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High-gap arthroplasty for the treatment of bony ankylosis of the temporomandibular joint: report of case
C L I N I C A L
resulted in loss of the resorbed abutment tooth, thus creating a com plex restorative situation. T h e original prosthesis is cur rently 14 years old, functioning well, and showing no apparent evidence of pathosis. Costly and time-consum ing remake proce dures were avoided and patient satisfac tion was maintained.
-------------------- J!iO A --------------------Dr. Brady is associate professor, d ep artm en t o f re storative dentistry, U niversity o f S o u th ern C alifornia School of D entistry, U niversity P a rk —M C 0641 Los Angeles, 90080-0641, a n d is in p riv ate p ractice, El C ajon, CA. A ddress requests for re p rin ts to the au th o r. 1. C ohen, S., an d B urns, R.C. Pathw ays o f the p u lp , ed 3. St. Louis, C. V. Mosby Co, 1984. 2. Ingle, J.I., an d T a in to r, J.F. Endodontics, ed 3. P h ilad e lp h ia , Lea & Febiger, 1985. 3. F rank, A.L. E x tern al-in tern al progressive resorp tio n an d its non su rg ical correction. J E ndod (10):473476, 1981. 4. W eine, F.S. E nd o d o n tic therapy, ed 3. St. Louis, C. V. Mosby Co, 1982. 5. G rossm an, L.I. E n d o d o n tic p ractice, ed 10. P h il adelphia, Lea & Febiger, 1981. 6. F othergill, J.A. C asual c o m m u n icatio n s: p in k spot. T ran s O dontol Soc G r Br 32(5):213-216, 1900.
7. A ndreasen, J.O . T ra u m a tic in ju ries of the teeth, ed 2. P h ilad elp h ia, W. B. Saunders C o, 1981. 8. A p p leb au m , E. In te rn a l reso rp tio n of teeth. Bull D ent Soc NY 5(3):21-26, 1938. 9. R ab in o w itch , B.Z. In tern al resorption. O ral Surg 10(2): 193-206, 1953. 10. M ount, G .J. Id io p ath ic intern al resorption: a report o n 15 cases. O ral Surg 33(5):801-809, 1972. 11. W arner, G .R ., a n d others. In te rn a l reso rp tio n of teeth: in te rp reta tio n of histologic findings. JADA 34(4):468-483, 1947. 12. G illespie, O.S. In te rn a l a n d external resorption. Penn D ent J 54(6): 103-104, 1951. 13. G ard n er, E.B. Fracture o f low er left central in c i sor: rep o rt of a case. JADA 35(11):838, 1947. 14. Fahid, A., an d T a in to r, J.F . Id io p a th ic internal reso rp tio n : rep o rt of an u n u su al case. C om pend Contin Educ D ent 6(4):288-294, 1985. 15. Som m er, R .F., a n d O strander, D.F. C linical endodontics, ed 3. P h ilad elp h ia, W. B. Saunders Co, 1966. 16. H eithersay, G.S. C linical e n dodontic a n d surgi cal m an ag em en t of tooth and associated bone resorp tion. In t E ndod J 18(2):72-92, 1985. 17. B erning, H .P ., an d L epp, F.L. Progressive in ternal reso rp tio n in pe rm a n e n t teeth. C iencia C ult 56(12):49-53, 1957. 18. T h o m a, K.H. C entral osteoclastic resorption of d en tin a n d com plete re p a ir w ith osteodentine in the p erm an en t to o th o f an ad u lt. D ent Item s 57(l):28-38, 1935.
