reconstruction of tmj

1. Management of PATIENTS WITH
end stage tmj diseases
1
PRESENTATION BY
ADITI RAJVANSHI
IIyr PG TRAINEE

2. 2
CONTENTS
INTRODUCTION
END STAGE DISEASE PROCESSES
BASIC ELEMENTS OF CARE
PAIN MANAGEMENT
TMJ RECONSTRUCTION - GOALS OF RECONSTRUCTION
DIFFFERENT TREATMENT MODALITIES
AUTOGENOUS
ALLOPLASTIC
DISTRACTION OSTEOGENESIS
BIOENGINEERING
CONCLUSION
REFERENCES

3. INTRODUCTION
• Worst disease state of an organ system.
• Negatively affected joint architecture and severe
functional impairment.
Petersons Principles Of Oral And Maxillofacial Surgery 3rd Ed
3

4. DISEASE PROCESSES LEADING
TO END STAGE TMJ DISEASE
4

5. 1. DEVELOPMENTAL
DISORDERS
 CONDYLAR AGENESIS/HYPOPLASIA
 CONDYLAR HYPERPLASIA
5

6. 2. NEOPLASMS
6

7. 3. ARTHRITIC DISEASES
7
Inflammatory disease
Degenerative disease

8. 8
4. ANKYLOSIS
5. TRAUMA
6. MULTIPLE PRIOR FAILED PROCEDURES

9. BASIC ELEMENTS OF CARE
 The patients commonly suffers from unrelenting pain and
severe limitation of jaw movement.
 In addition, they may also have facial asymmetry,
dysfunctional malocclusions, sensory and motor
abnormalities.
9

10. PAIN CONTROL STRATEGIES
 With few exceptions, pain is the primary chief
complaint of these patients and is often the principle
limiting factor in patients willingness to comply with
the recommended physical therapy.
 In addition, these patients often exhibits signs of
depression and are usually socially withdrawn.
10

11. PERIOPERATIVE
1. PREEMPTIVE ANALGESIA
Regional anesthesia
Opioid based GA
Ketamine
Ketorolac
2.IMMEDIATE POSTSURGICAL PERIOD
Regional anesthesia
Opioids( scheduled regimens)
Ketorolac 11

12. LONG TERM
1. PHARMACOLOGIC
Tricyclic antidepressants
Opioids(scheduled dose)
GABAergics(gabapentin, baclofen)
Non opioids(pain associated with inflammation)
2.NONPHARMACOLOGIC
Regular exercise
Heat/cold packs
Transcutaneous electrical nerve stimulation 12

13. TOTAL JOINT
RECONSTRUCTION
13

14. 14
GOALS OF RECONSTRUCTIVE JOINT
SURGERY
•Mandibular form and function
•Reduction of further suffering and disability
•Containment of excessive treatment and cost
•Prevention of further morbidity

15. 15
MANAGEMENT MODALITIES FOR TM JOINT
RECONSTRUCTION
Petersons Principles Of Oral And Maxillofacial Surgery 3rd ED

16. AUTOGENOUS BONE GRAFTING
Petersons Principles Of
Oral And Maxillofacial
Surgery 3rd Ed
16
ALLOPLASTIC TOTAL JOINT REPLACEMENT
TRANSPORT DISTRACTION OSTEOGENESIS
BIOENGINEERED TISSUES FOR TOTAL JOINT REPLACEMENT

17. AUTOGENOUS BONE GRAFTING
17

18. AUTOGENOUS BONE GRAFTING
REPLACEMENT OPTIONS
18
1. Costochondral graft
2. Sternoclavicular joint
3. Calvarium
4. Iliac crest
5. Fibula
6. 2nd, 4th & 5th metatarsophalangeal joint

19. COSTOCHONDRAL
GRAFT
19
First described by Sir Harold Gillies in the 1920s.
Most frequently recommended autogenous bone for the
reconstruction of the TMJ.
1
2
12
3
5
6
7
8
9
4
10
11
Costal cartilages
Costochondral joints

20. Atlas of Temporomandibular Joint Surgery, Second
edition
20

21. 21
Costochondral Rib Grafting. Atlas Oral Maxillofacial Surg Clin N Am 13 (2005) 139–149

