- Email: [email protected]
Temporary reconstruction of the lower jaw by condylar reimplantation
j. max.-fac. Surg. 14 (1986) J. max.-fac. Surg. 14 (1986) 221-226 © Georg Thieme Verlag Stuttgart • New York
Temporary Reconstruction of the Lower Jaw by Condylar Reimplantation Case Report Orestis Hadjianghelou Dept. of Maxillo-Facial Surgery, (Head: Prof. H. L. Obwegeser, M.D., D.M.D.) University Hospital, Ziirich, Switzerland Submitted 9 . 5 . 1985; accepted 3 0 . 9 . 1985
Introduction The adaptation either of the transplanted bone in primary intraoral reconstruction, or of the plate prosthesis in temporary intraoral reconstruction, is especially difficult when the defect extends to the subcondylar area of the ramus of the mandible. Because of this technical problem, resection of the condyle is generally included, even when it is not necessary for radical turnout removal. The restoration of T.M.J. functions is especially difficult, if after its disarticulation, a temporary prosthesis reconstruction extending into the glenoid fossa is performed. A whole series of prosthetic systems have been developed for the temporary reconstruction of the jaw. These systems enable the surgeon to reconstruct the mandible not only in cases of segmental defects but also if the condylar head is included in the resection by using a condylar prosthesis. By using a metal prothesis the glenoid fossa will possibly be exposed to a remodelling effect secondary to the changed functional situation. The resulting resorption processes may lead to penetration of the cranial base by the alloplastic condyle. In order to avoid possible untoward effects attributable to the condylar prosthesis in a case of temporary reconstruction following exarticulation, we have developed a technique of reimplanting the resected condyle instead of using a joint prosthesis. This technique was developed based on the experiences of Rossi and Arrigoni (1979), using the resected condyle together with autogenous iliac crest bone for primary reconstruction of the lower jaw defect. The patient was followed up for a period of 28 months, after which the definitive reconstruction was made, following the removal of the condyle. The removed condyle has been thoroughly examined. This single case is published in order to stimulate others to employ this method to obtain more experience on this subject.
Cases Report History and clinical findings The patient, a 59 year old female, 6 months before surgery noticed sudden mobility of the right second lower molar.
221
Summary An alternative method to temporary lower jaw reconstruction with a reconstruction plate prosthesis is described. To prevent penetration of an alloplastic condyle transplant through the skull base, and to restore joint function, we have reimplanted the resected condyle after its fixation to the reconstruction plate. Postoperatively, there have been no complications. Joint function has been almost completely restored. The reimplanted condyle has been investigated after 28 months. It has undergone remarkable changes.
Key-Words Condylar reimplantation - Temporary reconstruction - Mandibular reconstruction - TMJ.
After its extraction by her dentist, wound healing was extremely slow. Three months later, the right first lower molar was extracted for the same reason, again with delayed healing. Additionally, an ulcerating wound developed at the operation site. Because the ulcer did not heal, her dentist referred her to our clinic for further investigation. On admission, the patient was found to have a 1.5 cm ulcerating lesion in the area of the previously extracted tooth. The lingual and buccal cortices in the area of the ulcer were expanded. The panoramic radiograph showed localized bone destruction in the right mandibular body extending along the mandibular canal up into the ascending ramus. Submandibular and subdigastric painless, enlarged lymph nodes were present ipsilaterally in the neck.
Surgical Technique Biopsy of the ulcerating lesion revealed a malignant tumour, no further differentiation being possible. In view of this, a hemimandibulectomy with resection of surrounding (including subcutaneous) soft tissue was performed along with supra-omohyoid neck dissection. The articular disc was not removed. On inspecting the specimen we found that the condyle was tumour-free. At this point, we decided to reimplant the resected condylar head, using an AO plate to bridge the gap between condyle and mandibular body. The condyle was separated from the ascending ramus over a 2 x 1 cm. area. It was connected to an AO reconstruction plate with 2.7 mm. screws. To ensure the blood supply of the condyle 3 bur holes were made on the dorsal aspect, passing through the cortical into the cancellous bone (Fig. 1). Prior to the application of the plate prosthesis to the mandible, intermaxillary fixation was performed. The plate was formed so that a normal occlusal plane would result after the removal of the intermaxillary fixation. The plate was secured with 3 screws into the remaining mandible in the chin region. Thereby, the lower jaw defect was reconstructed in a functionally stable way. The intermaxillary fixation was removed immediately after osteosynthesis. The proper orientation of the plate was checked by inspecting the occlusion. After this the surrounding tissues were adapted and the intraoral wound was closed.
222
J. max.-fac. Surg. 14 (1986)
O. Hadjianghelou
Fig. 1 Posterior view of the resected condyle fixed to the AO plate. To ensure the blood supply three bur-holes have been made through the dorsal cortical plate.
Fig. 2 The patient two years postoperatively, with a maximal mouth opening of 40 mrn.
