Recibido: 25-03-2004

Aceptado: 11-04-2004

Médico Adjunto.
Servicio de Cirugía Oral y Maxilofacial.
Complejo Hospitalario Juan Canalejo. La Coruña, España.

Correspondencia:
Alvaro García-Rozado González
Rúa Perseo 15
15179 Oleiros, La Coruña, España.
E-mail: agrozado@canalejo.org

Introduction

Despite the considerable technical advances in our field over the last decades, the reconstruction of the temporomandibular joint (TMJ) is still controversial, and it continues to represent an important challenge to Oral and Maxillofacial surgeons. Among the therapeutic proposals which have been put forward for tissue defects of anatomical structures of this joint, there is reconstructive abstinence, autogenous tissue reconstruction and joint prostheses.

At the beginning of the 21st century it would be difficult to justify the non-reconstruction of a TMJ. This would have considerable aesthetic consequences for the patient; mandibular excursion would be significantly compromised, with a clear ipsilateral-lateral deviation of the mandible, and a loss of basic functions such as mastication or even swallowing.

Complete reconstruction of TMJ by means of grafts of flaps from the patient himself is still the technique of choice in most cases. The principal advantage is the biological compatibility of autogenous tissues, the use of which is traditionally associated with reconstructive techniques. Other advantages that have been highlighted are the ease with which they can be surgically manipulated, functional adaptability, minimal capacity for infection and for the development of immunology mechanisms, and the reduction in medical costs.¹ The latter are characteristics that give reconstruction by means of autogenous tissue a greater role in the protection of the biological and functional well-being of the patient. The possibility of the patient experiencing additional injury in the event of therapeutic failure is unlikely and of little consequence, as opposed to what happens with alloplastic prostheses.

Controversies

There are multiple indications established for TMJ reconstruction. Among them congenital defects should be included, as well as congenital absence of the condyle or hypoplasia, or secondary defects associated with a neoplastic processes, ankylosis, severe trauma, osteoathritis, infectious illnesses, advanced rheumatoid processes, or secondary reaction to alloplastic implants in TMJ.^2,3 Currently, and especially in North America, a considerable number of these reconstructions are advised as a result of iatrogenic situations following «imprudent» condyle resections and, more commonly, due to progressive destruction of the mandibular condyle as a result of repetitive surgery or indiscriminate use of alloplastic material.

The objective of these complex reconstructions includes the restoration of three-dimensional morphology and mandibular function, diminishing the limitations and symptomatology of the patient, and preventing the progression of the illness.^4,5 At the beginning of the 21st century giving prudent consideration to costs and efficiency of the different treatments is indispensable. With all this in mind, the ideal method of reconstruction continues to date being controversial. Proof of this is the great variety of reconstructive techniques described in the literature, with autogenous grafts as well as with alloplastic material.

Another aspect which gives rise to discussion is the manipulation of the articular meniscus and masticatory muscles in total reconstruction of the TMJ. In the event of a meniscectomy being necessary, a great many authors prefer the replacement of the joint disc. Even though polyethylene was the first alloplastic material used for the repair of the joint disc, silicone and polytetrafluoroethylene (PTFE) polymers have been the most popular synthetic components by a long margin over the last twenty years.^6,7 However, due to clinical and biological difficulties derived from osteoclastic activity which started with alloplastic material,^8,9 the reconstruction of the meniscus with autogenous tissue is gaining more followers. Among the tissues that have been described as substitutes of the articular meniscus, of note is fascia lata, muscular tissue, laminated tendon, dermis, costal cartilage or auricular cartilage.^10-14 As well as the inevitable morbidity of the donor site, complications with these grafts have been described, some so severe such as the development of cystic degeneration in the area of the skull base following the use of dermal grafts.¹⁵ Other disadvantages of autografts are derived from their variable survival capacity in the sinus of a closed cavity such as the TMJ, or their dubious ability to support the forces of masticatory function.

Straddled between alloplastic material and autogenous grafts in the replacement of the articular meniscus is lyophilized dura, a homologous material that was the object of encouraging studies,¹⁶ but about which there is very little in recent bibliography. Similarly the use of lyophilized cartilage has been reported as replacement material for the articular meniscus of the TMJ.¹⁷

New technologies based on tissue engineering have permitted the development of cartilaginous tissue, which can be used, in a number of ways in the reconstruction of the head and neck, and also in the substitution of joint discs.¹⁸

With regard to the surgical manipulation of mastication muscles, some authors suggest lateral pterygoid myotomy and its reattachment to the condylar neck, below the level of the condylectomy, in order to achieve a greater restoration of joint function.¹⁹ With this technique better results have been reported in important parameters such as in interincisor opening and lateral and protrusive movements.