22. ADVANTAGES
1. Growth potential
2.Easy accessibility &
adaptation
3.It has a cartilaginous cap
DISADVANTAGES
1. Unpredictable growth
2.Poor bone quality
3.Possible separation of
cartilage from the bone
4.Donor site complications –
pleural tear, pneumothorax
22

23. STERNOCLAVICULAR
JOINT
SNYDER et al. in 1971 reported the first sternoclavicular (SCJ)
whole joint graft consisting of a portion of the manubrium, the
intact capsule, and a portion of the clavicle.
23
CLAVICLE
ARTICULAR DISC
STERNOCLAVICULAR LIGAMENT
STERNUM

24. 24
In 1986, REID et al. reported a free-flap technique that
included the clavicular head of the pectoralis major muscle
and overlying skin, to provide a vascularized clavicular bone
graft.
For TMJ, they suggested splitting the clavicle
longitudinally and repositioning it with the attached flap as
the entire head of the clavicle was too large to fit into the
glenoid fossa.

25. 25
Later in 1994, WOLFORD
et al. reported splitting
the clavicle head and
applying only the superior
half of the clavicle for
condylar reconstruction.
Sternociavicular Grafts for Temporomanciibular Joint ReconstructionJ Oral Mexillofac Surg 52:119-128. 1994

26. ADVANTAGES
1. Similar anatomic
characteristics of condyle
2.Contains cartilaginous cap
3.Has growth potential
4.Regeneration of clavicle
DISADVANTAGES
1. Unacceptable scar location
2.Donor site complication –
• damage to greater vessels
• shoulder instability
• clavicle fracture
26

27. CALVARIAL BONE GRAFT
27
1. Easy accessibility &
adaptation
2.Minimal donor site
morbidity
3.Excellent for glenoid fossa
reconstruction
1. Mostly cortical bone
2.Lack of growth potential
3.Donor site complication –
• Dural tear
• alopecia
ADVANTAGES DISADVANTAGES

28. ILIAC
CREST
28
INNER LIP
OUTER LIP
TUBERCULUM
ANTERIOR SUPERIOR ILIAC SPINE
ANTERIOR INFERIOR ILIAC SPINE

29. 29
SMITH & ROBINSON used iliac bone grafts in a recurrent case of
bilateral TMJ dislocation, in a patient who had previously undergone
condylectomy.
An iliac graft is a chondro-osseous graft, and the graft consists of a
full-thickness piece of the iliac crest, including the overlying cartilage
layer as a cap.
MATUKAS et al. used a piece of iliac bone with a cartilage cap secured
to the glenoid fossa as a stump to prevent recurrence of TMJ ankylosis
in a child.

30. ADVANTAGES
1. Has a cartilage cap
2. Has potential for growth
3. More suitable for large
mandibular defects
DISADVANTAGES
1. Donor-site complications:
altered gait, poor scar/bone
contour, herniation of
abdominal contents, ilium
fracture, peritonitis, &
retroperitoneal haematoma
30

31. FREE FIBULA FLAP
Atlas of Temporomandibular Joint Surgery, Second edition 31

32. 32
• POSNICK et al. first reported a series of cases using the free fibula
flap for immediate reconstruction of paediatric mandibular tumours
in 1993.
• In 2000, WAX et al reported placement of the distal portion of the
flap directly into the glenoid fossa for condylar reconstruction.
• POTTER & DIERKS recommend fibula as the vascularized graft of
choice for defects of the mandibular condyle when the wound beds
are compromised or there are other conditions that preclude the
use of nonvascularized tissues.

33. 1. Longest and strongest
bone
2.Low donor site morbidity
3.Easy positioning
4.Excellent blood supply
5.Supports implants
1. Lacks articular cartilage
2. High incidence of peripheral
vascular disease
3. Decreased ankle strength
4. Technically demanding
5. Longer surgery duration and
anesthesia
6. Numbness of the lateral side of
the leg
33
ADVANTAGES DISADVANTAGES

34. 34
METATARSAL
The metatarsophalangeal (MTP) joint as a graft for
condylar replacement was reported in 1909 by
Bardenheur, as a half-joint transplant of the fourth
metatarsal using the metatarsal head for replacement
of the mandibular condyle.
In 1971, metatarsal as a nonvascularized free bone
graft for bilateral reconstruction of the TMJ was
reported by DINGMAN.
In 1985, TING et al. described the use of a free
vascularized second metatarsal for reconstruction of
the TMJ in four cases of ankylosis.

