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To cite this version: Boutault, Franck and Cavallier, Zoé and Lauwers,
Frédéric and Prevost, Alice Temporomandibular joint arthroplasty for
osteoarthrosis: a series of 24 patients that received a uni- or bilateral
inter-positional silicone sheet. (2018) Journal of Stomatology, Oral and
Maxillofacial Surgery, 119 (3). 199-203. ISSN 2468-7855
Temporomandibular
joint
arthroplasty
for
osteoarthrosis:
A
series
of
24
patients
that
received
a
uni-
or
bilateral
inter-positional
silicone
sheet
F. Boutault
*
,
Z.
Cavallier,
F.
Lauwers,
A.
Prevost
MaxillofacialSurgeryUnit,centrehospitalo-universitairedeToulouse,placeBaylac,31059Toulouse,France
1. Introduction
Theterm‘‘osteoarthrosis’’isfrequentlyconfusedwith ‘‘osteo-arthritis’’,whichcan bealsousedtocharacterizeosteoarticular degradationcausedbydifferentaetiologies,eitherinflammatoryor not[1].Theexactdefinitionof‘‘arthrosis’’focusesonthelossof cartilaginous surface leading to structural modifications tothe underlyingbone.Thesedegradationscanbecausedbyexcessive loading,acongenitalabnormality,aninflammatorydiseaseora posttraumaticevent,but is often simplycaused by thenormal ageing process. Osteoarthrosis of the temporomandibularjoint (TMJ)isaccompaniedbyseverealterationstothediscalcomplex andcanleadtoitstotaldestruction.Thereareseveralaetiologies for TMJ osteoarthrosis, including occlusal disturbances, post-traumaticsequelae,inflammatorydiseaseorcongenitalcondyle
dysplasia. Osteoarthrosis sometimes occurs after TMJ previous surgery,byexampleforasimplediscaldysfunction.
Clinical symptoms include articular noise, limited mouth opening(MO)andpain,whichcanbepermanentand isalways aggravatedbymastication.Oneneedstodistinguishosteoarthrosis fromTMJankylosis,wherethereismuchmoreseveredifficultyin MO,butonlyminorornopainandnoarticularnoise.Adiagnosis needstobeconfirmedfromavolumetricX-ray(CTscanorCone Beam), which shows collapse of the joint space, condyle deformation,thepresenceofgeodesorosteophytesandlimited motion.
Itisgenerallyagreedthatnon-invasivetreatmentsneedtobe tried first, suchas pharmacotherapy,physiotherapy or occlusal adjustments, with or without splints [2,3]. Surgery is only proposed for severe and persistent pain and/or functional impairment.Eventhoughsomeauthorsreportgoodearlyresults afteradiscectomy[4],IoannidesandFreihoferreported,in1988, thatalargenumberofstudieshadfoundprogressivedegradation ofclinicalandradiologicalstatus[5].However,thereiscurrently Keywords:
Temporomandibularjoint Osteoarthrosis
Interpositionalarthroplasty
Purpose:Toevaluatemid-termresultsfromusingasiliconesheetforinter-positionalarthroplastyin moderateorseverecasesofosteoarthrosisofthetemporo-mandibularjoint(TMJ).Toalsodetermineany remainingindicationsfromthismethod.
Patients andmethods:This retrospectivestudy includedpatientsthat underwentsurgery between 2008and2016.Pre-andpost-operativemouthopening(MO),accordingtointer-incisaldistance(mm) andpainscore(PS:0=nopainto4=veryseverepain)wererecordedfor24patients.Patientswere dividedaccordingtothicknessofthesiliconesheet(groupA:1.0mm,groupB:1.5mm).
Results:Thecohortincluded22females(92%).Meanageatsurgerywas55years13(26–80).Mean lengthoffollow-upwas26months24(6–80).MeanimprovementinMOwas8.2mm(+33%)andofPSwas 1.7(ÿ68%).MOwasnotimprovedfortwopatientsandworsenedforone.PSscoreimprovedforallpatients. NostatisticaldifferencewasfoundbetweengroupsAandB.Therewasalsoatendencyfordegradationof outcomesovertime.
