd or tough foods w ithout tra n sie n t joint discomfort. Consequently, they suggested use of an Figure 1. Auricular cartilage positioned and secured interpositional to the zygomatic arch as disk replacement. m aterial. Hall and Link fu rth er state th a t O ther surgeons believe th a t there are no published d ata replacing a defective or m issing reporting results better th an TM J disk is im portant to diskectomy using any known preventing ankylosis and interpositional (disk degenerative osseous changes replacem ent) m aterials.24 and to m aintain m andibular W ilkes9 reviewed his results m ovem ent.25 The ideal allow ith surgical tre a tm e n t of TM J plastic (synthetic) m aterial has in tern al derangem ents in a not been developed for use in group of 176 p atients w ith an the hum an TMJ. Most experi average follow-up period of 8.1 enced TM J surgeons agree th a t years. He found th a t disk recon a perm anent alloplastic structive procedures, used in interpositional im plant should early stages of internal de be avoided.26 C urrently, there rangem ent, are superior to disk are no long-lasting compatible rem oval operations. He believes m aterials available to w ith stand the w ear of function. th a t reconstructed joints repre sent a more physiological and U sing m aterials like silicone compatible condition. Wilkes sheets for weeks to m onths to fu rth e r states th a t a stable prevent postoperative fibrous condition exists after diskec adhesions or ankylosis is com tomy, b u t the situation is less mon.27 B ut surgeons today are th a n optim al and some m ost likely to consider autog functional disabilities occur. enous m aterial—cartilage,
SPECIALTIES M eyers25 endorses the derm al graft as ideally suited for use in the TM J because it is readily avail able, biologically acceptable, adaptable to functional loading, easy to place surgically and assum es disklike properties w ith tim e. The donor site is usually buttocks, lateral thigh or groin region. Derm al appendages undergo degeneration Figure 2. Post-auricular approach for harvesting after grafting to ear cartilage. th e recipient derm is, fascia or m uscle—when site.28,32 The derm al graft is replacing the disk.26 positioned w ithin the glenoid The TM J can be surgically fossa and secured to th e exposed via a pre-auricular, anterior capsule retrodiskal en daural or post-auricular tissue and collateral ligam ent approach. The resulting scar is attachm ents laterally. inconspicuous and cosmetic. Postoperatively, th e p a tie n t The ideal tissue for use in does not receive m axillom an replacem ent or repair of the dibular fixation and is disk should be available in encouraged to function by sufficient quantity, should have opening and closing gently after low donor site morbidity, m ini 48 to 72 hours. The p atien t m al resorption w ith viable receives a full liquid diet for the incorporation into the joint and first two weeks. An interincisal should w ithstand functional opening greater th a n 35 stresses.24 m illim eters is obtainable in A derm is graft appears to most cases eight weeks after m eet these criteria.28 Dermis as surgery by gradually increasing an interpositional disk replace function w ith jaw -opening m ent graft was advocated by exercises. An alternative Georgiade.29 O thers later re m ethod for range of motion ported clinical success w ith exercise is a commercially derm is as an interpositional obtainable CPM (continuous m aterial in th e hum an TM J.5,3031 passive motion) device. 1508
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M arkowitz and colleagues33 reported th eir results w ith free pericranial grafts in 83 joints. The graft is harvested through an incision about 5 centim eters in length, placed in the h air superior and posterior to the auricle. Their prelim inary results were encouraging w ith im provem ent in pain and dys function. The pericranial tissue is tough and resilient. It under goes early revascularization and m etaplastic change sim ilar to cartilage. Furtherm ore, it can be procured easily in large quantity from a donor site in close approxim ation to the recipient site. The donor site scar is inconspicuously hidden in the hairline. Temporalis muscle pericranial pedicled flaps have been advocated for disk replace m ent.3435 A portion of the tem poralis muscle and pericranium is elevated and rotated laterally or anteriorly to the zygomatic arch and posi tioned w ithin the glenoid fossa (Figure 1). Some patients experience persistent tem poral muscle tenderness and tem poral tendinitis. This procedure is principally indicated for TM J reconstruction after ankylosis or significant destructive degeneration. Autogenous cartilage from the external ear has been recommended as an interposi tional m aterial by surgeons.36,37 W hen properly performed, there is no residual deform ity of the ear (Figure 2,3). The cartilage is harvested from the ipsilateral ear w ith the incision placed behind the ear. The conchal bowl is excised, m aintaining perichondrium on the convex surface. Its unique shape allows it to fit the glenoid fossa. Some surgeons37 suture the cartilage
'SPECIALTIES to th e surrounding tissue in th e joint. O thers38'39 prefer to secure th e cartilage to the fossa a t the lateral aspect of the zygomatic arch w ith sutures (Figure 3). A prim ate study by Tucker and others38 docum ented the viability of th e ear cartilage w hen placed interpositionally in th e TM J. In th is anim al study, there was a variable am ount of fibrous connective tissue su r rounding the cartilage grafts, and one anim al developed fibrous adhesions betw een the condyle and the inferior surface of the graft. To prevent adhes ions, surgeons have placed a tem porary silicone sheet be tw een the condyle and cartilage for six to eight weeks (M.R. Tucker, D.D.S., R.G. M errill, M.Sc.D., D.D.S., personal communication, 1991). H all24 states th a t his early results w ith interpositional ear cartilage grafts were disap pointing and th a t he could not recom mend this as a preferred procedure over diskectomy. However, it has been our experience w ith 27 cases of interpositional e ar cartilage grafts over four years, th a t this m aterial has functioned well and is currently our preferred technique for TM J disk replacem ent. We do not use m axillom an dibular fixation postoperatively. We recom mend gradual pro gressive opening exercises to ensure an improved range of m andibular motion. Some su r geons use an occlusal splint to decrease joint loading during th e first few postoperative weeks or m onths. CONCLUSION
We have attem pted to present an overview of the questions 1510
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Figure 3. Temporalis muscle flap rotated down into the jo in t space.
