Temporomandibularjoint eminence augmentationby downfracture and inter-positional
N. M. Whear ~, J. D. Langdon ~, D. W, Macpherson 2 1Department of Oral and Maxillofacial Surgery, King's College Hospital Dental School, London, and 2Department of Oral and Maxillofacial Surgery, St Georges Hospital, London, UK
cartilage graft A new surgical technique N. M. Whear, J. D. Langdon, D. W. Macphel~'on." Temporomandibular joint eminence augmentation by down-fracture and inter-positional cartilage graft. A new surgical technique. J. Oral Maxillofac. Surg. 1991," 20." 357-359. Abstract. A new surgical technique for the treatment of recurrent temporomandibular joint subluxation or dislocation is described. Following a horizontal osteotomy and down-fracture of the articular eminence an inter-positional bovine cartilage xenograft is inserted in order to augment the vertical height of the eminence. The procedure combines simplicity with minimal post-operative morbidity. The increase in eminence height is both predictable and stable.
Subluxation and dislocation are characterized by hypermobility of the condyle. These conditions can arise from acute or chronic trauma or can arise spontaneously due to ligamentous laxity.Hypermobility is common, and in many individuals the condyle moves anterior to the articular eminence during maximal opening ~°. This may occasionally be complicated by subluxation and more rarely by dislocation (Fig. 1). The terms "subluxation" and "dislocation" are sometimes confused. When applied to the mandibular condyle subluxation implies a partial dislocation of the joint with temporary locking of the jaw. It is self-reducing. With dislocation, the condyle is held anterior to the articular eminence by muscle spasm. It is not selfreducing 1°. Subluxation is often painful and may progress to dislocation. Both conditions are exacerbated by repeated occurrence and therefore episodes become more frequent and occur more readily with the passage of time. Conservative or nonsurgical treatment methods have not proved effective for the chronic or recurrent situation 12. When subluxation becomes painful or accompanied by disc dysfunction and when dislocation becomes recurrent, surgery is indicated 2. A myriad of surgical procedures have been described for
the treatment ofhypermobility and these may be classified as: (i) restitution of the capsule and ligamentS'14'lS; (ii) limitation of forward movement by ligation of the condyleS; (iii) limitation of forward movement by augmentation of the eminence4717; (ivl elimination of the disloca-
Key words: temporomandibular joint; subluxation; eminence augmentation; bovine cartilage. Accepted for publication 27 June 1991
tion by removal of the eminenceS3; (v) prevention of the dislocation by removal of the activating muscle 1'6. The operation described here limits anterior movement of the mandibular condyle by increasing the height of the eminence.
Fig. 1. Detail of panoramic radiograph showing subluxation of the mandibular condyle on maximal mouth opening.
358
W h e a r et al. is then closed with 3/0 Vicryl. The authors have not found it necessary to stabilise the graft with wire or screw osteosynthesis (Fig. 4). The wound is closed in layers. Suction drainage is not required. The procedure is repeated on the contralateral side. A pressure dressing is placed for 24 h and a soft diet advised for 1 week after which a course of active mouth-opening exercises is prescribed. Of the 7 cases treated so far all patients have been cured of their subluxation/dislocation and an interincisal gap of between 35 mm and 40 mm has been rapidly achieved.
