J Oral Maxillofac 49:476-a,
Surg
1991
A Two-Stage Procedure for Temporomandibular Joint Disc Replacement Using Free Pericranial Grafts: A Preliminary Report N.R. MARKOWITZ, DMD,* T. PATTERSON III, DMD,t AND L. CAPUTA, DMD$ A preliminary study of the use of free pericranial grafts as an alternative to other autogenous or alloplastic materials for temporomandibular joint disc replacement is presented. Postoperative results show improved function and alleviation of other symptoms.
Advances in oral and maxillofacial surgery have led to the advent of a multitude of procedures to treat internal derangements of the temporomandibular joint (TMJ). Until 1960, discectomy was the primary mode of surgical treatment. I-8 In the early 196Os, however, numerous authors reported complications following discectomy.9-‘2 These findings led several authors to infer that discectomy alone leads to arthrosis, and that to avoid soft-tissue adhesions and osseous degeneration, reconstruction of the TMJ following discectomy appears indicated. Throughout the subsequent years various alloplastic and allogenic materials have been implanted in the TMJ. However, these materials also have met with complications. These complications and adverse tissue reactions have led many investigators to attempt to find an ideal autogenous graft material for disc replacement or repair. Many autogenous tissues, including dermis, muscle, fat, fascia lata, and cartilage, have been used as an interpositional
graft in TMJ reconstruction, with varying degrees of success. Risdon used autogenous pedicled medial pterygoid muscle in patients with ankylosis.21 Feinberg and Larsen have reported preliminary results in 13 patients using a pedicled temporalis musclepericranium graft.33 Dermis has been advocated by many authors since Loewe first introduced dermal grafting in 1913. Georgrade reported using dermis in patients with ankylosis and following discectomy, although no results were presented.23 Dermis has been used by Zetz and Irby to repair disc perforations.24 Tucke? and Stewart26 grafted dermis to the discs of monkeys,25-26 and showed incorporation of the dermis within this tissue. In 1987, Bonnington, Langan, and Jay reported epithelial inclusion cyst formation in dermal grafts placed in the TMJ.27 This finding has also been reported in hernia repair using dermis. Narang and Dixon reported the use of fascia lata grafts in two cases. Both patients had a decrease in symptoms and improved function. Autogenous cartilage grafts have been used for over 100 years in various reconstructive procedures since the initial work by Von Mangoldt in 1889 and Kong in 1896. Autogenous auricular cartilage has been used in TMJ discectomy. Perko was the first to use auricular cartilage following discectomy.28 Longacre and Gilby used autogenous cartilage as a interpositional graft in TMJ ankylosis.29 Rudelt reported on five patients using auricular cartilage postdiscectomy with favorable results.30 Witsenberg and Freihefor3’ used auricular cartilage in seven patients following discectomy, and reported
Received from the Department of Oral and Maxillofacial Surgery, University of Oklahoma, Oklahoma City. * Professor of Surgery, College of Medicine and Dentistry. t Chief Resident, College of Medicine. $ Formerly Chief Resident; currently, Assistant Professor, Oral and Maxillofacial Surgery, Medical College of Georgia, Augusta. Address correspondence and reprint requests to Dr Markowitz: Oral and Maxillofacial Surgery, College of Medicine, The University of Oklahoma Health Sciences Center, PO Box 26901, Oklahoma City, OK 73190-3048. 0 1991 American geons
Association
of Oral and Maxillofacial
Sur-
0278-2391/91/4905-0006$3.0010
476
477
MARKOWITZ ET AL
increased function and decreased symptoms. In 1990, Tucker reported the use of auricular cartilage grafts in primates. 32 Histologically, all the grafts showed viability as long as 24 weeks postsurgery. Also, decreased osseous degeneration was evident in all grafted joints compared with nongrafted joints. Another autogenous tissue that could be considered for disc replacement is pericranium. Pericranium has been used as a free graft for various reconstruction procedures, including frontal sinus obliteration. Since March 1987 at the University of Oklahoma, patients postdiscectomy have been treated with a two-stage reconstruction technique using free pericranial grafts. When indicated, patients have undergone TMJ arthroplasty with discectomy and temporary placement of a Silastic (Dow Coming, Midland, MI) implant. The second stage of reconstruction consists of removal of the Silastic implant and placement of a free pericranium graft. The purpose of this study was to describe the two-stage TMJ reconstruction technique using a free pericranium graft and to evaluate the preliminary clinical results of this reconstructive procedure . In the first stage, using a preauricular approach, an eminoplasty is performed and the disc is removed. The eminence is remodeled medially to create more room for the translating condyle. A .03-inthickness oval, 3-cm diameter sheet of reinforced Silastic is stabilized to the lateral aspect of the fossa with three transosseous 26-gauge wires. At 6 months, the Silastic is removed and it is replaced with a pericranial graft with the periosteal side facing the glenoid fossa to obliterate the dead space created by removal of the Silastic. The pocket is sutured laterally securing the pericranial graft to the soft-tissue capsule created around the Silastic, thus stabilizing the graft. Procurement Technique To obtain the pericranial graft, the patient is placed in the supine position with the head turned to the side to expose the TMJ, the auricle, and the scalp. The TMJ is prepared in the normal manner. The scalp just posterior to the ear, short of the midline of the head and posterior to the origin of the temporalis muscle, is then thoroughly scrubbed with Povidone soap (Parke-Davis, Stanley, UT). The hair is not shaved. With a sterile comb, a horizontal part in the hair approximately 5 to 7 cm in length is made posterior to the auricle (Fig 1). Povidone is then poured onto the area. Approximately 6 mL of lidocaine 2%, with 100,000 epinephrine,
i
FIGURE I. Postauricular scalp incision posterior and inferior the origin of the temporalis muscle.