associated w ith disk rem oval in TM J arthrotom y. M any experi enced, wellintentioned surgeons obviously differ in their opinions regarding tre a tm e n t in th is clinical situation. It is, however, likely th a t there are several sim ilar autogenous tissues th a t can be safely and predictably used for this purpose in the TM J. It is also likely th a t the Figure 4. Six-month postoperative view shows choice of tissue minimal cosmetic deformity. m ay be a failure of a TM J surgical m atte r of personal choice, procedure. experience and train in g of the F irst and critically, we m ust individual surgeons. O ther be certain th a t the patien t factors affect the success or
SPECIALTIES suffers from in tra-articu lar pathosis, which is the cause of pain and Dr. Adams was chief m andibular resident, Oral and dysfunction. Maxillofacial Surgery, Tripler The general Army Medical d entist should Center, Honolulu. He is now an oral elim inate and maxillofacial dental pain surgeon, Martin and help Army Community Hospital, Fort identify TM J Benning, Ga. 31905. dysfunction. Address reprint requests to Dr. The patien t Adams. and surgeon m ust have realistic expectations as to w hat can be accomplished w ith a particu lar surgical procedure. Knowledge of surgical options by the referring d entist can often assist in tre a tm e n t recom m endations. Finally, p atien t m otivation to postoperative rehabilitation of the joint is extrem ely im portant to th e ultim ate outcome. A program of physical therapy, eith er professionally or personally m anaged, is necessary to re tu rn adequate range of motion, a requisite to good pain-free function. The general d en tist’s participation is necessary to establish the final outcome of norm al occlusion and m asticatory function. ■ This article was prepared as p a rt of the participation of th e specialty organizations in th is section of JADA. Dr. M arkell Kohn, San Diego, is coordinator for th e oral and maxillofacial surgeons. Dr. Bach is colonel, U.S. Army, and chief and director, Residency T raining O ral and Maxillofacial Surgery, and chief, Hospital D entistry, T ripler Army Medical Center, Honolulu. Dr. W aite is associate professor and director, Residency T raining Program , and vice-chairm an, D epartm ent of O ral and Maxillofacial Surgery, School of D entistry,
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U niversity of A labam a a t Birm ingham . 1. DuBrul CE. Sicher and D uBrul’s oral anatom y. St. Louis: Ishiyaku EuroAmerica; 1988. 2. Blackwood H J. C ellular rem odeling in th e articu lar tissue. J D ent Res 1966;45(3) Supplement:480. 3. B row nm an K. Tem porom andibular joint arthrosis and its tre a tm e n t by extirpation of the disk. Acta C hir Scand 1947;95(Supplem ent 118): 19. 4. Dolwick MF. Diagnosis and etiology. In: Helm s CA, K atzberg RW, Dolwick MF, eds. In tern al derangem ents of the tem porom andibular joint. San Francisco: U niversity of California Press; 1983. 5. McCoy JM , Gotcher JE , C hase DC. Histologic grading of TM J tissue in internal derangem ent. J C raniom andibular P ract 1986;4:213-8. 6. Zetz MR, Irby WB. Repair of th e adult tem porom andibular joint m eniscus w ith an autogenous derm al graft. J Oral Maxillofac S urg 1984;42:167-71. 7. M cCarty WL J r., F a rra r W. Surgery for in tern al derangem ents of th e tem porom an dibular joint. J P rosthet D ent 1979;42(2):42. 8. M ercuri LG, Campbell RL, S hanaskin R. In tra-artic u la r m eniscus dysfunction surgery: a prelim inary report. O ral S urg O ral Med O ral Pathol 1982;54:6. 9. Wilkes CH. Surgical tre a tm e n t of in tern al derangem ents of the tem porom andibular joint. Arch Otolaryngol H ead Neck S urg 1991;117(l):64-72. 10. Piper MA. Microscopic disk preservation surgery of the tem porom andibular joint: disorders of the TM J II arthrotom y. O ral Maxillofac S urg Clin N orth Am. Philadelphia: Saunders; 1989:1(2):279. 11. L antz A. D iscitis m andibularis. C entrable C hir 1909;9:289. 12. Block M, K ent J , W alters P. Comparison of 5 diskectomy treatm en ts in prim ates. J O ral Maxillofac S urg 1989;47S:76. 13. H enny FA. The painful tem porom an dibular joint. J O ral S urg 1955;13:341. 