Postoperative course and late result Postoperatively, there were no complications. After four months the interincisal opening (spontaneous) was 38 mm., and 6 months postoperatively 40 ram. (Fig. 2). The lower jaw movement in comparison with the preoperative movements was essentially similar. Only the lateral movement to the left has been limited. The rotational and protrusive movements of the condyle have been retained. The postoperative condition had not changed by the 28th postoperative month, when the condyle was removed for definitive reconstruction of the defect with a bone graft. Several x-rays have been taken during the postoperative follow-up period. In this way we could precisely document the remodelling and degenerative processes which followed the reimplantation with subsequent almost normal function of the condyle. Fig. 3 shows the condyle two years and four months after reimplantation. The tomograms taken two years postoperatively show in detail the radiological appearance of the reimplanted condyle (Fig. 4): The head and the neck have become narrow and the surface appears rather irregular. A significant sharp bone protrusion from the head of the condyle has developed in a medial direction and is directed toward the articular prominence. The glenoid fossa has not undergone any pathological change.
lar disc was again not removed, therefore histological examination was not possible. Compared with the initial situation (Fig. 1) extensive configurative changes, including loss of the cartilaginous layer of the cranial surface can be indentified on the condyle (Fig. 5). It has become much narrower. On the anterior aspect of the lateral and medial poles of the condylar head bony prominences can be clearly identified. They are directed forward and have a rough surface, while the distal part of the head as well as most of the cranial portion are quite smooth. The microradiographs (Fig. 6) show the internal structure of the condyle. In the anterior aspect of the lateral (Fig. 6 a) and most of the medial pole (Fig. 6b, c, d) of the head, which macroscopically appears rough, a discontinuity of the normal cortical structure could be observed. The cancellous bone extends to the rough bone surface. The condyle was removed in the anterior part with the surrounding tissues, while in the posterior part the subperiosteal resection was performed. The histological examination showed therefore that in some parts the condylar surface was covered with periosteum or hyaline connective tissue which was converted in the outer layer into moderate cellular co|lagenous connective tissue. The anterior surface with the attachment of the muscle could be clearly identified (Fig. 7), in some instances at the anterior surface rests of hyaline cartilage can be seen under a layer of connective tissue. The histological sections showed, like the microradiographs, on the distal aspect of the condylar surface normal and regular cortical structures (Fig. 8 a). However in the
Macroscopic and histological findings of the excised condyle 28th months after the reimplantation we removed the condyle because adaptation of the definitive iliac crest transplant was not possible without its removal. The articu-
Temporary Reconstruction of the Lower Jaw
J. max.-fac. Surg. 14 (1986)
223
Fig. 3 The orthopantomogram taken two years postoperatively.
Fig. 4 a Fig. 4 a, b
Fig. 4 b
Tomograms show a plane through the lateral (a) and through the medial pole of the condylar head (b).
Fig. 5 The articulating surface and the anterior view of the excised condyle showing sites of sections for microradiographs.
Fig. 6 a-d
Microradiographs of the condylar neck and head area,
224
J. max.-fac. Surg. 14 (1986)
O. Hadjianghelou
Fig. 7 Periosteal lining P and muscle attachment M; anterior surface, mediat pole of condyle (undecaicified section, 5 #, polarised light).
Fig. 8 a
Fig. 8 b
Fig. 8 c
Fig. 8 a - c Degenerative changes on the reimplanted condyle: (a) Increased bone resorption in the anterior cortical plane, normal cortical structure distally.
(b) Bone surface with irregular bone formation and resorption cavities. c) Ingrowth of fibrous tissue into a resorption cavity on the bone surface. (Undecalcified sections, 5 #, HE a and b, Goldner c)
anterior part an increased bony resorption m the cortical plane can be seen. Primary osteomas were not present. The bone surface itself was lined by a thin layer of nonorganized bone of periosteal origin. Resorption cavities due to osteoclastic activity exist just under the surface (Fig. 8 b). Additional resorption with the rupture of the bone surface leads to the ingrowth of connective fibrous tissue into these cavities (Fig. 8 c). These changes on the surface are the result of the degenerative process. At the condylar neck, the plate is exactly adapted to the underlying bone. On the anterior surface, the bone apposition around the plate edges can be seen (Fig. 5). The penetration sites of the screws on the microradiographs (Fig. 6a) demonstrate that the screws have been firmly fixed to the bone, and that in the surrounding bone neither bone resorption nor inflammatory changes have taken place.
