TMJ Concepts Related Articles

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1 Page 1 of Henry CH, Wolford LM: Treatment outcomes for temporomandibular joint reconstruction after Proplast-Teflon implant failure. J Oral Maxillofac Surg 51: , 1993 Wolford LM, Cottrell DA, Henry CH: Temporomandibular joint reconstruction of the complex patient with the Techmedica custom-made total joint prosthesis. J Oral Maxillofac Surg 52:2-10, 1994 Mercuri LG, Wolford LM, Sanders B, White D, Hurder A, Henderson W: Custom CAD/CAM total temporomandibular joint reconstruction system: Preliminary multicenter report. J Oral Maxillofac Surg 53: , 1995 James RB: Surgical treatment of temporomandibular dysfunction (revised edition). Otolaryngology Vol. 3, Chapter 21, 1998 Mercuri LG: Considering total alloplastic temporomandibular joint replacement. Cranio 17:44-48, 1999 Mercuri LG: Subjective and objective outcomes in patients with a customfitted alloplastic temporomandibular joint prosthesis. J Oral Maxillofac Surg 57: , 1999 Mercuri LG: The use of alloplastic prostheses for temporomandibular joint reconstruction. J Oral Maxillofac Surg 58:70-75, 2000 Mercuri LG: The TMJ Concepts patient fitted total temporomandibular joint reconstruction prosthesis. Oral Maxillofac Surg Clinics North Am 12:73-91, 2000 Wolford LM, Mehra P: Custom-made total joint prostheses for temporomandibular joint reconstruction. Bayl Univ Med Cent Proc 13: , 2000 Quinn P: Pain management in the multiply operated temporomandibular joint patient. J Oral Maxillofac Surg 58:12-14, 2000, Suppl 2 A retrospective study of 107 patients (male, n = 13; female, n = 94) with 163 joints previously treated with Proplast-Teflon (PT; Vitek, Inc, Houston, TX) implants was performed. The average time in situ for the PT was 59.8 months (range, 2 to 126 months). Average length of follow-up was 84.6 months (range, 59 to 126 months). Only 12% of joints showed no significant osseous changes radiographically. Forty-five patients (42%) continue to have in situ PT implants and 36% of them experience pain that requires medication; 25% have developed an anterior open bite and malocclusion; 9% have limited vertical opening; and 40% are asymptomatic. Temporomandibular joint (TMJ) reconstruction after PT implant failure was performed with five different autologous tissues or a total joint prosthesis. Autologous tissues used to reconstruct the TMJ and the rates of success were as follows: 1) 31% free temporalis fascia and muscle graft with and 13% without sagittal split ramus osteotomy, 2) 8% dermis, 3) 25% conchal cartilage, 4) 12% costochondral grafts, and 5) 21% sternoclavicular grafts. The success rate decreased in all autologous tissue groups as the number of TMJ surgeries performed before reconstruction increased. Ankylosis was the most common cause of failure. Results of TMJ reconstruction with a total joint prosthesis were as follows: 1) 88% functional and occlusal stability of total joint prosthesis; 2) level of pain reduction was rated as 46% good, 38% fair, and 16% poor; and 3) an average interincisal opening of 27 mm at 24 months or less, and 33 mm at 25 months and beyond. A study of 56 patients (55 female, one male) with 100 reconstructed temporomandibular joints (TMJ) using the Techmedica custom-made total joint system (Techmedica Inc, Camarillo, CA) is presented. The patients ranged in age from 15 to 61 years (average, 39 years) and had 16 to 46 months' follow-up (average 30 months). Outcome groups were categorized as good, fair, or poor, based on clinical assessment. Results show that 35 patients (63%) with 58 joints (58%) had a good outcome, and 13 patients (23%) with 26 joints (26%) had a fair outcome, and 8 patients (14%) with 16 joints (16%) had a poor outcome. Patients with one or no previous temporomandibular joint surgeries had 86% in the good group, 14% in the fair group, and no patients in the poor group. In patients with two or more previous surgeries, the success rate decreased to 55% with good results, 26% with fair results and 19% with poor results. Long-term morbidity included five ramus prostheses that were removed or revised. Seventeen patients (30%) received further operations because of heterotopic bone formation, fibrosis, calcification, inflammation, and/or pain which occurred mostly in patients with previous Proplast/Teflon (Vitek, Inc, Houston, TX) implants. Continued pain has been associated with the poor group, which may be related to problems such as cervical neuropathy, sympathetic dystrophy, a residual inflammatory or immunologic reaction to Proplast/Teflon or silastic particles, fibrosis, calcification, heterotopic bone, or other unidentified factors. Purpose: The purpose was to test the outcome of a custom computer assisted design/computer assisted manufactured (CAD/CAM) total temporomandibular joint (rmj) reconstruction system. There were 215 patients (13 males and 202 females); the average age at reconstruction was 40.9 ±10.3 years (range, 15 to 77 years). Patients and Methods: There were 363 joints placed, 296 bilateral and 67 unilateral. The patients had TMJ problems for an average of 10.3 ± 7.0 years (range, 1 to 44 years), and had undergone a mean of 5.4 ± 4.8 (range, 0 to 28) prior unsuccessful surgeries. Preoperative and postoperative data were collected for up to 48 months using a standardized data collection format. Subjective data related to pain, function of the lower jaw, and diet, were obtained using a visual analogue scale. Objective measures of mandibular range of motion were made directly on the patient preoperatively and postoperatively. Results: Preliminary analysis of these data reveals a statistically significant decrease in pain, an increase in function, and improvement in diet (P <.0001) from the preoperative measurements to 1 and 2 years postoperatively. There was also improvement in mandibular vertical range of motion. The number of previous surgeries was a strong predictor of postoperative pain, function, and diet scores, as well as of maximal interincisal opening. A life table analysis of failures indicates good durability of the prosthesis over time. Conclusions: These preliminary data indicate that this custom CAD/CAM total TMJ reconstruction system seems to be useful in the treatment of the multiply operated, and/or anatomically mutilated TMJ. Patients with very advanced degenerative disease, ankylosis, post-traumatic condylar destruction, and multi-operated patients may be candidates for joint replacement with fossa and condylar