- Email: [email protected]
Use of a Silastic testicular implant in reconstruction of the temporomandibular joint of a 5-year-old child
Use of a Silastic testicular implant in reconstruction of the temporomandibularjoint of a 5-year-old child Stephen Wukelich, D.D.S.,+ James Marshull, M.D.,** Richard Walden, M.D., D.D.S., *** Bertram Bromberg, M.D., D.D.S.,“*** and Reuben Seldin, D.D.S.,****” New York, N. Y. KINGS
COUNTY
HOSPITAL
CENTER
A coned-out Silastic testicular implant was placed following the uneventful removal of an ankylosed temporomandibular joint in a B-year-old boy. Postoperative examinations revealed a marked improvement in the patient’s ability to open his mouth. The use of the testicular implant was of particular importance because, when placed shape. over the remaining portion of the ramus, it established a pseudoeondylar
T
he causes of temporomandibular joint ankylosis may be classified under the following general categories : ( 1) inflammatory, (2) neoplastic, (3) traumatic, and (4) idiopathic. In the case to be reported in this article, the disorder was of traumatic origin. Ankylosis results most frequently from trauma. Injury to the joint structures, associated muscles, and adjacent soft tissues causes hemorrhage and inflammation, and subsequent fibrosis can produce permanent limitation of movement. An ext.ra-articular ankylosis may result from trauma t.o the coronoid process or the zygomatic arch.= Fibrous or osseous ankylosis is a highly disabling condition which can rarely be treated successfully by conservative nonsurgical means and almost without *Formerly Chief Resident in Oral Surgery. **Formerly Chief Resident in Plastic Surgery. ***Member of attending staff in Plastic Surgery. *“**Chief of the Department of Plastic Surgery. *****Chief of the Department of Dentistry. 4
Silastic
Volume 32 X-umber 1
Pig. 1. Postoperative Mnrch, 1967.
reduction
of mandibular
fracture
with
testicular
crossed
implant
Kirschner
5
wires.
exception requires surgical correction. 2 In 1938 Kazanjian3 reported a series of cases and stressed the danger of injury to the middle cranial fossa during re moval of the condyle in cases of massive osseous ankylosis. In 1946 Dingman pointed out that surgical correction is the only effective treatment for ankylosis, and many authors, such as Thoma,5 Parker,6 and Kazanjian,3 have advised early surgical intervention to prevent deformity. In 1914 Blair’ presented a set of basic rules, which are perfectly applicable today, to follow in performing a condylectomy for correction of bony ankylosis : 1. Preauricular hockey stick incision. 2. Removal of a wide segment of bone. 3. Interposition of some material to prevent contact of residual raw bony surfaces. 4. Early postoperative motion. Kazanjian3 and Braithwaite and Hopper* interposed bovine cartilage after performing an osteotomy lower down on the ramus to avoid injuring the base of the skull during removal of the condyle. Many types of organic and inorganic material have been interposed to counteract the tendency to recurrence. Some of the materials used are fascia,g muscle tissue,lO tantalum,ll bone,12 dermis,13 cartilage,14 and Silastic in various forms.1SplG In children, removal or damage of the condylar growth center may cause a serious facial deformity. Periodic cephalometric and tomographic examination may be helpful in determining whether the ankylosis has caused destruction of the growth center. CASE REPORT Patient C. H., a Negro boy was first seen in 1967, at the age of 3 years, for treatment of a trumatic fracture of the left body of the mandible. Because of associated craniocerebral damage, reduction of the fracture was performed quickly, with crossed Kirschner wires used to hold the mandible in position. Subsequently, it was noted that the child was less and less able to open his jaw. In July, 1969, when the patient was 5 years old, measurements between the central incisor edges showed an excursion of only 10 to 11 mm. Tomographic
E‘ig. 1. Preoperative 1969.
Ifig.
roentgenogram
3. Silastic
of snkylosed
testicular
implant
left
prior
temporomandibular
joint.