R E P O R T S
19. R abinow itch, B.Z. Internal resorption. O ral Surg 33(2):263-282, 1972. 20. Stafne, E.C., and Slocumb, B.C. Idiopathic resorp tio n of teeth. Am J O rth o d 30( 1):41 -49, 1944. 21. Kaffee, I., a n d others. C hanges in the la m in a d u ra as a m an ifestatio n o f systemic diseases: re p o rt of a case a n d review of the literature. J E ndod 8(10):467470, 1982. 22. M orse, D .R . In te rn a l ro o t re so rp tio n . O ral H e alth 75(12):17-23, 1985. 23. K ahn, H ., an d others. A sim plified m ethod of co n stru ctin g a core follow ing e n dodontic treatm ent. J Prosthet D ent 37(l):32-36, 1977. 24. Brady, W .F. R esto ratio n of a n o n v ita l to o th to allow reuse of a preexisting cast crow n. CDS Rev 79(5):38-43, 1986. 25. Colley, I.T ., an d others. R eten tio n of post crow ns: an assessm ent o f the relative efficiency o f posts of different shapes a n d sizes. Br D ent J 124(2):63-69, 1968. 26. H enry, P .J. P hotoelastic analysis of p o st core restorations. A ust D ent J 22(3): 157-159, 1977. 27. B araban, D .J. A sim plified m eth o d for m a k in g posts an d cores. J Prosthet D ent 24(3):287-297, 1970. 28. G erstein, H ., an d B urnell, S.C. Prefabricated precision dowels. JAD A 68(6):787-791, 1964. 29. G erstein, H ., a n d Evanson, L. P recision posts or dowels. Ill D ent J 32(2):70-73, 1963. 30. H u d is, S.I., a n d G oldstein, G .R . R estoration of endodontically treated teeth: a review of the literature. J Prosthet D ent 55(l):33-38, 1986.
High-gap arthroplasty for the treatment of bony ankylosis of the temporomandibular joint: report of case Dean M. DeLuke, DDS
With the aid of recent refinements in tem poromandibular joint surgery, it is often possible to release a bony ankylosis directly within the joint space. The causes of bony ankylosis, various surgical techniques, and preoperative management are discussed within the framework of this report of case.
ony ankylosis of the temporoman dibular joint (TMJ) has occurred after various precipitating events.1 Infection, systemic or local, is one poten tial cause. Local sources of infection could include otitis, mastoiditis, or osteomyelitis of contiguous structures. Septicemia caused by subacute bacterial endocarditis, gonor rhea, m eningitis, or tuberculosis has also been im plicated. Trauma is a more com mon cause in the present era of antibiotics. Rheumatic disease, including end-stage rheumatoid arthritis and ankylosing spon
dylitis, may also result in ankylosis. In a review byTopazian,1approximately 18%of cases had no identifiable cause. Many surgical techniques for m anage ment have been described. In the growing child, costochondral grafting remains the preferred treatment of most surgeons. In the adult patient surgical techniques vary, both in the location of the ostectomy as well as in the choice of interpositional
B
Fig 1 ■ Preoperative o cclusion sho w in g deviation of m a n d ib u la r m id lin e to the right.
material. T he low horizontal gap or inter positional arthroplasty2involves creating a horizontal ostectomy below the level of the sigm oid notch. A pseudarthrosis then occurs at this level. The more com m only used technique today is the creation of a 1-cm gap at the level of the sigm oid notch. T his has been described by Walker3 and various other authors. Condylectomy, or high condylectomy, has been described by many, dating to the 19th century when Humphry performed the first condylec tomy in 1854. Total joint replacement is usually reserved for extensive, bilateral cases 0 1 cases in which previous operations have been performed where maintenance of vertical dim ension may be problematic.4 Interpositional materials include a va riety of alloplastic and autogenous sub stances. Autogenous sources include der mis, fascia, and muscle. Alloplasts include methyl methacrylate3 (usually described for the low-gap technique), silicone (which
DeLuke : ARTHROPLASTY FOR ANKYLOSIS OF TM J ■ 281
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has recently been linked to foreign body granulomatous reactions in adjacent tis sues5), Dacron-reinforced silastic, and Tef lon Proplast laminates. The superiority of placing some form of interpositional mate rial in favor of the pure gap techniques has been documented by Topazian.6 Report of case A 56-year-old female was examined with a progressive lim itation in degree of man dibular opening. Her medical history was significant in that she had undergone a tympanoplasty procedure for the left ear just before the onset of her joint symptoms 10 years earlier. T he operative report for this procedure included mention of an unusual am ount of TMJ exposure. Clinical exam ination disclosed a slight palpable expansion over the left TMJ. fnterincisal opening was limited to 16 mm, with deviation to the left on opening. The occlusion was deviated (Fig 1) with a shift of the mandibular midline to the right, and this had reportedly progressed slowly for several years. A panoramic radio graph (Fig 2) disclosed significant bony proliferation of the glenoid fossa, both anterior and posterior to the condylar head. A CT scan was obtained (Fig 3) that showed an osteoblastic process involving the left TMJ. There was no translatory movement of the condyle in comparison with the right side (Fig 3), which had normal translation. The meniscus was not visualized, although there did appear to be some preservation of joint space. T he clinical diagnosis was consistent with bony ankylosis of the left TMJ. The probable pathogenesis involved hemor rhage into the joint secondary to the m id dle ear surgery, followed by hematoma formation, fibrosis, and bony organization
Fig 3 ■ C T scan o f the ankylosed left T M J; there is n o condylar tra n sla tio n in the open position. C T scan of th e rig h t T M J. J o in t anatom y a p p ea rs n o rm al and the condyle translates dow n the a rtic u la r em inence in th e o p en p osition.