prostheses. Great advances have been made in developing biocompatible materials, improved designs for patient-fitted prostheses. These devices have treated internal derangement cases after multiple surgical and nonsurgical treatment failures, as well as restoring form and function following the removal of failed Vitek Proplast-Teflon (Houston, Texas) containing temporomandibular joint implants. This paper will provide practitioners dealing with complex, debilitated, functionless temporomandibular joint (TMJ) patients with information related to this treatment modality. They will then be able to address the indications for the use of alloplastic temporomandibular joint replacement devices, the devices presently available, the surgery involved in their placement, possible complications of implantation and post-operative outcomes and expectations with patients who would benefit from the implantation of these devices. Purpose: This study looked at prospective subjective and objective preoperative and postoperative outcome data from a set of multiply operated, anatomically mutilated, functionless, chronic temporomandibular joint (TMJ) pain patients who have undergone TMJ reconstruction with a custom-fitted prosthetic system. Patients and Methods: Two hundred fifteen patients (363 joints: 296 bilateral, 67 unilateral) who had undergone total TMJ reconstruction with a custom-fitted TMJ prosthesis (Techmedica; now TMJ Concepts, Camarillo, CA) made up the subjects reviewed in this study. The mean follow-up period was 30.7 months. The patients were divided into 3 groups based on the number of prior unsuccessful TMJ arthrotomies they had undergone (group 1 = 0 to 2; group 2 = 3 to 8; and group 3 = 9 or more). Results: Subjective improvement ratio data indicated that postoperatively group 1 had a 61.3% improvement in subjective parameters, group 2 had a 51.0% improvement, and group 3 had only a 27.5% improvement. Objective improvement ratio data showed that postoperatively group 3 had the largest increase in maximum interincisal opening, whereas the other groups had less improvement. Conclusion: The data from this study confirm, as previously reported in the literature, that the greater the number of surgical procedures performed on the TMJ, the less the chance of significant subjective improvement. Jaw joint (temporomandibular joint or TMJ) disease is estimated to affect 30 million Americans, with approximately 1 million new patients diagnosed each year (1). Although many of these patients can be managed with nonsurgical therapies, some patients require surgical intervention. The TMJ is a unique joint in that it does not function independently but works in tandem with its contralateral joint. Therefore, disease affecting 1 joint can either directly or indirectly affect the functioning and health of the contralateral joint. When surgical intervention of the TMJ is required, the joint can often be reconstructed with autogenous tissues. However, certain TMJ conditions and pathology require reconstruction with a total joint prosthesis for predictable treatment outcomes. Some of these conditions include 2 previous TMJ surgeries; previous TMJ alloplastic implants containing Proplast/ Teflon (PT), Silastic, acrylic, or bone cements; inflammatory or resorptive TMJ pathology; connective tissue or autoimmune disease (i.e., rheumatoid arthritis, psoriatic arthritis, scleroderma, Sjögren s syndrome, lupus, and ankylosing spondylitis); fibrous or bony ankylosis; absence of TMJ structures due to pathology, trauma, or congenital deformity; and tumors involving the condyle and mandibular ramus area. Currently, the only TMJ total joint prosthesis approved by the Food and Drug Administration (FDA) is the custom-made device manufactured by TMJ Concepts, Inc. (Camarillo, Calif). The device was manufactured by the same company under the name Techmedica, Inc. from 1989 to The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. One of the most difficult challenges facing oral and maxillofacial surgeons in evaluating multiply operated patients, aside from considering reconstructive options, is ascertaining appropriate pain management for these patients.

2 Page 2 of Wolford LM, Mehra P: Simultaneous temporomandibular joint and mandibular reconstruction in an immunocompromised patient with rheumatoid arthritis: A case report with 7-year follow-up. J Oral Maxillofac Surg 59: , 2001 Mercuri LG, Wolford LM, Sanders B, White D, Gobbie-Hurder A: Longterm follow-up of the CAD/CAM patient fitted total temporomandibular joint reconstruction system. J Oral Maxillofac Surg 60: , 2002 Wolford LM, Pitta MC, Reiche-Fischel O, Franco PF: TMJ Concepts/Techmedica custom-made TMJ total joint prosthesis: 5-year follow-up study. Int J Oral Maxillofac Surg 32: , 2003 Surgical reconstruction with a total joint prosthesis is sometimes required in patients with temporomandibular joint (TMJ) problems. In the 1980s, the Vitek-Kent TMJ total joint prosthesis and Vitek alloplastic articular disc (Vitek Inc, Houston, TX) were commonly used in TMJ reconstruction, but both these devices contained Proplast-Teflon (PT; Vitek Inc) as part of their components. Early reports regarding these products were very promising, with 91% of 5,070 procedures reported to have produced satisfactory results. However, continued long-term follow-up on these patients showed the PT implants had a very high failure rate. These implants fragmented and promoted a foreign body giant cell reaction (FBGCR), which continued to increase with time. Serious complications in the TMJ from PT implants included localized destruction of bone and soft tissues, unstable occlusion, lymphadenopathy, severe pain, headaches, perforation into the middle cranial fossa, immunologic dysfunction, and other systemic problems lems.3 The FBGCR may continue after removal of the implants, despite multiple debridements. This case report illustrates the long-term successful outcome of TMJ reconstruction in a rheumatoid arthritis patient with severe bilateral TMJ and mandibular destruction from PT in previously used Vitek-Kent total joint prostheses that resulted in significant functional and aesthetic facial deformity, severe facial pain, and sleep apnea. The patient was treated using a technique developed by the senior author (L.M.W.), using cranial bone grafts for mandibular ramus reconstruction and bilateral custom-made total TMJ prostheses (TMJ Concepts Inc, Camarillo, CA; formerly Techmedica Inc) for simultaneous TMJ reconstruction and