Figure 7 - uploaded by Larry M Wolford
Content may be subject to copyright.
Case 1. (a, b, c) Presurgery, the patient had a class I occlusion on the left side and a class II occlusion on the right side. (d, e, f) The occlusion remained stable 2 years after surgery.
Source publication
This study evaluated 1) the efficacy of packing autologous fat grafts around temporomandibular joint (TMJ) total joint prosthetic reconstructions to prevent fibrosis and heterotopic bone formation and 2) the effects on postsurgical joint mobility and jaw function. One hundred fifteen patients (5 males and 110 females) underwent TMJ reconstruction w...
Context in source publication
Context 1
... had severe TMJ and myofascial pain, headaches, and difficulty eating. He presented with a class I occlusion on the left side and a class II occlusion on the right side (Fig- ure 7a-c). There was massive heterotopic bone development and bony ankylosis surrounding the right TMJ (Figure 8a ...
Similar publications
In this study, a 3D finite element model of an intact mandible was used for the simulation of the movement of the lower jaw and analysis of the effects of TemporoMandibular Joint (TMJ) prosthesis replacement on the jaw movement. Seven bundles of muscle fibers were inserted in their appropriate positions following anatomical data. Digastric, geniohy...
Citations
... This obliterates the dead space and prevents the formation of a blood clot. Studies have shown fat grafting around prostheses to be favorable to lack of fat grafting when evaluating heterotopic bone formation, subsequent ankylosis, and maximum interincisal opening [39][40][41][42][43]. ...
Alloplastic temporomandibular total joint reconstruction provides an effective surgical treatment option for patients with end-stage temporomandibular joint disease. While temporomandibular disorders are often initially managed with non-surgical modalities, severe ankylosis, aberrant anatomic deformity, or loss of primary function necessitates surgical intervention in patients with late-stage disease. Modern advancements in the field of temporomandibular joint replacement, especially over the last three to four decades, have improved upon initial challenges of poor prosthetic design and improper material selection. Modern alloplastic prosthetic devices, including both stock and custom patient-fitted prostheses, have been shown to be both safe and effective in restoring temporomandibular form and function. Alloplastic temporomandibular total joint replacement now represents a successful surgical solution with advantages including improved accessibility, reduced operative time, earlier return to mobilization, and lower morbidity risks than autogenous methods. This chapter will provide an overview of the fundamental principles of temporomandibular joint replacement, indications for surgery, patient selection, stock versus custom prostheses, outcomes, and potential complications with reference to the current body of literature.
... Currently, only a few centers in the world have routinely included fat grafting as an integral part of their treatment programs. 6,22 Reluctance to adopt fat grafting protocols largely stems from a surgeon's decision to avoid a second donor site. Moreover, skepticism surrounding the fate and survival of these grafts continues to exist. ...
... Hence, the ''hemostatic fat ball technique'' prevents the formation of blood clots and subsequent organization of blood clots to form bone. 23 Furthermore, it creates a physical barrier and isolates the adjacent tissues from the joint space, thereby preventing the migration of pluripotent stem cells from the reactive tissues into the joint space to form heterotopic bone. 22 All these mechanisms invariably result in the reduction of inflammation, as well as an improved interincisal opening, and impede heterotopic bone formation. Wolford and Karras 5 were the first research group to show the advantages of fat grafting around alloplastic implants in the TMJ. ...