35. 1. Combination of articular
cartilage and bone upto
7cm
2. Fitting anatomy because
of small size
3. Has potential for growth
4. risk of degeneration and
reankylosis is low
1. Donor-site complications:
aesthetic loss of a toe
2. MTP joint being a simple hinge
joint does not follow the same
movements as the TMJ
3. usually complex and a lengthy
procedure
35
ADVANTAGES DISADVANTAGES

36. AUTOGENOUS GRAFTS
DERIVED FROM THE
VICINITY
36

37. CORONOID PROCESS
The use of coronoid process as a free autogenous
graft was introduced by YOUMANS & RUSSELL in 1969
for repairing defects of the mandible.
In 1989, HONG et al. reported the use of coronoid
process for condylar reconstruction.
37

38. 1. avoidance of a secondary
surgical site
2. in long-standing cases of
ankylosis the coronoid
process is usually elongated,
stiffer and sturdy
3. less bony resorption
1. cannot be used as a
substitute for condylar
reconstruction if involved in
ankylosis
38
ADVANTAGES DISADVANTAGES

39. POST BORDER OF RAMUS
In 1986, LOFTUS et al. reconstructed the
condyle by superior repositioning of the
pedicled stump of the proximal
condylar segment into the condylar
fossa as a local osseous pedicled graft
based on the lateral pterygoid.
39

40. 1. avoids the risk of a free graft
such as resorption, infection
and graft loss and donor-site
complications
2. provides bone of a size and
shape that is adequate for the
new condyle
3. histological characteristics are
similar
4. good and stable function
1. damage to the contour of
the mandibular angle
2. lack of growth
40
ADVANTAGES DISADVANTAGES

41. ANKYLOTIC MASS
GUNASEELAN reported three cases of ankylosis in which he
reused the ankylotic mass to replace the missing condyle.
ADVANTAGES: Dense bone with a smooth cortical surface
Recycling of bony ankylotic mass
DISADVANTAGES: Bulk resection is a must
Possibility of risking the nearby structures 41

42. 42
ALLOPLASTIC
RECONSTRUCTION OF
THE TM JOINT

43. COMPARISON OF AUTOGENOUS &
ALLOPLASTIC TMJ REPLACEMENT
AUTOGENOUS
• Biocompatible
• Donor site morbidity
• Ankylosis potential
• Longevity
• Young patient with growth
potential
• Lack of growth or overgrowth
ALLOPLASTIC
• Biocompatible
• No donor site morbidity
• Low ankylosis (heterotopic bone)
• Require revision/replacement
• Adult patient with growth
completion
• Mechanical wear
43

44. HISTORY
44
• In 1840, JOHN MURRAY CARNOCHAN was credited with the idea of
interposing material(wood) between the surfaces of a diseased joint.
• In 1890, a German surgeon, GLUCK reported total joint arthroplasties using
ivory prosthetic TMJ and hip joints that he stabilized with cement made of
colophony, pumice, and gypsum.
• RISDON in 1933 reported the treatment of an ankylosis of the TMJ by
interposing gold foil between the bony surfaces after a gap was created.

45. 45
• In 1946 EGGERS and in 1947 GOODSELL reported the use
of tantalum foil in cases of TMJ ankylosis.
• In 1951 CASTILIANO & KLEITSCH resurfaced the bone in
TMJ ankylosis with vitallium.
• In 1952 SMITH reported use of stainless steel in
hemiarthroplasty for ankylosis.
• In 1955 UENO reported results in TMJ ankylosis with
zirconia.