Conclusion:Thepoorreputationofprostheticdiscoplastywasnotasevidentinourseries,eventhough anatomicalandfunctionalstatusseemedtodeteriorateovertime.Thisisbecausetotal-jointprosthetic replacementisoftenproposedinstead.However,forelderlyorfragilepatientsthathaveseverepain,and regardingcost-benefitaspects,conventionalarthroplastycanstillbediscussed,especiallysinceFrench nationalhealth-careinsurancedoesnotyetsupportTMJprostheticreplacementforosteoarthrosis.
* Correspondingauthor.
general agreement on the necessity for disc replacement, particularlyincasesofosteoarthritis.Thisrequiresinterposition ofabiologicaloralloplasticmaterialinsteadofadiscalcomponent. Many interpositional materialshavebeenusedover thelast decades[6].Amongthem,Siliconesheets(Silastic1)iseasytouse
buthaveprovidedvariableresults.Foreachofthesereconstruction methods, several complications and poor outcomes have been described,leadingmanytoconsiderthattotalprosthetic replace-ment of the TMJ could be the best approach for cases of degenerativeosteoarthrosis[7].
Wehavecarriedoutinterpositionaldiscoplastyusingasilicone sheetformanyyearsinourdepartmentforcasesofmoderateor severedegenerativeTMJwithpermanentpainandlimitedMO.The primary objective of this study was to assess the technical specifications and evaluate mid-term results. The secondary objective wastodiscussthebenefit/riskratioand comparethis withtotal-jointprostheticreplacementandassessanyremaining indicationsfromthismethod.
2. Materialsandmethods
This retrospective study on TMJ surgery was performed between2008and2016.Weincludedaseriesof24patientswho benefited from arthroplasty with discoplasty and inserting a silicone sheet. Thirty joints were operated on using this technique;abilateralprocedurewasachievedforsixpatients. The inclusion criteria were patients were aged 18years; limited MO (but >15mm: if it was less, the pathology was classifiedasankylosis),severepainthatrequireddaily analge-sics, radiographic symptoms of osteoarthrosis but without fusionofthe bonecomponents,noprevioustraumaticlesions apart from those from a previous intervention,andfailure of conservativetreatments.
The surgical procedure was performed under general naso-endotracheal anaesthesia using a pre-auricular cutaneous ap-proach.Thejointwasexposedafterelevatingtheperiosteumofthe zygomatic arch and thecapsule was incised using a T-shaped model.Thefirststepwaseminectomy,asdescribedbyMyrhaug [8],toenhancevisibilityandtopermitremovalofresidualdiscal fragments. The articular surfaces were smoothed under direct visionwithacondyloplastythatincludedthelateralandmedial partofthecondyle,leadingtorestorationofaregularinterface.The height and regularity of the interface was finally checked in maximal intercuspidation position. For edentulouspatients, we usedtheirdentalprosthesis,ifavailable.
Thesecondstepofsurgerywastoreplacethediscwithasilicon sheet(Silastic1)1.0or1.5mmthickandcutintoa2.5mmsquare
withroundedcorners.Itwassecured usingthreetrans-osseous non-resorbablesutures,asshownonFig.1.Suctiondrainagewas insertedfor24haftersurgerybeforeclosingthewoundinlayers. All patients received a prophylactic antibiotherapy and an antalgicprotocoladjustedbythevisualanaloguescale.Theywere instructedtoeatanon-chewydietfor4weeksaftersurgery.Mild physiotherapy wasprescribedatonemonthaftersurgerywhen therewaslimitedMO.Allpatientswereseenforleastat6months postoperatively,andthenatvarioustimesdependingonaspectsof individualcases.
Overall,thefollowingparameterswererecorded:aetiological context,themodelofthesiliconsheet(dependingonitsthickness), the initialpostoperative evolution plus any eventual complica-tions, lengthofthefollow-upinmonths,MO(correspondingto inter-incisal distance in mm) preoperatively and at the final follow-up,andpainscore(PS),scaledfrom0to3(nopain,light pain,severepain,veryseverepain)preoperativelyandatthelast follow-up.