Autogenous grafts for the reconstruction of condyle defects

In the medical literature we find numerous publications, which advocate the advantages of reconstructing bone defects by means of autogenous grafts. In TMJ reconstruction various types of autogenous grafts have been used: costochondral, ^20-22 sternoclavicular,^23,24 fibular,²⁵ tibial, iliac crest,26 cranial calotte,²⁷ or metatarsal.^28,29 However, traditionally the most used by maxillofacial surgeons has been the costochondral graft.³⁰

The costochondral graft is autogenous tissue, which is traditionally the most accepted in TMJ reconstruction. Initially described by Gillies in 1920,³¹ the use of the cartilaginous component associated with the costal bone in temporomandibular arthroplasty was made popular by Longacre and Gilby in the 50´s decade.^32,33 The advantages described by McIntosh³⁴ are biological compatibility, simple work technique, accessibility, functional adaptability, versatility, and minimum additional morbidity for the patient. The growth possibility of the costochondral graft, due to the incorporation of growth centres in the transplant,³⁵ makes its application in child TMJ reconstruction ideal.

With regard to other autogenous grafts, the advantages of costochondral grafts reside in a low complication and morbidity incidence in the thorasic area, its adaptability to the mandibular bed, and especially the incorporation of a cartilaginous tissue pad which favours morphological and functional adaptation and reduces the later onset ankylosis. On the other hand, despite it being a non-vascularized graft, the costochondral graft appears to have less tendency to reabsorb, and on several occasions it has, with time, become larger and more resistant, even affecting the final result because of the excessive length of the ascending mandibular branch.³⁹ However, other authors prefer other reconstruction alternatives due to the inferior quality of the cortical and medical bone of the costochondral graft, the flexibility and elasticity of the bone, the facility for deformation on being subjected to continuous stress which gives rise to occlusal alterations, the possible separation of the bone and the cartilage of the graft, its possible fracture and unpredictable growth.^24,40

Among potential complications described, of note is the risk of fracture of the graft, infection with partial or total re-absorption of itself, morbidity of the donor site,⁴¹ the variable capacity of growth of the graft,³⁹ and especially the possibility of renewed ankylosis.⁴² Ankylosis following a costochondral graft is not very frequent, and in the majority of cases it occurs after a reconstruction carried out because of previous ankylosis. The interposition tissues described in the literature to minimize re-ankylosis are multiple, including temporal muscles, cartilage, fascia, fat, dermis, or skin (all of itNT).^10,14,43-46

In the literature there is certain controversy over the method of adaptation of the graft and its fixation.^47-49 Even though some authors prefer the use of mini-plates for the fixation of grafts, including making a «green stick» fracture so as to increase adaptation to the ascending mandibular branch and glenoid fossa, fixation with bicortical screws is equally suitable⁵¹ (Figs. 1 and 2).

Some authors consider that the sternoclavicular graft offers significant advantages as it is embryologically and histologically similar to the mandibular condyle, and with regards to potential growth, it is adaptable to the mandibular condyle area.^23,40 Wolford et al²⁴ defend the sternoclavicular graft obtained from the cranial half of the contralateral clavicle. Using the criteria that therapeutic success consists in the reduction or elimination of pain, obtaining stable occlusion and adequate mobility of the jaw, with an inter-incisor opening superior to 30 mm, these authors find better results in cases not previously reconstructed with prosthetic systems in which there is neither inflammatory pathology of the joint. In these cases, therapeutic success is rated as 93% of patients. Complete reconstruction of the TMJ with a portion of the sternal manubrium to substitute the portion of temporal bone of the joint has even been described.²³

Some authors favour the use of the sternoclavicular graft for the reconstruction of the mandible for growing patients, defending that growth capacity is compatible with the ascending branch of the mandible. However, others consider that there are no significant differences in the potential for mandibular growth between reconstructions with sternoclavicular and with costochondral grafts.^40,52

On the other hand, other authors consider that surgical complexity of the sternoclavicular graft, and potential morbidity of the donor site, have been discouraging with regard to their application in general as substitutes for the mandibular condyle.¹ In the clavicular donor site, 10% clavicular fractures have been reported, 50% of which required open reduction. ²⁴