46. 46
• In 1960, HENRY described replacement of an ankylosed TMJ
with prosthesis and Robinson reported correction of a TMJ
ankylosis by creating an artificial stainless steel fossa.
• In 1963, 1964 and 1970, CHRISTENSEN reported resurfacing of
the glenoid fossa with a thin vitallium fossa-eminence prosthesis
in cases of TMJ ankylosis. He added a ramus-condyle
component with a PMMA head and a vitallium ramal
component to create a total TMJ prosthesis.
• GARRETT and associates reported the use of a custom
modification of the standard Christensen total alloplastic TMJ
prosthesis.

47. 47
• SMALL et al in 1964 reported that Teflon seem more adaptable to
restoration of large mandibular reconstruction whereas Silastic seem
better suited for condyle.
• In 1970 HAHN & CORGILL first reported use of ramus condyle
hemiarthroplsty prosthesis for the treatment of ankylosis. Condyle
component was fabricated with dental PMMA and ramus
component with stainless steel wire mesh.
• In 1971, 1975, 1977 MORGAN et al reported another type of fossa
resurfacing device. It consisted of a vitallium eminence prosthesis
and silastic fossa components.
• In 1972, TAURUS first published the use of a custom made cast gold
ramus condyle hemiarticulation.

48. 48
• In 1974 HINDS et al reported the use of a Proplast – Teflon coated
vitallium ramus condyle component for hemiarticulation
reconstruction of TMJ.
• In 1974 KIEHN et al applied the principle of hip reconstruction to
TMJ reconstruction using HOWMEDICA vitallium mandibular
fossa plate reinforced on its temporal side with PMMA and a
vitallium modified CORGILL-HAHN ramus condyle prosthesis.
• In 1983 KENT reported the use of a Dacron/Proplast – Teflon and
later reported Dacron/Proplast – Teflon/Ultra high molecular
weight polyethylene(UHMWP) fossa as a prosthetic device for
total joint replacement.

49. 49
• In 1985 & 1990 SONNENBERG reported the use of a
total joint replacement device consisting of a Co-Cr-
Mo ramus condyle component that articulated
against UHMWP fossa.
• In 1995 MERCURI reported on preliminary results
with the use of patient specific CAD/CAM produced
total TMJ reconstruction.

50. Advantages of Alloplastic
Total Joint Replacement
• Rigid fixation allows immediate postoperative physical
therapy.
• No II donor site.
• Decreased surgical time (vs. autogenous bone).
• Mimics normal anatomy (CAD/CAM or patient-fitted TJR).
• Maintenance of stable occlusion (no remodeling).
50

51. Disadvantages of Alloplastic
Total Joint Replacement
• Device cost.
• Material wear and/or failure (screw loosening, fracture).
• Possible heterotopic bone formation (ankylosis).
• Possible need for revision and/or replacement.
• Size and design limitations (stock devices).
• No growth potential.
51

52. Indications of
Alloplastic Total Joint Replacement
1. Ankylosed, degenated or resorbed joints with severe
anatomic discrepancy.
2.Failed autogenous grafting.
3.Recurrent ankylosis.
4.Severe inflammatory joint disease.
52

53. Relative Contraindications to Alloplastic Total
Joint Replacement
Systemic
• Incomplete facial bone growth (child)
• Advanced medical-surgical risk
• Uncontrolled systemic disease
• Psychological instability
Local, Regional
• Insufficient hard and soft tissues to support the implants
• Active or recent infection (local or systemic)
• Allergy to prosthetic materials (rare)
• Uncontrolled parafunctional oral habit 53

54. TYPES OF ALLOPLASTIC TMJ
RECONSTRUCTION
STOCK PROSTHESIS
1. immediately available
2. Lower cost
3. Short treatment time
4. Requires bone removal
5. Potential micromovement
6. Placement versatility
CUSTOM PROSTHESIS
1. Made to fit
2. Higher cost
3. Longer treatment time
4. No/minimal removal of bone
5. No micromovement
6. Limited flexibility & versatility
54

55. CRITERIA FOR SUCCESS
1. Material must be biocompatible.
2.Functionally compatible.
3.Devices must be stable in situ.
55

56. 56
At present, there are three U.S. Food and Drug administration
(FDA)–sanctioned TMJ prosthetic systems available for
implantation.
1. The pre-1976 Amendment
Christensen stock as well as
the Christensen/Garrett
custom devices (TMJ Implant,
Inc., Golden, CO).