Discussion Osteotomy of the articular tubercle bending it down in front of the condyle as an impediment to forward m o v e m e n t has been described previously 9,11. These methods differ however, from the procedure described here. In the previous techniques the osteotomy involved only Fig. 3. The cartilage graft (a) in position augthe articular tubercle and therefore it is Fig. 2. The gap (a) created following horizonmenting the height of the articular eminence. tal osteotomy of the articular eminence and likely that success was in a large part Once in position it is trimmed laterally to lie due to post-operative fibrosis around down-fracture with an osteotome. The downflush with the zygomatic arch. fractured articular eminence is shown (b). the lateral ligament and joint capsule rather than actual augmentation of the otomy with the vertical limb placed anterieminence. When autogenous bone, Technique orly. It is important that the oste;otomy is not often obtained from the hip, is used to A standard preauricular approach to the temangulated in the coronal plane for this will augment the eminence, subsequent reporomandibular joint is used. Complete exresult in detachment of the articular tubercle : sorbtion and remodelling of the graft with no effect on the eminence. Once the posure of the joint is not required but only may be considerable, leading to loss of that needed to permit identification of the osteotomy is completed the eminence is much of the initial height gained. Also articular tubercle and exposure of the emidown-fractured (Fig. 2). Into the gap created an additional operative procedure is renence which lies medial to it. A horizontal is wedged a 5 mm thick piece of Chondroosteotomy of the eminence is commenced plast ® (Bioplasty Inc, MA, USA) the lateral quired with associated postoperative with a drill and completed with a fine osteoaspect of which is trimmed with a scalpel to morbidity. DAUTREY3 devised an elegant tome. With shallow eminentia it may be lie flush with the zygomatic root following osteoplastic procedure involving zygonecessary to perform an inverted "U' osteplacement (Fig. 3). The overlying periosteum matic arch down-fracture that results in an increase in the height of the eminence. Although this technique avoids the need for a separate procedure to harvest bone, it may be complicated by uncontrolled fracture of the arch with a resulting mobile fragment. Also, as REVINGTON14 has described, because the arch is lateral to the main mass of the condyle, it is advisable to check by a submentovertical radiograph pre-operatively that the condylar head will be adequately controlled by this procedure. It has sometimes been necessary to revise the Dautrey procedure by formal augmentation of the articular eminence. The use of metallic prostheses or silastic implants to limit condylar movement is often complicated by their loosening or displacement with function. Eminence down-fracture and interpositional cartilage grafting as described has distinct advantages over Fig. 4. Detail from panoramic radiograph following eminence down-fracture and interpoother methods of eminence augmentsitional cartilage graft. Note the site of the osteotomy and lack of subluxation when compared ation. It avoids the need for autologous with Fig. 1.
Eminence augmentation with bovine cartilage bone, the p r o c e d u r e is simple, requiring only limited exposure o f the j o i n t a n d it does n o t disturb i n t r a c a p s u l a r a n a t o m y . Cartilage is k n o w n to be dimensionally stable w h e n used as a graft material a n d thus the p l a n n e d increase in eminence height is likely to be m a i n t a i n e d . G r a d ual calcification o f the graft f u r t h e r enhances the long term stability. Use o f C h o n d r o p l a s t ®, which is processed bovine cartilage, also avoids the risks o f H I V t r a n s m i s s i o n t h a t m a y occur w h e n allogenic graft material is used. T h e procedure c o m b i n e s simplicity, safety a n d stability.
Acknowledgements.We would like to thank Mr R. Pydih and the Department of Medical Photography at St Georges Hospital for preparation of the clinical photographs.
References
1. BOWMAN K. New operation for luxation in the temporomandibular joint. Acta Chir Scand 1949: 99: 96-100. 2. CHAUSSEJM, RICHTERM, BETTEXA. Deliberate, fixed extra-articular obstruction. Treatment of choice for subluxation and true recurrent dislocation of the temporo-
mandibular joint. J Craniomaxillofac Surg 1987: 15: 137-140. 3. DAUTREYJ. Reflexions sur la chirurgie de l'articulation temporomandibulaire. Acta Stomatol Belgica 1975: 72:577 81. 4. FINDLAY IA. Operation for the arrest of excessive condylar movement. J Oral Surg 1964: 22: 110-17. 5. GEORGIADE N. Surgical correction of chronic luxation of the mandibular condyle. Plast Reconstr Surg 1965: 36: 339-42. 6. GOULD JF. Shortening of the temporalis tendon for hypermobility of the temporomandibular joint. J Oral Surg 1978: 36: 781-3. 7. HOWE AG, KENT JN, FARRELLCD, POIDMORE SJ. Implant of articular eminence for recurrent dislocation of the temporomandibular joint. J Oral Surg 1978: 36: 523-6. 8. HUDSON HNG. Operation for the recurrent subluxation of the temporomandibular joint. Br Med J 1945: 2: 354. 9. LINDEMANNA. Die chirurgische Behandlung der Erkrankungen des Kiefergelenks. Z Stomatol 1925: 23:395 406. 10. MACFARLANEWI. Recurrent dislocation of the mandible. Treatment of seven cases by a simple surgical method. Br J Oral Surg 1977: 14: 227-9. 11. MAYER L. Recurrent dislocation of the jaw. J Bone Joint Surg 1933: 15: 889-96.