is injected into the scalp for hemostasis and to balloon the galea aponeurosis off of the pericranium and the subcutaneous tissue. The part in the hair is then recombed with sterile K-Y jelly (E. Fougera & Co, Division of ByK-Gulden, Inc, Hicksville, NY), which will harden in several minutes, maintaining the part after the draping. Sterile drapes are then placed and stapled around the TMJ surgical site and the pericranium donor site. Similar draping can be done for bilateral TMJ cases. Finally, a drape is placed across the ear protecting the preauricular site and isolating the pericranial donor site. After waiting 5 minutes for hemostasis following injection of the lidocaine, an incision approximately 5 cm in length, beginning 4 cm posterior to the base of the auricle, is made with a no. 15 blade just through the galea aponeurosa to the pericranium (Fig 2). For bilateral cases, only one donor site is necessary, but the incision is longer (7 cm) to permit procurement of more pericranium. By incising in the part, minimal hair loss will occur. In over 300 scalp incisions for pericranial and cranial bone procurement, we have never noticed a bald spot occur-
478
TMJ RECONSTRUCTION
FIGURE 2.
USING FREE PERICRANIUM
Diagram of the scalp layers.
ring because of loss of hair. If the patient is balding, the incision may need to be modified to hide the scar, but generally, in the region behind the ear, even balding patients have some hair. Also, there have been no infections as a result of not shaving the hair. After the initial incision is completed, the subgaleal flap is undermined with a Metzenbaum scissors while maintaining pressure superiorly with the index finger and three 1.5cm Raney clips are placed on the flap. The same procedure is then performed on the inferior flap. Placing the Raney clips on one flap at a time prevents excessive blood loss. Using two Senn retractors, the pericranium and the subcutaneous tissue covering it are exposed (Fig 3). Care is taken to avoid the temporalis muscle, which should be superior to the exposure site. An elliptical incision at the edge of the retracted subgaleal flap is made to skull bone with a new no. 15 blade. For unilateral cases the diameter of the incision is 4 cm and for a bilateral case it is 8 cm. The periosteal graft is then elevated with tissue forceps and a periosteal elevator, and removed from the skull (Fig 4). It is stored in moist gauze for later use (Fig 5). The exposed skull is irrigated and checked for any hair that may have fallen into the wound. The galeal layer is then closed over the exposed skull with individual 3-OVicryl (Ethicon, Somerville, NJ) horizontal mattress sutures and the scalp is closed with skin staples. No drains are necessary. After the TMJ surgery is completed, the donor site is checked for hematoma formation. If a hematoma is discovered, it is aspirated with an 18gauge needle on a IO-mL syringe. The hair is rinsed with sterile water at the end of the TMJ surgery to wash out the Povidone soap. The donor site is then dressed with Bacitracin ointment (E. Fougera & Co) and a neurosurgical head dressing or Jobst dressing is placed for 1 or 2 days to prevent delayed hematoma formation. In 83 cases, five hematomas, which were easily aspirated, occurred 2 days postoperatively.
FIGURE 3.
Reflected subgaleal flap exposing the pericranium.
The patients are instructed not to shampoo their hair for 1 week. The staples are removed with a staple remover 2 weeks postoperatively (Fig 6). The staple remover allows the staples to be removed relatively painlessly, whereas using a hemostat to remove staples usually is painful. Removing the staples at 1 week has lead to separation of the scalp incision in some patients, with ensuing bleeding, inversion of hair, and prolonged healing time. Results
Since March 1987, 83 free pericranial grafts have been used for TMJ reconstruction in four groups of patients: 1) patients with failed alloplastic implants such as the Vitek (Houston, TX) TMJ prosthesis, and Silastic and Proplast-Teflon inter-positional implants (22 joints), 2) patients with severe arthritic changes of the condyle with associated disc perforation and destruction (15 joints), 3) patients undergoing reconstruction of the TMJ with sliding ramus osteotomies (15 cases), 4) patients with limited opening and severe pain or headache, and nonre-
MARKOWITZ ET AL
FIGURE 5. View of graft showing the dense periosteal connective tissue side of the pericranium. The graft is approximately l-mm thick.