Discussion After mandibular resection for malignant tumours, primary mandibular reconstruction either with free or microvascular anastamosed bone transplants should be done so as to rehabilitate masticatory function as well as to establish adequate facial contour (Obwegeser and Hadjianghelou, 1981; Hadjianghelou, 1984). For successful primary bone grafting, two conditions must be present: (1) a well vascularized transplant bed (2) a perfect wound closure. The quality and quantity of oral mucosa is a major factor in the success of a graft. In this patient, we achieved perfect closure of the intraoral incision. Because on the lateral aspect subcutaneous tissues had been included in the resection, the defect was surrounded only by skin on the buccal, and mucosa on the lingual aspect. Under these conditions, we decided to perform a temporary reconstruction using an
Temporary Reconstruction of the Lower Jaw AO plate. Prior to secondary reconstruction with iliac crest, free fat transplantation is performed in order to fill the soft tissue defect (Obwegeser and Sailer, 1979). A whole series of plate systems (Vitallium, Tantalum, Titanium and rust-free metals) have been developed for the temporary reconstruction of the jaw (Bowerman and Conroy, 1969; Catania and Cislaghi, 1969; Brdnemark et al., 1975; Schmoker et al., 1976; Schmoker, 1977; Reuther and Hausamen, 1977; SpiessI, 1980; Luhr, 1981; Kent, 1983). These systems enable the surgeon to reconstruct the mandible, not only in cases of segmental defects but also if the condylar head is included in the resection, by using a condylar prosthesis. Previous clinical investigation (Hadjianghelou, 1978) has shown that autologous bone transplantation, extending to the TMJ will undergo functional remodelling, with adaptation to the local topographic and functional requirements. The remodelling of the bone transplant is not accompanied by similar changes in the glen0id fossa. By using a metal prothesis, instead of the condyle itself, the glenoid fossa will possibly be exposed to the remodelling effect which exists secondary to the changed functional situation. The absence of protrusive movement leads to increased scar tissue fixation of the joint prothesis. This will lead to concentration of the mechanical stress on a limited area of the glenoid fossa. The resulting resorption processes may lead to penetration of the alloplastic condyle through the cranial base. Both primary reconstruction of a defect in the temporomandibular joint region with bone transplantation and temporary reconstruction with alloplastic material have as the primary aim the restoration of joint function. Lexer (1925) considered transplantation of joint parts or a whole joint to be the most important method for reconstruction of joint defects. The first transplantation of a half joint was carried out by Tietze (1902). The first successful transplantation of a whole joint was made by Lexer (1908). This development in joint surgery was begun by Tuffier (1901) with the reimplantation of a post-traumatic, totally dislocated and separated humerus head. Rossi and Arrigoni (1979) were the first to report the clinical reimplantation of a resected mandibular condyle. After hemiresection, the resected condyle was used together with autogenous iliac crest bone for the primary construction of the lower jaw defect with excellent functional results. Histological specimens from this patient, demonstrated the progressive transformation of the cartilaginous tissue of the condyle into scar tissue. Degenerative processes were noted 28 months after reimplantation. A notable feature was that, although a slow degenerative process had taken place, there was no evidence of pain or TMJ function alteration. The behaviour of autologous osteochondral condyle transplants has been investigated especially in respect of their inductive effect on the growth of the lower jaw. Roenning (1966) found only 50% of the rats in which he had transplanted the mandibular condyles intracerebrally showed destruction of the cartilage layer of the condyle. Similar results were reported by Peskin and Laskin (1965) after condylectomy and reconstruction with the contralateral condyle. The articulating surface was covered with fibrous connective tissue with had hyaline cartilage in the deep layer. Defects of the cartilaginous part have also been demonstrated experimentally by Koerner and Schuelle (1983) where the distal metatarsal epiphysis has been transplanted in children for the reconstruction of the mandibular
J. max.-fac. Surg. 14 (1986)
225
joint (Bardenheuer, 1909; Klapp and Schroeder, 1917; Stuteville and Lanfranchi, 1955). The animal experiments have shown that in cases of epiphyseal transplantation the extent of cartilage damage depends upon the dimensions of the bony part of this osteochondral transplantation (Harris and Hobson, 1956; Depalma et al., 1963; Harris et al., 1965). In considering the epiphyseal blood supply (Trueta et al., 1960 a, b, c), the bony part of the graft, depending on its thickness, represents a barrier which, after transplantation, is responsible for the delay of nutrient supply to the cartilage. The same finding has been observed by Roenning (1966) in his condylar transplantations. Koerner and Schuelle (1983) have shown that bony necrosis occurs in the central portion of the transplanted metatarsal epiphysis. Harris and Hobson (1956) observed the ingrowth of blood vessels in epiphyseal transplants occurring through the holes made by Kirschner wires. Heidsieck et al. (1979) have not observed condylar necrosis in transplantations in pigs; however the broad osteotomy area they created on the condylar head allowed a nutrient vascular supply to develop without the use of bur holes. We concluded that, in cases of condylar transplantation, by osteotomy below the collum, the blood supply to the condyle could be improved if several bur holes were made into the cortical plate. We prefer to use this technique in order to ensure adequate ingrowth of nutrient vessels and prevent central condylar necrosis. The histological findings concerning this patient have proved this. In our opinion reimplantation of the condyle is indicated in cases of lower jaw resection, where primary reconstruction is not carried out. When the adaptation of the reconstruction plate in the region of the condylar neck is technically difficult, exarticulation of the condyle with reimplantation can be performed. The possible untoward effects produced by a condylar prosthesis can thus be avoided. Conclusions
Condylar reimplantation by temporary reconstruction of the lower jaw combined with a reconstruction plate is a new operative technique. This procedure can be applied in cases where alloplastic condylar prostheses are used. Condylar reimplantation can prevent penetration of the glenoid fossa which can be caused by a condylar prosthesis. Condylar reimplantation is indicated in cases where the adaptation of a plate prosthesis reconstruction in the subcondylar area is difficult and for this reason the condyle has been included in the resection. The resected condyle can be reimplanted provided proper preparation; the condylar head undergoes extensive degenerative changes. In spite of this, normal temporomandibular joint function with rotation, lateral and protrusive movements can be achieved. When evaluating the result, it has to be noted that the articular disc was not included in the exarticulation.