of the fibrosed clot, culminating in ankylosis. Preoperative study models were mounted (Fig 4, left), and with m inim al occlusal adjustment, a projected postoperative occlu sal relation was obtained with restoration of dental m idlines (Fig 4, right). An interocclusal wafer was fabricated for use dur ing surgery as a guide in determining the condylar position in occlusion. T he left TMJ was exposed using a preauricular approach, and there was total obliteration of the joint space laterally (Fig 5, left). A 6-ram wedge of bone was removed and the remnant of the joint space was entered. T he medial depth of
the cut was monitored with calibrated osteotomes to protect vital structures. Fur ther arthroplasty was accomplished with reciprocating rasps and rotary instruments under direct vision (Fig 5, middle). The interocclusal wafer was placed by an assis tant and the condylar position in occlu sion assessed. An appropriately sized im plant was then selected (4.3-mm nonporous T eflon Proplast) impregnated in anti biotic solution, and secured to the lateral aspect of the glenoid fossa with stainless steel wire ligatures (Fig 5, right). T he histological findings are consistent with bony ankylosis (Fig 6). There are areas of lamellar bone formation and areas o f cartilagenous tissue with no cellular anaplasia or unusual mitotic activity. Antibiotics were prescribed for 2 weeks and a nonsteroidal anti-inflam m atory agent for 4 weeks. For several months, the patient continued a regimen of passive opening exercises in the m idline and in all excursions. No forced mechanical open ing exercises were prescribed. The patient maintains an interincisal opening of 38 mm 30 months postoperatively. Discussion With recent refinements in the surgical approach to the TMJ, the high (intraarticular) interpositional arthroplasty can be performed with less morbidity and fewer
282 ■ JADA, Vol. 115, August 1987
C L I N I C A L
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F ig 4 ■ Left, preoperative study models. W ith m in o r occlusal a d ju stm en t (right), a projected postoperative re la tio n sh ip is obtained.
F ig 5 ■ Left, in trao p e ra tiv e p h o to g ra p h o f the left T M J; n o te com plete a nkylosis of condyle to g lenoid fossa. M iddle, a wedge of bone has been rem oved, th e bony adhesions released, an d th e condyle recontoured. R ig h t, a 4.3-m m n o n p o ro u s T eflon P ro p last im p la n t w ith a rtic u la r em inence e x tension has been secured to the glenoid fossa.
F ig 6 ■ Left, low -pow er p h o to m ic ro g rap h sh o w in g areas of la m e lla r bone fo rm atio n . R ig h t, hig h pow er p h o to m ic ro g ra p h sho w in g n o c ellu lar anap lasia or u n u su a l m ito tic activity.
