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Multiple Faces of Alloplastic Multiple Faces of Alloplastic TMJ ReconstructionTMJ Reconstruction

A SCIENTIFICALLY INFORMATIVE PEER-REVIEWED PUBLICATION · VOLUME 4 · NUMBER 9

SEPTEMBER 2005

The TMJournaThe TMJournall

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Editorial Board

Patrick Abbey, DMD Private Practice

Oral & Maxillofacial Surgeon Tampa, Florida

Albert Lippincott III, BSE Engineering Consulting Services

Bioengineer Consultant Prior Lake, Minnesota

Ricardo Alexander, DDS Roosevelt-St. Luke’s Hospital

Director, Division of OMS New York, New York

COL Robert Bryan Roach United States Army (Brooke AMC)

Chief, Oral & Maxillofacial Surgery Fort Sam Houston, Texas

Robert W. Christensen, DDS, FAIMBE Rocky Mountain TMJ Surgical Conference

Executive Director Golden, Colorado

Subrata Saha, PhD Alfred University

Professor of Biomaterials Alfred, New York

James T. Curry, DDS Private Practice

Oral & Maxillofacial Surgeon Highlands Ranch, Colorado

Hermann Sailer, MD, DMD, PhD Private Practice

Professor and Oral & Maxillofacial Surgeon Zurich, Switzerland

Francis DiPlacido, DMD Private Practice, Past President AAOMS

Oral & Maxillofacial Surgeon Ft. Myers, Florida

Anthony Urbanek, DDS, MD Private Practice

Oral & Maxillofacial Surgeon Franklin, Tennessee

Eugene Keller, DDS, MDS The Mayo Clinic

Director, Department of OMS Rochester, Minnesota

Crayton R. Walker DDS, MD Private Practice

Oral & Maxillofacial Surgeon Salt Lake City, Utah

Barry Levine, DMD Private Practice Oral & Maxillofacial Surgeon

Tampa, Florida

Stephen Worrall, MD Consultant Surgeon, Hon. Sec. BAOMS

Oral & Maxillofacial Surgeon West Yorkshire, United Kingdom

Jerry V. Dollar, BA, MBA, FACHE

Editor-in-Chief Robert W. Christensen, DDS, FAIMBE

Executive Editor

Nancy L. Johnson Managing Editor

Matthew S. Christensen, BS, CCRA Clinical Researcher

Wm Lester Hardrick Surgical Video Journalist

Lynn M. Watwood, Jr., JD President

TMJournal, Volume IV, No. 9, September, 2005 Page 1

Temporomandibular Joint Surgery

THE MULTIPLE FACES OF ALLOPLASTIC TMJ RECONSTRUCTION

A SURVEY OF MULTIPLE SURGICAL SOLUTIONS

ROBERT W. CHRISTENSEN, DDS, FAIMBE

Executive Director, Rocky Mountain TMJ Surgical Conference Adjunct Professor, Bioengineering, Clemson University

AND

JAMES T. CURRY, DDS

Oral and Maxillofacial Surgeon

Private Practice, Highlands Ranch, CO

Key Words: Alloplastic, alloplasty, arthroplasty, Christensen, Condylar Prosthesis,

condyle, Curry, Fossa-Eminence Prosthesis, Glenoid Fossa, hemi-arthroplasty, implants, mandible, prosthesis, prostheses, surgical reconstruction, temporal bone, temporomandibular joint, TMD, TMJ.

Introduction

In this article we attempt to give a glimpse of several areas of usefulness of an alloplastic prosthesis system for reconstructing damaged portions of the human anatomy involving contiguous structures associated with the temporomandibular joint. Starting from the simpler form of reconstructive surgery in which internal derangement requires menisectomy and hemiarthroplasty using the Christensen Fossa-Eminence Prosthesis as a disc replacement to the more complicated total temporomandibular joint reconstruction, so the surgeon will gain some understanding of these surgical techniques in a variety of situations.


Background

For nearly 45 years Christensen has been a proponent of early alloplastic hemiarthroplasty of the temporomandibular joint, using the Christensen Fossa-Eminence Prosthesis in cases of middle and late stage internal derangement of the temporomandibular joint. When a surgeon elects to perform other autogenous graft surgical procedures as the first open joint procedures, some advantage is lost. The Christensen TMJ hemiarthroplasty is best described by all of the following words:

1. Reliable 2. Predictable 3. Durable 4. Protection to adjacent bone 5. Do-able 6. No serious secondary site morbidity 7. Shortened surgical time

8. Unilateral or bilateral 9. Normal mandibular motion 10. Immediate function and loading 11. Facial nerve damage rare 12. No need for post surgical IMF 13. Allows for uncomplicated revision surgery 14. Overall cost savings

Alloplastic Advantages

Let us explain these statements in greater detail.