a large mandibular advancement, along with maxillary osteotomies for correction of the iatrogenically induced severe dentofacial deformity. Purpose: The purpose of this study was the assessment of the long-term safety and effectiveness of the Techmedica (Camarillo, CA) CAD/CAM Total Temporomandibular Joint Reconstruction System (now called the TMJ Concepts Patient Fitted Total Temporomandibular Joint Reconstruction System, Ventura, CA). Patients and Methods: A survey was mailed to the available addresses of 170 (79%) of the 215 patients who had been implanted with the Techmedica System devices between 1990 and Seventy-nine (46%) surveys were returned by the US Postal Service as undeliverable. Three patients (1.4%) were reported as deceased in returns from relatives. Therefore, of the remaining 91 possible responses, 60 (65.9%) were returned. Fifty-eight (58) surveys, considered complete and valid (96.7%), representing 97 (39 bilateral, 19 unilateral) devices with a mean follow-up of ±15.5 months (range, 60 to 120 months) were analyzed. Subjective data related to pain, mandibular function, diet consistency, and present quality of life were collected using visual analog scales. Objective measures of mandibular interincisal opening and lateral excursions were obtained from direct measurements using the Therabite (Therabite, Philadelphia, PA) measuring scale provided in the survey with instructions as to its use. Results: Analysis of the subjective data at 10 years revealed a 76% reduction in mean pain scores and a 68% increase in mean mandibular function and diet consistency scores (P <.0001). Analysis of objective data revealed a 30% improvement in mandibular range of motion after 10 years (P =.0009). Long-term quality of life improvement scores were statistically related to the number of prior temporomandibular joint operations the patients had undergone. Conclusion: These data indicate that the CAD/CAM Patient Fitted Total Temporomandibular Joint Reconstruction System has proved to be a safe and effective long-term management modality in the patient population surveyed for this study. This prospective study evaluated the 5 to 8 year subjective and objective results of 42 consecutive patients who had TMJ reconstruction using the TMJ Concepts/Techmedica custom made total joint prosthesis. Criteria for use of the prosthesis included the following TMJ conditions: (1) multiply operated, (2) previous alloplastic implants, (3) osteoarthritis, (4) inflammatory or resorptive arthritis, (5) connective tissue or autoimmune disease, (6) ankylosis, and (7) absent or deformed structures. Thirty-eight of 42 patients (90%) with 69 TMJs reconstructed using the TMJ Concepts/Techmedica total joint prosthesis had appropriate data for inclusion in the study. The average age at surgery was 36 years and average follow-up was 73.5 months. The entire group and three subgroups were objectively evaluated for incisal opening, lateral excursions, and occlusal stability, while subjectively assessed for pain and jaw function. Paired t-test and comparison analyses were used to assess outcomes. For the group of 38 patients, there was statistically significant improvement in incisal opening (P=0.001), jaw function (P=0.001), and pain level (P=0.0001). Lateral excursion movements significantly decreased (P=0.04). The occlusion remained stable in all cases. Complications occurred in six patients. Comparison analysis of the three groups demonstrated significantly better outcomes for patients with fewer previous TMJ surgeries and without exposure to Proplast-Teflon or Silastic TMJ implants. This study demonstrated that the TMJ Concepts/Techmedica total joint prosthesis is a viable technique for TMJ reconstruction as a primary procedure and for patients with previous multiple TMJ surgeries and mutilated anatomy of the TMJ Wolford LM, Dingwerth DJ, Talwar RM, Pitta MC: Comparison of 2 temporomandibular joint total joint prosthesis systems. J Oral Maxillofac Surg 61: , 2003 Mercuri LG, Anspach WE III: Principles for the revision of total alloplastic TMJ prostheses. Int J Oral Maxillofac Surg 32: , 2003 Wolford LM: Concomitant temporomandibular joint and orthognathic surgery. J Oral Maxillofac Surg 61: , 2003 Purpose: The study goal was to evaluate the comparative outcomes of patients treated with temporomandibular joint (TMJ) total joint prostheses, using either the Christensen prosthesis (TMJ Inc, Golden, CO) (CP) or the TMJ Concepts prosthesis (TMJ Concepts Inc, Camarillo, CA; formerly Techmedica Inc) (TP). Patients and Methods: Forty-five consecutive patients treated with either CP or TP total joint prostheses were evaluated. The CP group consisted of 23 patients (40 prostheses; average patient age, 38.8 years). The TP group consisted of 22 patients (38 prostheses; average patient age, 38.5 years). The average number of previous operations for the CP group was 3.9, whereas it was 2.6 for the TP group. The CP and TP groups had an average follow-up of 20.8 and 33.0 months, respectively. Patients were evaluated for incisal opening and occlusal and skeletal stability. A visual analog scale was used for subjective assessment of TMJ pain (0 = no pain, 10 = worst pain), jaw function (0 = normal function, 10 = no function), and diet (0 = no limitations, 10 = liquids only). Statistical analysis was performed using an independent t test, and a value of P <.05 was considered significant. Results: The average postsurgical incisal opening for the CP group was 30.1 mm (increase of 6.7 mm), and that for the TP group was 37.3 mm (increase of 9.9 mm), indicating significant increase of the TP group (P =.008). The average postsurgical pain level for the CP group was 6.0, a decrease of 1.8, and that for the TP group was 4.1, a decrease of 3.1, indicating significant improvement for the TP group (P =.042). Postsurgical average jaw function for CP was 5.5, an improvement of 1.2. The postsurgical TP average was 3.9, an improvement of 3.0, showing significant improvement for the TP group (P =.008). Average postsurgical diet rating for the CP group was 5.4, an improvement of 1.8. The TP group average was 3.9, an improvement of 2.0, indicating significant improved eating ability for the TP group (P =.021). Skeletal and occlusal stability were good in both groups. Conclusion: The TP group had statistically significant improved outcomes compared with the CP group relative to postsurgical incisal opening, pain, jaw function, and diet. Both groups showed good skeletal and occlusal stability.