com plications. There are certain advan tages to this technique. By keeping the level of ostectomy close to the anatomic TMJ, more physiological function of the mandible is achieved. Lateral excursive movements remain intact, and because the joint function is more physiological, the period of painful postoperative physiother apy and the tendency toward relapse some times seen with low-gap techniques should be less likely. Conversely, the lim itations of this tech nique m ust be considered. Coronoid in volvement in the ankylosis process must be ruled out, as this w ould necessitate coronoidectomy. In this case, a low-gap technique m ight be more appropriate, or a
high-gap technique in conjunction with coronoidectomy. In extensive or bilateral cases of ankylosis, maintenance of vertical dimension may become problematic and total joint replacement may be indicated. Contraindications of any alloplast include certain systemic conditions such as uncon trolled diabetes, osteomyelitis, and allergy to the alloplast. Advantages of the nonporous Teflon Proplast laminate as an implant material include excellent biocom patibility as re ported by Kent,7 a low rate of infection, relative ease in placement, and the ability to m aintain a moderate am ount of vertical dim ension and restore articular eminence contour. T he Teflon surface allows for
smooth articulation w hile the Proplast surface allow s for tissue ingrowth. Further studies are still needed regarding long term durability in comparison with other alloplasts. Excessive joint loading caused by parafunctional habits or lack of poste rior occlusal support m ight predispose any alloplast to failure. Conclusion T he CT scan can be a valuable aid in determining the extent of ankylosis, there by indicating this technique in favor of another. In this case, there appeared to be some preservation of joint space, suggest ing that a cleavage plane w ithin the joint
DeLuke : ARTHROPLASTY FOR ANKYLOSIS OF TM J ■ 283
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REPORTS
m ig h t be o b ta in e d w ith o u t excessive c h is e lin g . D am ag e to the m id d le m e n in g e a l a rtery , th e in te rn a l m a x illa ry artery , o r m id d le c ra n ia l fossa fractu re c o u ld o ccu r fro m in ju d ic io u s use of chisels o r b u rs in a reas s u r ro u n d in g the jo in t. M oreover, w ith th e C T scan, co ro n al rec o n stru c tio n s c a n be o b ta in e d to assess the m e d ia l e x ten t o f a n k y lo sis.8 F in a lly , by preoperatively p la n n in g o c c lu s a l c h an g es, im m ed iate p o sto p e ra tiv e o cclu sal sta b ility ca n be p ro v id ed , th e need fo r seco n d ary o cclu sal a d ju s tm e n t is m in im ized, a n d p a tie n t fu n c tio n a n d c o m fo rt a re m a x im ized early in the p o sto p erativ e period.
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284 ■ JADA, Vol. 115, August 1987
Dr. D eLuke is a tte n d in g oral surgeon, Ellis H ospital a n d St. C lare’s H ospital, and is in private practice; 1070 N o tt St, Schenectady, NY 12308. Address requests for re p rin ts to the author.
T h e in te rp o sitio n a l im p la n t described in this article was designed by Dr. J o h n Kent a n d m anufactured by Vitek. A dd itio n al inform ation about the products m en tio n ed in th is m an u scrip t may be available from the a u th o r. N eith er the a u th o r n o r the A m erican D ental A ssociation has any com m ercial interests in the p ro d ucts m entioned.
1. T o p a z ia n , R .G . Etiology of ankylosis o f the tem p o ro m a n d ib u la r jo in t: analysis of 44 cases. J O ral Surg 22(5):227-233, 1964. 2. K am eros, J., a n d H im m elfarb, R. T rea tm e n t of tem p o ro m an d ib u lar jo in t ankylosis w ith m ethyl m e th acrylate in te rp o sitio n a l arthroplasty. J O ral Surg
33(4):282-287, 1975. 3. W alker, R.V. A rthroplasty of the ankylosed tem p o ro m a n d ib u la r jo in t. T ra n s In t C o n f O ra l Surg 4:279-283, 1973. 4. Kent, J.N ., and others. T e m p o ro m an d ib u lar jo in t condylar prosthesis: a ten year report. J O ra l M axillofac S urg 41(4):245-254, 1983. 5. Dolw ick, M .F., and A ufdem orte, T.B . Silicone induced foreign body reaction a n d lym phadenopathy after tem porom andibular jo in t arthroplasty. O ral Surg 59(5):449-452, 1985. 6. T o pazian, R .G . C om parison of g a p a n d in te rp o sitio n arth ro p lasty in the treatm ent of te m p o ro m a n d ib u la r jo in t ankylosis. J O ral S urg 24(5):405-409, 1966. 7. Kent, J ., an d Zide, M. W ound h ealin g : bone and biom aterials. O tolaryngol C lin N o rth A m 17(2):284* 290, 1984. 8. T u ck er, M .R., a n d others. V ersatility o f C T scan n in g for evaluation of m a n d ib u la r hypom obilities. J M axillofac Surg 14{2):89-92, 1986.
resulted in loss of the resorbed abutment tooth, thus creating a com plex restorative situation. T h e original prosthesis is cur rently 14 years old, functioning well, and showing no apparent evidence of pathosis. Costly and time-consum ing remake proce dures were avoided and patient satisfac tion was maintained.