Purpose: There is limited evidence in the literature about fat grafting in the management of temporo-mandibular joint ankylosis (TMJA). The purpose was to investigate which interpositional fat grafting technique is superior in the operative management of TMJA. The specific aim was to compare the volumetric change and maximal mouth opening (MIO) when pedicled buccal fat or abdominal fat is interposed in patients being treated for TMJA. Patients and Methods: A randomized controlled trial was conducted on TMJA patients divided into 2 groups: Pedicled buccal fat pad was used for interposition in group A, whereas abdominal fat was used in group B. At the end of 1 year, the volumetric change in fat was analyzed by comparing immediate postop-erative and 1-year follow-up magnetic resonance imaging (MRI). MIO and re-ankylosis were recorded. Categorical variables were analyzed by the c 2 test or Fisher exact test. Continuous variables were compared using the t test and Wilcoxon signed rank test. Linear regression analysis was performed. Results: A total of 36 patients (51 joints [15 bilateral and 21 unilateral]) were included, comprising 18 in group A and 18 in group B. The mean preoperative MIO measured 6.8 mm in group A and 4.2 mm in group B. The mean immediate postoperative MRI fat volume was 4.3 cm 3 in group A and 10.8 cm 3 in group B. One-year follow-up MRI showed a fat retention rate of 32.44% in group A and 58.17% in group B. The rate of volumetric shrinkage was 67.5% in group A and 41.9% in group B (P < .001). Analysis of variance showed a statistically significant difference between volumetric shrinkage and both treatment groups (P < .001). MIO improved to 30.6 mm in the pedicled buccal fat pad group (group A) and 41.9 mm in the abdominal fat group (group B) (P < .001). No re-ankylosis occurred in either group at 1-year follow-up.
... Surgical gowns and gloves were changed. After the implantation of the TJP, the gap around the prosthesis was filled with fat obtained from the abdomen to prevent heterotopic ossification (HO), thereby reducing the rate of re-ankylosis ( Fig. 3C) [16,17]. The surgical incision was closed in layers with a drain placed inside the wound. ...
Objective
Unilateral temporomandibular joint ankylosis with jaw deformity (UTMJAJD) may require simultaneous total joint prosthesis (TJP) reconstruction, sagittal split ramus (SSRO), and Le Fort I osteotomies. The purpose of this study was to evaluate outcomes in patients treated with these procedures.
Methods
Patients diagnosed UTMJAJD between 2016 and 2018 were selected for the study. Mandible-first procedure was performed after ankylosis release with TJP on the ankylosed side and SSRO on the contralateral side. Le Fort I osteotomy with and without genioplasty was lastly performed. Maximal incisor opening (MIO), facial symmetry, and jaw and condyle stability were compared before, after operation, and during follow-ups.
Results
Seven patients were included in the study. Their average chin deviation was 9.5 ± 4.2 mm, and maxillary cant was 5.1 ± 3.0°. After operation, jaw deformity significantly improved, with chin deviation corrected 7.6 ± 4.1 mm (p = 0.015) and advanced 5.9 ± 2.5 mm (p = 0.006). After an average follow-up of 26.6 ± 17.1 months, MIO significantly increased from 11.4 ± 9.3 to 35.7 ± 2.6 mm (p = 0.000). The occlusion was stable with no significant positional or rotational changes of the jaw (p > 0.05). There was no obvious condylar resorption during follow-ups.
Conclusion
Simultaneous TJP reconstruction, SSRO, and Le Fort I osteotomy are reliable and effective methods for the treatment of UTMJAJD.
... If this is a bilateral case the same steps are repeated on the contralateral side. Fat harvested from the abdomen is then placed circumferentially around the prosthetic condyle so as to prevent heterotopic bone formation (52)(53)(54). Copious saline and betadine irrigation is recommended at both the endaural and submandibular incisions. The incisions are closed in layered fashion. ...
... TMJ reconstruction with autogenous bone grafts or alloplastic TJP is subject to the development of fibrosis and heterotopic/reactive bone around the articulating areas resulting in functional impairment and pain. Fat grafts packed around the articulating areas of the TMJ TJP significantly improves the treatment outcomes for the following reasons: (I) dead space around the articulating areas is eliminated; (II) blood clot forming around the grafts or TJP is eliminated; (III) bone growth and fibrosis is inhibited; (IV) pain is decreased; and (V) TMJ function improved (48)(49)(50). ...
... Wolford et al. (48)(49)(50) and Mercuri et al. (51) have previously reported on the use of fat grafts packed around the articulating area of the TJP, harvested from the abdomen or buttock. The post-surgical incidence of periimplant fibrosis and heterotopic/reactive bone formation is significantly reduced. ...