FIGURE 4. Subpericranial the pericranium.
incision with partial reflection of
ducing anteriorly displaced or perforated discs demonstrated by arthrogram or TMJ MRI (31 joints). All patients had significant TMJ signs and symptoms preoperatively, including limited opening; popping, clicking, or crepitus; chronic lateral headaches; and point tenderness or pain over the TMJ. All patients were told that the use of pericranium was investigational and they all consented to its use. The mean follow-up was 20 months, with a range of 6 to 36 months. The mean age of the patients was 46 years, with a range of 18 to 71 years. There were 45 women and 10 men. Twenty-seven cases were unilateral (15 right side; 12 left side) and 28 cases were bilateral. The mean intercisal opening preoperatively was 26 mm, with a range of 4 mm to 5 1 mm. Postoperatively, the mean opening was 41 mm, with a range of 21 mm to 55 mm. Vigorous physiotherapy monitored by the clinicians was incorporated 3 weeks postoperatively after Silastic (first stage) and pericranium (second stage) insertion. This included jaw exercises, chewing one pack of sugar-free gum per
day, and, in nine cases, manipulation with tongue blades. The patients who failed to achieve interincisal openings greater than 35 mm were either noncompliant with their physiotherapy or were patients who had previous multiple TMJ operations. Thirty cases reported squeaking noises after Silastic placement, which resolved as the capsule formed around the Silastic. Twenty-seven patients reported recurrence of joint noise and headaches at 4 to 6 months after Silastic placement, which resolved after Silastic removal and replacement with free pericranium. A majority of the Silastic implants showed holes or tears along the reinforcing Dacron (Dow-Corning, Midland, MI) fibers. Forty-eight patients reported resolution of their popping, clicking, or crepitus after placement of the pericranium. Of the seven TMJs that had recurrence of joint noise, none of the patients reported severe pain, but they were concerned about the noise. Five of these patients were undergoing active orthodontic care, which may have had some influence of the recurrence of joint noise. In all cases, the postoperative occlusion remained stable. All patients reported initial resolution or improvement of their headaches and joint pain. Four patients complained of worsening pain after 1 year, and recurrence of joint noise. Two patients were reoperated, and two were lost to follow-up. In both cases the pericranial graft appeared intact. Another layer of pericranium was placed in the glenoid fossa, and
480
TMJ RECONSTRUCTION
USING FREE PERICRANIUM
FIGURE 6. The scalp incision 2 weeks postoperatively after removal of the skin staples.
both patients reported resolution of their joint pain and noise. Discussion Histologically, pericranium is a tissue with properties that makes it potentially useful for TMJ reconstruction. It is durable, tough, and resilient. The superficial layer is highly vascular loose areolar connective tissue and the deeper layer is dense tibrous connective tissue (periosteum) that is adherent to the skull (Fig 7). The free graft appears to be incorporated into the TMJ by early revascularization and it provides a nidus for fibrous ingrowth that insulates the joint. A histologic specimen was obtained from one patient 3 years postoperatively, when an osteotomy was performed. The histology showed that the graft had revascularized and had undergone metaplastic changes similar to cartilage (Fig 7). There have been no significant adverse effects noted radiologically in the bony architecture of the joint in postoperative TMJ transcranial or panoramic radiographs, as noted in early studies with discectomy alone, and no evidence of foreign-body reactions. The graft is not attached to the temporalis muscle, which may create a painful joint as reported with pedicled temporalis pericranial grafts where the temporalis muscle is potentially compressed by the condyle.33 The advantages of pericranium over the use of dermis include the large amount of pericranium
FIGURE 7. Photomicrograph of a free pericranial graft after 3 years in function exhibiting highly vascular, loose connective tissue and deeper dense fibrous connective tissue (hematoxylineosin stain, original magnification X200).
