ANESTHESIA/FACIAL PAIN

Rec

Ma

De

Does Ultrasonic Resorbable Pin FixationOffer Predictable Results for AugmentationEminoplasty in Recurrent Dislocations?

eived

rmara U

*Profes

yResidezAssocixResidekResideAddres

partme

Selcuk Basa, DDS, PhD,* G€okhan G€ocmen, DDS,y Altan Varol, DDS, PhD,zBerfin Karatas, DDS, PhD,x and Ayseg€ul Sipahi, DDS, PhDk

Purpose: To assess the outcome of interpositional calvarial block grafting fixed with an ultrasonic

resorbable system (SonicWeld, KLS Martin, M€uhlheim, Germany) for augmentation eminoplasty in chronic

recurrent condylar dislocations.

Patients and Methods: We designed and implemented a retrospective cohort study. Eight female

patients (mean age 48 years) were treated. The primary predictor variable was time (preoperative vs

postoperative). The primary outcome variable was cessation of dislocation. The secondary outcome vari-ables were the height of the articular eminences (HAE), maximum interincisal opening, pain score

(visual analog scale [VAS]), postoperative magnetic resonance imaging (MRI) findings, and facial nerve

paralysis.

Results: All 8 patients had been experiencing recurrent dislocations a mean of 10 times eachmonth pre-

operatively. None of the patients had experienced a dislocation at 2 years postoperatively. The preopera-

tive mean HAE was 5.75 and the VAS score for pain was 72.5. The mean vertical HAE was 15.75 mm, and

the mean VAS score for pain was 11.2 at 12months postoperatively. Complete resorption of the SonicWeld

pins was observed on the first year follow-up computed tomography scans. Of the 8 patients, 3 presented

with disc displacement without reduction and 2 with disc displacement with reduction on the postoper-

ative MRI scan, and none of the patients had a facial nerve deficit at 24 months of follow-up.

Conclusions: Fixation of cortical calvarial grafts using the ultrasonic resorbable system for augmentation

eminoplasty provided sufficient stabilization and favorable outcomes. Degradation of the osteosynthesismaterial and the absence of intermaxillary fixation were the most advantageous parts of the technique.

� 2014 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 72:1468-1474, 2014

Patients with recurrent chronic dislocation (RCD) can

present with variations in articular anatomy, severe

internal derangement, and myofascial disorders. Man-

agement of dislocations can be grouped basically

under blocking and nonblocking procedures. The

blocking procedures have included titanium mini-plates,1 Silastic implants (Dow Corning, Midland,

MI), metallic eminence prostheses, eminence grafting

with autogenous grafts,2-6 the Leclerq procedure,7

Dautrey’s procedure,8,9 capsular plication, and

from Department of Oral and Maxillofacial Surgery,

niversity Faculty of Dentistry, Istanbul, Turkey.

sor.

nt.

ated Professor.

nt.

nt.

s correspondence and reprint requests to Dr G€ocmen:

nt of Oral and Maxillofacial Surgery, Marmara University

1468

stabilization of the condyle to zygomatic arch

with anchors.2

Nonblocking options have included midline mandi-

bulotomy, eminectomy with or without discectomy or

discoplasty,10 arthroscopic eminectomy or thermal

capsulorrhaphy,11 sclerosing agents, intermaxillaryfixation (IMF), bandaging, and a soft diet.12 Ramus

osteotomies (bilateral sagittal split osteotomy, intraoral

vertical ramus osteotomy, and inverted L osteotomy)

have been mainly performed in prolonged cases with

Faculty of Dentistry, Istanbul, Turkey; e-mail: gocmengokhan@

hotmail.com

Received March 14 2013

Accepted March 27 2014

� 2014 American Association of Oral and Maxillofacial Surgeons

0278-2391/14/00366-8$36.00/0

http://dx.doi.org/10.1016/j.joms.2014.03.030

BASA ET AL 1469

serious fibrosis, hindering closure of an open bite and

obtaining occlusion.13 Augmentation eminoplasty

(AE) can be achieved with inlay or onlay bone grafts

using wire, titanium hardware, or resorbable systems.