1. RELIABLE - We mean that as an implant it will maintain its shape and position where placed.

2. PREDICTABLE - The results measured by pain reduction and interincisal

opening increase are predictable and repeatable.


3. DURABLE - The CO-CR metal prosthesis, though slim in contour, is very

durable when placed against the temporal bone and secured with screws. 4. PROTECTION TO ADJACENT BONE -When a Fossa-Eminence Prosthesis is

properly and securely placed, it will have no deleterious effect on the adjacent temporal bone or articulating natural condyle.

5. DO ABLE - The surgical accomplishment of this hemiarthroplastic procedure is

easily performed by well trained and experienced oral and maxillofacial surgeons. 6. REQUIRES NO SERIOUS SECONDARY SITE SURGERY - Although

placement of a fat graft in the TMJ surgical site may require removal of a small amount of fat from an abdominal incision site, it is not debilitating.

7. SHORTENED SURGICAL PROCEDURE - The Christensen TMJ

hemiarthroplasty procedure is frequently performed in less than an hour. 8. UNILATERAL OR BILATERAL TMJ HEMIARTHROPLASTY – Can be

performed allowing for more normal pain reduced performance. 9. NORMAL MANDIBULAR MOTION - Lateral and protrusive jaw motions are

usually left intact. 10. IMMEDIATE POST OP FUNCTION AND LOADING - The patient will be

encouraged to open and close the jaws and resume normal diet within a few days. 11. FACIAL NERVE DAMAGE RARE - Due to the lesser amount of surgery

required. 12. NO NEED FOR POST-SURGICAL IMF - IMF may only be needed during the

intra-operative time period. 13. ALLOWS FOR UNCOMPLICATED REVISION SURGERY - This is due to the

fact CO-CR does not osteointegrate. 14. OVERALL COST SAVINGS - Due to the lessoned chance for repeatable

revision surgeries as seen in cases where autogenous grafting is the procedure. When we consider that over 900,000 joint surgeries are accomplished annually in the U.S, not including TMJ surgeries, and that 100 % of those orthopedic procedures are alloplastic procedures, then why are we, as oral and maxillofacial surgeons, using autogenous grafting solutions 90% of the time in our annual 40,000 TMJ surgeries? This is an especially important question to ask when autogenous joint reconstruction shows failure rates between 69 and 92 percent of the time.


Historical Perspective

When Marius Smith-Peterson, MD accomplished his first mold hip arthroplasty, using a glass substance, in 1923 that was not only news but new to the orthopedic community. Before that time fascia-latta was being used to reconstruct the hip with marginal results.

From that moment forward the orthopedic surgeons began to experiment with alloplasts for use in their hip joint reconstructive surgeries. They developed a new paradigm. No longer would autogenous materials dominate the orthopedic experience in hip joint arthroplasty. Within 9 years Dr. Smith-Peterson and his office partner, Otto Aufranc, MD began using CO-CR as the substance their hip joint mold arthroplasty was made of. We as oral and maxillofacial surgeons need to change our thinking on how we manage and treat our middle to late stage internal derangement patient’s TMJ problem where the meniscus is displaced and degeneration of the tissues is or has occurred.

Perhaps Dr. Don Chase, Professor of Oral and Maxillofacial Surgery and Director of the OMS Training Program at the University of Tennessee School of Medicine, said it best. He recognized that most frequently the displaced meniscus showed a histologic and morphologically compromised structure incapable of repair and should be excised and replaced with the Christensen Fossa-Eminence Prosthesis. Dr. D. Lamar Byrd, Professor Emeritus of Oral and Maxillofacial Surgery at Baylor University, School of Medicine, summed it up by saying that the Christensen TMJ hemiarthroplasty was a very predictable and useful procedure. Some 41 years earlier, the world famed head and neck anatomist, Harry Sicher, MD when speaking about the Christensen TMJ hemiarthroplasty made the statement that this surgical procedure did little to disturb the normal anatomy of a temporomandibular joint. In May 1963, Otto Aufranc, MD, Professor of Orthopedic Surgery at Harvard University, School of Medicine and Professor of Orthopedic Surgery and Chairman of the Department of Orthopedic Surgery at Massachusetts Hospital, wrote Christensen to compliment him on his development of this surgical technique which he had recently read about in the American Journal of Arthroplasty, January 1963. In that letter he complimented Christensen by stating, “This is a real contribution to the art of surgery of the disabled joint….and I have nothing further to add but to compliment you on your good work.”