-------------------- J!iO A --------------------Dr. Brady is associate professor, d ep artm en t o f re storative dentistry, U niversity o f S o u th ern C alifornia School of D entistry, U niversity P a rk —M C 0641 Los Angeles, 90080-0641, a n d is in p riv ate p ractice, El C ajon, CA. A ddress requests for re p rin ts to the au th o r. 1. C ohen, S., an d B urns, R.C. Pathw ays o f the p u lp , ed 3. St. Louis, C. V. Mosby Co, 1984. 2. Ingle, J.I., an d T a in to r, J.F. Endodontics, ed 3. P h ilad e lp h ia , Lea & Febiger, 1985. 3. F rank, A.L. E x tern al-in tern al progressive resorp tio n an d its non su rg ical correction. J E ndod (10):473476, 1981. 4. W eine, F.S. E nd o d o n tic therapy, ed 3. St. Louis, C. V. Mosby Co, 1982. 5. G rossm an, L.I. E n d o d o n tic p ractice, ed 10. P h il adelphia, Lea & Febiger, 1981. 6. F othergill, J.A. C asual c o m m u n icatio n s: p in k spot. T ran s O dontol Soc G r Br 32(5):213-216, 1900.
7. A ndreasen, J.O . T ra u m a tic in ju ries of the teeth, ed 2. P h ilad elp h ia, W. B. Saunders C o, 1981. 8. A p p leb au m , E. In te rn a l reso rp tio n of teeth. Bull D ent Soc NY 5(3):21-26, 1938. 9. R ab in o w itch , B.Z. In tern al resorption. O ral Surg 10(2): 193-206, 1953. 10. M ount, G .J. Id io p ath ic intern al resorption: a report o n 15 cases. O ral Surg 33(5):801-809, 1972. 11. W arner, G .R ., a n d others. In te rn a l reso rp tio n of teeth: in te rp reta tio n of histologic findings. JADA 34(4):468-483, 1947. 12. G illespie, O.S. In te rn a l a n d external resorption. Penn D ent J 54(6): 103-104, 1951. 13. G ard n er, E.B. Fracture o f low er left central in c i sor: rep o rt of a case. JADA 35(11):838, 1947. 14. Fahid, A., an d T a in to r, J.F . Id io p a th ic internal reso rp tio n : rep o rt of an u n u su al case. C om pend Contin Educ D ent 6(4):288-294, 1985. 15. Som m er, R .F., a n d O strander, D.F. C linical endodontics, ed 3. P h ilad elp h ia, W. B. Saunders Co, 1966. 16. H eithersay, G.S. C linical e n dodontic a n d surgi cal m an ag em en t of tooth and associated bone resorp tion. In t E ndod J 18(2):72-92, 1985. 17. B erning, H .P ., an d L epp, F.L. Progressive in ternal reso rp tio n in pe rm a n e n t teeth. C iencia C ult 56(12):49-53, 1957. 18. T h o m a, K.H. C entral osteoclastic resorption of d en tin a n d com plete re p a ir w ith osteodentine in the p erm an en t to o th o f an ad u lt. D ent Item s 57(l):28-38, 1935.