14. G uralnic WK, Agan LB, M errill RG. Tem porom andibular joint afflictions. N Engl J Med 1978;299(3): 123-9. 15. Posewillo D. Surgery of th e tem porom andibular joint. In: Zarb GA, Carlsson GE, eds. Tem porom andibular joint function and dysfunction. Copenhagen: M unksgaard; 1979:397-431. 16. Y aillen DM, Shapiro PA, Luschei ES, Feldm an GR. Tem porom andibular joint m eniscectom y—Effects on jo in t structure and m asticatory function in m acaca fascicularis. J Maxillofac Surg 1979;7:255-64. 17. Sprinz R. The role of th e m eniscus in th e healing process following excision of the articu lar surfaces of the m andibular joint in rabbits. J A nat 1963;97:345. 18. Agerber G, S unberg M. Changes in the tem porom andibular joint after surgical treatm en t. O ral S urg O ral Med O ral Pathol 1971;32:865. 19. Boman K. Tem porom andibular joint arthrosis and its treatm en t by extirpation of th e disk. Acta C hir Scand 1947;95:156. 20. Tolvanen M, O ikarinen VJ, Wolf J. A 30-year follow-up study of tem porom an dibular jo in t meniscectomies. Br J O ral Maxillofac S urg 1988;26:311-6. 21. Eriksson L, W estesson PL. Long-term evaluation of meniscectomy of the tem porom andibular joint. J O ral Maxillofac
S urg 1985;43:263. 22. Silver CM. Long-term resu lts of meniscectom y of th e tem porom andibular joint. J C raniom andibular P ra ct 1984;3:47. 23. Brown WA. In tern al derangem ent of th e tem porom andibular joint: Review of 214 patients following meniscectomy. Can J Surg 1980;23:30. 24. H all DH, Link J J . Diskectomy alone and w ith ea r cartilage interposition grafts in joint reconstruction. In: D isorders of the TM J II arthrotom y. O ral S urg O ral Med Oral Pathol 1989;1(2):329. 25. M eyer RA. Autogenous derm al g rafts in reconstruction of tem porom andibular joint. In: D isorders of th e TM J II arthrotom y. Oral Surg O ral Med O ral Pathol 1989; 1(2):351-6. 26. M errill RG. Preface: D isorders of the TM J II: arthrotom y. O ral S urg O ral Med O ral Pathol 1989;1(2):16. 27. T ucker MR, B urkes E J. Tem porary silastic im plantation following diskectomy in the p rim ate tem porom andibular joint. J Oral Maxillofac S urg 1989;47:1290-5. 28. S tew art HM, H ann JR , DeTomasi DC, Neville BW, DeChamplain RW. Histologic studies of derm al grafts following im plantation for tem porom andibular joint meniscal p erfo ratio n s prelim inary study. Oral Surg Oral Med Oral Pathol 1986;62:481-5. 29. Georgiade N. The surgical correction of tem porom andibular jo in t dysfunction by m eans of autogenous derm al grafts. P last Reconstr S urg 1962;30:68. 30. Topazian RG. Comparison of gap and interpositional arthroplasty in th e treatm en t of tem porom andibular jo in t ankylosis. J O ral Surg 1966;24:405. 31. M eyer R. The autogenous derm al graft in tem porom andibular joint disc surgery. J Oral Maxillofac S urg 1988;46:948. 32. Thompson N. The subcutaneous derm is graft: a clinical and histological study in m an. P last R econstr Surg 1960;26:1. 33. M arkowitz NR, P atterson T, C aputa L. A tw o-stage procedure for tem porom andibular joint disc replacem ent using tem poralis pericranial grafts: A prelim inary report. J O ral Maxillofac Surg 1991;49:476-81. 34. Feiberg SE, L arsen PE. The use of a pedicled tem poralis m uscle—pericranial flap for replacem ent of the TM J disc: prelim inary report. J O ral Maxillofac S urg 1989;47:142-6. 35. A lbert TW, M errill RG Tem poralis myofascial flap for reconstruction of th e tem porom andibular joint. In: D isorders of th e TM J II: arthrotom y. O ral Maxillofac S urg Clin N orth Am. P hiladelphia:Saunders; 1989:l(2):341-9. 36. W istsenburg B, F reihofer HPM. Replacem ent of the pathological tem porom an dibular articu lar disc using autogenous cartilage of th e external ear. In t J O ral Surg 1984;13:401. 37. M atukas VJ, L achner J . The use of autologous auricular cartilage for tem porom andibular joint disc replacem ent: a prelim inary report. J Oral Maxillofac Surg 1984;13:401. 38. T ucker MR, Kennedy MC, Jacorvay JR. Autogenous auricular cartilage im plantation following diskectomy in the prim ate tem porom andibular joint. J O ral Maxillofac Surg 1990;48:38-44.