3 Page 3 of Mercuri LG, Giobbie-Hurder A: Long-term outcomes after total alloplastic temporomandibular joint reconstruction following exposure to failed materials. J Oral Maxillofac Surg 62: , 2004 Westermark A, Koppel D, Leiggener C: Condylar replacement alone is not sufficient for prosthetic reconstruction of the temporomandibular joint. Int J Oral Maxillofac Surg 35: , 2006 Wolford LM: Factors to consider in joint prosthesis systems. Bayl Univ Med Cent Proc 19: , 2006 Indresano AT, Mobati D: History of temporomandibular joint surgery. Oral Maxillofac Surg Clinics North Am 18: , 2006 Mercuri LG: Total joint reconstruction Autologous or alloplastic. Oral Maxillofac Surg Clinics North Am 18: , 2006 Mercuri LG, Edibam NR, Giobbie-Hurder A: Fourteen-year follow-up of a patient-fitted total temporomandibular joint reconstruction system. J Oral Maxillofac Surg 65: , 2007 Herrera AF, Mercuri LG, Petruzzelli G, Rajan P: Simultaneous occurrence of 2 different low-grade malignancies mimicking TMJ dysfunction. J Oral Maxillofac Surg 65: , 2007 Total alloplastic temporomandibular joint (TMJ) reconstruction is often necessary because of the significant bony destruction resulting from failed Proplast-Teflon (Vitek, Houston, TX) and/or Silastic (Dow Corning, Arlington, TX) foreign body inflammatory reactions. Multiply operated and functionless, TMJ patients likewise have undergone total alloplastic reconstruction. Many of these patients were also exposed to failed TMJ implant materials. It was the purpose of this study to evaluate a population representative of both these groups of patients reconstructed with the Techmedica (now, TMJ Concepts, Ventura, CA) Total TMJ System to determine whether the long-term subjective and objective outcomes were affected by either the presence of the previously failed TMJ implant materials, the number of prior procedures, or both. One hundred ninety-eight patients who had been implanted with 332 Techmedica System total joints between 1990 and 1994 where divided into 4 groups based on their prior exposure to failed TMJ implant materials: group I, Proplast-Teflon (82 patients, 135 joints); group II, Silastic (28 patients, 46 joints); group III, both Proplast-Teflon and Silastic (25 patients, 46 joints); and group IV, no prior exposure to Proplast-Teflon or Silastic (63 patients, 105 joints). The mean followup was months (range, 2 to 120 months). To determine whether exposure to either or both failed implant materials affected the long-term subjective and objective outcome variables, the groups were compared statistically using multivariate mixed modeling with age, sex, number of prior operations, years with TMJ problem, prior implant type, and implant sides as independent variables, and the relevant baseline measure as covariates. Results: For the subjective variables, patients exposed to Proplast-Teflon or Silastic had significantly higher mean pain scores long-term. The type of prior failed TMJ implant material was not statistically significant with regard to function. Patients exposed to Proplast-Teflon reported poorer diet consistency scores long-term. Objectively, patients with 5 or fewer prior TMJ surgeries exposed to neither failed implant or Silastic reported better long-term mean maximum interincisal opening than did those patients exposed to Proplast-Teflon or both failed materials. However, for patients with 6 or more prior TMJ surgeries, those exposed to Proplast-Teflon or both failed materials reported less decrease in mean maximum interincisal opening over time. These data confirm what has been observed clinically, that in the population studied, multiply operated patients previously exposed to failed Proplast-Teflon alone or both failed Proplast-Teflon and Silastic have poorer reported long-term outcomes with alloplastic reconstruction. However, the total alloplastic TMJ reconstruction devices used in this study remained functional. Prosthetic reconstruction of the temporomandibular joint (TMJ) is a controversial method of treatment. This paper presents 2 cases that illustrate the problem with prosthetic reconstruction of the condylar head with no fossa reconstruction. In both cases, severe erosion and heterotopic bone formation occurred, and the patients underwent installation of total TMJ prostheses to replace the previous, partial ones. In joint reconstruction, the techniques and materials that provide the best outcomes for patients have been debated. The main points of controversy relate to the use of hemiarthroplasties versus total joint prostheses with metal-on-metal versus metal-on-polyethylene articulations. This article investigates these areas as well as the applicability of the techniques and materials and the complications that can occur. Hypersensitivity to materials used in joint prostheses is relatively common but often unrecognized. Although the discussion applies to all joints, the temporomandibular joint (TMJ) is emphasized. For TMJ reconstruction, metal-on-polyethylene articulation in total joint prostheses provides better treatment outcomes than metal-on-metal articulation. This article reviews past surgical treatments for TMJ and their rationale. Because of poor outcomes with alloplastic materials in the 1980s, many experts believed TMJ surgery had failed. Those who advocated nonsurgical treatment condemned the entire discipline without recognizing the benefits of many surgical approaches. Only after 20 years of "good science" has TMJ surgery reemerged with many procedures proven highly effective. The functional goals of temporomandibular joint (TMJ) reconstruction are the same regardless of whether they are accomplished with autogenous tissues or alloplastic materials. Which of these reconstruction modalities is best suited for an individual case should depend on the nature of the defect, the pathology that created that defect, the history of the course of the patient's prior nonsurgical and surgical interventions and the response to each, and most importantly on the evidence from refereed literature that supports the choice of alloplast verses autogenous reconstruction based on scientific data. This article provides an evidence-based review of the autogenous and alloplastic TMJ reconstruction literature. The reader can then more accurately determine which of these two modalities provides the most appropriate option for the management of the above conditions so as to achieve the functional goals. Purpose: The purpose of this study was to continue the assessment of the safety and effectiveness of the Patient-Fitted Total Temporomandibular Joint Reconstruction System (now, TMJ Concepts Patient- Fitted Total Temporomandibular Joint Reconstruction System, Ventura, CA; previously referred to as Techmedica, Camarillo, CA, the CAD/CAM Patient-Fitted Total Temporomandibular Joint Reconstruction System). Patients and Methods: Questionnaires were mailed to the available addresses of 193 patients who had been implanted with Techmedica/TMJ Concepts devices between 1990 and Of 193 recorded addresses, 149 (77.2%) were valid, and 44 (22.7%) were returned by the US Postal Service as undeliverable. Two (1%) surveys were r ed; both were returned completed. A total of 61 (31.6%) surveys were returned properly completed. This represented 102 devices (41 bilateral, 20 unilateral), with a mean follow-up of 11.4 years (standard deviation [SD] 3.0; range, 0 to 14). Subjective data related to pain, perception of mandibular function, diet