1
to shaping.
examination revealed what appeared to be complete bony ankylosis of the left temporomandibular joint, and surgic.al exploration was therefore undertaken. Cn Aug. 20, 1969, the patient was taken to the operating room, where nasotracheal intubation was followed by routine preparation and draping. A hocky stick incision was made in the preauricular region, but not to a downward level that would have endangered the trunk of the facial nerve. The primary incision was made only through the skin. The disseetion was carried across the mandible itself, and a clamp-cut technique was employed to avoid damaging branches of the facial nerve. Since extreme caution is required in procedures of this kind, each piece of tissue to be dissected was isolated and tested with a clamp prior to cutting. Muscular movement in the region of the frontalis and orbicularis oculi muscles during testing would indicate stimulation to those branches of the facial nerve. Even though these branches may not be severed during a surgical procedure, temporary paralysis as a result of stretching is possible. It was noted that the condyle was completely fused to the malar rim and that the fascial capsule was absent. A Hall air drill with a cross-cut fissure bur and a chisel and mallet were used to remove the condylar head, including the intercondylar notch, thus molding the jaw. Caution was exercised to avoid traumatizing the internal maxillary artery. A small Silastic testicular implant was halved, shaped, and inserted as the interposition prosthesis. Significant mandibular motion was readily apparent after insertion.
Volume Number
Silastic
32 1
Fig. 4. Silastic
Fig. 5. Maximum
implant
testicular
implant
7
in place. Aug. 20, 1969.
preoperative
opening
of mandible.
The wound was irrigated with a Kantrex solution and closed with interrupted chromic sutures. A running subcuticular suture of 4-O stainless steel was used for skin closure. A pressure dressing was maintained for 48 hours following the operation. The patient was placed on a program of exercises with bubble gum and spring clothespins, beginning 24 hours postoperatively. At that time the mouth opening measured 30 mm. between the central incisor edges. One month later the mouth opening was measured at 36 mm., and the patient was comfortable and able to masticate with ease. Subsequent examinations 58 and 16 months following surgical intervention disclosed that the patient was still able to to achieve a mouth opening of 35 to 36 mm. and that he remained completely comfortable.
DISCUSSION
Although the importance of leaving the temporomandibular joint inviolable during development to prevent damage to the growth center was appreciated in this case, the absence of any normal joint arrangement and the patient’s subsequent inability to masticate made surgical intervention necessary. Silastic has
Fig. 6. Mouth opening place. Aug. 21, 1969.
Pig.
7. Mouth
opening
of 30 mm. 24 llou~~ podoperati\xly.
of 36 mm. 5 months
postoperatively.
Kate
prwsure
January,
bandage
in
1970.
been successfully employed as a temporomandibular joint prosthesis in recent years. In this case a small Silastic testicular implant (Dow Corning) proved to be ideal for recreating a condylar surface. Recently, Hoopes and associates I7 have suggested a retroauricular approach as superior to the more classic incisions for exposure and cosmetic effect. The obvious advantage is transection of the external auditory canal. Although in this case the ultimate cosmetic result obtained through the usual hockey stick approach was excellent, the retroauricular incision may prove to produce a better scar, particularly in Negro patients.17 Because of the unbalanced pull of the masticatory muscles, the abnormal
Volume Number
32 1
Silastic
testicular
implant
9
mandibular drift noted preoperatively has persisted since the surgical procedure. In addition, loss of the condylar growth center may very well result in an altered mandibular growth pattern. SUMMARY The ankylosed temporomandibular joint of a 5-year-old boy was removed uneventfully, and a coned-out Silastic testicular implant was placed. Postoperative examinations revealed an improvement of the patient’s ability to open the mandible, from an original 10 to 11 mm. to 36 mm., 5 months postoperatively. Exercise with bubble gum and spring clothespins were of great benefit during the immediate postoperative period. The use of the testicular implant was of particular importance because, when placed over the remaining portion of the ramus, it established a pseudocondylar shape. REFERENCES
Joint. ILO Snrinefield. I Ill.. I 1959.I Charles C Thomas 1. Sarnat. B. G.: The TemDoromandibular Publisher, pp. 222-226. A of the Temporomandibular Joint, Philadelphia, 2. Schwartz. L. : Disorders _ I 1959. W. B. Saunders’Company, pp. 272-276. V. H.: Ankylosis of the Temporomandibular Joint, Amer. J. Orthodont. Oral 3. Kazanjian, Surg. 24: 1181, 19838. 4. Dinpman. R. 0.: Ankvlosis of the Temnoromandibular Joint. Amer. J. Orthodont. Oral I Surg. 321 120-125, 194%. 5. Thoma, K. H.: Ankylosis of the Temporomandibular Joint, Amer. J. Orthodont. Oral Surg. 32: ;: 8. 9. 10.
11. 12.
13.
14. 15. 16. 17.
250,1946.