Metatarsal bone grafts have a long history as condyle substitutes, since Bardenheuer first described them in 1906.⁵³ They permit an excellent anatomical adaptation to the temporal fossa, but the absence of cartilage favours the development of ankylosis. Even though they conserve a potential for epiphysarian growth, their capacity for adapting to the growth and function of the mandible does not appear to be adequate. Studies by Dingman and Grabb in the mid-sixties²⁸ showed that there was a progressive re-absorption of non-vascularized metatarsian grafts used in the reconstruction of the condyle in five patients, with the resulting retrognathia and lateral deviation of the mandible. This led to the technique being abandoned. Later, in 1986, Datillo et al⁵⁴ published the successful reconstruction of the TMJ with the second, free, vascularized metatarso phalangeal joint, pedicled to dorsalis pedis artery and comitant veins. Other later works, despite only being in a reduced number of cases, confirmed the suitability of this reconstruction technique in condyle defects, with excellent aesthetic and functional results, including long term follow-up cases^55,56 and growing patients.⁵⁷

The invasion by osteogenic distraction mechanisms has meant a great advance in the reconstructive options for the head and neck. Even though the possibilities go beyond the scope of this article, considering bone reconstruction at the present time is impossible, without giving some thought to the uses, which the distractors on the market give us. Numerous references can be found in the medical literature on bone transport and distraction of the ascending mandibular branches to replace a condyle,^58-60 and even on distraction of autogenous grafts previously used for refinement of aesthetic and functional results.⁶¹

The principal disadvantages that are attributed to autogenous grafts in reconstruction of the TMJ are derived from the addition of inevitable donor site morbidity, and of the variableness of biological behaviour with regard to reabsorption capacity, development of ankylosis, and growth of the graft.³⁴ However, the greatest disadvantage is probably that the start of postoperative rehabilitation of the joint is delayed.^5,62

The role of microsurgery in TMJ reconstruction

At the present time, the transfer of vascularized, autogenous tissue based on microsurgery techniques, is a form of treatment widely accepted in our anatomic area. Studies based on clinical evidence and experience suggest that associated morbidity is relatively low and the risks, from the patient's point of view, are acceptable. In this sense, the principal advantages of microsurgical temporomandibular reconstruction are the best tri-dimensional stability in the long term, reconstructive versatility and the minimum capacity for developing complications.⁶³

The reconstruction of the TMJ with vascularized metatarsal has been mentioned previously. In 2003, Landa et al⁵⁶ published excellent results in a long-term following of 5 patients reconstructed with the second microvascularized metatarso phalangeal joint.

Even though microsurgical reconstructions of the TMJ have been described with the iliac crest,^64,65 the free flap most frequently used in these reconstructions is the fibula. In our clinical practice, the majority of cases do not concern specific TMJ reconstructions, rather a wide range of mandibular defects, which involve this joint (Fig. 3). The philosophy behind functional reconstruction with the insertion of soft tissue and the fixation of muscular structures to the neocondyle, allows better functional results to be achieved in the long term. Mitek^® type anchor systems have proved their usefulness in this type of reconstruction (Figs. 4,5 and 6).

Similarly, excellent results have been found in the literature with microvascularized fibular flaps in children.⁶⁷

Even though there is an unpredictable tendency for re-absorption and degenerative changes in the long term, disadvantages classically attributed to free nonmicrovascularized grafts; there are also references in the literature to morphological alterations in longer follow- up studies of vascularized bone grafts. Guyot et al68 found that the fibular neo-condyle in radiological long-term follow-ups remodelled itself in terms of rounding and thinning of the stump.

Recurrent dislocation of the TMJ

Two main groups of surgical techniques have been described for cases of recurrent dislocation of the TMJ: the first group of surgery designed to eliminate the possible factors which lead to the condyle blocking before the articular eminence and a second group which aimed to minimize the excursions of the mandibular condyle during oral aperture.

In this article on reconstruction of the TMJ with autogenous grafts, we refer to those surgical techniques intended to create an obstacle for the translation of the mandibular condyle during oral aperture through augmentation of the height of the temporal eminence. This is done by means of a glenotemporal osteotomy and the interposition of an inlay graft in the articular eminence, a technique made popular by Norman. Even though excellent results with alloplastic materials⁷⁰ have been described, the advantages of autogenous tissue are equally stated in these cases. The large majority of authors defend the use of bone grafts obtained from the neighbouring temporoparietal region, with the additional advantage that the same surgical incision used^71,72 (Figs. 7 and 8). In spite of this, other authors prefer the use of grafts from the iliac crest.⁷³

Discussion

Surgical intervention of the temporomandibular joint has two main objectives: restoration of the joint's normal anatomy, and the decompression of joint structures. Both requirements should lead to a clinical situation of lack of pain and the recovery of joint function. These final objectives have to be very present when considering the option of reconstruction of the TMJ.