consistency, and current quality of life were collected with the use of visual analog scales. Objective measures of maximum interincisal opening (MIO) were obtained from direct measurements with the Therabite Measuring Scale (Atos Medical, Milwaukee, WI), which was provided in the survey along with instructions on its use. Results: Analysis of subjective data showed a significant reduction in pain scores and an increase in mandibular function and diet consistency scores (P.001). Analysis of objective data showed an improvement in mandibular range of motion after 14 years (P.02). Among all respondents, 85% reported quality of life (QOL) scores that showed improvement since baseline. Long-term quality of life improvement scores also were found to be statistically related to the number of previous temporomandibular joint operations the patient had undergone. Conclusions: Outcome data presented show that the Patient- Fitted Total Temporomandibular Joint Reconstruction System continues to be a safe, effective, and reliable long-term management modality for the specific patient population surveyed in this study. The incidence of 2 histologically distinct concurrent malignant tumors in adjacent anatomical regions of the head and neck is uncommon. When the presenting symptoms overlap, it can make their diagnosis very difficult. This article presents a case of a 72-year-old female patient with a left parotid low-grade mucoepidermoid carcinoma and a myxoid fibrosarcoma of the left temporomandibular joint (TMJ) condylar head in which the presenting symptoms were similar to those found on temporomandibular joint disorders (TMD) Xy WH, Ma XC, Guo CB, Yi B, Bao SD: Synovial chondromatosis of the temporomandibular joint with middle cranial fossa extension. Int J Oral Maxillofac Surg 36: , 2007 Mercuri LG: A rationale for total alloplastic temporomandibular joint reconstruction in the management of idiopathic/progressive condylar resorption. J Oral Maxillofac Surg 65: , 2007 Synovial chondromatosis of the temporomandibular joint (TMJ) is relatively rare. An unusual case with extension through the glenoid fossa and into the middle cranial fossa is reported. Invasion of the infratemporal fossa and the middle cranial fossa was seen on both computed tomography and magnetic resonance imaging. Complete removal of the loose bodies with excision of the affected synovium is the accepted treatment of synovial chondromatosis. A conservative approach should be followed while trying to eliminate any remaining lesion in the infratemporal fossa and the middle cranial fossa. An overview of previously reported cases of synovial chondromatosis with cranial extensions is also presented. Idiopathic condylar resorption (ICR), also known as progressive condylar resorption (PCR), is described by Arnett et al as a dysfunctional remodeling of the temporomandibular joint (TMJ) manifested by morphologic change (decrease condylar head volume), decreased ramal height, and progressive mandibular retrusion in the adult or decreased mandibular growth in the juvenile. Patients undergoing orthodontic treatment and/or orthognathic surgery can also be affected by ICR/ PCR, resulting in occlusal instability, maxillomandibular skeletal malrelationships, TMJ dysfunction, and pain. Management options have included orthotics to minimize excessive physical stress by decreasing the loading on the joint; non-loading orthodontic and orthognathic surgical procedures after 6 to 12 months of remission ; deferment of any treatment until complete remission ; arthroscopic lysis and lavage; total TMJ reconstruction with autogenous costochondral graft; maxillary orthognathic surgery only for correction of occlusal discrepancies only and to avoid involvement of the mandible; distraction osteogenesis; and combined bimaxillary orthognathic/tmj disc repositioning surgery. Based on the ICR/PCR pathophysiology model proposed by Arnett, accepted bone biology remodeling/resorption paradigms, review of the oral and maxillofacial surgery ICR/PCR management outcomes literature, and the author s experience with 8 cases, a rationale for the use of total alloplastic TMJ reconstruction in ICR/PCR will be presented.

4 Page 4 of Wolford LM, Pinto LP, Cardenas LE, Molina OR: Outcomes of treatment with custom-made temporomandibular joint total joint prostheses and maxillomandibular counter-clockwise rotation. Bayl Univ Med Cent Proc 21:18-24, 2008 The first 25 consecutive patients with high occlusal plane angulation, dysfunction, and pain who were treated with temporomandibular joint (TMJ) total joint prostheses and simultaneous maxillomandibular counterclockwise rotation were evaluated before surgery (T1), immediately after surgery (T2), and at the longest follow-up (T3) for surgical movements and long-term stability. Subjective ratings were used for patients facial pain/headache, TMJ pain, jaw function, diet, and disability, and objective functional changes were determined by measuring maximum incisal opening and lateral excursive movements. Results showed that the areas of greatest surgical change included an average decrease in the occlusal plane of 13.3 degrees with advancement at point B of 13.4 mm and at the genial tubercles of 16.3 mm. At longest follow-up, relapse was 0.7 degrees, 0.8 mm, and 1.2 mm, respectively, with no statistically significant changes. Significant subjective pain and dysfunction improvements were observed (P 0.001). Maximum incisal opening increased, but lateral excursion decreased. Those who had two or more previous TMJ surgeries showed greater levels of dysfunction at T1 and T3 than those who had one or no previous surgeries, but otherwise patients presented similar amounts of absolute changes. In conclusion, end-stage TMJ patients can achieve significant improvement in their pain, dysfunction, dentofacial deformity, and airway problems in one operation with TMJ reconstruction and mandibular advancement using TMJ custom-made total joint prostheses and simultaneous maxillary osteotomies for maxillomandibular counterclockwise rotation. This paper provides a review of the current knowledge of temporomandibular joint total replacement systems. An electronic Medline search was performed to identify all the relevant Englishlanguage, peer-reviewed articles published during Twenty-eight references were considered for review, seven of which were reviews, 17 clinical trials or case series, and four Guarda-Nardini L, Manfredini D, Ferronato G: Temporomandibular joint single-patient case reports. Therapeutic outcomes were encouraging for all three total prosthetic systems for which follow-up data from a consistent sample of patients exist. A lack of total replacement prosthesis: Current knowledge and considerations for the homogeneity between studies in patient selection and indications for the intervention was noted. A better integration between clinical and research settings is needed to achieve a future. Int J Oral Maxillofac Surg 37: , 2008 standardized definition of the rationale and indications for total temporomandibular joint replacement. Findings from the available studies are promising, and need to be confirmed by multicenter trials taking into account interoperator variability. Mercuri LG: Osteoarthritis, osteoarthrosis, and idiopathic condylar resorption. Oral Maxillofac Surg Clinics North Am 20: , 2008 Wolford LM, Morales-Ryan CA, Morales PG, Cassano DS: Autologous fat grafts placed around temporomandibular joint total joint prostheses to prevent heterotopic bone formation. Bayl Univ Med Cent Proc 21: , 2008 Sidebottom AJ: Assessment and initial management of temporomandibular joint disorders. ENT News 17:71-74, 2008 The term "osteoarthritis" has classically been defined as a low-inflammatory arthritic condition. The term "osteoarthrosis," a synonym for osteoarthritis in the medical orthopedic literature, has recently come to be identified in the dental/temporomandibular joint (TMJ) disorders literature with any noninflammatory arthritic condition that results in similar degenerative changes as in osteoarthritis. The term "idiopathic condylar resorption," also known as "progressive condylar resorption," is described as a dysfunctional remodeling of the TMJ manifested by morphologic change, decreased ramal height, progressive mandibular retrusion in the adult, or decreased mandibular growth in the juvenile. This article discusses the diagnosis and management of osteoarthritic TMJ disorders and idiopathic condylar resorption. 