References
Bardenheuer; cited in Lexer, E.: Die freien Transplantationen. Neue Deutsche Chirurgie 26 b, Teil II, Enke Stuttgart (1924) Bowerman, J. E, B. Conroy: A universal kit in Titanium for immediate replacement of the resected mandible. Brit. J. Oral Surg. 6 (1969) 223
226
J. max.-fac. Surg. 14 (1986)
O. Hadjianghelou: Temporary Reconstruction of the Lower Jaw
Briinemark, P. I., J. Lindstrtm, O. Halldn, P. H. Jeppson, A. Oehman: Reconstruction of the defective mandible. Scand. J. Ptast. Reconstr. Surg. 9 (1975) 116 Catania, V. C., E. Cislaghi: Evoluzione delle endoprotesi mandibolari immediate, secondo la nostra esperienza. Ctin. Od. Pr. 15 (1969) 60 Depalma, A. F., Th. T. Tsaltas, G. G. Mauler: Viability of osteochondral grafts as determined by uptake of S3s. J. Bone Joint Surg. 45A (1963) 1565 Hadjianghelou, 0.: Ergebnisse der Unterkieferrekonstruktionen. Eine vergleichende Untersuchung. Fortschr. Kiefer Gesichtschir. 27 (1978) 107 Hadjianghelou, 0.: Chirurgische Konzepte zur Behandlung der Mundschleimhaut-Malignome des Unterkiefers und Mundbodens. Schweiz. Mschr. Zahnmed. 94 (1984) 928 Harris, W. R., K. W. Hobson: Histological changes in e×perimentally displaced upper femoral epiphysis in rabbits. J. Bone Joint Surg. 38B (1956) 914 Harris, W.R., R. Martin, M. Tile: Transplantation of epiphyseal plates. An experimental study. J. Bone Joint Surg. 47A (1965) 897 Heidsieck, C., W. Wiipper, R. Biissler: Freie Replantation des Kiefergelenkfortsatzes im Tierexperiment. Fortschr. Kiefer Gesichtschir. 28 (1979) 22 Kent, J. N., D. J. Misiek, R. K. Akin, E. C. Hinds, Ch. A. Homsy: Temporomandibular joint condylar prosthesis. J. Oral Max-fac. Surg. 41 (1983) 245 Klapp, R., H. Schroeder: Die Unterkieferschussbrfiche. Meusser, Berlin (1917) Koerner, D., H. Schuelle: Untersuchungen fiber die plastische Rekoustruktion des Kiefergelenkes im Kindesalter. In: Regionale plastische und rekonstruktive Chirurgie im Kindesalter. Ed.: W. Kley und C. Naumann, Springer, Berlin-Heidelberg-New York, (1983) Lexer, E.: Substitution of whole or half joints from freshly amputated Extremities by free plastic operation. Surg. Gynec. Obstet. 6 (1908) 601 Lexer, E.: Joint transplantation and arthoplasty. Surg. Gynec. Obstet. 40 (1925) 782 Luhr, H. G.: Das Mandibular-Rekonstruktions-System MRS. Indikation und operative Technik der Defektfiberbrfickung am Unterkiefer. In: Implantate und Transplantate in der Plastischen und Wiederherstellungschirurgie, Ed. CottaH. and A.K. Matini, Springer, Berlin-Heidelberg-New York, (1981) Obwegeser, H. L., O. Hadjianghelou: Demolizione Mandibulare e sua riconstructione immediata. In: Trattamento dei tumori mandibulari e paramandibulari; probtemi chirurgici, riconstruttivi e riabilitativi. Ed.: D. Bottazi and R. Brusati, University of Parma, (1981)
Obwegeser, H. L., H. F. Sailer: Erfahrungen mit der ffeien Fettransplantation zur Konturkorrektur im Gesichtsbereich. Fortschr. Kiefer Gesichtschir. 24 (1979) 51 Peskin, S., D. M. Laskin: Constribution of autogenous condylar grafts to mandibular growth. Oral Surg. 20 (1965) 517 Reuther, J., J. E. Hausamen: System zur alloplastiscben Oberbr/ickung von Unterkieferdefekten. Dtsch. Zahn~irztl. Z. 32 (1977) 334 Roenning, 0.: Observations on the intracerebral transplantation of the mandibular condyle. Acta odont, scand. 24 (1966) 443 Rossi, G., G. Arrigoni: Reimplantation of the mandibular condyle in cases of intraoral resection and reconstruction of the mandible. J. Max.-Fac. Surg. 7 (1979) 1 Schmoker, R., B. Spiessl, R. Mathys: A total mandibular plate to bridge large defects of the mandible. New concepts in maxitlo-facial bone surgery. Springer, Berlin-Heidelberg-New York, (1976) Schmoher, R.: Eine Rekonstruktionsp!atte zur Ueberbr/ickung gr6l~erer Knochendefekte im Unterkiefer. Aktuelle Traumatol. 7 (1977) 199 Spiessl, B.: A new Method of anatomical reconstruction of extensive defects of mandible with autogenous cancellous bone. J. Max.-Fac. Surg. 8 (1980) 78 Stuteville, 0. H., R. P. Lafranchi: Surgical reconstruction of the temporomandibular joint. Amer. J. Surg. 90 (1955) 940 TietzG A.: Ersatz des resezierten unteren Radiusendes durch eine Grof~zehenphalange. Verhandl. d. Deutschen Ges. f. Chit. Einunddreifligster Congress 1 (1902) 77 Trueta, J., J. D. Morgan: The vascular contribution to osteogenesis I. Studies by injection method. J. Bone Joint Surg. 42B (1960 a) 97 Trueta, J., K. Little: The vascular contribution to osteogenesis IL Studies with electron microscope. J. Bone Joint Surg. 42B (1960 b) 367 TruetG J., S. Amato: The vascular contribution to osteogenesis IIL Changes in the growth cartilage caused by experimental induced ischaemia. J. Bone Joint Surg. 42B (1960 c) 571 Tuffier, T.: R&ection chondroplastique de la t&e hum4rale pour fracture comminutive. Pr4sentation du malade quatre mois aprhs l'op4ration. Bull. M4m. Soc. Chir. Paris 27 (1901) 492
Dr. O. Hadjianghelou M.D., D.M.D. Kieferchirurgische Klinik Universit~itsspital Zurich Frauenklinikstrasse 10 CH 8091 Zurich - Schweiz
Temporary Reconstruction of the Lower Jaw by Condylar Reimplantation Case Report Orestis Hadjianghelou Dept. of Maxillo-Facial Surgery, (Head: Prof. H. L. Obwegeser, M.D., D.M.D.) University Hospital, Ziirich, Switzerland Submitted 9 . 5 . 1985; accepted 3 0 . 9 . 1985