R E P O R T S
19. R abinow itch, B.Z. Internal resorption. O ral Surg 33(2):263-282, 1972. 20. Stafne, E.C., and Slocumb, B.C. Idiopathic resorp tio n of teeth. Am J O rth o d 30( 1):41 -49, 1944. 21. Kaffee, I., a n d others. C hanges in the la m in a d u ra as a m an ifestatio n o f systemic diseases: re p o rt of a case a n d review of the literature. J E ndod 8(10):467470, 1982. 22. M orse, D .R . In te rn a l ro o t re so rp tio n . O ral H e alth 75(12):17-23, 1985. 23. K ahn, H ., an d others. A sim plified m ethod of co n stru ctin g a core follow ing e n dodontic treatm ent. J Prosthet D ent 37(l):32-36, 1977. 24. Brady, W .F. R esto ratio n of a n o n v ita l to o th to allow reuse of a preexisting cast crow n. CDS Rev 79(5):38-43, 1986. 25. Colley, I.T ., an d others. R eten tio n of post crow ns: an assessm ent o f the relative efficiency o f posts of different shapes a n d sizes. Br D ent J 124(2):63-69, 1968. 26. H enry, P .J. P hotoelastic analysis of p o st core restorations. A ust D ent J 22(3): 157-159, 1977. 27. B araban, D .J. A sim plified m eth o d for m a k in g posts an d cores. J Prosthet D ent 24(3):287-297, 1970. 28. G erstein, H ., an d B urnell, S.C. Prefabricated precision dowels. JAD A 68(6):787-791, 1964. 29. G erstein, H ., a n d Evanson, L. P recision posts or dowels. Ill D ent J 32(2):70-73, 1963. 30. H u d is, S.I., a n d G oldstein, G .R . R estoration of endodontically treated teeth: a review of the literature. J Prosthet D ent 55(l):33-38, 1986.
High-gap arthroplasty for the treatment of bony ankylosis of the temporomandibular joint: report of case Dean M. DeLuke, DDS
With the aid of recent refinements in tem poromandibular joint surgery, it is often possible to release a bony ankylosis directly within the joint space. The causes of bony ankylosis, various surgical techniques, and preoperative management are discussed within the framework of this report of case.
ony ankylosis of the temporoman dibular joint (TMJ) has occurred after various precipitating events.1 Infection, systemic or local, is one poten tial cause. Local sources of infection could include otitis, mastoiditis, or osteomyelitis of contiguous structures. Septicemia caused by subacute bacterial endocarditis, gonor rhea, m eningitis, or tuberculosis has also been im plicated. Trauma is a more com mon cause in the present era of antibiotics. Rheumatic disease, including end-stage rheumatoid arthritis and ankylosing spon
dylitis, may also result in ankylosis. In a review byTopazian,1approximately 18%of cases had no identifiable cause. Many surgical techniques for m anage ment have been described. In the growing child, costochondral grafting remains the preferred treatment of most surgeons. In the adult patient surgical techniques vary, both in the location of the ostectomy as well as in the choice of interpositional
B
Fig 1 ■ Preoperative o cclusion sho w in g deviation of m a n d ib u la r m id lin e to the right.
material. T he low horizontal gap or inter positional arthroplasty2involves creating a horizontal ostectomy below the level of the sigm oid notch. A pseudarthrosis then occurs at this level. The more com m only used technique today is the creation of a 1-cm gap at the level of the sigm oid notch. T his has been described by Walker3 and various other authors. Condylectomy, or high condylectomy, has been described by many, dating to the 19th century when Humphry performed the first condylec tomy in 1854. Total joint replacement is usually reserved for extensive, bilateral cases 0 1 cases in which previous operations have been performed where maintenance of vertical dim ension may be problematic.4 Interpositional materials include a va riety of alloplastic and autogenous sub stances. Autogenous sources include der mis, fascia, and muscle. Alloplasts include methyl methacrylate3 (usually described for the low-gap technique), silicone (which
DeLuke : ARTHROPLASTY FOR ANKYLOSIS OF TM J ■ 281
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R E P O R T S
has recently been linked to foreign body granulomatous reactions in adjacent tis sues5), Dacron-reinforced silastic, and Tef lon Proplast laminates. The superiority of placing some form of interpositional mate rial in favor of the pure gap techniques has been documented by Topazian.6 Report of case A 56-year-old female was examined with a progressive lim itation in degree of man dibular opening. Her medical history was significant in that she had undergone a tympanoplasty procedure for the left ear just before the onset of her joint symptoms 10 years earlier. T he operative report for this procedure included mention of an unusual am ount of TMJ exposure. Clinical exam ination disclosed a slight palpable expansion over the left TMJ. fnterincisal opening was limited to 16 mm, with deviation to the left on opening. The occlusion was deviated (Fig 1) with a shift of the mandibular midline to the right, and this had reportedly progressed slowly for several years. A panoramic radio graph (Fig 2) disclosed significant bony proliferation of the glenoid fossa, both anterior and posterior to the condylar head. A CT scan was obtained (Fig 3) that showed an osteoblastic process involving the left TMJ. There was no translatory movement of the condyle in comparison with the right side (Fig 3), which had normal translation. The meniscus was not visualized, although there did appear to be some preservation of joint space. T he clinical diagnosis was consistent with bony ankylosis of the left TMJ. The probable pathogenesis involved hemor rhage into the joint secondary to the m id dle ear surgery, followed by hematoma formation, fibrosis, and bony organization
Fig 3 ■ C T scan o f the ankylosed left T M J; there is n o condylar tra n sla tio n in the open position. C T scan of th e rig h t T M J. J o in t anatom y a p p ea rs n o rm al and the condyle translates dow n the a rtic u la r em inence in th e o p en p osition.
