Larry M. Wolford

Treatment Outcomes for Temporomandibular Joint Reconstruction After Proplast- Teflon Implant Failure

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.(ABSTRACT TRUNCATED AT 250 WORDS)

Modification of the mandibular ramus sagittal split osteotomy

The sagittal split osteotomy of the mandibular ramus is a common procedure used in the correction of mandibular deformities. Modifications of the procedure will be presented for advancement and setback of the mandible. Major advantages of this technique include controlled splitting of the segments and predictable positional control of the proximal segment. The advantages and disadvantages of rigid skeletal stabilization are discussed, as well as application to the modified mandibular ramus sagittal split osteotomy.

Custom CAD/CAM total temporomandibular joint reconstruction system: Preliminary multicenter report☆

PURPOSE The purpose was to test the outcome of a custom computer assisted design/computer assisted manufactured (CAD/CAM) total temporomandibular joint (TMJ) reconstruction system. PATIENTS AND METHODS 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). 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. CONCLUSION 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.

Soft tissue changes associated with double jaw surgery

The purpose of this study was to evaluate the amount, direction, and predictability of the soft tissue changes associated with simultaneous maxillary impaction and mandibular advancement surgery. The results suggested that the soft tissue responses were similar to those seen in single jaw procedures, with the exception of the changes seen in the nasolabial angle and in the area of the lower lip and chin. The type of soft tissue manipulation employed, in particular the use of the alar base cinch suture and V-Y closure techniques, were important factors in determining the response of the upper lip to the surgery. The maxillary soft tissues moved forward 90% of the hard tissue change and showed 20% shortening of the upper lip, with the changes in the nasolabial angle being due primarily to the degree of the maxillary rotation. A predictable progressive increase was seen in the horizontal movement of the mandibular soft tissues ranging from 73% of the hard tissue change at the lower lip to 100% at pogonion. The vertical movement of the mandibular soft tissue was greater than that of underlying hard tissues, particularly in the area of the lower lip as it was freed from the effects of the maxillary incisors.

Long-term bone ingrowth and residual microhardness of porous block hydroxyapatite implants in humans.

PURPOSE This study examined the ingrowth of bone into coralline, porous hydroxyapatite (HA) block (Interpore 200) over long periods after orthognathic surgery and analyzed their microhardness as a measure of the structural integrity of the ingrown bone as well as of the HA. MATERIALS AND METHODS Twenty-five maxillary HA implants (4 to 138 months of implantation; mean, 32 months) were removed from 17 patients. These implants had been placed into the lateral maxillary wall, juxtapositioned to the maxillary sinus during orthognathic surgery, and were harvested for analysis after voluntary consent. RESULTS Microscopic examination showed normal bone morphology in all implants; no inflammatory response was observed. Histomorphometric measurements indicated that there was significant bone ingrowth in all implants, with an overall mean of 23+/-7% bone (range, 7% to 31%), 51%+/-7% HA matrix (range, 39% to 65%), and the remainder being soft tissue or void at 26%+/-9% (range, 10% to 40%). No significant difference in microhardness values between the bone in the implant and the bone surrounding the implant was noted, indicating that the structural integrity of the porous block HA/bone aggregate had been maintained. Bone ingrowth appeared to plateau around 20 months, reaching an equilibrium in which the relative amount of osseous tissue remained constant. CONCLUSION Based on the findings in this study, porous block HA is a viable material for long-term implantation in the maxilla during orthognathic surgery.

Idiopathic condylar resorption: Diagnosis, treatment protocol, and outcomes

Idiopathic condylar resorption is a poorly understood progressive disease that affects the TMJ and that can result in malocclusion, facial disfigurement, TMJ dysfunction, and pain. This article presents the diagnostic criteria for idiopathic condylar resorption and a new treatment protocol for management of this pathologic condition. Idiopathic condylar resorption most often occurs in teenage girls but can occur at any age, although rarely over the age of 40 years. These patients have a common facial morphology including: (1) high occlusal and mandibular plane angles, (2) progressively retruding mandible, and (3) Class II occlusion with or without open bite. Imaging usually demonstrates small resorbing condyles and TMJ articular disk dislocations. A specific treatment protocol has been developed to treat this condition that includes: (1) removal of hyperplastic synovial and bilaminar tissue; (2) disk repositioning and ligament repair; and (3) indicated orthognathic surgery to correct the functional and esthetic facial deformity. Patients with this condition respond well to the treatment protocol presented herein with elimination of the disease process. Two cases are presented to demonstrate this treatment protocol and outcomes that can be achieved. Idiopathic condylar resorption is a progressive disease that can be eliminated with the appropriate treatment protocol.