The Lindemann-Norman technique is an old technique

performed as an oblique osteotomy with an interposi-

tional graft tapped into the glenotemporal osteotomy

to augment the deficient eminence.2

The use of nonresorbable titanium screw and plate

osteosynthesis has been questionable for augmenta-

tion of the articular eminence because of the risk of

graft resorption and screw loosening. These can result

in loosening and additional complications with the

fixation material inside the joint cavity.1

The purpose of the present study was to determine

whether resorbable pin usage in the fixation of inlaycalvarial bone grafts for augmentation eminoplasty

can provide optimal outcomes and resistance against

dynamic forces of the condyle. We hypothesized that

usage of ultrasonic fixation for the Lindemann-

Norman procedure would be a predictable method.

The specific aims of the present study were to offer

a new technique for an older procedure and to eval-

uate the outcomes and effects on the temporomandib-ular joint (TMJ) complex.

Patients and Methods

STUDY DESIGN AND SAMPLE

To address our research purposes, we designed andimplemented a retrospective cohort study. The study

sample was derived from the population of patients

presenting to the University of Marmara Faculty of

Dentistry from 2008 to 2012 for the evaluation and

management of RCD. The patients included in the pre-

sent study had a documented diagnosis of RCD. The

participants were limited to those patients who had

undergone surgery for RCD within the previous 4years. The data were collected directly from the

patient records. Patients without both preoperative

and postoperative recorded measurements of the

outcome variables were excluded. The clinical

research ethics committee of Istanbul Yeditepe

University approved the present study, which was in

compliance with the World Medical Association’s

Declaration of Helsinki as it relates to medical researchprotocols and ethics.

STUDY VARIABLES

The primary predictor variable in the presentstudy was time (preoperative vs postoperative).

The primary outcome variable was the cessation of

dislocation. The secondary outcome variables were

the height of the articular eminences (HAE), the

maximum interincisal opening (MIO), visual analog

scale (VAS) score for pain, postoperative magnetic

resonance imaging (MRI) findings, and facial nerve

deficit. The preoperative and 1-year postoperative

HAEs were measured and compared with the find-

ings from the computed tomography (CT) scans

(Fig 1). Postoperative MRI scans were obtained for

all patients at 24 months. The pain scores were

recorded using a VAS, and facial nerve paralysiswas classified using the grading system of House

and Brackmann. The preoperative measurements

were taken at the visit before surgery, and the post-

operative measurements recorded at the 12- and

24-month follow-up visits.

PATIENT SELECTION AND TREATMENT

All patients had experienced recurrent episodes of

condylar dislocations monthly (mean frequency 10

times) and had required medical assistance for manual

reduction. All patients were American Society of Anes-thesiologists Class I. The preoperative assessment was

performed from CT scans (Digital Imaging and

Communications in Medicine file format), and data

processing was performed using Mimics software

(Materialise, Leuven, Belgium).

All patients underwent surgery under nasotracheal

anesthesia. Preauricular access with an Al Kayat and

Bramley modification (n = 1) and a short temporalextension (n = 7) was performed, and dissection was

developed to skeletonize the articular eminences.

A transverse osteotomy of the articular eminence

was performed with a sagittal saw (NSK Nakanishi,

Kanuma, Japan), and all eminences were green frac-

tured completely in the lateromedial direction, preser-

ving attachment of the medial periosteum (Fig 2).

The monocortical calvarial grafts were harvestedthrough a 4-cm-long parietal scalp incision using

fine burs and chisels. In 1 patient, the calvarial graft

was harvested through a cranial extension of the Al

Kayat-Bramley flap to avoid a secondary approach.

The grafts were shaped in pyramidal form and

tapped into the osteotomy sites (Fig 3). At least 1

SonicWeld pin (KLS Martin, M€ulhleim, Germany),

12 mm long, was used to fix the inferior stump(the articular segment of the AE) to inlay the calva-

rial grafts and the remaining upper border of the

zygomatic arch (Fig 4). Three eminences had insuffi-

cient bone volume (<6 mm in height) to obtain

adequate fixation. An extra pin was inserted in

each of those 3 cases, requiring additional stability

from the upper pole, which was generally the root

of the zygomatic arch.Dietary restrictions and a soft diet (regimen 1) were

prescribed to all patients for 4 weeks. No IMF was

used, and all patients were advised to have minimal

mouth opening during the early recovery period.