359
12. MILLER GA, MURPHY EJ. External pterygoid myotomy for recurrent mandibular dislocation. Review of the literature and report of a case. Oral Surg 1976: 42: 705 16. 13. MYRHAUGH. A new method of operation for habitual dislocation of the mandible. Acta Odontol Scand 1951: 9:247 61. 14. REVlNGTONPJD. The Dautrey procedurea case for reassessment. Br J Oral Maxillofac Surg 1986: 24: 217-20. 15. SANDERS B, NEWMAN R. Surgical treatment for recurrent dislocation or chronic subluxation of the temporomandibular joint. Int J Oral Surg 1975: 4: 17983. 16. SHULTZ LW. Twenty years' experience in treating hypermobility of the temporomandibular joint. Am J Surg 1956: 92: 225 8. 17. THOMA KH. Oral surgery. St. Louis: Mosby, 1969: 510. Address: N. M. Whear M.B., F.R.C.S. (Ed). ED.S.R.C.S. Senior Registrar Oral and Maxillofacial Surgery Maxillofacial Unit St Richard's Hospital Spitalfield Lane Chichester West Sussex PO19 4SE England
N. M. Whear ~, J. D. Langdon ~, D. W, Macpherson 2 1Department of Oral and Maxillofacial Surgery, King's College Hospital Dental School, London, and 2Department of Oral and Maxillofacial Surgery, St Georges Hospital, London, UK
cartilage graft A new surgical technique N. M. Whear, J. D. Langdon, D. W. Macphel~'on." Temporomandibular joint eminence augmentation by down-fracture and inter-positional cartilage graft. A new surgical technique. J. Oral Maxillofac. Surg. 1991," 20." 357-359. Abstract. A new surgical technique for the treatment of recurrent temporomandibular joint subluxation or dislocation is described. Following a horizontal osteotomy and down-fracture of the articular eminence an inter-positional bovine cartilage xenograft is inserted in order to augment the vertical height of the eminence. The procedure combines simplicity with minimal post-operative morbidity. The increase in eminence height is both predictable and stable.
Subluxation and dislocation are characterized by hypermobility of the condyle. These conditions can arise from acute or chronic trauma or can arise spontaneously due to ligamentous laxity.Hypermobility is common, and in many individuals the condyle moves anterior to the articular eminence during maximal opening ~°. This may occasionally be complicated by subluxation and more rarely by dislocation (Fig. 1). The terms "subluxation" and "dislocation" are sometimes confused. When applied to the mandibular condyle subluxation implies a partial dislocation of the joint with temporary locking of the jaw. It is self-reducing. With dislocation, the condyle is held anterior to the articular eminence by muscle spasm. It is not selfreducing 1°. Subluxation is often painful and may progress to dislocation. Both conditions are exacerbated by repeated occurrence and therefore episodes become more frequent and occur more readily with the passage of time. Conservative or nonsurgical treatment methods have not proved effective for the chronic or recurrent situation 12. When subluxation becomes painful or accompanied by disc dysfunction and when dislocation becomes recurrent, surgery is indicated 2. A myriad of surgical procedures have been described for
the treatment ofhypermobility and these may be classified as: (i) restitution of the capsule and ligamentS'14'lS; (ii) limitation of forward movement by ligation of the condyleS; (iii) limitation of forward movement by augmentation of the eminence4717; (ivl elimination of the disloca-
Key words: temporomandibular joint; subluxation; eminence augmentation; bovine cartilage. Accepted for publication 27 June 1991
tion by removal of the eminenceS3; (v) prevention of the dislocation by removal of the activating muscle 1'6. The operation described here limits anterior movement of the mandibular condyle by increasing the height of the eminence.