Thisstudywasapprovedbytheresearchscientificboard(DRCI) at our institution, and was designed according to the WMA DeclarationofHelsinki.
2.1. Analyses
AlldatawererecordedonanExcelsheet(Microsoft C).Statistical studyincludedmean,standarddeviation,Studenttestandcorrelation coefficient,performedonaPClaptop(HewlettPackard C).
3. Results
Allrecorded data are shown in Table 1. Of the24 patients included(twomales[8%],22females[92%]),meanageatsurgery was5513years(range:26ÿ80).Theoverallmeanfollow-upwas 2624months(range:6ÿ80).Theaetiologicalfactorsareshownin Table2.Fiveofthesevenpatientspreviouslyoperatedhavehada siliconesheetinsertedatthattime.Onlyoneofthesefivepatientshad undergonesurgerywithinourunitandusingourtechnique;theother fourhadundergoneprevioussurgerywithoutfixationofthesilicone sheet.Thissheethadlaterbecomedisplacedanddamaged.
Duringthefirsttwodayspost-surgery,allpatientsconsidered paintobelessthanitwaspreoperatively,exceptforthreepatients thatneededlevel-2antalgicsforaweek.Noiatrogenicinfections nordelayedhealingwereobserved.Afrontalparesiaoccurredin sixpatientswithcompleterecoveryby6monthspost-surgery.
The average preoperative MO was 24.76.7mm and was 32.86.4mmatthelastfollow-up.Thus,themeanimprovement was 8.2mm, which was highly significant in Student’s t-test
(P<0.0001). However, four patientshad noor only very limited improvementinMO,andonepatienthadareductionof2mm.
TheaveragePSwas2.5preoperativelyand0.8atthelast follow-up.Themeanimprovementinthisscorewas1.7units,whichwas highly significant in Student’s t-test (P<0.0001). No patient experiencedworsepainaftersurgery.
In orderto determine therole of thesilicone thickness,we dividedtheseriesintotwogroups:
groupA(10patients)wherethepatientsreceiveda 1.0-mm-thicksiliconesheet;
group B (14 patients) where they received a 1.5-mm-thick siliconesheet.
Fig.1.Thesiliconesheetinpositionattheendofsurgeryandsecuredbythree trans-osseoussilksuturestothezygomaticarch(rightside).
Thechoiceofthethicknessduringsurgerywasnotrandomized butdependedonseveralfactors,includingthesizeoftheinterface tobefilled,thepersonalpreferenceofthesurgeonandsometimes theavailabilityofthematerialatthetimeofsurgery.
The two groups were similarregarding age(mean agewas 55.6yearsingroupAand54.8yearsingroupB),preoperativeMO (24.4mmingroupAversus24.9mmingroupB)andPS(2.4in groupAversus2.5ingroupB).Theonlydifferencebetweenthe twogroupswasthelengthoffollow-up:i.e.32.0monthsforgroup Aversus21.6monthsforgroupB(thispointisdiscussedfurther below).Attheendoffollow-up,themeanimprovementinMOwas 7.6mm in group A versus 8.6mm in group B. The mean improvementinPSwas1.6ingroupAand1.7ingroupB.There werenostatisticaldifferencesbetweenthetwogroupsregarding thesetwoparameters.
The lengths of follow-ups were compared with the clinical resultsbyacorrelationtest.ResultsareshownonFig.2(forMO) andFig.3(forPS).NostatisticalrelationshipwasfoundforMO (P=0.171)orPS(P=0.122).Nevertheless,therewastrendtowards deteriorationofoutcomesovertime.
4. Discussion
Inthepast,autogenoustissuesweregenerallyconsidered to make good disc substitutes. For example, dermal grafts were
proposedbyGeorgiadeetal.manyyearsago[9]andmorerecently by Meyer etal. [10] and produced relativelygood resultsafter 50monthsfor50%ofpatients.Theuseofauricularcartilagegrafts hasbeenproposedbyseveralauthors[6].Svenssonetal.reported on a series of 23 patients that underwent surgery using this technique [11]: however, the graft needed to be removed subsequently for 30% of these patients after a mean period of 26 months. These poor results occurred mainly in cases of degenerativelesions,includingpatientsthathadprevioussurgery. Thebestresultsseemedtobecorrelatedwiththeintegrityofthe bonystructures.