Even though that statement was made some 42 years ago, its content is still true. This is evident with well over 22,000 of these Fossa-Eminence Prostheses having been placed as either a hemiarthroplasty or as the superior portion of a TJR. These prostheses have proven their reliability, durability, predictability and longevity, not to mention cost saving benefit to patient and insurance carriers alike over these 44 plus years. Can you imagine the benefit to the patient who has had only one surgery some 40 years ago for placing the Christensen TMJ implant as a hemiarthroplasty, and none since?

Case Study # 1 The simplicity of placing the Fossa-Eminence Prostheses, bilaterally, in a 52 year-old female patient has been described earlier in the TMJournal. In this discussion we will limit our relating of all of the details, but minimize it so you, as the surgeon, might learn a little more about this surgical procedure which has worked so well for over 44 years and counting. This patient had been under conservative TMJ therapies which included drug therapy, occlusal equilibration, and splint therapy for over a years time before an MRI of her temporomandibular joints was suggested. Pain and limit jaw motion and function had been the main complaint of the patient. The radiologist reported marked non-reducing meniscal displacements bilaterally and moderate bony degenerative changes in condyles and fossa bilaterally. The patient sought a second opinion and contacted Dr. Christensen who promptly suggested a consultation with Dr. James Curry. Let us take a moment to review a brief viewing of the surgical placement of the Fossa-Eminence Prostheses in this patient’s temporomandibular joints. Starting with the left TMJ,

In the photo at left, the patient is seen 48 hours before surgery that will correct internal derangement by placement of the Christensen Fossa-Eminence Prosthesis. At right, the pre-operative x-ray of the patient is shown


In the coronal CT view, we see evidence of Wilkes Stage IV degeneration of the right temporomandibular joint.

The inferior view of the SLA model, prepared from the CT scan of the patient, shows the position and outline of the Fossa-Eminence Prostheses.

A right lateral view of the SLA model of the skull shows the Fossa-Eminence Prosthesis from a lateral perspective.

The left view of the SLA model shows the same perspective for the left Fossa-Eminence Prosthesis.


The skin incision is started in the pre-auricular fold and continues behind the tragus and within the ear.

Any bleeding vessels are either electro-coagulated or tied off.

The deeper dissection continues.


The meniscal tissues will be grasped and excised.

The “stock” sizer is tried against the SLA model to show the approximate sizing of the implant against the bone.

The sizer is now held up in the surgical field, adjacent to the wound. The sizer is in an inverted position.


The sizer is shown against the bone at the base of the skull.

The actual Fossa-Eminence Prosthesis is held over the wound, just prior to placement against the bone.

Again, the FEP fits properly.

The occlusion is checked.

The prosthesis is in place.

The wound is being closed.


The skin closure begins.

The skin wound incision is fully closed.

In the photo above, the surgeon irrigates the ear canal. A similar procedure was accomplished on the patient’s right TMJ. There was a more noticeable degeneration of the condyle’s articular surface on the MRI and visually during surgery. Because of this alteration in the condyle’s articular surface a minimal recontouring was accomplished using a rotary diamond instrument.


The following few photographs show highlights of this right TMJ surgery.

The right natural condyle is seen, with its degenerated surface.

Recontouring the condyle.

The Fossa-Eminence Prosthesis is ready for implanting.

The implant is secured.

The occlusion and jaw motion are checked

The wound is closed.


The patient opens 40 mm on the table.

The patient is seen 72 hours after surgery.

Opening, closing, and eating all types of foods.

Case Commentary

This hemiarthroplastic surgical technique is useful in patients where only one temporomandibular joint requires surgical intervention or where both joints require reconstructive surgery either as a hemiarthroplasty or a mixture of hemi and total joint arthroplasty. It is an encouraging fact that when a hemiarthroplasty has been performed as the first surgical procedure in a given joint, where negligible bone degeneration has occurred, the hemiarthroplasty may prevent the need for transitioning to a total joint arthroplasty in some 95% of the patients so operated. There will be a great percentage of time when the “stock” Fossa-Eminence Prosthesis will be used for either a hemiarthroplasty or total joint arthroplasty. We will not, at this point, go into all of the reasons why a “stock” or “Patient-Specific” implant will be needed for a hemiarthroplasty.