There is no doubt at present as to the excellent results, which can be achieved with autogenous grafts in the reconstruction of the TMJ. However, what has been noted has been that the incidence of pain, especially with recurrent ankylosis and complications, is greater in those patients that have been subjected to multiple interventions of the joint.⁷⁴ According to some authors, total replacement of the TMJ structures with certain alloplastic prostheses can give better results in patients that have been subjected to multiple interventions and that have avascular necrosis of the condylar segment.^75-77 However, other authors propose a more spread out approach using autogenous tissue as a definitive reconstruction technique.¹

With patients that have experienced treatment failure with alloplastic prostheses, and removal has been necessary, it has been demonstrated that the osteoclastic reaction persists even after the removal of the implant, probably as a result of the dissemination of particles into the adjacent soft tissue.⁷⁸ Because of this, eliminating all adjacent, pathological tissue is advised before planning renewed reconstruction. ¹ It would only be normal to be inclined towards the placement of another prosthesis. However, some authors prefer monitoring a patient during at least 12 months, clinically as well as radiologically, so as to evaluate any sign of progression of the pathological situation, and only then carry out secondary reconstruction of the TMJ with autogenous grafts.^1,34 This philosophy of delaying autogenous reconstruction allows for the maturing of scar tissue, obtaining revascularization, re-establishing muscle tone, and resolving or minimizing previous inflammatory responses. Premature re-intervention would increase potential morbidity, scarring and the risk of redevelopment of ankylosis.

Some authors consider that the TMJ prostheses are better for reproducing the normal anatomy of the joint, restoring vertical dimension with greater fidelity.⁷⁹ The recent development of made-to-measure, individual prostheses for each patient^80,81 has, in this respect, had a great influence. In all events, autogenous tissue has traditionally demonstrated an adequate surgical malleability regarding defect adaptation. This "adaptability" of autogenous grafts even appears to persist spontaneously, and once placed in the recipient bed, they adapt and re-mould themselves adequately to the function to which they are subjected.⁴⁷

Other advantages, which are commonly attributed to the TMJ prostheses, refer to prevention of donor site morbidity, decrease in operative time, immediate initiation of physical rehabilitation and minimizing the recurrence possibility of joint ankylosis. The discomfort which autogenous reconstruction produces in the patient in the donor site is obvious. However, it rarely entails any significant predicament for the patient, and there is generally a favourable riskbenefit balance. If this is not the case, the reconstruction criteria of the surgeon should obviously be different.

In a comparative study of autogenous grafts and prostheses in a group of patients with similar pathologies of TMJ Saeed et al⁸² found excellent results in subjective parameters such as pain and mastication limitation, and in objective parameters such as inter-incisor opening. The patients in both groups showed a significant improvement in symptomatology. However, the number of patients that needed further surgical intervention was greater in the autogenous graft group.

The potential disadvantages of alloplastic prostheses are fundamentally determined by their poor wear characteristics and material breakdown. At the same time these materials can lead to a release of particles, which set off foreign body reaction, and this can lead to important osteoclastic activity by giant cells. The physiopathological mechanism of this destructive reaction is not yet altogether comprehended, even though Zardeneta el al⁸³ proposed that it was the adherence of reactive proteins to liberated particles of polytetrafluoroethylene (PTFE) that lead to a immunological response. Other studies have demonstrated that foreign materials stimulate certain cellular responses like the secretion of inflammatory mediators such as the interleukin -1 or prostaglandin E -2.^84,85

There are abundant reports in the medical literature on the release of residual particles in neighbouring soft tissue next to the prostheses, as well as the dissemination of regional lymphatic ganglia.^75,78,86,87 This liberation of residue seems even to continue following the removal of the prosthesis. In this sense, the destructive activity seems progressive over time, and many patients that have not experienced it are susceptible to suffering devastating consequences with the passing of time. All these circumstances can lead to potential loss of the implant, destruction of neighbouring tissues, deformation or re-absorption of the fossa or eminence. This can lead to potential intracranial complications, or set off an occlusal change, displacement of the prosthesis, or even its fracture. The osteolysis process around the fixation screws or around the prosthesis itself could lead to its complete instability and encourage a fibrosis process and the re-absorption of neighbouring structures.

