Temporomandibular joint reconstruction with alloplastic prosthesis: the outcomes of four cases
© The Author(s). 2017
Received: 21 November 2016
Accepted: 26 January 2017
Published: 25 March 2017
The purpose of this study is to evaluate the outcomes of four patients receiving stock Biomet TMJ prosthesis for reconstruction of the TMJs.
TMJ reconstruction with stock Biomet TMJ prosthesis was performed in four patients who had joint damages by trauma, tumor, resorption, and ankylosis, which represent the indications of alloplastic prosthesis.
Loss of condyle from trauma and resorption of joint are good indications for prosthesis, but the patients should be informed about limitation of jaw movement. In case of structural damage of TMJ by tumor, tumor recurrence should be considered before planning TMJ reconstruction. Considering heterotopic bone formation in case of ankylosis, periodic follow-up and special surgical technique are required.
Given careful treatment planning and understanding the functional limitation of TMJ prosthesis, alloplastic prosthesis is a safe and effective management option for the reconstruction of TMJs.
KeywordsTemporomandibular joint Reconstruction Alloplastic prosthesis Biomet Indication
Anatomic structural damages of temporomandibular joints (TMJs) such as trauma, tumor, resorption, and ankylosis require removal of pathologic structures and reconstruction of TMJs. The goals of TMJ reconstruction are (1) improved mandibular form and function, (2) reduction of pain and disability, (3) containment of excessive treatment and cost, and (4) prevention of further morbidity . Alloplastic total TMJ reconstruction is a management option for patients with anatomically and pathologically compromised dysfunctional TMJs. Several devices are available, including TMJ Concepts (Ventura, CA, USA), TMJ Implants (Golden, CO, USA), and Biomet (Jacksonville, FL, USA). In contrast to an individually designed prosthesis, such as TMJ Concepts, Biomet is a stock product system. It is a two-component system comprised of fossa and mandibular components which are available in several sizes. Using templates, surgeons can select suitably sized components during the operation. The stock prosthesis has advantages of lower cost, shorter treatment time frames, and more placement versatility than customized prosthesis . Recently, as the use of stock alloplastic TMJ prosthesis (Biomet) has increased, several studies have reported stable and satisfactory results [3–5]. The authors present the outcomes of four patients receiving TMJ reconstruction using Biomet involving, respectively, trauma, tumor, resorption, and ankylosis.
Four patients receiving TMJ reconstruction using alloplastic prosthesis
Tumor (carcinoma of right external auditory canal)
Deviated mandible, unstable occlusion
Anterior open bite
Pain, limited mouth opening
Limited mouth opening
Sharp pain and swelling by tumor recurrence
No further inflammation
Mandibular deflection when opening the mouth
In case 2, involvement of the TMJ by carcinoma of the external auditory canal necessitated condyle resection. Although reconstructive surgery was successful, the patient still suffered from uncontrolled primary tumor. When the symptoms of tumor recurrence first developed, they were ascribed to postoperative infection of prosthesis because metal artifacts from the prosthesis made the images difficult to interpret. Alloplastic prosthesis is a reconstructive option for tumors around TMJs but is not suitable to patients who need to have a CT or MRI taken to identify further pathologic changes.
Severe inflammatory joint disease is another indication for alloplastic TMJ prosthesis. In case 3, severe inflammation of TMJs caused bilateral condylar resorption in rheumatoid arthritis. Alloplastic reconstruction of TMJ was planned to stop disease progression, which was aggravating anterior open bite. Severe inflammatory joint disease has been reported to have the best results with alloplastic reconstruction in terms of predictable results . Counterclockwise rotation of mandible is considered a destabilizing factor in orthognathic surgery. Using a prosthesis, however, stable function without relapse is expected according to the literature [6, 9]. The patient has been followed up for 2 years with no evidence of relapse.
TMJ ankylosis is also a good indication for reconstruction with prosthesis, especially in patients with recurrent fibrosis and bony ankylosis . In case 4, the risk of re-ankylosis after gap arthroplasty was considered high because of the underlying disease, ankylosing spondylitis. Total reconstruction of TMJ with prosthesis was planned to avoid the risk of re-ankylosis. The patient has restored his former range of mouth opening, but his jaw still deviates to the affected side, which is accounted for by the prosthesis rather than re-ankylosis. In contrast with TMJ, which functions in both rotational and translational patterns, the prosthesis functions in a purely rotational pattern due to the loss of lateral pterygoid muscle attachment. Limited movement of jaw to the nonprosthesis side and deviation of jaw to the prosthesis side are inevitable.
There are some limitations of TMJ reconstruction with alloplastic prosthesis. Because alloplastic prosthesis cannot follow growth, the use of prosthesis in a growing patient is limited. Long-term data on material wear and stability of TMJ prosthetics is still needed. Nevertheless, due to its advantages over autogenous graft such as (1) immediate jaw function, (2) low risk of re-ankylosis, (3) no need for a secondary donor site, (4) decreased surgery time, and (5) mimicking normal anatomy , alloplastic prosthesis is widely used to reconstruct TMJs.
Several studies have reported satisfactory results of TMJ reconstruction with alloplastic prosthesis. Mercuri et al. reported long-term outcome of 193 patients (mean follow-up of 11.4 years), which showed a significant reduction in pain and an increase in mandibular function and range of motion after TMJ reconstruction using customized prosthesis (TMJ Concepts) . A study by Westermark who evaluated 12 patients treated with stock prosthesis (Biomet) after a follow-up time of up to 8 years reported an increased mean jaw-opening capacity and elimination of joint-related pain . Also, a 3-year follow-up study of 288 patients treated with stock prosthesis (Biomet) by Giannakopoulos et al. showed significant improvement in pain level, jaw function, and incisal opening .
The above four cases of trauma, tumor, resorption, and ankylosis represent the indications of alloplastic prosthesis. Loss of condyle from trauma and resorption of joint are good indications for prosthesis, but the patients should be informed about limitation of jaw movement. In case of structural damage of TMJ by tumor, recurrence of tumor should be considered before planning TMJ reconstruction. Considering heterotopic bone formation in case of ankylosis, periodic follow-up and special surgical technique are required.
TMJ reconstruction with alloplastic prosthesis is indicated in cases of specific TMJ conditions and pathology with irreversible joint damage. Given careful treatment planning and understanding the functional limitation of TMJ prosthesis, alloplastic prosthesis is a safe and effective management option for the reconstruction of TMJs.
J-HP, EJ, and HC are responsible for the data collection, drafting the article, and the critical revision of the article. HJK is responsible for the conception and design of the study, the critical revision of the article, and the approval of the article. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
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