Case Study # 2

We do want to show a couple of instances where the “custom” metal Fossa-Eminence Prosthesis is mandatory. GUN SHOT WOUND REQUIRING HEMIARTHROPLASTY This young lady was struck by a bullet fired into her left temporal bone region. It caused minor brain damage, loss of hearing in the left ear, severe compound, comminuted fracture of her left temporal bone in the area of her left TMJ, compound fracture of her right mandibular angle, and compound fracture of her mandibular symphysis. She underwent early surgery to debride the area of comminution and dural damage to her left cranial region and early treatment of her mandibular fractures. It was nearly one year before any reconstructive surgical procedure could be contemplated for her left TMJ. It


was at that time that a CT scan was accomplished for her necessary cranial reconstruction. Fibrous ankylosis had occurred in the area of her left TMJ.

The necessary SLA model was constructed so that the shape and size of the necessary temporal bone prosthesis could be determined. It was amazing that the cortical surface of the natural condyle was not disturbed by the trauma, thus only a hemiarthroplasty was indicated. From the three photos above, one can see the size and shape of the temporal bone prosthesis required. The patient’s post-operative course was uneventful and her jaw opening increased from 7 mm to 30 mm. In the following photos, we see the pre-op and post-op opening measurements. The photo at bottom right shows a post-op radiograph of the Patient-Specific™ Partial Joint Prosthesis in place. (Surgery by Dr. Adele Tawfilis, prosthesis designed and manufactured by TMJ Implants, Inc.)

In the case described above, the natural condyle was intact and not injured so that a hemiarthroplasty was possible and the natural condyle would be allowed to function against the metal implant.


Case Study # 3

CONDYLAR FRACTURE AND ANKYLOSIS – HEMIARTHROPLASTY ON A 4 YEAR-OLD The next case to be described is that of a 4 year-old girl who had suffered a severe, traumatic injury to her right TMJ, at age 2 years, which caused a condylar fracture that was left untreated and eventually ankylosed. It was decided to attempt a hemiarthroplasty using the Christensen Fossa-Eminence Prosthesis after a gap arthroplasty had been accomplished so the prosthesis could be fitted into the new, surgically prepared glenoid fossa of the temporal bone. A picture of the FEP secured in place is shown at right. This allows for mobility of the previously ankylosed mandible and so the region of the condylar neck might be sculpted to resemble a natural condyle.

The pre-surgical CT scan for the patient X-Ray of patient, 8 years post-op, showing FEP When the prosthesis had been placed and the condylar neck had been shaped it was found that the meniscus was misplaced anteriorly and medially from its natural position. The condition of the meniscus was such that it could be draped over the newly formed condyle and just inferior to the FEP and attached to the capsular tissues with sutures.

In both photos, at left, the patient is shown at the 12-year post-operative point. This 4 year-old girl has matured to be a 17 year-old young lady with normal mandibular and facial development.


Alloplastic Hemiarthroplasty There are as many different uses for the “stock” and “Patient-Specific” Fossa-Eminence Prostheses as one could imagine. In some patients it will be used to cover a cranial base perforation as well as act as a normal prosthetic fossa liner. In some other case it will be part of rebuilding the zygomatic arch as well as act as a normal prosthetic fossa-eminence structure. Or it could rebuild the greater portion of the temporal bone and include the normal anatomy of the articulating portion of the TMJ enclosed as part of the temporal bone. In all of these situations the advantage of using the cast CO-CR prosthesis becomes evident. The structural stability and firmness of this type of metal prosthesis is very evident and useful, as is the thinness and bio-compatibility of the metal. It also retains the availability of a proper articulating surface for the opposing CO-CR condylar prosthesis in case that becomes a necessity.

Total TMJ Arthroplasty

Now let’s consider total joint arthroplasty using the Christensen TMJ implant system. Here again the need for a total TMJ arthroplasty may be confined to reconstructing just the normal anatomic structures of the temporomandibular joint.

This can be accomplished either unilaterally or bilaterally as total TMJ arthroplasty, or could incorporate a PJR (Partial Joint Reconstruction) on one side and a TJR (Total Joint Reconstruction) on the contralateral side. There are several advantages of the all metal, Co-CR, partial joint and/or all metal, CO-CR, total joint prostheses. By using the structural strength of the CO-CR metal for the Fossa-Eminence Prosthesis it is possible to reconstruct the joint in its proper anatomic location thus allowing for the normal rotation of the mandible. That is especially true where a bony ankylosis is present and the newly created joint will be placed in its proper position anatomically.