Introduction The adaptation either of the transplanted bone in primary intraoral reconstruction, or of the plate prosthesis in temporary intraoral reconstruction, is especially difficult when the defect extends to the subcondylar area of the ramus of the mandible. Because of this technical problem, resection of the condyle is generally included, even when it is not necessary for radical turnout removal. The restoration of T.M.J. functions is especially difficult, if after its disarticulation, a temporary prosthesis reconstruction extending into the glenoid fossa is performed. A whole series of prosthetic systems have been developed for the temporary reconstruction of the jaw. These systems enable the surgeon to reconstruct the mandible not only in cases of segmental defects but also if the condylar head is included in the resection by using a condylar prosthesis. By using a metal prothesis the glenoid fossa will possibly be exposed to a remodelling effect secondary to the changed functional situation. The resulting resorption processes may lead to penetration of the cranial base by the alloplastic condyle. In order to avoid possible untoward effects attributable to the condylar prosthesis in a case of temporary reconstruction following exarticulation, we have developed a technique of reimplanting the resected condyle instead of using a joint prosthesis. This technique was developed based on the experiences of Rossi and Arrigoni (1979), using the resected condyle together with autogenous iliac crest bone for primary reconstruction of the lower jaw defect. The patient was followed up for a period of 28 months, after which the definitive reconstruction was made, following the removal of the condyle. The removed condyle has been thoroughly examined. This single case is published in order to stimulate others to employ this method to obtain more experience on this subject.
Cases Report History and clinical findings The patient, a 59 year old female, 6 months before surgery noticed sudden mobility of the right second lower molar.
221
Summary An alternative method to temporary lower jaw reconstruction with a reconstruction plate prosthesis is described. To prevent penetration of an alloplastic condyle transplant through the skull base, and to restore joint function, we have reimplanted the resected condyle after its fixation to the reconstruction plate. Postoperatively, there have been no complications. Joint function has been almost completely restored. The reimplanted condyle has been investigated after 28 months. It has undergone remarkable changes.
Key-Words Condylar reimplantation - Temporary reconstruction - Mandibular reconstruction - TMJ.
After its extraction by her dentist, wound healing was extremely slow. Three months later, the right first lower molar was extracted for the same reason, again with delayed healing. Additionally, an ulcerating wound developed at the operation site. Because the ulcer did not heal, her dentist referred her to our clinic for further investigation. On admission, the patient was found to have a 1.5 cm ulcerating lesion in the area of the previously extracted tooth. The lingual and buccal cortices in the area of the ulcer were expanded. The panoramic radiograph showed localized bone destruction in the right mandibular body extending along the mandibular canal up into the ascending ramus. Submandibular and subdigastric painless, enlarged lymph nodes were present ipsilaterally in the neck.
Surgical Technique Biopsy of the ulcerating lesion revealed a malignant tumour, no further differentiation being possible. In view of this, a hemimandibulectomy with resection of surrounding (including subcutaneous) soft tissue was performed along with supra-omohyoid neck dissection. The articular disc was not removed. On inspecting the specimen we found that the condyle was tumour-free. At this point, we decided to reimplant the resected condylar head, using an AO plate to bridge the gap between condyle and mandibular body. The condyle was separated from the ascending ramus over a 2 x 1 cm. area. It was connected to an AO reconstruction plate with 2.7 mm. screws. To ensure the blood supply of the condyle 3 bur holes were made on the dorsal aspect, passing through the cortical into the cancellous bone (Fig. 1). Prior to the application of the plate prosthesis to the mandible, intermaxillary fixation was performed. The plate was formed so that a normal occlusal plane would result after the removal of the intermaxillary fixation. The plate was secured with 3 screws into the remaining mandible in the chin region. Thereby, the lower jaw defect was reconstructed in a functionally stable way. The intermaxillary fixation was removed immediately after osteosynthesis. The proper orientation of the plate was checked by inspecting the occlusion. After this the surrounding tissues were adapted and the intraoral wound was closed.
222
J. max.-fac. Surg. 14 (1986)
O. Hadjianghelou
Fig. 1 Posterior view of the resected condyle fixed to the AO plate. To ensure the blood supply three bur-holes have been made through the dorsal cortical plate.
Fig. 2 The patient two years postoperatively, with a maximal mouth opening of 40 mrn.