Hydroxylapatite as a bone graft substitute in orthognathic surgery: Histologic and histometric findings

The use of porous hydroxylapatite (HA) as a substitute for bone in grafting associated with orthognathic surgical procedures was studied histologically and histometrically. The surgical procedures included maxillary downgrafting, advancement, setback, superior repositioning with expansion, and mandibular advancement and chin augmentation. Seventeen biopsies were obtained from nine patients after successful healing from 4.7 to 16.4 months postoperatively. Anatomic sites of the biopsies included maxillary wall, interdental region, palatal midline, chin, and mandible. In addition, nine implants representing six planned and three unplanned exposures were retrieved from nine patients. One biopsy from a successful implant was decalcified and thin-sectioned to provide better cell detail of the antral lining of the implant. The remaining biopsies were sectioned undecalcified to permit backscattered electron imaging with a scanning electron microscope. Each of the 17 biopsy specimens contained bone ingrowth. The decalcified specimen showed an intact submucosa with loss of the mucosal epithelium due to prolonged acid exposure. The biopsies were composed of 48.5% HA matrix, 18.0% bone ingrowth, and 33.5% soft tissue or vascular space. The HA matrix surface area averaged 9.4 mm2/mm3 with 62.1% of the surface covered by appositional bone ingrowth. The nine exposed implants contained connective tissue ingrowth only at their margins, with little or no bone being present. This graft-like biologic response to a porous HA matrix confirmed its ability to serve as a bone graft substitute in clinical applications. The absence of any decrease over time confirmed the relative permanence of the HA matrix. The lack of inflammatory cells in the biopsies, along with the formation of a connective tissue protective barrier in the exposed specimens, suggests that host responses to contamination were not impaired by the porous HA matrix.

Occlusal plane alteration in orthognathic surgery

This article discusses correction of functional and esthetic deformities by surgically increasing or decreasing the occlusal plane angulation. Clockwise rotation, or increase of the occlusal plane angulation, is a well-accepted technique in orthognathic surgery. However, counterclockwise rotation (decrease of the occlusal plane angulation), has not been a well-accepted treatment approach. The functional and esthetic characteristics of the low occlusal plane and the high occlusal plane facial types are presented, specific surgical approaches to alteration of the occlusal plane are described, and the long-term stability of results with both clockwise and counterclockwise rotations of the occlusal plane are discussed. Cases illustrating the application of these surgical approaches are presented.

Sternoclavicular grafts for temporomandibular joint reconstruction

This study evaluated the long-term outcomes of 52 sternoclavicular grafts for temporomandibular joint (TMJ) reconstruction in 38 patients. Patients were divided into three groups according to preoperative diagnosis and evaluated an average of 45 months (range, 10 to 84 months) postsurgery. Group 1 consisted of 14 patients (24 joints) with previous Proplast/Teflon implants (P/T; Vitek, Inc, Houston, TX;); successful reconstruction was achieved in only four patients (29%) and seven joints (29%). Group 2 included 10 patients (14 joints) with inflammatory TMJ pathology (non-P/T); success occurred in five patients (50%) and eight joints (57%). Group 3 consisted of 14 patients (14 joints) with non-P/T and noninflammatory TMJ pathology. Success in this group occurred in 13 patients (93%) and 13 joints (93%), with only one failure. The results of this study support the use of the sternoclavicular graft for TMJ reconstruction in a select group of patients and demonstrate a high failure rate in patients with previous P/T implants.

Occlusal plane alteration in orthognathic surgery–Part II: Long-term stability of results

Alteration of the occlusal plane may be indicated in patients who present with either low occlusal plane (LOP) facial type or the high occlusal plane (HOP) facial type. Surgical alteration with double jaw surgery to increase or decrease the occlusal plane angulation may be required to achieve optimal functional and esthetic results. This study evaluated the stability of results in two groups of patients. Group 1 consisted of 14 patients who underwent surgical increase of the occlusal plane angulation with a postsurgical follow-up average of 23 months. The average surgical increase in occlusal plane angulation was 5.6°. Several anatomic landmarks were evaluated relative to stability of results. Postsurgical changes that were statistically significant included a postsurgical anterior facial heigh change (-0.8 mm), ramus height change (-0.3 mm), and a change in mandibular plane angle (-0.5°). These changes were due, in part, to the removal of the occlusal splint allowing some autorotation of the mandible superiorly and settling in of the occlusion. There was no significant change in any of the other parameters evaluated. Group 2 consisted of 27 patients, with a mean follow-up of 21 months, that had an average surgical decrease in occlusal plane angulation of 8.8° with double jaw surgery. There was an 8 mm advancement of the mandible at point B, and a 10 mm advancement at pogonion. The maxilla was moved 3 mm superiorly at point A, and the maxillary first molar showed no significant vertical movement. The postsurgical changes demonstrated no statistically significant horizontal movement of the mandible. There were significant changes for the horizontal position of point A (-0.5 mm) and maxillary depth (-0.5°). The posterior aspect of the maxilla settled superiorly an average of 1 mm. There was statistically significant decreases for anterior facial height (-1.7 mm) and the vertical height of the ramus (-0.7 mm), which were at least partially due to the removal of the interocclusal splint and the settling in of the occlusion. This study confirms the stability of increasing or decreasing the occlusal plane angulation with double jaw surgery in the presence of healthy and stable temporomandibular joints.