MARKOWITZ ET AL
available and the close approximation of the donor site to the TMJ. The donor site scar is hidden in the hairline, with no secondary deformity, as opposed to exposed dermal graft sites in the leg or buttock that can be unsightly. Morbidity in the donor site has been minimal. There are no ambulation problems and, therefore, a shorter hospitalization. The procurement technique is simple, and it takes an experienced clinician approximately 10 to 15 minutes to expose the area, obtain the graft, and close the donor site. Disadvantages include the complaints of patients at 1 month, after resolution of the numbness in the incision site, that there is some hypersensitivity in the scalp when combing the hair. This has resolved in all cases after several months. Another disadvantage is that the procedure requires two stages. This preliminary study indicates the use of free pericranial grafts may be a viable alternative to other autogenous graft materials used for TMJ reconstruction. References 1. Annandale T: On the displacement of the inter-articular cant of the jaw and its treatment by operation. Lancet 1:411, 1887 2. Lanz A: Discitis Mandibulonis. Zentralbl Chir 9289, 1909 3. Pringle JH: Displacement of the mandibular meniscus and its treatment. Br J Surg 9:385, 1918 4. Ashhurst APC: Recurrent unilateral subluxation of the mandible. Ann Surg 73:712, 1921 5. Wakely C: The mandibular joint. Ann Roy Co11 Surg Eng 2:111, 1948 6. Dingman RO, Moorman WC: Meniscectomy in the treatment of lesion of the TMJ. J Oral Surg 9:214, 1951 7. Kiehn CL: Meniscectomy for internal derangement of the temporomandibular joint. Am J Surg 83:369, 1952 8. Silver CM, Simon SD: Meniscus injuries of the TMJ. J Bone Joint Surg 38A:541, 1959 9. Reichenbach E, Grimm G: Indikation and prognose der diskasexeiston. Fortschritte der Kiefer- und Gesichts Chirurgie, vol 6. Stuttgart, Thieme, 1960 10. Mayer D: Zur Frage der Dsikusenferuug bei der deformicrenden Arthopathic der Krefergelenkes. Dtsch Zahnaerztliche Zeitschr 19:28, 1964 11. Agerberg G, Landberg M: Change in the TMJ after surgical treatment. Oral Surg 32:865, 1971 12. Brown K: TMJ arthrosis and its treatment by extirpation of the disc. Acta Chir Stand 85: 118, 1947 13. Baer WS: Arthroplasty with the aid of animal membrane. Am J Orthop Surg 94:171, 1918
481
14. Hansen WC, Deshazo BW: Silastic Reconstruction of TMJ Meniscus. Plast Reconstr Surg 43:388, 1%9 15. Davis PKB, Jones SM: The complications of Silastic implants: Experience with 137 consecutive cases. Br J Plast Surg 24405, 1971 16. Nalbandran RM: Synourtis and iymphadenopathy in silicone arthroplasty implants. J Bone Joint Surg65:280, 1983 17. Dolwick MF. Aufdemorte TB: Silicone-induced foreign body reaction and lymphadenopathy after TMJ arthroplasty. Oral Surg 59449, 1985 18. Kiersch TA: The use of Proplast Teflon implants for meniscectomy and disc repair in TMJ. Presented at the 1984 Clinical Congress on TMJ Surgery, San Diego, CA, January 1984 19. Gallagher DM, Wolford LM: Comparison of Silastic and Proplast implants in TMJ after condylectomy for osteoarthritis. J Oral Maxillofac Sure 40:627. 1982 20. Timmis DP, Argon SB, Von Siches JE: Comparative study of alloplastic materials for TMJ disc replacement in rabbits. J Oral Maxillofac Surg 441:541, 1986 21. Risdon F: Ankylosis of temporomandibular joint. J Am Dent Assoc 21:1933, 1934 22. Loewe 0: Ueber Hautimplantation an stelle der freign foszienpolastik. Muncher Medizinsche Wochenschrift 60: 1320, 1913 23. Georgrade NC: The surgical correction of TMJ dysfunction by means of autogenous dermal grafts. Plast Reconstr Surg 30:68, 1962 24. Zetz MR, Irby WB: Repair of the adult TMJ meniscus with an autogenous dermal graft. J Oral Maxiilofac Surg 42: 167, 1948 25. Stewart HM, Hann FR: Histologic fate of dermal grafts following implantation for TMJ men&al perforation: Preliminary study. Oral Surg 62:481, 1989 26. Tucker MR, Jacoway FR, White RP: Autogenous dermal grafts for repair of TMJ disc perforation. J Oral Maxillofac Surg 44:781, 1986 27. Bonnington G, Langan M, Joy ED: Epithelial inclusion cyst in TMJ after dermal graft. J Oral Maxillofac Surg 45:705, 1987 28. Perko M: Indikationen and kontraindikationen fur chirangische eingriffe am krefergeleuk. Sohmeiz. Mschr Zahnheilk 83:73, 1973 29. Longacre JJ, Gilby RF: Use of autogenous cartilage in arthroplasty for true ankylosis of the TMJ. J Plast Reconstr Surg 7:4, 1951 30. Rudeh HG: Symptomatik und behaudlungsergebnisse bei diuskushtxationen des kiefergelenkes. Schueiz. Mschr Zahnheilk 91:566, 1981 31. Witsenburg BH, Freihofer: Replacement of the pathological TMJ articular disc using autogenous cartilage of the external ear. Int J Oral Surg 13401, 1984 32. Tucker MR, Kennedy MC, Jacaway JR: Autogenous auticular cartilage implantation following discectomy in the primate TMJ. J Oral Maxillofac Sure 48:38. 1990 33. Feinberg SE, Larsen PE: The use of lpedicied temporalis muscle-pericranial flap for replacement of TMJ disc. J Oral Maxillofac Surg 47:142, 1989 34. Markowitz NR, Allan P, Duffy MT: Reconstruction of the mandibular condyle using ramus osteotomies: A preliminary report. J Oral Maxillofac Surg 47:367, 1989
Surg
1991
A Two-Stage Procedure for Temporomandibular Joint Disc Replacement Using Free Pericranial Grafts: A Preliminary Report N.R. MARKOWITZ, DMD,* T. PATTERSON III, DMD,t AND L. CAPUTA, DMD$ A preliminary study of the use of free pericranial grafts as an alternative to other autogenous or alloplastic materials for temporomandibular joint disc replacement is presented. Postoperative results show improved function and alleviation of other symptoms.