Postoperative course and late result Postoperatively, there were no complications. After four months the interincisal opening (spontaneous) was 38 mm., and 6 months postoperatively 40 ram. (Fig. 2). The lower jaw movement in comparison with the preoperative movements was essentially similar. Only the lateral movement to the left has been limited. The rotational and protrusive movements of the condyle have been retained. The postoperative condition had not changed by the 28th postoperative month, when the condyle was removed for definitive reconstruction of the defect with a bone graft. Several x-rays have been taken during the postoperative follow-up period. In this way we could precisely document the remodelling and degenerative processes which followed the reimplantation with subsequent almost normal function of the condyle. Fig. 3 shows the condyle two years and four months after reimplantation. The tomograms taken two years postoperatively show in detail the radiological appearance of the reimplanted condyle (Fig. 4): The head and the neck have become narrow and the surface appears rather irregular. A significant sharp bone protrusion from the head of the condyle has developed in a medial direction and is directed toward the articular prominence. The glenoid fossa has not undergone any pathological change.
lar disc was again not removed, therefore histological examination was not possible. Compared with the initial situation (Fig. 1) extensive configurative changes, including loss of the cartilaginous layer of the cranial surface can be indentified on the condyle (Fig. 5). It has become much narrower. On the anterior aspect of the lateral and medial poles of the condylar head bony prominences can be clearly identified. They are directed forward and have a rough surface, while the distal part of the head as well as most of the cranial portion are quite smooth. The microradiographs (Fig. 6) show the internal structure of the condyle. In the anterior aspect of the lateral (Fig. 6 a) and most of the medial pole (Fig. 6b, c, d) of the head, which macroscopically appears rough, a discontinuity of the normal cortical structure could be observed. The cancellous bone extends to the rough bone surface. The condyle was removed in the anterior part with the surrounding tissues, while in the posterior part the subperiosteal resection was performed. The histological examination showed therefore that in some parts the condylar surface was covered with periosteum or hyaline connective tissue which was converted in the outer layer into moderate cellular co|lagenous connective tissue. The anterior surface with the attachment of the muscle could be clearly identified (Fig. 7), in some instances at the anterior surface rests of hyaline cartilage can be seen under a layer of connective tissue. The histological sections showed, like the microradiographs, on the distal aspect of the condylar surface normal and regular cortical structures (Fig. 8 a). However in the
Macroscopic and histological findings of the excised condyle 28th months after the reimplantation we removed the condyle because adaptation of the definitive iliac crest transplant was not possible without its removal. The articu-
Temporary Reconstruction of the Lower Jaw
J. max.-fac. Surg. 14 (1986)
223
Fig. 3 The orthopantomogram taken two years postoperatively.
Fig. 4 a Fig. 4 a, b
Fig. 4 b
Tomograms show a plane through the lateral (a) and through the medial pole of the condylar head (b).
Fig. 5 The articulating surface and the anterior view of the excised condyle showing sites of sections for microradiographs.
Fig. 6 a-d
Microradiographs of the condylar neck and head area,
224
J. max.-fac. Surg. 14 (1986)
O. Hadjianghelou
Fig. 7 Periosteal lining P and muscle attachment M; anterior surface, mediat pole of condyle (undecaicified section, 5 #, polarised light).
Fig. 8 a
Fig. 8 b
Fig. 8 c
Fig. 8 a - c Degenerative changes on the reimplanted condyle: (a) Increased bone resorption in the anterior cortical plane, normal cortical structure distally.
(b) Bone surface with irregular bone formation and resorption cavities. c) Ingrowth of fibrous tissue into a resorption cavity on the bone surface. (Undecalcified sections, 5 #, HE a and b, Goldner c)
anterior part an increased bony resorption m the cortical plane can be seen. Primary osteomas were not present. The bone surface itself was lined by a thin layer of nonorganized bone of periosteal origin. Resorption cavities due to osteoclastic activity exist just under the surface (Fig. 8 b). Additional resorption with the rupture of the bone surface leads to the ingrowth of connective fibrous tissue into these cavities (Fig. 8 c). These changes on the surface are the result of the degenerative process. At the condylar neck, the plate is exactly adapted to the underlying bone. On the anterior surface, the bone apposition around the plate edges can be seen (Fig. 5). The penetration sites of the screws on the microradiographs (Fig. 6a) demonstrate that the screws have been firmly fixed to the bone, and that in the surrounding bone neither bone resorption nor inflammatory changes have taken place.
Discussion After mandibular resection for malignant tumours, primary mandibular reconstruction either with free or microvascular anastamosed bone transplants should be done so as to rehabilitate masticatory function as well as to establish adequate facial contour (Obwegeser and Hadjianghelou, 1981; Hadjianghelou, 1984). For successful primary bone grafting, two conditions must be present: (1) a well vascularized transplant bed (2) a perfect wound closure. The quality and quantity of oral mucosa is a major factor in the success of a graft. In this patient, we achieved perfect closure of the intraoral incision. Because on the lateral aspect subcutaneous tissues had been included in the resection, the defect was surrounded only by skin on the buccal, and mucosa on the lingual aspect. Under these conditions, we decided to perform a temporary reconstruction using an