Parker. D. B.: Ankvlosis of the Temooromandibular Joint. J. Oral Sure. 6: 42. 1948. Blair, ?. P.: Operative Treatment Gf Ankylosis of the ~emporoman~bular joint, Surg. Gynec. & Obstet. 19: 436, 1914. Braithwaite. F.. and HODDer. F.: Ankvlosis of the Temnoromandibular Joint. Brit. J. I Plast. Surg.‘5: iO5, 1952. L L ’ Straith, C. L., and Lewis, J. R.: Ankylosis of the Temporomandibular Joint, Plast. Reconstruct. Surg. 3: 464, 1948. Pickrell, K. L., Wilde, N. J., Edwards, B. F, Broadbent, T., and Georgiade, N.: The Correction of Ankylosis of the Jaw and Associated Deformities of the Face, Ann. Surg. 134: 55. 1951. Function After Condylectomy, J. Amer. Smith, ‘A. E., and R.obinson, M.: Mandibular Dent. Ass. 46: 304, 1953. of the Temporomandibular Stuteville, 0. H.. and Lanfranchi. R. P.: The Reconstruction Joint in the Rhesus Monkey: Cli&cal Application, Trans. First Int. Con& Plast. Surg., Stockholm and Uppsala, August, 1955, p. 264. Georgiade, N., Altany, F., and Pickrell, K.: Experimental Clinical Evaluation of Autogenous Dermal Grafts Used in the Treatment of Temporomandibular Joint Ankylosis, Plast. Reconstruct. Sur.p. 19: 321-335. 1957. Hinds, E. C., and- Sills, A. H.: Cartilage Block Arthroplasty for the Correction of Temporomandibular Joint Disturbances, Amer. J. Sure. 98: 787-795. 1959. Rob&son, M.: Temporomandibular Jo&t Ankylosis Corrected by Creating a False Silastic Sponge Fossa, J. S. Calif. Dent. Ass. 36: 14-16, 1968. Bromberg, B. E., Song, I. C., and Radlauer, C. B.: Surgical Treatment of Massive Bony Ankylosis of the Temporomandibular Joint, Plast. Reconstruct. Surg. 43: 66, 1969. Hoopes, J. E., Jabaley, M. E., and Wolfort, F. G.: Operative Treatment of Fractures of the Mandibular Condyle in Children: A Post-auricular Approach. Presented before the American Society of Plastic & Reconstructive Surgeons Inc., St. Louis, MO., Oct. 14, 1969.
Reprint
requests
to :
Dr. Stephen Wukelich 16 Lindenwood Rd. Stoneham, Mass. 02180
COUNTY
HOSPITAL
CENTER
A coned-out Silastic testicular implant was placed following the uneventful removal of an ankylosed temporomandibular joint in a B-year-old boy. Postoperative examinations revealed a marked improvement in the patient’s ability to open his mouth. The use of the testicular implant was of particular importance because, when placed shape. over the remaining portion of the ramus, it established a pseudoeondylar
T
he causes of temporomandibular joint ankylosis may be classified under the following general categories : ( 1) inflammatory, (2) neoplastic, (3) traumatic, and (4) idiopathic. In the case to be reported in this article, the disorder was of traumatic origin. Ankylosis results most frequently from trauma. Injury to the joint structures, associated muscles, and adjacent soft tissues causes hemorrhage and inflammation, and subsequent fibrosis can produce permanent limitation of movement. An ext.ra-articular ankylosis may result from trauma t.o the coronoid process or the zygomatic arch.= Fibrous or osseous ankylosis is a highly disabling condition which can rarely be treated successfully by conservative nonsurgical means and almost without *Formerly Chief Resident in Oral Surgery. **Formerly Chief Resident in Plastic Surgery. ***Member of attending staff in Plastic Surgery. *“**Chief of the Department of Plastic Surgery. *****Chief of the Department of Dentistry. 4
Silastic
Volume 32 X-umber 1
Pig. 1. Postoperative Mnrch, 1967.
reduction
of mandibular
fracture
with
testicular
crossed
implant
Kirschner
5
wires.