57. 57
2. The 1999 FDA-approved
TMJ Concepts patient
fitted device (TMJ
Concepts [previously
Techmedica], Ventura,CA)

58. 58
3. The 2006 FDA-
approved Biomet
Microfixation total
joint stock device.

59. 59
Stock alloplastic reconstruction
of
the TMJ

60. Atlas of
Temporomandibular
Joint Surgery, Second
edition
60
Kent‐Vitek
total joint
prosthesis

61. 61
SYNTHES SYSTEM

62. Atlas of Temporomandibular
Joint Surgery, Second edition62
Delrin‐Timesh
Condylar
Prosthesis

63. Atlas of Temporomandibular Joint Surgery, Second edition
63
Christensen
prostheses

64. Atlas of Temporomandibular Joint Surgery,
Second edition
64
Type III Christensen prosthesis

65. Atlas of Temporomandibular Joint Surgery,
Second edition
65
Biomet stock prosthesis

66. CUSTOM ALLOPLASTIC
RECONSTRUCTION OF
THE TM JOINT
66

67. 67
Prosthetic manufacturing is done using one of the two
methods.
The first method introduced utilizes anatomic models
produced from a CT scan. These models are then used to
fabricate the custom prosthesis via an initial computer‐aided
wax model.

68. Atlas of Temporomandibular Joint Surgery, Second edition
68

69. Atlas of
Temporomandibular Joint
Surgery, Second edition
69

70. Atlas of Temporomandibular Joint Surgery, Second edition
70
The single‐stage approach requires planning and design
replication on the model surgery, with osteotomy sites and
bone contouring marked.

71. 71
A second method for surgical planning and custom device
design utilizes computer modeling entirely.
Mandibular repositioning and osteotomy placement can be
planned on the virtual model and the device is designed and
incorporated into the planning session.

72. Atlas of Temporomandibular Joint Surgery, Second edition
72

73. Atlas of Temporomandibular Joint Surgery,
Second edition
73

74. Atlas of Temporomandibular Joint Surgery,
Second edition
74

75. Principles for the revision of
total alloplastic TMJ prostheses
Reasons for failures
1. Failure of the concept
2. Failure of embodiment
3. Failure of implantation technique
4. Limitations of the technology
75
PRINCIPLES FOR THE REVISION OF TOTAL ALLOPLASTIC TMJ PROSTHESES. INT. J. ORAL
MAXILLOFAC. SURG. 2003; 32: 353–359

76. CAUSES OF PAIN
Applying the principles discussed by GHELMAN for total knee revision to
the TMJ, there are two causes for pain in patients with alloplastic joint
prostheses:
 1. Mechanical
1. The most common cause of mechanical pain is a loose prosthetic
component. This is characterized by activity-related pain at the joint.
Imaging helps make this diagnosis.
2. The most common type of prosthetic component failure is wear. This
can lead to breakage, osteolysis, and loosened screws.
76
PRINCIPLES FOR THE REVISION OF TOTAL ALLOPLASTIC TMJ PROSTHESES. INT. J. ORAL MAXILLOFAC. SURG. 2003; 32: 353–359

77. 77
Biological
 Infection—characterized by pain that is constant. Effusion on
physical examination, erythema and drainage later
Neurological problems
1. RSD—reflex sympathetic dystrophy after total joint
replacement leads to excessive pain. Limitation of joint
function is common. Cutaneous hypersensitivity is present.
2. Neuroma formation
3. Frey’s Syndrome
Muscle fatigue and spasm

78. 78
INDICATIONS FOR REVISION
The following should be the indications for revision of an alloplastic TMJ
reconstruction device, based on the work of BOURNE.
1. Failed component/components
2. Breakage of a component or components and/or fixation screws
3. Aseptic loosening
4. Subacute or chronic infection
5. Osteolysis
6. Peri-prosthetic bone fracture
7. Ankylosis

79. DISTRACTION
OSTEOGENESIS
James McNamara stated that - “distraction osteogenesis means the
slow movement apart (distraction) of two bony segments in a
manner such that new bone is allowed to fill in the gap created by
the separating bony segments.”
In 1997, STUCKI-MCCORMICK was the first to apply transport
distraction osteogenesis (DO) for TMJ reconstruction in two cases of
tumour involving the condyle.
79