Advances in oral and maxillofacial surgery have led to the advent of a multitude of procedures to treat internal derangements of the temporomandibular joint (TMJ). Until 1960, discectomy was the primary mode of surgical treatment. I-8 In the early 196Os, however, numerous authors reported complications following discectomy.9-‘2 These findings led several authors to infer that discectomy alone leads to arthrosis, and that to avoid soft-tissue adhesions and osseous degeneration, reconstruction of the TMJ following discectomy appears indicated. Throughout the subsequent years various alloplastic and allogenic materials have been implanted in the TMJ. However, these materials also have met with complications. These complications and adverse tissue reactions have led many investigators to attempt to find an ideal autogenous graft material for disc replacement or repair. Many autogenous tissues, including dermis, muscle, fat, fascia lata, and cartilage, have been used as an interpositional
graft in TMJ reconstruction, with varying degrees of success. Risdon used autogenous pedicled medial pterygoid muscle in patients with ankylosis.21 Feinberg and Larsen have reported preliminary results in 13 patients using a pedicled temporalis musclepericranium graft.33 Dermis has been advocated by many authors since Loewe first introduced dermal grafting in 1913. Georgrade reported using dermis in patients with ankylosis and following discectomy, although no results were presented.23 Dermis has been used by Zetz and Irby to repair disc perforations.24 Tucke? and Stewart26 grafted dermis to the discs of monkeys,25-26 and showed incorporation of the dermis within this tissue. In 1987, Bonnington, Langan, and Jay reported epithelial inclusion cyst formation in dermal grafts placed in the TMJ.27 This finding has also been reported in hernia repair using dermis. Narang and Dixon reported the use of fascia lata grafts in two cases. Both patients had a decrease in symptoms and improved function. Autogenous cartilage grafts have been used for over 100 years in various reconstructive procedures since the initial work by Von Mangoldt in 1889 and Kong in 1896. Autogenous auricular cartilage has been used in TMJ discectomy. Perko was the first to use auricular cartilage following discectomy.28 Longacre and Gilby used autogenous cartilage as a interpositional graft in TMJ ankylosis.29 Rudelt reported on five patients using auricular cartilage postdiscectomy with favorable results.30 Witsenberg and Freihefor3’ used auricular cartilage in seven patients following discectomy, and reported
Received from the Department of Oral and Maxillofacial Surgery, University of Oklahoma, Oklahoma City. * Professor of Surgery, College of Medicine and Dentistry. t Chief Resident, College of Medicine. $ Formerly Chief Resident; currently, Assistant Professor, Oral and Maxillofacial Surgery, Medical College of Georgia, Augusta. Address correspondence and reprint requests to Dr Markowitz: Oral and Maxillofacial Surgery, College of Medicine, The University of Oklahoma Health Sciences Center, PO Box 26901, Oklahoma City, OK 73190-3048. 0 1991 American geons
Association
of Oral and Maxillofacial
Sur-
0278-2391/91/4905-0006$3.0010
476
477
MARKOWITZ ET AL
increased function and decreased symptoms. In 1990, Tucker reported the use of auricular cartilage grafts in primates. 32 Histologically, all the grafts showed viability as long as 24 weeks postsurgery. Also, decreased osseous degeneration was evident in all grafted joints compared with nongrafted joints. Another autogenous tissue that could be considered for disc replacement is pericranium. Pericranium has been used as a free graft for various reconstruction procedures, including frontal sinus obliteration. Since March 1987 at the University of Oklahoma, patients postdiscectomy have been treated with a two-stage reconstruction technique using free pericranial grafts. When indicated, patients have undergone TMJ arthroplasty with discectomy and temporary placement of a Silastic (Dow Coming, Midland, MI) implant. The second stage of reconstruction consists of removal of the Silastic implant and placement of a free pericranium graft. The purpose of this study was to describe the two-stage TMJ reconstruction technique using a free pericranium graft and to evaluate the preliminary clinical results of this reconstructive procedure . In the first stage, using a preauricular approach, an eminoplasty is performed and the disc is removed. The eminence is remodeled medially to create more room for the translating condyle. A .03-inthickness oval, 3-cm diameter sheet of reinforced Silastic is stabilized to the lateral aspect of the fossa with three transosseous 26-gauge wires. At 6 months, the Silastic is removed and it is replaced with a pericranial graft with the periosteal side facing the glenoid fossa to obliterate the dead space created by removal of the Silastic. The pocket is sutured laterally securing the pericranial graft to the soft-tissue capsule created around the Silastic, thus stabilizing the graft. Procurement Technique To obtain the pericranial graft, the patient is placed in the supine position with the head turned to the side to expose the TMJ, the auricle, and the scalp. The TMJ is prepared in the normal manner. The scalp just posterior to the ear, short of the midline of the head and posterior to the origin of the temporalis muscle, is then thoroughly scrubbed with Povidone soap (Parke-Davis, Stanley, UT). The hair is not shaved. With a sterile comb, a horizontal part in the hair approximately 5 to 7 cm in length is made posterior to the auricle (Fig 1). Povidone is then poured onto the area. Approximately 6 mL of lidocaine 2%, with 100,000 epinephrine,
i
FIGURE I. Postauricular scalp incision posterior and inferior the origin of the temporalis muscle.