The most efficient autogenous material seems to be the temporalismuscleflap,asdescribedbyFeinbergetal.[12].Ina smallseries(13patients),resultsforMOweregood,butthe follow-up period was less than 9months. More recently, DeMerle compared theresultsfor MOandPS withabdominal fat grafts versustemporalismyofascialflaps[13].Asexpected, theresults werebetterfortheflap,butalmostallpatientspresentedinitially withanisolateddiscdisplacementwithoutadegenerativelesion. Indeed,thelong-termoutcomesforthisflapareunknown,asitis unlikelythattheywouldremainintactformorethanafewweeks [14].Furthermore,itisknownthatitcanbetechnicallydifficultto achieveagoodsilksuturewithintheinnerpartofthejoint.
Alloplasticmaterialshavelogicallybeenusedformanyyearsto avoid the problems encountered with autogenous techniques. Siliconeimplantswereintroducedin1968asaninterpositional materialforthereconstructionofarthriticorseverelydamaged jointsafterevidencehadbeenobtainedregardingits biocompati-bility[15].Thetendencyforafibrouscapsuletoformarounda silicone implant is well known but can be useful in specific conditionssuchasTMJsurgery.However,asreportedbyMercuri [16],theAmericanAssociationofOralandMaxillofacialSurgeons’ Society decided,inNovember 1992,that theuseofpermanent Silastic1implantsshouldbediscontinued,exceptwhenusedto
preventrecurrenceofankylosis.Sincethen,itappearsthattheuse ofaTMJtotalprosthesishasbecomethegold-standardformany surgeons, not only for TMJ ankylosis, but also for cases of
Table2
Distributionoftheaetiologicalfactors.
Mainaetiologicalfactor No.ofpatients
PrevioussurgeryontheTMJ 7
Isolatedocclusaldisturbance 5
Inflammatorydisease 4
Intra-articularcontusion 3
Idiopathic 5
Occlusaldisturbancewassometimesobservedcombinedwitheachoneoftheother aetiologies.
Table1
Dataforstudypatients.
No. Gender Age(years) Survey(months) Silastic1
(mm)
MO PS
Right Left Pre-surg Post-surg Difference Pre-surg Post-surg Difference
1 F 50 70 1.0 25 25 0 3 2 ÿ1 2 F 26 80 1.0 28 37 9 2 1 ÿ1 3 F 42 80 1.0 23 26 3 3 1 ÿ2 4 M 38 28 1.5 1.5 12 28 16 1 0 ÿ1 5 F 57 60 1.5 38 44 6 3 1 ÿ2 6 F 51 6 1.5 1.5 18 18 0 3 2 ÿ1 7 F 59 16 1.5 31 37 6 3 1 ÿ2 8 F 66 20 1.5 25 42 17 2 0 ÿ2 9 F 41 50 1.5 32 30 ÿ2 3 2 ÿ1 10 F 61 45 1.5 1.5 15 31 16 3 0 ÿ3 11 F 69 6 1.5 25 35 10 3 1 ÿ2 12 F 55 22 1.5 10 25 15 2 1 ÿ1 13 F 53 19 1.0 25 30 5 3 1 ÿ2 14 F 73 21 1.0 1.0 15 38 23 2 0 ÿ2 15 F 55 12 1.5 32 44 12 2 0 ÿ2 16 F 71 22 1.0 1.0 25 32 7 2 1 ÿ1 17 F 30 12 1.5 1.5 27 34 7 3 2 ÿ1 18 F 66 10 1.5 30 32 2 2 0 ÿ2 19 F 66 6 1.0 28 32 4 2 1 ÿ1 20 F 55 10 1.0 25 30 5 3 1 ÿ2 21 F 80 6 1.0 25 35 10 2 1 ÿ1 22 M 63 6 1.5 30 40 10 2 0 ÿ2 23 F 57 9 1.5 23 28 5 3 1 ÿ2 24 F 40 6 1.0 25 35 10 3 0 ÿ3
Age:ageatthetimeofsurgery;Survey:measuredinmonthsbetweensurgeryandthelastclinicalcontrol;Silastic1
:depthofthesiliconesheet;MO:mouthopeningin millimetres;PS:PainScore(0=nopain,1=lightpain,2=severepain,3=veryseverepain).