of the fibrosed clot, culminating in ankylosis. Preoperative study models were mounted (Fig 4, left), and with m inim al occlusal adjustment, a projected postoperative occlu sal relation was obtained with restoration of dental m idlines (Fig 4, right). An interocclusal wafer was fabricated for use dur ing surgery as a guide in determining the condylar position in occlusion. T he left TMJ was exposed using a preauricular approach, and there was total obliteration of the joint space laterally (Fig 5, left). A 6-ram wedge of bone was removed and the remnant of the joint space was entered. T he medial depth of
the cut was monitored with calibrated osteotomes to protect vital structures. Fur ther arthroplasty was accomplished with reciprocating rasps and rotary instruments under direct vision (Fig 5, middle). The interocclusal wafer was placed by an assis tant and the condylar position in occlu sion assessed. An appropriately sized im plant was then selected (4.3-mm nonporous T eflon Proplast) impregnated in anti biotic solution, and secured to the lateral aspect of the glenoid fossa with stainless steel wire ligatures (Fig 5, right). T he histological findings are consistent with bony ankylosis (Fig 6). There are areas of lamellar bone formation and areas o f cartilagenous tissue with no cellular anaplasia or unusual mitotic activity. Antibiotics were prescribed for 2 weeks and a nonsteroidal anti-inflam m atory agent for 4 weeks. For several months, the patient continued a regimen of passive opening exercises in the m idline and in all excursions. No forced mechanical open ing exercises were prescribed. The patient maintains an interincisal opening of 38 mm 30 months postoperatively. Discussion With recent refinements in the surgical approach to the TMJ, the high (intraarticular) interpositional arthroplasty can be performed with less morbidity and fewer
282 ■ JADA, Vol. 115, August 1987
C L I N I C A L
R E P O R T S
F ig 4 ■ Left, preoperative study models. W ith m in o r occlusal a d ju stm en t (right), a projected postoperative re la tio n sh ip is obtained.
F ig 5 ■ Left, in trao p e ra tiv e p h o to g ra p h o f the left T M J; n o te com plete a nkylosis of condyle to g lenoid fossa. M iddle, a wedge of bone has been rem oved, th e bony adhesions released, an d th e condyle recontoured. R ig h t, a 4.3-m m n o n p o ro u s T eflon P ro p last im p la n t w ith a rtic u la r em inence e x tension has been secured to the glenoid fossa.
F ig 6 ■ Left, low -pow er p h o to m ic ro g rap h sh o w in g areas of la m e lla r bone fo rm atio n . R ig h t, hig h pow er p h o to m ic ro g ra p h sho w in g n o c ellu lar anap lasia or u n u su a l m ito tic activity.