is injected into the scalp for hemostasis and to balloon the galea aponeurosis off of the pericranium and the subcutaneous tissue. The part in the hair is then recombed with sterile K-Y jelly (E. Fougera & Co, Division of ByK-Gulden, Inc, Hicksville, NY), which will harden in several minutes, maintaining the part after the draping. Sterile drapes are then placed and stapled around the TMJ surgical site and the pericranium donor site. Similar draping can be done for bilateral TMJ cases. Finally, a drape is placed across the ear protecting the preauricular site and isolating the pericranial donor site. After waiting 5 minutes for hemostasis following injection of the lidocaine, an incision approximately 5 cm in length, beginning 4 cm posterior to the base of the auricle, is made with a no. 15 blade just through the galea aponeurosa to the pericranium (Fig 2). For bilateral cases, only one donor site is necessary, but the incision is longer (7 cm) to permit procurement of more pericranium. By incising in the part, minimal hair loss will occur. In over 300 scalp incisions for pericranial and cranial bone procurement, we have never noticed a bald spot occur-
478
TMJ RECONSTRUCTION
FIGURE 2.
USING FREE PERICRANIUM
Diagram of the scalp layers.
ring because of loss of hair. If the patient is balding, the incision may need to be modified to hide the scar, but generally, in the region behind the ear, even balding patients have some hair. Also, there have been no infections as a result of not shaving the hair. After the initial incision is completed, the subgaleal flap is undermined with a Metzenbaum scissors while maintaining pressure superiorly with the index finger and three 1.5cm Raney clips are placed on the flap. The same procedure is then performed on the inferior flap. Placing the Raney clips on one flap at a time prevents excessive blood loss. Using two Senn retractors, the pericranium and the subcutaneous tissue covering it are exposed (Fig 3). Care is taken to avoid the temporalis muscle, which should be superior to the exposure site. An elliptical incision at the edge of the retracted subgaleal flap is made to skull bone with a new no. 15 blade. For unilateral cases the diameter of the incision is 4 cm and for a bilateral case it is 8 cm. The periosteal graft is then elevated with tissue forceps and a periosteal elevator, and removed from the skull (Fig 4). It is stored in moist gauze for later use (Fig 5). The exposed skull is irrigated and checked for any hair that may have fallen into the wound. The galeal layer is then closed over the exposed skull with individual 3-OVicryl (Ethicon, Somerville, NJ) horizontal mattress sutures and the scalp is closed with skin staples. No drains are necessary. After the TMJ surgery is completed, the donor site is checked for hematoma formation. If a hematoma is discovered, it is aspirated with an 18gauge needle on a IO-mL syringe. The hair is rinsed with sterile water at the end of the TMJ surgery to wash out the Povidone soap. The donor site is then dressed with Bacitracin ointment (E. Fougera & Co) and a neurosurgical head dressing or Jobst dressing is placed for 1 or 2 days to prevent delayed hematoma formation. In 83 cases, five hematomas, which were easily aspirated, occurred 2 days postoperatively.
FIGURE 3.
Reflected subgaleal flap exposing the pericranium.
The patients are instructed not to shampoo their hair for 1 week. The staples are removed with a staple remover 2 weeks postoperatively (Fig 6). The staple remover allows the staples to be removed relatively painlessly, whereas using a hemostat to remove staples usually is painful. Removing the staples at 1 week has lead to separation of the scalp incision in some patients, with ensuing bleeding, inversion of hair, and prolonged healing time. Results
Since March 1987, 83 free pericranial grafts have been used for TMJ reconstruction in four groups of patients: 1) patients with failed alloplastic implants such as the Vitek (Houston, TX) TMJ prosthesis, and Silastic and Proplast-Teflon inter-positional implants (22 joints), 2) patients with severe arthritic changes of the condyle with associated disc perforation and destruction (15 joints), 3) patients undergoing reconstruction of the TMJ with sliding ramus osteotomies (15 cases), 4) patients with limited opening and severe pain or headache, and nonre-
MARKOWITZ ET AL
FIGURE 5. View of graft showing the dense periosteal connective tissue side of the pericranium. The graft is approximately l-mm thick.