Another advantage of the metal/metal articulation is the superior wear propensity of the Co-CR material as compared to the wear of the titanium or cobalt against the softer UHMWPE. As has been shown in the orthopedic literature, the wear debris generated by metal against the UHMWPE is the greatest cause of hip joint failure due to the osteolysis caused by the wear of the UHMWPE material.


Case Study # 4

Let us briefly look at surgical pictures of a patient who required bilateral TJR of his temporomandibular joints. When the disease or destructive process has developed to the level where a TJR is necessary, then the decision has to be made, will a “stock” Condylar or Fossa-Eminence Prosthesis be useable or will it be necessary to have the patient have a CT scan of the skull so that a stereolithographic (SLA) model can be made. From that model the surgeon and implant manufacturer can decide on the shape and size of the necessary Patient-Specific™ prostheses. There are many factors such as available bone, quality of bone, strength of masticatory force, and others which need to be considered.

Radiograph of Patient Specific™ Bilateral TMJ Implants

There are, of course, many surgical decisions which need to be made such as, should the CT scan be made with the patient’s teeth in occlusion or separated? Will the desired post-op occlusion be different from the pre-op occlusion? When the SLA model is fabricated should it be generated as a one-piece model with mandible and teeth as seen pre-operatively or a two-piece model with the mandible and teeth able to be moved into a new post-operative position?

The size of the prostheses will determine the position and length of the skin incisions. Generally speaking the FEP can be placed using the minimal pre-auricular or endaural incisions. The CP, again depending on size and length, will require at a minimum the retro-mandibular incision, or if a hemi-mandibular prosthesis is to be placed then the incision more likely will entail a more anterior, sub-mandibular incision, or a combination of both.

Generally speaking, the FEP is placed first then the CP is placed through the retro or sub-mandibular approach. Frequently, the coronoid processes are elongated with the fibers of the temporalis muscle(s) preventing normal mandibular opening. If so, coronoidectomies must be considered. The mandible is secured in IMF during the time the CP is being secured by screws and the IMF can usually be removed at the end of the surgery.


Above left, we see the placement of the Condylar Prosthesis for total joint reconstruction. The photo above right shows the base of the Condylar Prosthesis, as well as the placement of the Fossa-Eminence Prosthesis and Condylar Prosthesis articulating surface resting in the Fossa-Eminence Prosthesis. Patients are generally kept on a softer diet for one or two weeks then can gradually increase the firmness of the diet to normal.

Juvenile TMJ Case

CONDYLAR HYPOPLASIA LEADING TO BONY ANKYLOSIS The treatment of juveniles, for a variety of temporomandibular joint disorders, can also be accomplished with the use of the Christensen Fossa-Eminence Prosthesis. The following case shows how the oral and maxillofacial surgeon was able to meet the needs of the TMJ, and at the same time was able to meet the distraction osteogenesis needs of the patient. All of these were accomplished in a single one-stage operation.

A 9 year-old boy with a birth injury involving his left mandibular condyle.

The SLA model shows that the condyle is ankylosed to the base of the skull.


The Fossa-Eminence Prosthesis is placed in the left TMJ after minimal gap arthroplasty which establishes mobility.

The jaw opens to 30 mm as the opening is measured during surgery.

The distraction device causes major bone separation in the ramus, below the arthroplasty.


Five weeks after the surgery, the

patient opens to 30 mm and is able to eat all foods

Challenging TMJ Cases

UNILATERAL GOLDENHARR SYNDROME This particular 19 year-old male was born missing the left ear structures, left zygoma, and left posterior mandible. Several attempts were made, at earlier ages, to restore the zygoma, mandible, and temporomandibular joint using rib grafts. Unfortunately, not enough improvement was made and it became necessary to accomplish a left alloplastic reconstruction of the left zygomatic arch, temporomandibular joint, and posterior mandible. The following photographs show the reconstructive surgical procedure accomplished by Dr. Timothy Carrion. (Prostheses designed and manufactured by TMJ Implants, Inc.)


BILATERAL GOLDENHARR SYNDROME In the following 15 year-old female patient, we see the effects of bilateral Goldenharr syndrome. This anomaly is characterized by a developmental deformity of aural structures, posterior mandible, and some ocular deficiency. She had many attempts at temporomandibular joint and mandible reconstruction using rib grafts. When the present surgeon, Dr. Jay Selznick, contacted the author about reconstructive surgery, Dr. Christensen recommended a CT scan, compliant to TMJ Implants, Inc.’s protocol, so that a careful assessment of the problem could be undertaken. Through collaboration between the operating surgeon and Dr. Christensen, the proper design and fabrication of the prostheses could occur. The five photos below show the prostheses and surgical implantation. (Surgery by Dr. Jay Selznick, prostheses designed and manufactured by TMJ Implants, Inc.)