FIGURE 1. Preoperative 3-dimensional simulation of the proce-dure.

Basa et al. Ultrasonic Resorbable Pin Fixation and AugmentationEminoplasty. J Oral Maxillofac Surg 2014.

FIGURE 3. Inlay placement of the prepared pyramidal-shapedcalvarial graft is tapped until the medial pole of the AE has beenaugmented.

Basa et al. Ultrasonic Resorbable Pin Fixation and AugmentationEminoplasty. J Oral Maxillofac Surg 2014.

1470 ULTRASONIC RESORBABLE PIN FIXATION AND AUGMENTATION EMINOPLASTY

Results

Eight female patients with mean age of 48 years

underwent surgery. One patient underwent bilateral

augmentation, and the remaining patients underwent

surgery on 1 side. They were followed for 24 months

postoperatively. None of the patients experienced

dislocation during the 24-month postoperative period.

Of the 8 patients, 1 had developed mild dysfunction of

the temporal branch of facial nerve; however, itsnormal function had returned within 24 months.

Two patients with postoperative clicking experienced

disc displacement with reduction, and three experi-

enced disc displacement without reduction (Fig 5,

Table 1). The mean preoperative height of the AE

was 5.75 mm. The mean mouth opening was 35.875

FIGURE2. Full transverse osteotomy of the articular eminence witha sagittal saw.

Basa et al. Ultrasonic Resorbable Pin Fixation and AugmentationEminoplasty. J Oral Maxillofac Surg 2014.

mm at 12 months and 38 mm at 24 months postoper-

atively. The Student t test of the preoperative and post-

operative MIO values showed a statistically significant

decrease in the MIO (P < .001). All patients had tran-

sient trismus for 2 weeks immediately postoperatively.

The mean VAS pain score was 11.25 postoperatively.The mean vertical HAE was 15.75 mm. The preopera-

tive and postoperative VAS and HAE values showed a

statistically significant decrease (P < .001; Table 2).

The SonicWeld pin had resorbed completely at the 1-

year follow-up CT scan. No foreign body reactions or

osteolysis around the screws was found (Fig 6).

Discussion

The results of the present study have confirmed the

hypothesis that ultrasonic resorbable fixation provides

the necessary immobilization to allow osseous healing

under the dynamic discocondylar complex. Thepatients who underwent surgery with this technique

reported no recurrence and satisfactory articular func-

tion. From the results of our study, resorbable pin fix-

ation of calvarial grafts offers quite predictable results

in the management of CRD.

A variety of treatment modalities are available for

chronic recurrent condylar dislocation. Nonblocking,

but function-limiting, methods have generally beenbased on the impairment of associated components

of the articulation. Ybema et al14 reported a high clin-

ical success rate of 95% in 16 patients for 86months af-

ter arthroscopic electrocautery of retrodiscal tissues.15

FIGURE 5. Magnetic resonance imaging scan revealed discdisplacement without reduction at 24 months postoperatively.

Basa et al. Ultrasonic Resorbable Pin Fixation and AugmentationEminoplasty. J Oral Maxillofac Surg 2014.

FIGURE 4. A SonicWeld pin, 12 mm long, was used to fix the infe-rior stump to the inlay graft and the remaining upper border of thezygoma.

Basa et al. Ultrasonic Resorbable Pin Fixation and AugmentationEminoplasty. J Oral Maxillofac Surg 2014.

BASA ET AL 1471

However, the triangulation technique requires a longlearning curve and expensive operating hardware for

arthroscopic TMJ surgery. Kuttenberger and Hardt1

treated 20 patients (39 joints) using a miniplate emino-

plasty blocking method and found plate fractures in 7

patients within 3 to 7 years postoperatively. Undt

et al7 reported a greater recurrence rate with oblique

zygomatic osteotomy (LeClerc procedure). Eminec-

tomy will lead to intensive scarification of the upperjoint space, resulting in decreased translatory capacity

of the discocondylar complex.