Fig. 1. Detail of panoramic radiograph showing subluxation of the mandibular condyle on maximal mouth opening.
358
W h e a r et al. is then closed with 3/0 Vicryl. The authors have not found it necessary to stabilise the graft with wire or screw osteosynthesis (Fig. 4). The wound is closed in layers. Suction drainage is not required. The procedure is repeated on the contralateral side. A pressure dressing is placed for 24 h and a soft diet advised for 1 week after which a course of active mouth-opening exercises is prescribed. Of the 7 cases treated so far all patients have been cured of their subluxation/dislocation and an interincisal gap of between 35 mm and 40 mm has been rapidly achieved.
Discussion Osteotomy of the articular tubercle bending it down in front of the condyle as an impediment to forward m o v e m e n t has been described previously 9,11. These methods differ however, from the procedure described here. In the previous techniques the osteotomy involved only Fig. 3. The cartilage graft (a) in position augthe articular tubercle and therefore it is Fig. 2. The gap (a) created following horizonmenting the height of the articular eminence. tal osteotomy of the articular eminence and likely that success was in a large part Once in position it is trimmed laterally to lie due to post-operative fibrosis around down-fracture with an osteotome. The downflush with the zygomatic arch. fractured articular eminence is shown (b). the lateral ligament and joint capsule rather than actual augmentation of the otomy with the vertical limb placed anterieminence. When autogenous bone, Technique orly. It is important that the oste;otomy is not often obtained from the hip, is used to A standard preauricular approach to the temangulated in the coronal plane for this will augment the eminence, subsequent reporomandibular joint is used. Complete exresult in detachment of the articular tubercle : sorbtion and remodelling of the graft with no effect on the eminence. Once the posure of the joint is not required but only may be considerable, leading to loss of that needed to permit identification of the osteotomy is completed the eminence is much of the initial height gained. Also articular tubercle and exposure of the emidown-fractured (Fig. 2). Into the gap created an additional operative procedure is renence which lies medial to it. A horizontal is wedged a 5 mm thick piece of Chondroosteotomy of the eminence is commenced plast ® (Bioplasty Inc, MA, USA) the lateral quired with associated postoperative with a drill and completed with a fine osteoaspect of which is trimmed with a scalpel to morbidity. DAUTREY3 devised an elegant tome. With shallow eminentia it may be lie flush with the zygomatic root following osteoplastic procedure involving zygonecessary to perform an inverted "U' osteplacement (Fig. 3). The overlying periosteum matic arch down-fracture that results in an increase in the height of the eminence. Although this technique avoids the need for a separate procedure to harvest bone, it may be complicated by uncontrolled fracture of the arch with a resulting mobile fragment. Also, as REVINGTON14 has described, because the arch is lateral to the main mass of the condyle, it is advisable to check by a submentovertical radiograph pre-operatively that the condylar head will be adequately controlled by this procedure. It has sometimes been necessary to revise the Dautrey procedure by formal augmentation of the articular eminence. The use of metallic prostheses or silastic implants to limit condylar movement is often complicated by their loosening or displacement with function. Eminence down-fracture and interpositional cartilage grafting as described has distinct advantages over Fig. 4. Detail from panoramic radiograph following eminence down-fracture and interpoother methods of eminence augmentsitional cartilage graft. Note the site of the osteotomy and lack of subluxation when compared ation. It avoids the need for autologous with Fig. 1.