Temporary Reconstruction of the Lower Jaw AO plate. Prior to secondary reconstruction with iliac crest, free fat transplantation is performed in order to fill the soft tissue defect (Obwegeser and Sailer, 1979). A whole series of plate systems (Vitallium, Tantalum, Titanium and rust-free metals) have been developed for the temporary reconstruction of the jaw (Bowerman and Conroy, 1969; Catania and Cislaghi, 1969; Brdnemark et al., 1975; Schmoker et al., 1976; Schmoker, 1977; Reuther and Hausamen, 1977; SpiessI, 1980; Luhr, 1981; Kent, 1983). These systems enable the surgeon to reconstruct the mandible, not only in cases of segmental defects but also if the condylar head is included in the resection, by using a condylar prosthesis. Previous clinical investigation (Hadjianghelou, 1978) has shown that autologous bone transplantation, extending to the TMJ will undergo functional remodelling, with adaptation to the local topographic and functional requirements. The remodelling of the bone transplant is not accompanied by similar changes in the glen0id fossa. By using a metal prothesis, instead of the condyle itself, the glenoid fossa will possibly be exposed to the remodelling effect which exists secondary to the changed functional situation. The absence of protrusive movement leads to increased scar tissue fixation of the joint prothesis. This will lead to concentration of the mechanical stress on a limited area of the glenoid fossa. The resulting resorption processes may lead to penetration of the alloplastic condyle through the cranial base. Both primary reconstruction of a defect in the temporomandibular joint region with bone transplantation and temporary reconstruction with alloplastic material have as the primary aim the restoration of joint function. Lexer (1925) considered transplantation of joint parts or a whole joint to be the most important method for reconstruction of joint defects. The first transplantation of a half joint was carried out by Tietze (1902). The first successful transplantation of a whole joint was made by Lexer (1908). This development in joint surgery was begun by Tuffier (1901) with the reimplantation of a post-traumatic, totally dislocated and separated humerus head. Rossi and Arrigoni (1979) were the first to report the clinical reimplantation of a resected mandibular condyle. After hemiresection, the resected condyle was used together with autogenous iliac crest bone for the primary construction of the lower jaw defect with excellent functional results. Histological specimens from this patient, demonstrated the progressive transformation of the cartilaginous tissue of the condyle into scar tissue. Degenerative processes were noted 28 months after reimplantation. A notable feature was that, although a slow degenerative process had taken place, there was no evidence of pain or TMJ function alteration. The behaviour of autologous osteochondral condyle transplants has been investigated especially in respect of their inductive effect on the growth of the lower jaw. Roenning (1966) found only 50% of the rats in which he had transplanted the mandibular condyles intracerebrally showed destruction of the cartilage layer of the condyle. Similar results were reported by Peskin and Laskin (1965) after condylectomy and reconstruction with the contralateral condyle. The articulating surface was covered with fibrous connective tissue with had hyaline cartilage in the deep layer. Defects of the cartilaginous part have also been demonstrated experimentally by Koerner and Schuelle (1983) where the distal metatarsal epiphysis has been transplanted in children for the reconstruction of the mandibular
J. max.-fac. Surg. 14 (1986)
225
joint (Bardenheuer, 1909; Klapp and Schroeder, 1917; Stuteville and Lanfranchi, 1955). The animal experiments have shown that in cases of epiphyseal transplantation the extent of cartilage damage depends upon the dimensions of the bony part of this osteochondral transplantation (Harris and Hobson, 1956; Depalma et al., 1963; Harris et al., 1965). In considering the epiphyseal blood supply (Trueta et al., 1960 a, b, c), the bony part of the graft, depending on its thickness, represents a barrier which, after transplantation, is responsible for the delay of nutrient supply to the cartilage. The same finding has been observed by Roenning (1966) in his condylar transplantations. Koerner and Schuelle (1983) have shown that bony necrosis occurs in the central portion of the transplanted metatarsal epiphysis. Harris and Hobson (1956) observed the ingrowth of blood vessels in epiphyseal transplants occurring through the holes made by Kirschner wires. Heidsieck et al. (1979) have not observed condylar necrosis in transplantations in pigs; however the broad osteotomy area they created on the condylar head allowed a nutrient vascular supply to develop without the use of bur holes. We concluded that, in cases of condylar transplantation, by osteotomy below the collum, the blood supply to the condyle could be improved if several bur holes were made into the cortical plate. We prefer to use this technique in order to ensure adequate ingrowth of nutrient vessels and prevent central condylar necrosis. The histological findings concerning this patient have proved this. In our opinion reimplantation of the condyle is indicated in cases of lower jaw resection, where primary reconstruction is not carried out. When the adaptation of the reconstruction plate in the region of the condylar neck is technically difficult, exarticulation of the condyle with reimplantation can be performed. The possible untoward effects produced by a condylar prosthesis can thus be avoided. Conclusions
Condylar reimplantation by temporary reconstruction of the lower jaw combined with a reconstruction plate is a new operative technique. This procedure can be applied in cases where alloplastic condylar prostheses are used. Condylar reimplantation can prevent penetration of the glenoid fossa which can be caused by a condylar prosthesis. Condylar reimplantation is indicated in cases where the adaptation of a plate prosthesis reconstruction in the subcondylar area is difficult and for this reason the condyle has been included in the resection. The resected condyle can be reimplanted provided proper preparation; the condylar head undergoes extensive degenerative changes. In spite of this, normal temporomandibular joint function with rotation, lateral and protrusive movements can be achieved. When evaluating the result, it has to be noted that the articular disc was not included in the exarticulation.