... Grafted autologous fat (buccal fat pad, dermal fat) serves as a barrier, helping prevent dead space, hematomas, and heterotrophic bone formation, minimizing contact between the glenoid fossa and condyle of the mandible, and preventing fibrosis around the joint by stimulating stem cells to form more adipocytes and new blood vessels (angiogenesis). Wolford et al. 3 first used abdominal dermal fat in alloplastic TMJ replacements. Dermal fat grafts hide scars, involve facile and rapid harvesting and minimal heterotrophic calcification, and, most importantly, limit the chances of re-ankylosis. ...
Re-ankylosis is a common postoperative complication of temporomandibular joint (TMJ) ankylosis surgery. Various surgical options to prevent reankylosis, both with and without interpositional material, have been discussed in the literature. However, no standardized protocol has been suggested for management or prevention of TMJ ankylosis. This paper discusses the probable causes behind TMJ re-ankylosis and presents a case of unilateral TMJ re-ankylosis, which was managed by gap arthroplasty using an autologous abdominal dermal fat graft as an interpositional material and closely monitored for signs of relapse. Autologous fat graft acted as an effective barrier between the glenoid fossa and mandibular condyle, thus preventing dead space, hematoma and heterotrophic bone formation. A brief review of the literature and update on TMJ re-ankylosis are also presented.
... It may also be considered the use of costochondral grafts or TMJ replacement. Also, when the disc is involved, discectomy must be regarded as a simultaneous treatment with or without a temporal flap rotation to fill the space or a free fat graft obtained from the peri-umbilical area to avoid dead space within the joint (Wolford et al., 2008). Currently there is no consensus on management depending on the extent, severity or location of the lesions. ...
The aim of this study was to systematically review the diagnosis and management of temporomandibular joint synovial chondromatosis (TMJ-SC). Using a systematic study design based on the PRISMA guideline, the researchers implemented and analyzed a cohort of relevant publications indexed by PubMed, Embase, Medline, and LILACS between January 1990 and December 2022. The outcomes of interest were demographics of the primary studies, and Clinical, radiological, and therapeutic data associated with TMJ-SC. The study samples included 8 studies presenting 121 TMJ-SC cases (73.6% female; 100% unilateral; 53.7% left-sided; mean age, 43.3 ± SD 5,80 [range, 21-81]. Non-specific symptoms were mostly reported, including TMJ pain, noise and local inflammation, and/or malocclusion. Radiographically, loose bodies, masses with low-signal foci, and calcification were common charateristics. Until now, there has been no internationally accepted consensus on diagnosis and management of TMJ-SC. Arthroscopic surgery should be performed on masses confined to the superior TMJ space, while open arthroplasty is indicated in cases with the extra-articular extension. A combination of both treatment methods may be necessary, when the lesion locates extending beyond the medial groove of the condyle.
... The utilization of fat grafts harvested from the abdomen or groin has been widely reported as an excellent approach to fill the dead-space surrounding the joint prosthesis [40][41][42][43]. The authors frequently employ this technique in the majority of cases, although it does involve an additional procedure for fat harvesting. ...
... Notably, there have been no signs of heterotopic bone formation observed in these patients to date. [40][41][42][43]. The authors frequently employ this technique in the majority of cases, although it does involve an additional procedure for fat harvesting. ...
The treatment of patients with severe temporomandibular joint (TMJ) disorders and associated skeletal discrepancies presents a complex challenge for oral and maxillofacial surgeons. It is widely recognized that TMDs can impact the stability and outcomes of surgical treatments for dentofacial deformities. Consequently, addressing TMDs prior to or in conjunction with orthodontic or surgical interventions may be necessary to achieve optimal and long-lasting results. Alloplastic temporomandibular joint replacement (TMJR) and orthognathic surgery have emerged as the standard approach due to their predictability, long-term stability and excellent outcomes when addressing end-stage TMJ disease in conjunction with DFDs as it provides a comprehensive solution to address both functional and aesthetic aspects of these patients’ conditions. Understanding the appropriate utilization of TMJR in conjunction with orthognathic surgery can lead to improved treatment planning and successful outcomes for patients with complex TMJ disorders and associated dentofacial deformities. This review aims to discuss the indications, preoperative evaluation, staging, sequencing, and surgical considerations involved in utilizing alloplastic TMJ replacement in the presence of dentofacial deformities.