Eminence augmentation with bovine cartilage bone, the p r o c e d u r e is simple, requiring only limited exposure o f the j o i n t a n d it does n o t disturb i n t r a c a p s u l a r a n a t o m y . Cartilage is k n o w n to be dimensionally stable w h e n used as a graft material a n d thus the p l a n n e d increase in eminence height is likely to be m a i n t a i n e d . G r a d ual calcification o f the graft f u r t h e r enhances the long term stability. Use o f C h o n d r o p l a s t ®, which is processed bovine cartilage, also avoids the risks o f H I V t r a n s m i s s i o n t h a t m a y occur w h e n allogenic graft material is used. T h e procedure c o m b i n e s simplicity, safety a n d stability.
Acknowledgements.We would like to thank Mr R. Pydih and the Department of Medical Photography at St Georges Hospital for preparation of the clinical photographs.
References
1. BOWMAN K. New operation for luxation in the temporomandibular joint. Acta Chir Scand 1949: 99: 96-100. 2. CHAUSSEJM, RICHTERM, BETTEXA. Deliberate, fixed extra-articular obstruction. Treatment of choice for subluxation and true recurrent dislocation of the temporo-
mandibular joint. J Craniomaxillofac Surg 1987: 15: 137-140. 3. DAUTREYJ. Reflexions sur la chirurgie de l'articulation temporomandibulaire. Acta Stomatol Belgica 1975: 72:577 81. 4. FINDLAY IA. Operation for the arrest of excessive condylar movement. J Oral Surg 1964: 22: 110-17. 5. GEORGIADE N. Surgical correction of chronic luxation of the mandibular condyle. Plast Reconstr Surg 1965: 36: 339-42. 6. GOULD JF. Shortening of the temporalis tendon for hypermobility of the temporomandibular joint. J Oral Surg 1978: 36: 781-3. 7. HOWE AG, KENT JN, FARRELLCD, POIDMORE SJ. Implant of articular eminence for recurrent dislocation of the temporomandibular joint. J Oral Surg 1978: 36: 523-6. 8. HUDSON HNG. Operation for the recurrent subluxation of the temporomandibular joint. Br Med J 1945: 2: 354. 9. LINDEMANNA. Die chirurgische Behandlung der Erkrankungen des Kiefergelenks. Z Stomatol 1925: 23:395 406. 10. MACFARLANEWI. Recurrent dislocation of the mandible. Treatment of seven cases by a simple surgical method. Br J Oral Surg 1977: 14: 227-9. 11. MAYER L. Recurrent dislocation of the jaw. J Bone Joint Surg 1933: 15: 889-96.
359
12. MILLER GA, MURPHY EJ. External pterygoid myotomy for recurrent mandibular dislocation. Review of the literature and report of a case. Oral Surg 1976: 42: 705 16. 13. MYRHAUGH. A new method of operation for habitual dislocation of the mandible. Acta Odontol Scand 1951: 9:247 61. 14. REVlNGTONPJD. The Dautrey procedurea case for reassessment. Br J Oral Maxillofac Surg 1986: 24: 217-20. 15. SANDERS B, NEWMAN R. Surgical treatment for recurrent dislocation or chronic subluxation of the temporomandibular joint. Int J Oral Surg 1975: 4: 17983. 16. SHULTZ LW. Twenty years' experience in treating hypermobility of the temporomandibular joint. Am J Surg 1956: 92: 225 8. 17. THOMA KH. Oral surgery. St. Louis: Mosby, 1969: 510. Address: N. M. Whear M.B., F.R.C.S. (Ed). ED.S.R.C.S. Senior Registrar Oral and Maxillofacial Surgery Maxillofacial Unit St Richard's Hospital Spitalfield Lane Chichester West Sussex PO19 4SE England