We compared the outcomes both radiographically

(CT) and clinically. The HAE was calculated, and mea-

surements were made using a software program to

predict the optimal height and articular movements.

Patients showed no recurrence and no difficulty incondylar translation. The method provides several

benefits compared with other known augmentation

methods. The calvarium has numerous advantages,

including a large amount of cortical bone, minimal

morbidity, long-term resistance to resorption, and

the advantage of a hidden scar at the same surgical

region. However, the possible adverse complications

include dural tears, arachnoid bleeding with subse-quent hematoma, and scalp infection.12

Considerable anatomic variations can occur in the

glenoid fossa, 1 of which can be in the mediolateral

direction. Anatomic variations should be considered

in every case. Medial augmentation of the articular

eminence is important in cases in which the condylar

head is quite small, because medial escape of the

condyle during condylar translation can cause persis-tence of dislocation.15 Therefore, a full bony cut of

the medial pole of the AE should be included within

the osteotomy, and the bony graft should be inserted

in the full mediolateral dimension to allow augmenta-

tion of the medial pole. The glenotemporal osteotomy

level should have an adequate amount of bone at the

inferior part to obtain the optimal bone height for

augmentation.16

Glenotemporal osteotomy and inlay augmentation

has been presented as a predictable technique in a

case series without any fixation.5,6 Nardini et al16

reported a case managed successfully with bilateral

augmentation eminoplasty using calvarial grafts.

Table 1. DEMOGRAPHIC PREOPERATIVE AND POSTOPERATIVE PATIENT DATA

Pt. No. Site Age (yr)

Monthly Preoperative

Dislocation

Frequency

Dislocation

Recurrence

(2 yr)

Facial Nerve

Deficit

(1 yr)

Facial Nerve

Deficit

(2 yr)

Postoperative

MRI Findings

(2 yr)

1 Unilateral 49 10 None Normal Normal DDwoR

2 Unilateral 44 3 None Normal Normal DDwR

3 Bilateral 50 15 None Normal Normal None

4 Unilateral 48 15 None Mild dysfunction Normal DDwoR

5 Unilateral 48 20 None Normal Normal DDwR

6 Unilateral 46 2 None Normal Normal None

7 Unilateral 50 5 None Normal Normal DDwoR

8 Unilateral 51 10 None Normal Normal None

Mean 48.25 10 — — — —

Abbreviations: DDwoR, disc displacement without reduction; DDwR, disc displacement with reduction; MRI, magneticresonance imaging; Pt. No., patient number.

Basa et al. Ultrasonic Resorbable Pin Fixation and Augmentation Eminoplasty. J Oral Maxillofac Surg 2014.

1472 ULTRASONIC RESORBABLE PIN FIXATION AND AUGMENTATION EMINOPLASTY

Fernandez-Sanroman2 treated 8 patients with augmen-

tation eminoplasty using monocortical parietal grafts.

He did not use any fixation, but just tapped the bicort-

ical grafts into the glenotemporal osteotomy site.2 No

dislocation was reported in that case series during 18

months of follow-up.2

Studies with or without fixation have generally

revealed no recurrence; however, we preferred touse at least 1 resorbable pin in such a dynamic region.

During condylar translation, the shearing forces are

concentrated on the augmented articular eminence,

which could interfere with the healing process of

the bone grafts. When stability against the shearing

forces was compared between resorbable pins and ti-

tanium screws in condylar fractures, no significant

disadvantages were observed for pin fixation.17 Wethought the shearing forces that threaten graft immo-

bilization and overall success of the treatment could

be resisted using resorbable ultrasonic pins. The

resorbable ultrasonic pins also showed good stability

to the shearing forces in condylar fractures.

The risk of graft resorption is always present owing

to stress shielding, which can result in secondary

infection, loosening, palpability, and additional com-plications with the fixation material.18 Biodegradable

fixation systemswill be mechanically weaker than tita-

nium systems19; however, the titanium hardware can

cause artifacts on CT scans and the same complica-

tions. Elimination of the secondary operation risk of

removal of titanium screws is another disadvantage

of titanium screws.