80. Principles of Distraction Osteogenesis (Ilizarov)
80
1. Surgical procedure
a. Corticotomy
b. Device application
2. Latency period (3–7 days)
3. Activation period
a. Rate (1.0 mm/day)
b. Rhythm (daily to four times/day)
4. Consolidation period (8–12 wk)
5. DO device removal

81. ADVANTAGES OVER AUTOGENOUS
GRAFTING
81
1. Creating a functional joint without using interpositional
material.
2.Avoidance of donor site morbidity.
3.Rigid distraction device allows immediate postoperative
physical therapy.
4.Risk of bone graft necrosis & resorption is greatly reduced.
5.Simultaneous correction of secondary deformities
6.Decreases the risk of surgery, and the possibility of relapse

82. 82
DISADVANTAGES
1. lengthy procedure
2. requires close monitoring of the patient
3. may cause pintract soft-tissue infection, bone infection
and psychological problems

83. Distraction Osteogenesis for Temporomandibular Joint Reconstruction. J Oral Maxillofac
Surg 66:718-723, 2008
83

84. TISSUE
ENGINEERING
84

85. 85
• Tissue engineering has demonstrated significant potential for
the skeletal repair that may be applied to the treatment of
craniofacial tissue loss.
• Standard approach to tissue engineering is to seed the cells on
a 3D biomaterial scaffold. This scaffold creates a 3D
environment that promotes tissue development of cells.
• Gene vectors, soluble factors and chemical signals may be
incorporated into the scaffold to promote tissue development
during in vitro incubation or in vivo implantation.

86. 86
Scaffold choices: naturally derived and synthetic scaffold
materials have been used.
Multiple research have described several biomaterials with
osteoconductive properties –
1. Titanium
2. Natural/coralline hydroxyapatite
3. Porous hydroxyapatite
4. Bioglass
5. Calcium phosphate
6. Photopolymerizable polyanhydrides
7. Polyester copolymers
8. Polyglycolic acid

87. 87
Tissue engineering could be applied to regenerate localized
defects or, theoretically, the entire articulating condylar surface.
Implementation could take one of three approaches:
1. ex vivo growth of tissue on the scaffold/ biologic composite in
a bioreactor before implantation on the mandible;
2. implantation of the scaffold/biologic composite at secondary
surgical site before implantation on the mandible; and
3. direct implantation at the mandible site.

88. 1. Nerve injuries
2.Damage to adjacent vessels
3.Damage to adjacent structures
4.Frey’s syndrome
5.Malpositioning of the prosthesis
6.Infection
88
COMPLICATIONS OF TMJ SURGERY

89. NERVE INJURIES
Nerve injuries can occur to cranial nerves V and VII.
Damage to the CN VII is a known risk in this procedure as it lies
directly over the surgical field of entry.
Damage to cranial nerve V is possible in both the placement of
the joint with the screws leading into the inferior alveolar canal,
or exceeding the medial aspect of the joint and entering into
the base of the skull
89

90. DAMAGE TO VESSELS
Intraoperative bleeding in total joint replacements can occur
from some of the major vessels located in the surgical field,
including the maxillary artery, temporal artery, masseteric
artery, and facial artery.
Furthermore, as there is muscle stripping and cutting, especially
of the masseter and both pterygoid muscles, there can be a
significant amount of oozing of that musculature. 90

91. The most clinically important vessel that could be damaged in
TMJ surgery is the maxillary artery, which runs behind the neck
of the condyle and at the level just above the sigmoid notch.
91

92. DAMAGE TO ADJACENT STRUCTURES
Most relevant structures related to joint replacement TMJ
surgery are the 3 areas –
1. surrounding the condylar component, including the external
and internal structures of the ear,
2. the anatomic areas medial to the joint (specifically the base of
the skull), and
3. damage to the superior aspect of the glenoid fossa into the
intracranial space. 92