FIGURE 4. Subpericranial the pericranium.
incision with partial reflection of
ducing anteriorly displaced or perforated discs demonstrated by arthrogram or TMJ MRI (31 joints). All patients had significant TMJ signs and symptoms preoperatively, including limited opening; popping, clicking, or crepitus; chronic lateral headaches; and point tenderness or pain over the TMJ. All patients were told that the use of pericranium was investigational and they all consented to its use. The mean follow-up was 20 months, with a range of 6 to 36 months. The mean age of the patients was 46 years, with a range of 18 to 71 years. There were 45 women and 10 men. Twenty-seven cases were unilateral (15 right side; 12 left side) and 28 cases were bilateral. The mean intercisal opening preoperatively was 26 mm, with a range of 4 mm to 5 1 mm. Postoperatively, the mean opening was 41 mm, with a range of 21 mm to 55 mm. Vigorous physiotherapy monitored by the clinicians was incorporated 3 weeks postoperatively after Silastic (first stage) and pericranium (second stage) insertion. This included jaw exercises, chewing one pack of sugar-free gum per
day, and, in nine cases, manipulation with tongue blades. The patients who failed to achieve interincisal openings greater than 35 mm were either noncompliant with their physiotherapy or were patients who had previous multiple TMJ operations. Thirty cases reported squeaking noises after Silastic placement, which resolved as the capsule formed around the Silastic. Twenty-seven patients reported recurrence of joint noise and headaches at 4 to 6 months after Silastic placement, which resolved after Silastic removal and replacement with free pericranium. A majority of the Silastic implants showed holes or tears along the reinforcing Dacron (Dow-Corning, Midland, MI) fibers. Forty-eight patients reported resolution of their popping, clicking, or crepitus after placement of the pericranium. Of the seven TMJs that had recurrence of joint noise, none of the patients reported severe pain, but they were concerned about the noise. Five of these patients were undergoing active orthodontic care, which may have had some influence of the recurrence of joint noise. In all cases, the postoperative occlusion remained stable. All patients reported initial resolution or improvement of their headaches and joint pain. Four patients complained of worsening pain after 1 year, and recurrence of joint noise. Two patients were reoperated, and two were lost to follow-up. In both cases the pericranial graft appeared intact. Another layer of pericranium was placed in the glenoid fossa, and
480
TMJ RECONSTRUCTION
USING FREE PERICRANIUM
FIGURE 6. The scalp incision 2 weeks postoperatively after removal of the skin staples.
both patients reported resolution of their joint pain and noise. Discussion Histologically, pericranium is a tissue with properties that makes it potentially useful for TMJ reconstruction. It is durable, tough, and resilient. The superficial layer is highly vascular loose areolar connective tissue and the deeper layer is dense tibrous connective tissue (periosteum) that is adherent to the skull (Fig 7). The free graft appears to be incorporated into the TMJ by early revascularization and it provides a nidus for fibrous ingrowth that insulates the joint. A histologic specimen was obtained from one patient 3 years postoperatively, when an osteotomy was performed. The histology showed that the graft had revascularized and had undergone metaplastic changes similar to cartilage (Fig 7). There have been no significant adverse effects noted radiologically in the bony architecture of the joint in postoperative TMJ transcranial or panoramic radiographs, as noted in early studies with discectomy alone, and no evidence of foreign-body reactions. The graft is not attached to the temporalis muscle, which may create a painful joint as reported with pedicled temporalis pericranial grafts where the temporalis muscle is potentially compressed by the condyle.33 The advantages of pericranium over the use of dermis include the large amount of pericranium
FIGURE 7. Photomicrograph of a free pericranial graft after 3 years in function exhibiting highly vascular, loose connective tissue and deeper dense fibrous connective tissue (hematoxylineosin stain, original magnification X200).