In our study group, with the advantage of themelting and welding phenomenon of the SonicWeld

system, the calvarial grafts were fixed with satisfactory

primary stability that could prevent graft displacement

during forced mouth opening. Smooth eminence

topography with optimal calvarial graft healing and

complete resorption of the biodegradable pins was

observed on the 1-year follow-up CT scans (Fig 5).

Some patients had insufficient volume of the inferior

bone stump and surface to fix the inlay grafts; thus,

we used the superior margin of the articular eminence

to place the ultrasonic pins in a superoinfe-

rior direction.

All investigators have recommended immediatelimited mouth opening or immobilization for healing

of the grafted articular eminences.6 Current trends in

oral-maxillofacial surgery have been centered on

increased postoperative comfort and a quicker return

to social life. The longer immobilization periods in

such operations can be avoided by the use of fixation

materials. We did not immobilize the jaw owing to the

rigid fixation of the grafted eminences. In addition, allpatients were instructed to follow the dietary restric-

tions and to consume a soft diet (regimen 1).

The treated patients did not report any joint pain

during the postoperative follow-up period. The pro-

gression of mouth opening was satisfactory (43.8

mm preoperatively to 35.8 mm postoperatively).

The primary goal of therapy was to restore the form

and function in patients with RCD. This includedcorrection and prevention of dislocation, limited

pain in the joint, and elimination or reduction of

any noise.7 However, all patients with recurrent dislo-

cations have the potential of having intra-articular dis-

orders. Increasing the steepness of the posterior

slope of the articular eminence will predispose

patients to the occurrence of disc derangements.20

Similarly, we observed anterior disc displacementswithout reduction in 3 operated joints and anterior

disc displacement with reduction in 2 cases on the

postoperative MRI scans. Because preoperative MRI

scans were lacking, we could not state whether

the internal derangements had been present

Table

2.RES

ULT

SOFTH

ESTU

DEN

TTTE

STOFTH

ESEC

ONDARYOUTC

OMES

Pt.No.

VASScore

HAE

MIO

Preoperatively

Postoperatively

(12mo)

Preoperatively

Postoperatively

(12mo)

Preoperatively

Postoperatively

(12mo)

Postoperatively

(24mo)

170

10

715

45

37

38

260

10

516

43

34

37

390

10

414

44

33

36

470

10

516

40

34

34

570

10

617

42

34

35

680

10

616

45

39

42

780

20

818

50

40

44

860

10

514

42

36

38

Mean

�SD

72.5

�10.350

11.25�

3.535

5.75�

1.281

15.75�

1.388

43.875�

2.997

35.875�

2.587

38�

3.4226

Pvalue

<.001

<.001

<.001

Abbreviations:HAE,heightofthearticulareminences;MIO

,maxim

um

interincisal

opening;Pt.No.,patientnumber;SD

,stan

darddeviation;VAS,visualan

alogscale.

Basa

etal.Ultrasonic

Resorbable

Pin

FixationandAugmen

tationEminoplasty.JOralMaxillofacSurg

2014.

FIGURE 6. The SonicWeld pin was seen to have been resorbedcompletely on the first year follow-up CT scans. No foreign bodyreactions or osteolysis around the screws was found.

Basa et al. Ultrasonic Resorbable Pin Fixation and AugmentationEminoplasty. J Oral Maxillofac Surg 2014.

BASA ET AL 1473

preoperatively or had developed after the joint sur-

gery. Long-term postoperative positional changes of

the articular disc and retrodiscal tissues could

lead to osteoarthritis in such cases. Therefore, the

question is whether discal repositioning should

be performed simultaneously with augmentationeminoplasty or a ‘‘wait and see protocol’’ should

be followed. The augmentation eminoplasty is an

extracapsular procedure that does not violate the

intracapsular environment. However, joint surgery

covering both the intra- and the extracapsular struc-

ture can cause intracapsular fibrosis and postopera-

tive limitations of mouth opening.7 Our preference

was to first stop the recurrent dislocations and thento monitor patients closely for the occurrence of

any internal derangements and osteoarthritis.

We found a great benefit in using SonicWeld biode-

gradable pin fixation for augmentation eminoplasty.

The most significant advantage was the primary stabil-

ity and biodegradation achieved.

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