93. MALPOSITION OF THE PROSTHESIS
The dental occlusion must be set appropriately before the
condylar and fossa components are set. Passive stable
occlusion should be obtained.
A second possibility is that the condyle is poorly situated, and
even though the occlusion is stable as soon as the
intermaxillary fixation is released, the condyles returns back to
an unfavorable spot.
Additionally, postoperative dislocations can occur. 93

94. INFECTIONS OF THE
TEMPOROMANDIBULAR JOINT
Infections can be divided into acute, subacute, or chronic.
In the acute phase, it is conceivable to treat the patient with
antibiotics and/or open the joint, wash it out, and reseal it.
The subacute phase is somewhat less clear, and can have a
mixed response.
 In the chronic phase, it is almost imperative that the
components be removed, especially the fossa. 94

95. 95
Reaction to foreign bodies, especially nickel or titanium, can
occur.
Postoperative pain can be considered a potential
complication..
Poor range of motion after surgery can be another
postoperative problem. Most patients have lost their
pterygoid muscular function and therefore cannot translate
or go side to side.

96. CONCLUSION
The patient with end-stage TMJ disease is typically afflicted by severe
unrelenting pain, restricted jaw function, facial deformity, depression
and financial hardships.
Given the complexities involved, these patients pose a significant
challenge and many give a history of prior surgeries.
In few instances medical management is advised with primary
treatment objectives typically being pain management and
improvement in jaw movements but may require total joint
replacement eventually. 96

97. 97
REFERENCES
 Peterson's Principles of Oral And Maxillofacial Surgery 2nd ed.
 Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
 Atlas of Human Anatomy - Frank H. Netter 6th ed
 Atlas of Temporomandibular Joint Surgery 2nd ed – Quinn
 Management of temporomandibular disorders and occlusion, 6th ed – Okeson
 Fonseca Vol. II
 Custom-Made Total Temporomandibular Joint Prostheses. Atlas Oral Maxillofacial Surg
Clin N Am 13 (2005) 83–89.
 Total Reconstruction of the Temporomandibular Joint with a Stock Prosthesis. Atlas
Oral Maxillofacial Surg Clin N Am 19 (2011) 221–232.
 Patient-Fitted (“Custom”) Alloplastic Temporomandibular Joint Replacement Technique
Atlas Oral Maxillofacial Surg Clin N Am 19 (2011) 233–242.

98. 98
 Complications of TMJ Surgery. Oral Maxillofacial Surg Clin N Am 27 (2015) 109–124.
 sternociavicular grafts for temporomanciibular joint reconstruction j oral mexillofac
surg 52:119-128. 1994.
 temporomandibular joint devices: treatment factors and outcomes. oral surg oral
med oral pathol oral radiol endod 1997;83:143-9.
 alloplastic temporomandibular joint reconstruction. oral surgery oral medicine oral
pathology june 1998 volume 85, number 6
 costochondral rib grafting. atlas oral maxillofacial surg clin n am 13 (2005) 139–149.
 the christensen temporomandibular joint prosthesis system - david a. Gerard.
 Distraction Osteogenesis for Temporomandibular Joint Reconstruction. J Oral
Maxillofac Surg 66:718-723, 2008

99. 99
• The-use-of-autogenous-tissues-for-temporomandibular-joint-reconstruction. J Oral
Maxillofac Surg 58:63-69,2000.
• Reconstruction of the temporomandibular joint autogenous compared with
alloplastic. British Journal of Oral and Maxillofacial Surgery (2002) 40, 296–299
• Evaluation of Long-Term Stability in Second Metatarsal Reconstruction of the
Temporomandibular Joint. J Oral Maxillofac Surg . 2003;61:65-71.
• Principles for the revision of total alloplastic TMJ prostheses. Int. J. Oral Maxillofac.
Surg. 2003; 32: 353–359.
• Advances in skeletal tissue engineering with hydrogels. Orthod Craniofacial Res 8,
2005; 150–161.
• Free grafting of autogenous coronoid process for condylar reconstruction in patients
with TMJ ankylosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2008;106:662-7.
• Autogenous grafts for condylar reconstruction in treatment of TMJ ankylosis: current
concepts and considerations for the future. Int. J. Oral Maxillofac. Surg. 2012; 41: 94–
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