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 with total joint prostheses and simultaneous fat grafts (88 bilateral and 27 unilateral) for a total of 203 joints. The abdominal fat grafts were packed around the articulating portion of the joint prostheses after the fossa and mandibular components were stabilized. Patients were divided into two groups: group 1 (n = 76 joints) received Christensen total joint prostheses, and group 2 (n = 127 joints) received TMJ Concepts total joint prostheses. Clinical and radiographic assessments were performed before surgery, immediately after surgery, and at long-term follow-up. In group 1, maximal incisal opening (MIO) increased 3.5 mm, lateral excursions (LE) decreased 0.2 mm, and jaw function improved 1.9 levels. In group 2, MIO increased 6.8 mm, LE decreased 1.4 mm, and jaw function improved 2.4 levels. The improvement for MIO and patient perception of jaw function in both groups was statistically significant; no significant difference was found for LE. There was no radiographic or clinical evidence of heterotopic calcifications or limitation of mobility secondary to fibrosis in either group. Twenty-five Christensen prostheses (33%) were removed because of device failure and/or metal hypersensitivity; no fibrosis or heterotopic bone formation was seen at surgical removal. Four TMJ Concepts prostheses (3%) were removed because of metal hypersensitivity. In all instances, removal of the prostheses was unrelated to the autologous fat grafting. Ten patients (8.7%) developed complications involving the fat donor site: two patients (1.8%) developed abdominal cysts requiring surgery, and eight patients (6.9%) developed seroma formation requiring aspiration. Autologous fat transplantation is a useful adjunct to prosthetic TMJ reconstruction to minimize the occurrence of excessive joint fibrosis and heterotopic calcification, consequently providing improved range of motion and jaw function. Temporomandibular joint (TMJ) problems are a common cause of morbidity in general and ENT practice. Around 30% of the population will complain of problems related to the joint at some stage during their life, with around 10% of the population having one ormore TMJ symptomor sign at any one time. Differential diagnosis can be confusing and patients are often considered to have earache and referred for ENT advice. The following article will aim to aid the general practitioner and ENT surgeon in diagnosing TMJ disorders and in primary management, with advice when onward referral for maxillofacial surgery advice is appropriate. Multiple reports document that a foreign-body giant cell reaction forms around Proplast-Teflon temporomandibular joint (TMJ) implants. This results in destruction of surrounding bone and Abramowicz S, Dolwick MF, Lewis SB, Dolce C: Temporomandibular joint instability of the implants. This case presents a patient whose Proplast-Teflon TMJ implants became displaced into her middle cranial fossa. The staged reconstruction of this patient is reconstruction after failed teflon-proplast implant: Case report and literature described, including removal of the TMJ implants, reconstruction of the defect, concomitant orthodontic treatment and final reconstruction with TMJ Concepts1. This process involved a review. Int J Oral Maxillofac Surg 37: , 2008 multidisciplinary approach between several medical and dental specialties. At her 3-year follow up, the patient had a stable postoperative result. Mercuri LG, Ali FA, Woolson R: Outcomes of total alloplastic replacement with periarticular autogenous fat grafting for management of reankylosis of the temporomandibular joint. J Oral Maxillofac Surg 66: , 2008 Speculand B: Current status of replacement of the temporomandibular joint in the United Kingdom. Br J Oral Maxillofac Surg 47:37-41, 2009 Purpose: The purpose of this investigation was to review the subjective, objective, and quality of life outcomes in a group of temporomandibular joint (TMJ) reankylosis patients managed by total alloplastic replacement surgery with a patient fitted system augmented with periarticular autogenous fat grafts to prevent the reformation of heterotopic bone. A review of the literature regarding the use of autogenous fat as evidence for its efficacy in such cases is also presented. Patients and Methods: All 20 TMJ reankylosis patients (4 males, 16 females) who had undergone total TMJ replacement with the TMJ Concepts (Ventura, CA) Patient-Fitted Total TMJ Prosthesis System were studied. Thirteen patients had bilateral, 7 unilateral for a total of 33 joint replacements. All patients had autogenous fat harvested from the abdomen and grafted around the articulating portion of the prostheses at implantation. The patients subjective variable outcomes of TMJ pain, mandibular function, diet consistency, quality of life since the reconstruction, and objective variable of maximal interincisal opening were obtained in a detailed questionnaire and follow-up phone calls. Results: Analysis of the subjective outcomes data showed improvement in reported pain, increased jaw function, and diet consistency. Further, a significant number of these patients reported improvement in their quality of life after surgery. Analysis of the objective outcomes data showed a significant increase in the maximum interincisal opening postreplacement that was maintained. Conclusions: In the patients followed over the course of this study, total alloplastic replacement with a patientfitted prosthesis seemed to provide a safe and effective management for reankylosis of the TMJ. Autogenous fat transplantation seems to be a useful adjunct as its use seems to minimize the recurrence of joint heterotopic calcification, consequently providing improved and consistent range of mandibular motion Total replacement of the temporomandibular joint (TMJ) has been done in the UK since The three currently available systems are the Christensen system, the TMJ Concepts system and the Lorenz (BMF) system. Data from surgeons who replace TMJ were collated up to May There were nine units (eight NHS, one private) offering replacement. The TMJ Concepts system is the most popular of the three systems. Units are treating between five and 12 patients each year with an estimated total annual workload of patients. The current total costs range from to for bilateral replacement. The most worrying complication is infection, which may affect up to 2.6% of patients.