exception requires surgical correction. 2 In 1938 Kazanjian3 reported a series of cases and stressed the danger of injury to the middle cranial fossa during re moval of the condyle in cases of massive osseous ankylosis. In 1946 Dingman pointed out that surgical correction is the only effective treatment for ankylosis, and many authors, such as Thoma,5 Parker,6 and Kazanjian,3 have advised early surgical intervention to prevent deformity. In 1914 Blair’ presented a set of basic rules, which are perfectly applicable today, to follow in performing a condylectomy for correction of bony ankylosis : 1. Preauricular hockey stick incision. 2. Removal of a wide segment of bone. 3. Interposition of some material to prevent contact of residual raw bony surfaces. 4. Early postoperative motion. Kazanjian3 and Braithwaite and Hopper* interposed bovine cartilage after performing an osteotomy lower down on the ramus to avoid injuring the base of the skull during removal of the condyle. Many types of organic and inorganic material have been interposed to counteract the tendency to recurrence. Some of the materials used are fascia,g muscle tissue,lO tantalum,ll bone,12 dermis,13 cartilage,14 and Silastic in various forms.1SplG In children, removal or damage of the condylar growth center may cause a serious facial deformity. Periodic cephalometric and tomographic examination may be helpful in determining whether the ankylosis has caused destruction of the growth center. CASE REPORT Patient C. H., a Negro boy was first seen in 1967, at the age of 3 years, for treatment of a trumatic fracture of the left body of the mandible. Because of associated craniocerebral damage, reduction of the fracture was performed quickly, with crossed Kirschner wires used to hold the mandible in position. Subsequently, it was noted that the child was less and less able to open his jaw. In July, 1969, when the patient was 5 years old, measurements between the central incisor edges showed an excursion of only 10 to 11 mm. Tomographic
E‘ig. 1. Preoperative 1969.
Ifig.
roentgenogram
3. Silastic
of snkylosed
testicular
implant
left
prior
temporomandibular
joint.
1
to shaping.
examination revealed what appeared to be complete bony ankylosis of the left temporomandibular joint, and surgic.al exploration was therefore undertaken. Cn Aug. 20, 1969, the patient was taken to the operating room, where nasotracheal intubation was followed by routine preparation and draping. A hocky stick incision was made in the preauricular region, but not to a downward level that would have endangered the trunk of the facial nerve. The primary incision was made only through the skin. The disseetion was carried across the mandible itself, and a clamp-cut technique was employed to avoid damaging branches of the facial nerve. Since extreme caution is required in procedures of this kind, each piece of tissue to be dissected was isolated and tested with a clamp prior to cutting. Muscular movement in the region of the frontalis and orbicularis oculi muscles during testing would indicate stimulation to those branches of the facial nerve. Even though these branches may not be severed during a surgical procedure, temporary paralysis as a result of stretching is possible. It was noted that the condyle was completely fused to the malar rim and that the fascial capsule was absent. A Hall air drill with a cross-cut fissure bur and a chisel and mallet were used to remove the condylar head, including the intercondylar notch, thus molding the jaw. Caution was exercised to avoid traumatizing the internal maxillary artery. A small Silastic testicular implant was halved, shaped, and inserted as the interposition prosthesis. Significant mandibular motion was readily apparent after insertion.
Volume Number
Silastic
32 1
Fig. 4. Silastic
Fig. 5. Maximum
implant
testicular
implant
7
in place. Aug. 20, 1969.
preoperative
opening
of mandible.
The wound was irrigated with a Kantrex solution and closed with interrupted chromic sutures. A running subcuticular suture of 4-O stainless steel was used for skin closure. A pressure dressing was maintained for 48 hours following the operation. The patient was placed on a program of exercises with bubble gum and spring clothespins, beginning 24 hours postoperatively. At that time the mouth opening measured 30 mm. between the central incisor edges. One month later the mouth opening was measured at 36 mm., and the patient was comfortable and able to masticate with ease. Subsequent examinations 58 and 16 months following surgical intervention disclosed that the patient was still able to to achieve a mouth opening of 35 to 36 mm. and that he remained completely comfortable.
DISCUSSION
Although the importance of leaving the temporomandibular joint inviolable during development to prevent damage to the growth center was appreciated in this case, the absence of any normal joint arrangement and the patient’s subsequent inability to masticate made surgical intervention necessary. Silastic has
Fig. 6. Mouth opening place. Aug. 21, 1969.
Pig.
7. Mouth
opening
of 30 mm. 24 llou~~ podoperati\xly.
of 36 mm. 5 months
postoperatively.