MARKOWITZ ET AL
available and the close approximation of the donor site to the TMJ. The donor site scar is hidden in the hairline, with no secondary deformity, as opposed to exposed dermal graft sites in the leg or buttock that can be unsightly. Morbidity in the donor site has been minimal. There are no ambulation problems and, therefore, a shorter hospitalization. The procurement technique is simple, and it takes an experienced clinician approximately 10 to 15 minutes to expose the area, obtain the graft, and close the donor site. Disadvantages include the complaints of patients at 1 month, after resolution of the numbness in the incision site, that there is some hypersensitivity in the scalp when combing the hair. This has resolved in all cases after several months. Another disadvantage is that the procedure requires two stages. This preliminary study indicates the use of free pericranial grafts may be a viable alternative to other autogenous graft materials used for TMJ reconstruction. References 1. Annandale T: On the displacement of the inter-articular cant of the jaw and its treatment by operation. Lancet 1:411, 1887 2. Lanz A: Discitis Mandibulonis. Zentralbl Chir 9289, 1909 3. Pringle JH: Displacement of the mandibular meniscus and its treatment. Br J Surg 9:385, 1918 4. Ashhurst APC: Recurrent unilateral subluxation of the mandible. Ann Surg 73:712, 1921 5. Wakely C: The mandibular joint. Ann Roy Co11 Surg Eng 2:111, 1948 6. Dingman RO, Moorman WC: Meniscectomy in the treatment of lesion of the TMJ. J Oral Surg 9:214, 1951 7. Kiehn CL: Meniscectomy for internal derangement of the temporomandibular joint. Am J Surg 83:369, 1952 8. Silver CM, Simon SD: Meniscus injuries of the TMJ. J Bone Joint Surg 38A:541, 1959 9. Reichenbach E, Grimm G: Indikation and prognose der diskasexeiston. Fortschritte der Kiefer- und Gesichts Chirurgie, vol 6. Stuttgart, Thieme, 1960 10. Mayer D: Zur Frage der Dsikusenferuug bei der deformicrenden Arthopathic der Krefergelenkes. Dtsch Zahnaerztliche Zeitschr 19:28, 1964 11. Agerberg G, Landberg M: Change in the TMJ after surgical treatment. Oral Surg 32:865, 1971 12. Brown K: TMJ arthrosis and its treatment by extirpation of the disc. Acta Chir Stand 85: 118, 1947 13. Baer WS: Arthroplasty with the aid of animal membrane. Am J Orthop Surg 94:171, 1918
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14. Hansen WC, Deshazo BW: Silastic Reconstruction of TMJ Meniscus. Plast Reconstr Surg 43:388, 1%9 15. Davis PKB, Jones SM: The complications of Silastic implants: Experience with 137 consecutive cases. Br J Plast Surg 24405, 1971 16. Nalbandran RM: Synourtis and iymphadenopathy in silicone arthroplasty implants. J Bone Joint Surg65:280, 1983 17. Dolwick MF. Aufdemorte TB: Silicone-induced foreign body reaction and lymphadenopathy after TMJ arthroplasty. Oral Surg 59449, 1985 18. Kiersch TA: The use of Proplast Teflon implants for meniscectomy and disc repair in TMJ. Presented at the 1984 Clinical Congress on TMJ Surgery, San Diego, CA, January 1984 19. Gallagher DM, Wolford LM: Comparison of Silastic and Proplast implants in TMJ after condylectomy for osteoarthritis. J Oral Maxillofac Sure 40:627. 1982 20. Timmis DP, Argon SB, Von Siches JE: Comparative study of alloplastic materials for TMJ disc replacement in rabbits. J Oral Maxillofac Surg 441:541, 1986 21. Risdon F: Ankylosis of temporomandibular joint. J Am Dent Assoc 21:1933, 1934 22. Loewe 0: Ueber Hautimplantation an stelle der freign foszienpolastik. Muncher Medizinsche Wochenschrift 60: 1320, 1913 23. Georgrade NC: The surgical correction of TMJ dysfunction by means of autogenous dermal grafts. Plast Reconstr Surg 30:68, 1962 24. Zetz MR, Irby WB: Repair of the adult TMJ meniscus with an autogenous dermal graft. J Oral Maxiilofac Surg 42: 167, 1948 25. Stewart HM, Hann FR: Histologic fate of dermal grafts following implantation for TMJ men&al perforation: Preliminary study. Oral Surg 62:481, 1989 26. Tucker MR, Jacoway FR, White RP: Autogenous dermal grafts for repair of TMJ disc perforation. J Oral Maxillofac Surg 44:781, 1986 27. Bonnington G, Langan M, Joy ED: Epithelial inclusion cyst in TMJ after dermal graft. J Oral Maxillofac Surg 45:705, 1987 28. Perko M: Indikationen and kontraindikationen fur chirangische eingriffe am krefergeleuk. Sohmeiz. Mschr Zahnheilk 83:73, 1973 29. Longacre JJ, Gilby RF: Use of autogenous cartilage in arthroplasty for true ankylosis of the TMJ. J Plast Reconstr Surg 7:4, 1951 30. Rudeh HG: Symptomatik und behaudlungsergebnisse bei diuskushtxationen des kiefergelenkes. Schueiz. Mschr Zahnheilk 91:566, 1981 31. Witsenburg BH, Freihofer: Replacement of the pathological TMJ articular disc using autogenous cartilage of the external ear. Int J Oral Surg 13401, 1984 32. Tucker MR, Kennedy MC, Jacaway JR: Autogenous auticular cartilage implantation following discectomy in the primate TMJ. J Oral Maxillofac Sure 48:38. 1990 33. Feinberg SE, Larsen PE: The use of lpedicied temporalis muscle-pericranial flap for replacement of TMJ disc. J Oral Maxillofac Surg 47:142, 1989 34. Markowitz NR, Allan P, Duffy MT: Reconstruction of the mandibular condyle using ramus osteotomies: A preliminary report. J Oral Maxillofac Surg 47:367, 1989