References
Bardenheuer; cited in Lexer, E.: Die freien Transplantationen. Neue Deutsche Chirurgie 26 b, Teil II, Enke Stuttgart (1924) Bowerman, J. E, B. Conroy: A universal kit in Titanium for immediate replacement of the resected mandible. Brit. J. Oral Surg. 6 (1969) 223
226
J. max.-fac. Surg. 14 (1986)
O. Hadjianghelou: Temporary Reconstruction of the Lower Jaw
Briinemark, P. I., J. Lindstrtm, O. Halldn, P. H. Jeppson, A. Oehman: Reconstruction of the defective mandible. Scand. J. Ptast. Reconstr. Surg. 9 (1975) 116 Catania, V. C., E. Cislaghi: Evoluzione delle endoprotesi mandibolari immediate, secondo la nostra esperienza. Ctin. Od. Pr. 15 (1969) 60 Depalma, A. F., Th. T. Tsaltas, G. G. Mauler: Viability of osteochondral grafts as determined by uptake of S3s. J. Bone Joint Surg. 45A (1963) 1565 Hadjianghelou, 0.: Ergebnisse der Unterkieferrekonstruktionen. Eine vergleichende Untersuchung. Fortschr. Kiefer Gesichtschir. 27 (1978) 107 Hadjianghelou, 0.: Chirurgische Konzepte zur Behandlung der Mundschleimhaut-Malignome des Unterkiefers und Mundbodens. Schweiz. Mschr. Zahnmed. 94 (1984) 928 Harris, W. R., K. W. Hobson: Histological changes in e×perimentally displaced upper femoral epiphysis in rabbits. J. Bone Joint Surg. 38B (1956) 914 Harris, W.R., R. Martin, M. Tile: Transplantation of epiphyseal plates. An experimental study. J. Bone Joint Surg. 47A (1965) 897 Heidsieck, C., W. Wiipper, R. Biissler: Freie Replantation des Kiefergelenkfortsatzes im Tierexperiment. Fortschr. Kiefer Gesichtschir. 28 (1979) 22 Kent, J. N., D. J. Misiek, R. K. Akin, E. C. Hinds, Ch. A. Homsy: Temporomandibular joint condylar prosthesis. J. Oral Max-fac. Surg. 41 (1983) 245 Klapp, R., H. Schroeder: Die Unterkieferschussbrfiche. Meusser, Berlin (1917) Koerner, D., H. Schuelle: Untersuchungen fiber die plastische Rekoustruktion des Kiefergelenkes im Kindesalter. In: Regionale plastische und rekonstruktive Chirurgie im Kindesalter. Ed.: W. Kley und C. Naumann, Springer, Berlin-Heidelberg-New York, (1983) Lexer, E.: Substitution of whole or half joints from freshly amputated Extremities by free plastic operation. Surg. Gynec. Obstet. 6 (1908) 601 Lexer, E.: Joint transplantation and arthoplasty. Surg. Gynec. Obstet. 40 (1925) 782 Luhr, H. G.: Das Mandibular-Rekonstruktions-System MRS. Indikation und operative Technik der Defektfiberbrfickung am Unterkiefer. In: Implantate und Transplantate in der Plastischen und Wiederherstellungschirurgie, Ed. CottaH. and A.K. Matini, Springer, Berlin-Heidelberg-New York, (1981) Obwegeser, H. L., O. Hadjianghelou: Demolizione Mandibulare e sua riconstructione immediata. In: Trattamento dei tumori mandibulari e paramandibulari; probtemi chirurgici, riconstruttivi e riabilitativi. Ed.: D. Bottazi and R. Brusati, University of Parma, (1981)
Obwegeser, H. L., H. F. Sailer: Erfahrungen mit der ffeien Fettransplantation zur Konturkorrektur im Gesichtsbereich. Fortschr. Kiefer Gesichtschir. 24 (1979) 51 Peskin, S., D. M. Laskin: Constribution of autogenous condylar grafts to mandibular growth. Oral Surg. 20 (1965) 517 Reuther, J., J. E. Hausamen: System zur alloplastiscben Oberbr/ickung von Unterkieferdefekten. Dtsch. Zahn~irztl. Z. 32 (1977) 334 Roenning, 0.: Observations on the intracerebral transplantation of the mandibular condyle. Acta odont, scand. 24 (1966) 443 Rossi, G., G. Arrigoni: Reimplantation of the mandibular condyle in cases of intraoral resection and reconstruction of the mandible. J. Max.-Fac. Surg. 7 (1979) 1 Schmoker, R., B. Spiessl, R. Mathys: A total mandibular plate to bridge large defects of the mandible. New concepts in maxitlo-facial bone surgery. Springer, Berlin-Heidelberg-New York, (1976) Schmoher, R.: Eine Rekonstruktionsp!atte zur Ueberbr/ickung gr6l~erer Knochendefekte im Unterkiefer. Aktuelle Traumatol. 7 (1977) 199 Spiessl, B.: A new Method of anatomical reconstruction of extensive defects of mandible with autogenous cancellous bone. J. Max.-Fac. Surg. 8 (1980) 78 Stuteville, 0. H., R. P. Lafranchi: Surgical reconstruction of the temporomandibular joint. Amer. J. Surg. 90 (1955) 940 TietzG A.: Ersatz des resezierten unteren Radiusendes durch eine Grof~zehenphalange. Verhandl. d. Deutschen Ges. f. Chit. Einunddreifligster Congress 1 (1902) 77 Trueta, J., J. D. Morgan: The vascular contribution to osteogenesis I. Studies by injection method. J. Bone Joint Surg. 42B (1960 a) 97 Trueta, J., K. Little: The vascular contribution to osteogenesis IL Studies with electron microscope. J. Bone Joint Surg. 42B (1960 b) 367 TruetG J., S. Amato: The vascular contribution to osteogenesis IIL Changes in the growth cartilage caused by experimental induced ischaemia. J. Bone Joint Surg. 42B (1960 c) 571 Tuffier, T.: R&ection chondroplastique de la t&e hum4rale pour fracture comminutive. Pr4sentation du malade quatre mois aprhs l'op4ration. Bull. M4m. Soc. Chir. Paris 27 (1901) 492
Dr. O. Hadjianghelou M.D., D.M.D. Kieferchirurgische Klinik Universit~itsspital Zurich Frauenklinikstrasse 10 CH 8091 Zurich - Schweiz