TEMPOROMANDIBULAR JOINT

RECONSTRUCTION
 CONTENTS
Introduction
GOALS OF TREATMENT
TMJ BIOMECHANICS
INDICATION AND CONTRAINDICATION
TMJ RECONSTRUCTION
TMJ TJR HISTORY
TMJ TJR BIOMATERIALS
TMJ TJR DEVICES : STOCK AND CUSTOM
ADVANCE TJR TECHNIQUES
COMPLICATION
FUTURE ADVANCES : BIOENGINEERED TISSUE TMJ TJR
TMJ ANATOMY
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TMJ KINEMATICS
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• Mercuri et al. found that TMJ TJR patients could obtain 24.9 mm of opening before surgery.
• After TMJ TJR with a patient-fi tted joint replacement, maximum interincisal opening
increased 36 % after 3 and 10 years and 74 % after 14 years .

Mercuri LG, Edibam NR, Giobbie-Hurder A. Fourteen-year follow-up of a patient-fi tted total
temporomandibular joint reconstruction system. J Oral Maxil Surg. 2007;65(6):1140–8
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PRIMARY GOALS OF TREATMENT

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INDICATIONS
1. Degenerative disease
2. Osteoarthritis
3. Inflammatory joint disease
4. ReAnkylosis.
5. IRREPARABLE CONDLYAR FRACTURE
6. AVASCULAR NECROSIS
7. OSTECHONDRONDITIS DESICANS OF TMJ
8. FAILED RECONSTRUCTION WITH AUTOGENOUS GRAFTS
9. CONGENITAL ABNORMALITIS/SYNDROMES
10.MULTIPLE OPERATED TMJ WITH FAILED RESULTS
11.SEVERE FUNCTIONAL LIMITATION
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CONTRAINDICATION
• INTRACAPSULAR INFECTION

• SEVERELY MEDICALLY COMPROMISED PATIENT

• Poor bone quality or deficient bone

• History of metal allergy

• Patients who require surgical correction of tmj other than

replacement .
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RECONSTRUCTION
AUTOGENOUS

ALLOPLASTICTISSUE ENGINEERING
• FIBULAR HEAD
• STERNOCLAVICULAR
• METACARPAL
• COSTOCHONDRAL
• ILIAC CREST
• CORONOID
• POSTERIOR BORDER
OF RAMUS
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• COBALT CHROMIUM ALLOY

• ALLOYED TITANIUM
• COMMERCIALLY PURE
TITANIUM
• ULTRAHIGH
MOLECULAR WT
POLYETHYLENE
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TMJ TJR BIOMATERIALS /ALLOPLASTIC

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Kent vitek chhristensen Biomet

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BIOMET
PROSTHESIS
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TYPE – 2
KENT
VITAK TECHMEDI
PROSTHE A [TMJ
SIS CONCEPTS]
ALLOPLAST
IC
PROSTHESI
S
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DONOR SITE ALTERNATIVE

AUTOGENOUS
RECONSTRUCTION
Ramus condyle unit Glenoid fossa lining

TEMPORALIS MYOFASCIAL FLAP

Ccg, SCG BUCCAL PAD FAT
Free Fibular graft DERMIS GRAFT

FASCIA
METATARSAL GRAFT
AURICULAR CARTILAGE GRAFT
ILIAC CREST GRAFT
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SURGICAL TECHNIQUE TO
APPROACH TMJ
1. Preauricular approach and its modifications: Al-Kayat &
Bramley, Dingman, Blair, Thoma etc.
2. Post-auricular approach and its modifications
3. Endaural approach and its modifications
5. Retromandibular approach (Transparotid /
Retroparotid)
6. Rhytidectomy approach (Face-Lift)
7. Coronal approach (Hemi / Bi)
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CONCLUSION

THE SUBFASCIAL APPROACH SIGNIFICANTLY

IMPROVED INTRAOPERATIVE OUTCOMES AND
DEEP SUBFASCIAL APPROACH WAS
COMPARATIVELY SAFE WITH FEWER
INCIDENCE OFFACIAL NERVE INJUR
Y.
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RATIONALE
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COSTOCHRONDRAL PROCEDURE
CONTROVERSIES

GRAFT OUTCOME

INDICATION AND
CONTRAINDICATION •
• NO /ABSENT condyle • • Zero to 1
• previous TMJ
•
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surgeries (for free • Custom-fitted

grafts) total joint
• Both hard and soft prosthesis are
tissues are required unavailable
(vascularized fibula • Patient
graft) preference
• Growth center • Allergy to metals
transplant indicated in total joint
(rib or SCG) prosthesis
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Presentation title • Previously failed

• Contraindications TMJ allografts or
• Multiple TMJ surgeries autogenous grafts
(2 or more previous • Polyarthropathies
procedures) • Concomitant TMJ
• Connective tissue and orthognathic
autoimmune disease surgeries are
or inflammatory indicated
disease
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SURFACE
MARKING
Manubrium marked
5th -6 th rib palpated and marked
Female : inframammary crease line
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CCG HARVESTING
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CONTOVERSIES
HERALDING CCG
1.
Growth pattern of ccg graft is
2. extremely underpredictable .
3. mandibular overgrowth on grafted site is more
troublesome
 Ankylosis is common problem after tmj
reconstruction woth ccg.
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POTENTIAL
REASON FOR
OVERGROWTH

LENGTH OF CARTILAGE IS DIRECTY

RESPONSIBLE FOR AMOUNT OF growth
capacity of Cartilage.
medra et al : overgrowth of CCG – LENGTH OF CARTILAGE IS 10-15MM.
ROYCHOUDHARY et al 2-4 MM OF CARTILAGE BEST TO NEGATE THE GROWTH.
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CCG TMJ CONCLUSION

❑FAT GRAFTING TO REDUCE HETEROTRPHIC BNE FROMATION
❑CARTILAGE CAP HEIGHT 2-4 MM
❑DECORTICATION
❑FIXATION WITH SCREWS]
❑MMF FOR 7-10 DAYS [ MICROMOTIONS AND STRAINS}
❑POSTOP PHYSIOTHERPAY
❑LONGER FOLLOW UP
❑IMMEDIATE INTERVENTION IN CASE OF REANKYLOSIS
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OUTLINE OF INCISION AND

TECHNIQUE
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• INCISING TEMPORALIS
FASCIA
• DISSECTION OF JOINT
CAPSULE
• INCISING THE CAPSULE
• DISSECTION CARRIED
INFERIORLY TO REACH
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THE SUBPERIOSTEAL PLANE

TO REACH THE CONDYLE .
Vasculature
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DIAMOND RASP FOR EMINOPLASTY AND

TO OBTAIN STABILITY OF PROSTHESIS
AND CORRECT ORIENTATION
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PROSTHESIS IN
PLACE
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COMPLICATION
• INTRAOP • POSTOP
• HEMRRHAGE –MIDDLE
MENINGEAL , FACIAL
AND MAXILLARY
ARTERY
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FACIAL NERVE
• a safe zone approximately 0.8 to 1.8 mm in front of the tragus and
approximately 10 mm inferior to the root of the glenoid fossa
SSI –PERIMPLANT
PROSTHETIC INFECTION
 Tissue engineering devices may
even reduce the need for TJR
devices by giving surgeons the
tools to regenerate the damaged
structures of the TMJ
completely.
Challenges for this approach
include an optimal selection of
cells, scaffold materials, and
growth factors that work
together.
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