Some authors stress the lack of flexibility of these prostheses for adapting to the morphology of the ascending mandibular branch, especially the length, and their limited adaptability to the glenoid fossa, as an additional element in the development of all these complications.¹ Aside from this is its morphological long-term stability, which is not recommended in growing patients.⁵ Other disadvantages described of heterologous material are its capacity for causing the formation of dystrophy bone, the development of severe infectious complications, and the substantial increase in costs associated with this reconstruction.⁸⁹

Some patients report discomfort due to the absence of lateral motility, and with metal prostheses neuralgias appear and sensitivity disorders in cold temperatures. On the other hand, with other non-metallic systems made with acrylic or silicone derivatives, in addition to being less resistance to the forces have to be supported, soft tissue complications can develop such as skin and mucous dehiscence, or inflammatory responses. In the case of tumours which are likely undergo radiotherapy, the possibility of developing complications is increased enormously due to vascularization being impossible.

The addition of a glenoid cavity-like alloplastic element in the prosthetic system of the TMJ permitted a better relation between the superior and inferior joint neo-surfaces, presumably a better functioning of the system, and additional protection for the cranial cavity. However, there is an increase in the capacity for developing infectious complications, destructive reactions of giant cells, re-absorption of anatomic structures and development of restrictive fibrosis between the implants and live tissue. All these disadvantages have led some authors to affirm that the reconstruction of the TMJ with alloplastic prostheses is only a second option in nearly all cases.^1,34

In the decade of the 70s and the 80s, we have witnessed an unusual increase in the number of surgical intervention of the TMJ. In North America this surgical boom has been especially remarkable, based on a series of circumstances. On the one hand, North American specialists in Oral and Maxillofacial surgery developed a special interest in TMJ surgery probably due to the training of an excessive number of young specialists for the social needs of that moment, who found and excellent opportunity for satisfying their professional and intellectual expectations with this type of surgery. These circumstances coincided with a phase of intense commercial effort to popularise the replacement of joint structures with alloplastic material. Thirdly, there is a certain associated consensus on the part of insurance companies with regard to generous refunds for this type of surgery.³⁴

With all these premises, there is currently a general idea that, in those times, interventions on the TMJ were too many and too aggressive, and that on many occasions there have been disastrous consequences as a result of this. Great part of that iatrogenic therapy was the result of the abuses of alloplastic materials for the reconstruction of the glenoid fossa, the articular disc or the mandibular condyle. It is currently impossible to establish just how much of that iatrogenic therapy could have been avoided with more rational indications for TMJ surgery and the use of autogenous tissue for reconstruction.

All these considerations, together with the histological and functional characteristics which surround this joint, lead authors of recognized international prestige such as McIntosh, ¹ to limit the indications for TMJ replacement with alloplastic prostheses to geriatric patients and to temporary reconstructions following ablative surgery, and until there is later reconstruction with autogenous grafts once the potential for a pathological relapse has been minimized.

Other authors,⁵ on the contrary, consider that in complex reconstructions the primordial objective is the restoration of mandibular function and form, and that the reduction of pain is a secondary objective, as it is an intrinsic component of joint dysfunction. They defend in this way the reconstruction with alloplastic material as it allows for better bio-mechanic rehabilitation, without taking into consideration the biological response to the pathology of the TMJ to the same degree.

The meticulous surgeon has to recognise that the reconstruction of the TMJ by means of autogenous grafts is not exempt of potential complications and sequelae. However, these difficulties are more predictable and much more rectifiable than the secondary ones of joint prostheses.

Conclusions

Autogenous tissue has to date given better service and versatility than alloplastic prostheses in the reconstruction of TMJ. This does not signify that autogenous grafts and flaps are not exempt from complications and sequelae, but these are less frequent and more rectifiable than those caused by prostheses. Also, the possibility for introducing additional complications for the patient is clearly inferior.

Over the next years we will probably witness changing reconstructive tendencies in conjunction with technological advances in biomaterials and in tissue engineering.^90,91 Until this technological breakthrough arrives, which will allow us to overcome the disadvantages of using alloplastic prostheses, autogenous tissue will continue being the better reconstructive option in a greater proportion of cases.

Acknowledgements

Our thanks to Dr. Martin-Granizo for his kind invitation to carry out this work.

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