In this case, it was decided to reshape the cranial base in both right and left TMJ areas so that proper Fossa-Eminence Prostheses could be secured to the base and sides of the temporal bones. Then it would be helpful to remove the areas of previous rib grafts, so the symphysis, which was positioned to the right of the maxillary midline, could be correctly aligned and then secured by the metal mandibular prosthesis. This device would extend


from one fossa area around to the opposite side fossa. To properly occlude the few mandibular teeth against the maxillary teeth, it would be necessary to remove a section of the left symphysis with the lateral incisor and secure the remaining halves of the mandible in the mandibular prosthesis. The patient later had orthodontic and dental restorative procedures accomplished. She is now 4 years post-op and doing very well. Her case was presented on Fox Network’s “Ripley’s Believe It or Not!” aired in September 2003 as well as the internationally syndicated “Montel Show” in July 2004.

In the left and center photos above, we see the patient prior to surgery. A post-operative photo of the patient (above right) shows substantial improvement. TREACHER COLLINS SYNDROME Recently, we have seen many more congenital or developmental cranio-facial anomalies, where variations in these previously described therapies have been indicated. One such patient is seen in the following 3-D CT reconstruction (photos below). The patient is a 22-year old male who was born with agenesis of aural structures, zygomas, and posterior mandible, bilaterally. He had numerous attempts at reconstruction with little success. Rib grafts were the main mode of treatment and ankylosis was always the result. It was interesting to note that the ankylosis occurred with the mandible in the open position.


For this 22-year old patient it was necessary to perform bilateral TMJ arthroplasty and reconstruction with Patient-Specific™ Fossa-Eminence and Condylar Prostheses, which would attach along the lateral surface of temporal bone, since the zygomatic bone areas were largely obliterated by previously placed rib grafts. The position of the FEP would be placed exactly where the ankylosis occurred, somewhat anterior of the normal glenoid fossa. It was impossible to identify the exact location of the bilateral facial nerves, where they would normally exit from the base of the skull, making the anterior position of the newly created TM joints a wiser decision.

Pre-Operative Photo

Post-Operative Photo


When the right and left TMJ Fossa-Eminence Prostheses had been properly placed, using pre-fabricated sizers as the pattern for bone removal, then it was time to reposition and reconstruct the condyles along with repositioning of the mandible into its proper intermaxillary relationship. When this was accomplished, the jaw was allowed to open and close naturally (Photos on previous page). Treacher-Collins Syndrome Case # 2 In the following case, (facial photos below) we once again see the effects of Treacher-Collins Syndrome, as well as an alloplastic reconstruction technique to improve the condition of the patient.

The prostheses designed and implanted for this patient are shown in the three photos above. Following this surgical procedure the patient has made a rather uneventful recovery and his parents, the doctors and the patient are well pleased with the improved facial esthetics and improved temporomandibular joint, speech, and masticatory function. (Facial photos, following page) The post-op Lateral skull and P-A skull x-rays are seen showing the presence of the Christensen TMJ and mandibular prostheses (next page).


Perhaps the long term efficacy of this alloplastic technique will need to be determined, but in other patient cases using these same Christensen custom prostheses, the patients have done very well over a multiple 12-year time span, thus making all involved rather sure this patient will also do very well. There are several other considerations, which should be mentioned. In some of these patients it may only be necessary to place the Fossa-Eminence Prosthesis against the base of the skull to prevent ankylosis and then accomplish distraction osteogenesis to elongate the ramus and/or body of the mandible. Dental implants may later be necessary to assist in proper masticatory function and esthetics.

Conclusion

The patient treatments described briefly in this article truly show the faces of TMJ arthroplasty in the year 2005. The TMJ hemiarthroplasty described within these pages can be accomplished on children as young as 90 days old and adults in their 90’s. When cases of disease, trauma, or


developmental deformity occur in the infant’s or adolescent’s temporomandibular joints, the placement of the Fossa-Eminence Prosthesis will relieve the ankylosis, and in most cases will allow the mandible to grow normally. At times, distraction osteogenesis will be necessary to improve or correct any deficiency in mandibular growth. Another area in which a rather new technique may be very useful is in the use of piezosurgery to relieve mandibular joint bony ankylosis. This technique uses a modified ultrasonic wave frequency (60-200 mm/sec) to cut the hard bony structure, but not injure the deeper adjacent tissues, nerves, or blood vessels. The final point we would like to make is that the most recent FDA Orthopedic Devices Panel recommended approval of the all metal hip resurfacing device. (See photo at right.) This total joint metal-on-metal (Co-Cr) device in many ways mimics the TMJ Implants, Inc device, which employs the very same metal. The earliest Christensen total TMJ devices (circa 1962), are shown in the picture below. The case involved a 17 month-old baby’s jaw, had condylar resurfacing and glenoid fossa resurfacing as well.