5 Page 5 of Dela Coleta KE, Wolford LM, Gonçalves JR, dos Santos Pinto A, Pinto LP, Cassano DS: Maxillo-mandibular counter-clockwise rotation and mandibular advancement with TMJ Concepts total joint prostheses: Part 1 Skeletal and dental stability. Int J Oral Maxillofac Surg 38: , 2009 Sidebottom AJ: Current thinking in temporomandibular joint management. Br J Oral Maxillofac Surg 47:91-94, 2009 Manemi RV, Fasanmade A, Revington PJ: Bilateral ankylosis of the jaw treated with total alloplastic replacement using the TMJ concepts system in a patient with ankylosing spondylitis. Br J Oral Maxillofac Surg 47: , 2009 Coleta KED, Wolford LM, Gonçalves JR, dos Santo Pinto A, Cassano DS, Gonçalves DAG: Maxillo-mandibular counter-clockwise rotation and mandibular advancement with TMJ Concepts total joint prostheses: Part II Airway changes and stability. Int J Oral Maxillofac Surg 38: , 2009 The purpose of this study was to evaluate skeletal and dental stability in patients who had temporomandibular joint (TMJ) reconstruction and mandibular counterclockwise advancement using TMJ Concepts total joint prostheses (TMJ Concepts Inc. Ventura, CA) with maxillary osteotomies being performed at the same operation. All patients were operated at Baylor University Medical Center, Dallas TX, USA, by one surgeon (Wolford). Forty-seven females were studied; the average post-surgical follow-up was 40.6 months. Lateral cephalograms were analyzed to estimate surgical and post-surgical changes. During surgery, the occlusal plane angle decreased 14.9 ± 8.0. The maxilla moved forward and upward. The posterior nasal spine moved downward and forward. The mandible advanced 7.9 ± 3.5 mm at the lower incisor tips, 12.4 ± 5.4 mm at Point B, 17.3 ± 7.0 mm at menton, 18.4 ± 8.5 mm at pogonion, and 11.0 ± 5.3 mm at gonion. Vertically, the lower incisors moved upward -2.9 ± 4.0 mm. At the longest follow-up post surgery, the maxilla showed minor horizontal changes while all mandibular measurements remained stable. TMJ reconstruction and mandibular advancement with TMJ Concepts total joint prosthesis in conjunction with maxillary osteotomies for counter-clockwise rotation of the maxillomandibular complex was a stable procedure for these patients at the longest follow-up. The management of temporomandibular joint (TMJ) disorders in secondary care has progressed through the 1990s from a condition dealt with by generalists to one with an increasing number of surgeons with a subspecialist interest. Within this latter group there is a subgroup of those with a specific training towards joint replacement surgery. Increasingly patients who previously had surgery for pain are being managed with non-surgical options. Alternative pain management regimens with the introduction of botulinum toxin as well as tricyclic medication have reduced the need for any invasive management. The surgical management of the TMJ has been revolutionised by the introduction of arthroscopy in the late 1970s. The use of arthroscopy and arthrocentesis has lead to a reduction in indications for open joint surgery. There is no longer a perceived need to correct internal derangement with disc repositioning surgery. The primary management of acute restriction of opening and joint pain is now with arthrocentesis and arthroscopy. Degenerative and ankylotic conditions of the joint can be safely treated by the use of alloplastic joint replacement, which has less morbidity and more predictable outcomes than costochondral grafting, with the latter still the method of choice in children. The revolution continues with the introduction of national guidelines and databases supported by BAOMS. Minimal documentation exists regarding bilateral temporomandibular joint (TMJ) involvement in ankylosing spondylitis (AS) and surgical management of this specific manifestation. Use of TMJ concepts prostheses in AS patients has not been previously described. This case demonstrates that TMJ replacement with prosthetic joints in AS is technically possible and appropriate. The purpose of this study was to evaluate the anatomical changes and stability of the oropharyngeal airway and head posture following TMJ reconstruction and mandibular advancement with TMJ Concepts custom-made total joint prostheses and maxillary osteotomies with counter-clockwise rotation of the maxillo-mandibular complex. All patients were operated at Baylor University Medical Center, Dallas TX, USA, by one surgeon (Wolford). The lateral cephalograms of 47 patients were analyzed to determine surgical and post-surgical changes of the oropharyngeal airway, hyoid bone and head posture. Surgery increased the narrowest retroglossal airway space 4.9 mm. Head posture showed flexure immediately after surgery ( 5.6 ± 6.7) and extension long-term post surgery (1.8 ± 6.7); cervical curvature showed no significant change. Surgery increased the distances between the third cervical vertebrae and the menton 11.7 ± 9.1 mm and the third cervical vertebrae and hyoid 3.2 ± 3.9mm, and remained stable. The distance from the hyoid to the mandibular plane decreased during surgery (-3.8 ± 5.8 mm) and after surgery (-2.5 ± 5.2 mm). Maxillo-mandibular advancement with counter-clockwise rotation and TMJ reconstruction with total joint prostheses produced immediate increase in oropharyngeal airway dimension, which was influenced by long-term changes in head posture but remained stable over the follow-up period. 