Kate
prwsure
January,
bandage
in
1970.
been successfully employed as a temporomandibular joint prosthesis in recent years. In this case a small Silastic testicular implant (Dow Corning) proved to be ideal for recreating a condylar surface. Recently, Hoopes and associates I7 have suggested a retroauricular approach as superior to the more classic incisions for exposure and cosmetic effect. The obvious advantage is transection of the external auditory canal. Although in this case the ultimate cosmetic result obtained through the usual hockey stick approach was excellent, the retroauricular incision may prove to produce a better scar, particularly in Negro patients.17 Because of the unbalanced pull of the masticatory muscles, the abnormal
Volume Number
32 1
Silastic
testicular
implant
9
mandibular drift noted preoperatively has persisted since the surgical procedure. In addition, loss of the condylar growth center may very well result in an altered mandibular growth pattern. SUMMARY The ankylosed temporomandibular joint of a 5-year-old boy was removed uneventfully, and a coned-out Silastic testicular implant was placed. Postoperative examinations revealed an improvement of the patient’s ability to open the mandible, from an original 10 to 11 mm. to 36 mm., 5 months postoperatively. Exercise with bubble gum and spring clothespins were of great benefit during the immediate postoperative period. The use of the testicular implant was of particular importance because, when placed over the remaining portion of the ramus, it established a pseudocondylar shape. REFERENCES
Joint. ILO Snrinefield. I Ill.. I 1959.I Charles C Thomas 1. Sarnat. B. G.: The TemDoromandibular Publisher, pp. 222-226. A of the Temporomandibular Joint, Philadelphia, 2. Schwartz. L. : Disorders _ I 1959. W. B. Saunders’Company, pp. 272-276. V. H.: Ankylosis of the Temporomandibular Joint, Amer. J. Orthodont. Oral 3. Kazanjian, Surg. 24: 1181, 19838. 4. Dinpman. R. 0.: Ankvlosis of the Temnoromandibular Joint. Amer. J. Orthodont. Oral I Surg. 321 120-125, 194%. 5. Thoma, K. H.: Ankylosis of the Temporomandibular Joint, Amer. J. Orthodont. Oral Surg. 32: ;: 8. 9. 10.
11. 12.
13.
14. 15. 16. 17.
250,1946.
Parker. D. B.: Ankvlosis of the Temooromandibular Joint. J. Oral Sure. 6: 42. 1948. Blair, ?. P.: Operative Treatment Gf Ankylosis of the ~emporoman~bular joint, Surg. Gynec. & Obstet. 19: 436, 1914. Braithwaite. F.. and HODDer. F.: Ankvlosis of the Temnoromandibular Joint. Brit. J. I Plast. Surg.‘5: iO5, 1952. L L ’ Straith, C. L., and Lewis, J. R.: Ankylosis of the Temporomandibular Joint, Plast. Reconstruct. Surg. 3: 464, 1948. Pickrell, K. L., Wilde, N. J., Edwards, B. F, Broadbent, T., and Georgiade, N.: The Correction of Ankylosis of the Jaw and Associated Deformities of the Face, Ann. Surg. 134: 55. 1951. Function After Condylectomy, J. Amer. Smith, ‘A. E., and R.obinson, M.: Mandibular Dent. Ass. 46: 304, 1953. of the Temporomandibular Stuteville, 0. H.. and Lanfranchi. R. P.: The Reconstruction Joint in the Rhesus Monkey: Cli&cal Application, Trans. First Int. Con& Plast. Surg., Stockholm and Uppsala, August, 1955, p. 264. Georgiade, N., Altany, F., and Pickrell, K.: Experimental Clinical Evaluation of Autogenous Dermal Grafts Used in the Treatment of Temporomandibular Joint Ankylosis, Plast. Reconstruct. Sur.p. 19: 321-335. 1957. Hinds, E. C., and- Sills, A. H.: Cartilage Block Arthroplasty for the Correction of Temporomandibular Joint Disturbances, Amer. J. Sure. 98: 787-795. 1959. Rob&son, M.: Temporomandibular Jo&t Ankylosis Corrected by Creating a False Silastic Sponge Fossa, J. S. Calif. Dent. Ass. 36: 14-16, 1968. Bromberg, B. E., Song, I. C., and Radlauer, C. B.: Surgical Treatment of Massive Bony Ankylosis of the Temporomandibular Joint, Plast. Reconstruct. Surg. 43: 66, 1969. Hoopes, J. E., Jabaley, M. E., and Wolfort, F. G.: Operative Treatment of Fractures of the Mandibular Condyle in Children: A Post-auricular Approach. Presented before the American Society of Plastic & Reconstructive Surgeons Inc., St. Louis, MO., Oct. 14, 1969.
Reprint
requests
to :
Dr. Stephen Wukelich 16 Lindenwood Rd. Stoneham, Mass. 02180