... Recurrence of TMJA due to heterotopic bone formation has been documented in approximately 50 % of cases [11]. To mitigate the occurrence of such complications, it is advisable to employ the placement of an abdominal fat pad surrounding the alloplastic TMJ [12]. ...
Introduction and importance:
Temporomandibular joint (TMJ) ankylosis can be effectively managed through the utilization of autogenous grafts or alloplastic TMJ prostheses. Alloplastic TMJ prostheses are available in two forms: stock or custom. Custom alloplastic TMJ prostheses represent an emerging treatment modality for TMJ ankylosis.
Presentation of the case:
A 47-year-old female patient presented with a 30-year history of complete inability to open her mouth, chew, speak, and be on a liquid diet. Bilateral TMJ ankylosis and a nine mm right-sided chin deviation were noted. A bilateral osteoarthectomy was performed, followed by reconstruction of the TMJ using a custom alloplastic TMJ prosthesis via an extended preauricular and submandibular approach. The abdominal fat pad was utilized for interposition to prevent recurrence. Genioplasty was carried out through a vestibular approach, shifting the chin nine mm to the left. Postoperatively, the patient achieved a 30 mm mouth opening, and correction of facial asymmetry resulting from chin deviation was observed.
Clinical discussion:
Treatment options for TMJ ankylosis include autogenous grafts and alloplastic materials. Autografts have limitations such as prolonged surgery, resorption, undergrowth/overgrowth, donor site morbidity, and graft fracture. Stock alloplastic TMJ prostheses may not suit all patients due to anatomical variations. Thus, custom alloplastic TMJ prostheses have emerged as the preferred treatment modality for adult TMJ ankylosis.
Conclusion:
Custom alloplastic TMJ prostheses are considered an optimal treatment modality for reconstructing the TMJ in adult patients with TMJ ankylosis.
... B. ein Fettgewebeinterponat dar [2,37]. Wolford et al. [38] beschrieben 2008 den Einsatz von Fettgewebetransplantaten z. B. mit periumbilikalem Fett, die in den Hohlraum um die Prothesen eingefügt werden, als sichere und vorteilhafte Variante, um Komplikationen und die Anzahl an möglichen Folgeeingriffen zu reduzieren [2,3,8,36]. ...
Since the advent of modern total alloplastic temporomandibular joint replacement systems (TMJ-TJR) which clinically offer favourable and stable long-term results, and with comparatively recently approved innovative systems, TMJ-TJR has once again become a principal focus of clinical interest. Although TMJ-TJR has traditionally been reserved for cases intractable to conservative and conventional surgical procedures, i.e. multiply operated and severely damaged TMJs (so-called “end-stage disease”, or Wilkes stage V+), the range of clinical indications of TMJ-TJR has been continuously expanded. Previously, TMJ-TJR was considered a “last resort” for TMJ destruction as a part of temporomandibular disorders and for ankylosis. However, its present indications may suit rather earlier treatments, e.g. in the case of autoimmune diseases refractory to pharmacological therapy, as a reconstructive option for syndromic (e.g. Goldenhar syndrome) patients, or in the case of mandibular defects (e.g. after ablative oncological surgery, osteochemonecrosis, etc.). Subject to both well-balanced and well-established indications, as well as well-trained TMJ surgeons, TMJ-TJR can currently be considered an efficient and reliable tool, specifically for treating end-stage diseases. After being “hyped” over several years in the past, there is now a growing trend among TMJ surgeons urging for strict indications and a caveat to the use of TMJ-TJR as a “panacea”. This narrative review delineates current aspects of TMJ-TJR based on evidence-based and consensus-based data (i.e. German S3 guideline, AWMF register number 007-106, 2020) with special interest placed on biomaterials, indications, contraindications, risks and complications.