Generally, we will prefer to remove the degenerated condylar head and replace it with a Condylar Prosthesis. However, on occasion, we have considered only a resurfacing of the condyle’s articular surface.


Recommended Reading

Alexander R. Temporomandibular Joint (TMJ) Replacement: An Update on Methods. Private Hospital Healthcare Europe; Theatre & Surgery, 2002, pp T35-37. Anderson G, Russell R, Christensen R, Gerard D, Hudson J, Chase DC. Thirty Year Follow-up of Patients with Alloplastic TMJ Prostheses. Presented at AADR/IADR 1993 Meeting. Britton C, Christensen RW, Curry JT. Use of the Christensen TMJ Fossa-Eminence Prosthesis™ System: A Retrospective Clinical Study. Surgical Technology International X, 2002, pp 273-281. Campbell P, Shen F, McKellop H. Biologic and Tribologic Considerations of Alternative Bearing Surfaces. Joint Replacement Institute and J. Vernon Luck Orthopaedic Research Center Hospital, Clinc Orthop, January 2004 No. 418. Chase DC, Hudson JW, Gerard DA, Russell R, Chambers K, Curry JR, Latta JE, Christensen RW. The Christensen Prosthesis: A Retrospective Clinical Study. Oral Surg Oral Med Oral Pathol, 1995; 80: pp 273-8. Christensen RW. Mandibular Joint Arthrosis Corrected by the Insertion of a Cast-Vitallium Glenoid Fossa Prosthesis: A New Technique, Oral Surg Oral Med Oral Pathol, June 1964 (Vol. 17) No. 6, pp 712-722. Christensen RW. Arthroplastic Implantation of the Temporomandibular Joint (Chapter 29) Oral Implantology Vol. II No. 2, Cranin N (ed.), 1970. Christensen RW, Alexander R, Curry JT, Christensen MS, Dollar, JV. Hemi and Total TMJ Reconstruction Using the Christensen Prostheses. Surgical Technology Intl XII, 2004. Christensen RW. Surgical Correction of Complete Bilateral Ankylosis of the Mandible. Oral Surg Oral Med Oral Pathol, December 1955 (Vol. 8) No 12: pp 1235-1244. Christensen RW. Surgical Treatment of Mandibular Ankylosis. Use of a Cast Vitallium Glenoid Fossa. Dental Radiology and Photography, 1964 (Vol. 37) No. 1. Christensen RW. The Correction of Mandibular Ankylosis by Arthroplasty and Insertion of a Cast Vitallium Glenoid Fossa Prosthesis: A New Technique. A Preliminary Report of Three Cases. AM J Orthopedics, January 1963; 5: pp 16-24. Christensen, RW. The Temporomandibular Joint Prosthesis Eleven Years Later. J Oral Implantology, 1971 (Vol. II) No. 2: pp 34-8. Christensen RW, Curry J, Tomassetti B, Dollar JV. Meta-Comparison as a Tool in Predicting and Validating Treatment Outcomes in Alloplastic TMJ Reconstructive Surgery: Report of Multiple Studies. The TMJournal, Vol 4, No 3, March 2005. Collins CP, Collins PC, Christensen RW. An Alloplastic Alternative to Autogenous Material in Temporomandibular Joint Surgery. Critical Reviews Biomedical Engineering, 1998, 5: pp 403-4. Curry JT. The Effects of Hemiarthroplasty Utilizing a Metal Fossa Prosthesis on the Mandibular Condyle: A Retrospective Review. TMJournal, 2001 (Vol. 1) Issue 1: pp 6-12.