com plications. There are certain advan tages to this technique. By keeping the level of ostectomy close to the anatomic TMJ, more physiological function of the mandible is achieved. Lateral excursive movements remain intact, and because the joint function is more physiological, the period of painful postoperative physiother apy and the tendency toward relapse some times seen with low-gap techniques should be less likely. Conversely, the lim itations of this tech nique m ust be considered. Coronoid in volvement in the ankylosis process must be ruled out, as this w ould necessitate coronoidectomy. In this case, a low-gap technique m ight be more appropriate, or a
high-gap technique in conjunction with coronoidectomy. In extensive or bilateral cases of ankylosis, maintenance of vertical dimension may become problematic and total joint replacement may be indicated. Contraindications of any alloplast include certain systemic conditions such as uncon trolled diabetes, osteomyelitis, and allergy to the alloplast. Advantages of the nonporous Teflon Proplast laminate as an implant material include excellent biocom patibility as re ported by Kent,7 a low rate of infection, relative ease in placement, and the ability to m aintain a moderate am ount of vertical dim ension and restore articular eminence contour. T he Teflon surface allows for
smooth articulation w hile the Proplast surface allow s for tissue ingrowth. Further studies are still needed regarding long term durability in comparison with other alloplasts. Excessive joint loading caused by parafunctional habits or lack of poste rior occlusal support m ight predispose any alloplast to failure. Conclusion T he CT scan can be a valuable aid in determining the extent of ankylosis, there by indicating this technique in favor of another. In this case, there appeared to be some preservation of joint space, suggest ing that a cleavage plane w ithin the joint
DeLuke : ARTHROPLASTY FOR ANKYLOSIS OF TM J ■ 283
CLINICAL
REPORTS
m ig h t be o b ta in e d w ith o u t excessive c h is e lin g . D am ag e to the m id d le m e n in g e a l a rtery , th e in te rn a l m a x illa ry artery , o r m id d le c ra n ia l fossa fractu re c o u ld o ccu r fro m in ju d ic io u s use of chisels o r b u rs in a reas s u r ro u n d in g the jo in t. M oreover, w ith th e C T scan, co ro n al rec o n stru c tio n s c a n be o b ta in e d to assess the m e d ia l e x ten t o f a n k y lo sis.8 F in a lly , by preoperatively p la n n in g o c c lu s a l c h an g es, im m ed iate p o sto p e ra tiv e o cclu sal sta b ility ca n be p ro v id ed , th e need fo r seco n d ary o cclu sal a d ju s tm e n t is m in im ized, a n d p a tie n t fu n c tio n a n d c o m fo rt a re m a x im ized early in the p o sto p erativ e period.
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284 ■ JADA, Vol. 115, August 1987
Dr. D eLuke is a tte n d in g oral surgeon, Ellis H ospital a n d St. C lare’s H ospital, and is in private practice; 1070 N o tt St, Schenectady, NY 12308. Address requests for re p rin ts to the author.
T h e in te rp o sitio n a l im p la n t described in this article was designed by Dr. J o h n Kent a n d m anufactured by Vitek. A dd itio n al inform ation about the products m en tio n ed in th is m an u scrip t may be available from the a u th o r. N eith er the a u th o r n o r the A m erican D ental A ssociation has any com m ercial interests in the p ro d ucts m entioned.
1. T o p a z ia n , R .G . Etiology of ankylosis o f the tem p o ro m a n d ib u la r jo in t: analysis of 44 cases. J O ral Surg 22(5):227-233, 1964. 2. K am eros, J., a n d H im m elfarb, R. T rea tm e n t of tem p o ro m an d ib u lar jo in t ankylosis w ith m ethyl m e th acrylate in te rp o sitio n a l arthroplasty. J O ral Surg
33(4):282-287, 1975. 3. W alker, R.V. A rthroplasty of the ankylosed tem p o ro m a n d ib u la r jo in t. T ra n s In t C o n f O ra l Surg 4:279-283, 1973. 4. Kent, J.N ., and others. T e m p o ro m an d ib u lar jo in t condylar prosthesis: a ten year report. J O ra l M axillofac S urg 41(4):245-254, 1983. 5. Dolw ick, M .F., and A ufdem orte, T.B . Silicone induced foreign body reaction a n d lym phadenopathy after tem porom andibular jo in t arthroplasty. O ral Surg 59(5):449-452, 1985. 6. T o pazian, R .G . C om parison of g a p a n d in te rp o sitio n arth ro p lasty in the treatm ent of te m p o ro m a n d ib u la r jo in t ankylosis. J O ral S urg 24(5):405-409, 1966. 7. Kent, J ., an d Zide, M. W ound h ealin g : bone and biom aterials. O tolaryngol C lin N o rth A m 17(2):284* 290, 1984. 8. T u ck er, M .R., a n d others. V ersatility o f C T scan n in g for evaluation of m a n d ib u la r hypom obilities. J M axillofac Surg 14{2):89-92, 1986.