47 end-stage TMJ patients with high occlusal plane angulation, treated with TMJ custom-fitted total joint prostheses and simultaneous maxillo-mandibular counter-clockwise rotation were evaluated for pain and dysfunction presurgery (T1) and at the longest follow-up (T2). Patients subjectively rated their facial pain/headache, TMJ pain, jaw function, diet and disability. Pinto LP, Wolford LM, Buschang PH, Bernardi FH, Gonçalves JR, Objective functional changes were determined by measuring maximum interincisal opening (MIO) and laterotrusive movements. Patients were divided according to the number of previous Cassano DS : Maxillo-mandibular counter-clockwise rotation and failed TMJ surgeries: Group 1 (0 1), Group 2 (2 or more). Significant subjective pain and dysfunction improvements (37 52%) were observed ( 0.001). MIO increased 14% but lateral mandibular advancement with TMJ Concepts total joint prostheses: Part excursion decreased 60%. The groups presented similar absolute changes, but Group 2 showed more dysfunction at T1 and T2. For patients who did not receive fat grafts around the III Pain and dysfunction outcomes. Int J Oral Maxillofac Surg 38: , prostheses and had previous failure of proplast/teflon and or silastic TMJ implants, more than half required surgery for TMJ debridement and removal of foreign body giant cell reaction and 2009 heterotopic bone formation. Endstage TMJ patients can be treated in one operation with TMJ custom-made total joint prostheses and maxillo-mandibular counter-clockwise rotation, for orrection of dentofacial deformity and improvement in pain and TMJ dysfunction; Group 1 patients had better results than Group 2 patients. Ingawale S, Goswami T: Temporomandibular joint: Disorders, treatments, and biomechanics. Ann Biomed Eng 37: , 2009 Coleta KED, Wolford LM, Gonçalves JR, dos Santos Pinto A, Cassano DS, Gonçalves DAG: Maxillo-mandibular counter-clockwise rotation and mandibular advancement with TMJ Concepts total joint prostheses: Part IV Soft tissue response. Int J Oral Maxillofac Surg 38: , 2009 Driemel O, Braun S, Müller-Richter UDA, Behr M, Reichert TE, Kunkel M, Reich R: Historical development of alloplastic temporomandibular joint replacement after 1945 and state of the art. Int J Oral Maxillofac Surg 38: , 2009 Temporomandibular joint (TMJ) is a complex, sensitive, and highly mobile joint. Millions of people suffer from temporomandibular disorders (TMD) in USA alone. The TMD treatment options need to be looked at more fully to assess possible improvement of the available options and introduction of novel techniques. As reconstruction with either partial or total joint prosthesis is the potential treatment option in certain TMD conditions, it is essential to study outcomes of the FDA approved TMJ implants in a controlled comparative manner. Evaluating the kinetics and kinematics of the TMJ enables the understanding of structure and function of normal and diseased TMJ to predict changes due to alterations, and to propose more efficient methods of treatment. Although many researchers have conducted biomechanical analysis of the TMJ, many of the methods have certain limitations. herefore, a more comprehensive nalysis is necessary for better understanding of different movements and resulting forces and stresses in the joint components. This article provides the results of a state-of-the-art investigation of the TMJ anatomy, TMD, treatment options, a review of the FDA approved TMJ prosthetic devices, and the TMJ biomechanics. The purpose of this study was to evaluate soft tissue response to maxillomandibular counter-clockwise rotation, with TMJ reconstruction and mandibular advancement using TMJ Concepts1 total joint prostheses, and maxillary osteotomies in 44 females. All patients were operated at Baylor University Medical Center, Dallas TX, USA, by one surgeon (Wolford). Eighteen patients had genioplasties with either porous block hydroxyapatite or hard tissue replacement implants (Group 2) 26 had no genioplasty (Group 1). Surgically, the maxilla moved forward and upward by counter-clockwise maxillo-mandibular rotation with greater horizontal movement in Group 2. Vertically, both groups showed diversity of maxillo-mandibular mean movement. Group 1 showed a consistent 1: 0.97 ratio of hard to soft tissue advancement at pogonion; Group 2 results were less consistent, with ratios between 1: 0.84 and 1: Horizontal changes in upper lip morphology after maxillary advancement/impaction, VY closure, and alar base cinch sutures showed greater movement in both groups, than observed in hard tissue. Counterclockwise rotation of the maxillo-mandibular complex using TMJ Concepts total joint prostheses resulted in similar soft tissue response as previously reported for traditional maxillo-mandibular advancement without counter-clockwise rotation of the occlusal plane. The association of chin implants, in the present sample, showed higher variability of soft tissue response. The variety of temporomandibular joint (TMJ) prostheses and condylar reconstruction plates available is in contradiction to their rare application. This emphasizes that alloplastic TMJ reconstruction is still evolving. This article reviews the history of TMJ reconstruction. Medline as well as public and private libraries have been searched. Current systems are reviewed. Prosthetic devices can be differentiated into fossa-eminence prostheses, ramus prostheses and condylar reconstruction plates, and total joint prostheses. Fossa and total joint prostheses are recommended when the glenoid fossa is exposed due to excessive stress (degenerative disorders, arthritis, ankylosis, multiply operated pain patients). Singular replacement of the condyle is preferred as a temporary solution in ablative surgery. The use of prosthetic devices for long-term replacement should be restricted to selected cases, taking care to retain the disk, in order to prevent penetration into the middle cranial fossa. The term condylar reconstruction plate reflects this more clearly than ramus prosthesis which suggests permanent reconstruction. Long-term studies comparing the functional and aesthetic results of the various prostheses and condylar reconstruction plates are not available, which leaves the choice to personal experience.