Curry J, Latta J. An Evaluation of Christensen TMJ Prostheses in 58 Consecutive Patients. Presented at AADR/IADR 1993 Meeting. Dollar JV. Comparative Analysis of Weight Bearing Surfaces in Joint Arthroplasty: A Review of the Technologies Available. The TMJournal, Vol. 3, No. 10, November 2004. Dollar JV, Christensen, MS. Stereolithography Anatomical (SLA) Modeling: Applications for Surgical Planning, Patient Education, and Prostheses Design. The TMJournal, Vol. 3, No.4, April 2004. Dollar JV. Temporomandibular Joint Surgery: Educated Patient – Enhanced Outcomes. The TMJournal, Vol. 3, No.3, March 2004. Hensher R. TM Joint Hemi-Arthroplasty. TMJournal, 2002 (Volume 2) Issue 1: pp 10-13. Kummoona R. Functional rehabilitation of ankylosed temporomandibular joints. Oral Surg October 1978; 46 (4): pp 495-505. McKay E, Russell R, Christensen R, Curry J, Latta J, Gerard D, Hudson J, Chase D. Placement of a Christensen Fossa-Eminence Prosthesis in the Absence of the Meniscus. Presented at AADR/IADR 1993 Meeting. McLeod NMH, Saeed NR, Hensher R. Internal Derangement of the Temporomandibular Joint Treated by Discectomy and Hemi-Arthroplasty with a Christensen Fossa-Eminence Prosthesis. British Journal of Oral and Maxillofacial Surgery, 2001 39: pp 63-66. Park J, Keller EE, Reid KI. Surgical Management of Advanced Degenerative Arthritis of Temporomandibular Joint With Metal Fossa-Eminence Hemijoint Replacement Prosthesis: An 8-Year Retrospective Pilot Study. JOMS. February 2004 62: pp 320-8. Robbins JL. Rehabilitation after Temporomandibular Joint Surgery: A Review of the Literature and Guidelines for Practice. TMJournal, 2002 (Vol. 2) Issue 1: pp 39-41. Tawfillis A, Chappell ET, Farhood VW. Alloplastic Reconstruction of Temporal Bone and Glenoid Fossa Defect. JOMS, 2002 60: pp 1079-1082. Van Loon J, De Bont L, Boering G. Evaluation of Temporomandibular Joint Prostheses: Review of the Literature from 1946 to 1994 and Implications for Future Prosthesis Designs. J Oral Maxillofac Surg, 1995 53: pp 984-96. Woodbury SC, Stanton DC, Quinn PD, Beanland DR, Foote JW. Options for Immediate Reconstruction of the Traumatized Temporomandibular Joint. The Journal of Cranio-Maxillofac Trauma, 1998 4(2): pp 22-29


Coming in October 2005

A new article written by Robert Christensen, DDS, FAIMBE, Crayton Walker, DDS, MD, and Jerry V. Dollar, MBA, FACHE of the

Rocky Mountain TMJ Surgical Conference

Publisher and Distributor of Publisher and Distributor of The TMJournalThe TMJournal

Rocky Mountain TMJRocky Mountain TMJ Surgical ConferenceSurgical Conference

Golden, Colorado USAGolden, Colorado USA

Jerry V. Dollar, BA., MBA, FACHE Executive Secretary Rocky Mountain TMJ Surgical Conference Golden, Colorado USA [email protected] www.tmjournal.com (V) +1 303.277.1338 (F) +1 303.277.1421

For Additional Information, Contact:For Additional Information, Contact:

The Rocky Mountain TMJ Surgical Conference is Dedicated to The Rocky Mountain TMJ Surgical Conference is Dedicated to Advancing Knowledge in the Treatment of TMJ DisordersAdvancing Knowledge in the Treatment of TMJ Disorders

Would you like to see the Rocky Mountain TMJ Would you like to see the Rocky Mountain TMJ Surgical Conference conducted in your locale?Surgical Conference conducted in your locale?

Annual sessions are held in Golden, Colorado every January, however the Surgical Conference can come to you too! In the past 12 years we have conducted sessions in England, the Canary Islands, and all over the United States. We would be very pleased to discuss your specific needs.

UPDATE - VIENNA: The RMTMJSC was pleased to speak at the 17th ICOMS Congress last month. In the photos above (L-R) are: Mrs. And Dr. Di Placido with Dr. and Mrs. Christensen; Dr. Di Placido, Dr. Christensen, Dr. Finkelshtern, Dr. Nikitin, and Dr. Gutierrez; Dr. and Mrs. Ewers and Dr. and Mrs. Christensen. In the photos below (L-R) are: Dr. Christensen and Dr. Undt; Dr. and Mrs. Christensen with the Nigerian delegation; Dr. Gao and Dr. Christensen. As a result of this conference, the RMTMJSC has been invited to speak at over one dozen conferences around the world over the next two years.

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