degenerativeosteoarthritis[17].Meanwhile,inourseries,MOwas improvedby33%andPSdecreasedby68%atthefinalexamination. These resultscorrespond tothepatient’s request.Theseresults seem tobebetterthan thoseof Schliephake[3],but ourmean follow-uptimewasmuchshorter(26monthsvs.7years).They reportedonmorphologicalmodificationstothecondyle,asseenin later X-rays, withflattened condyle headand osteophytes. We havealsonotedsuchdeformationsinseveralofourcases.Even thoughtherewasnostatisticalsignificanceinFigs.2and 3,the progressive degradation is probably ineluctable, though rather slow.Some authorsreportedthepossibilityoffragmentationof these sheets, which may then cause foreign-body giant-cell reactions incervicallymphnodes[18].Theyhaveidentifiedthe poor strengthof siliconeanditsability tobeperforatedand/or fragmented,asshowninFig.4.Meanwhile,inmostofthesecases, therewereerrorsduringsurgeryregardingthelackoffixationor
insufficientcoverageofthecondylehead.Inordertoavoidthis type of complication, we could expect better results with the thickersheet(1.5mminsteadof1.0mm).However,surprisingly, wewereunabletofindanydifferenceinsuccessratebetweenthe two thicknesses of silicone sheets. This means that the main problemwasprobablythebiomechanicalstatusinsidethejoint andnotthestrengthofthematerialitself.
Becauseoftheriskofdegradationofclinicalstatusovertime, manyauthorsnowthinkthatthereisnosatisfactoryconservative treatment for cases of TMJ osteoarthrosis and propose total prostheticreplacementinsteadasisdoneforTMJankylosiswith satisfactorylong-termresults[19].O’Connorrecentlypublisheda paperona seriesof24 patientsthatunderwent TMJprosthetic replacementfor an inflammatory diseasewith good functional results[20].GoodresultshavebeenalsoreportedbyGruberetal. [21]inaprospectiveanalysiswherethemostcommondiagnosis
Fig.2.CorrelationdiagrambetweenMOandthetimeofthefinalexamination.Eachpatientisrepresentedbyabluesquare.
was degenerative disease. However, they mention some dis-advantagestotheTMJprosthesis:theinterventionislongerand moreaggressivewithincreasedrisksincludingmorbidity, exces-sivebleedingleadingtobloodtransfusion,infection,anddefinitive facialpalsy. Eventhoughit is rarelymentioned, theability for mandibularprotractionislost.Therealcostoftheprocedureisnot fully known, but it is obviously much greater than for a conservativetechnique.Furthermore, itis notsupportedbythe HealthInsuranceServiceSysteminsomecountries,particularlyin FrancewheretheTMJprosthesisisreservedforcasesofankylosis. Inconclusion, thepoor reputation ofsilicone-sheet implants didnotseemtobeasevidentinourseries.Eventhoughanoptimal methodfordiscreplacementhasnotyetbeenfound,siliconecan beusedwithsuccess, butusing arigoroustechniqueand strict fixation.Itisasimple,quick,andnon-expansivemethodthathasa lowrateofcomplications.However,itseemsthatanatomicaland functionalresultsdecrease withtime, thus it shouldmostlybe usedforelderlyorfragilepatientsthathaveseverepainandlow mobility.Forothercases,it iscertainlybettertoperforma TMJ prosthetictotalreplacement.Wehopethatmodificationstothe Frenchhealth-caresystemwillbemadeandpermitinthefuture betterresultsinthemanagementofTMJosteoarthrosis.
Disclosureofinterest
Theauthorsdeclarethattheyhavenocompetinginterest.
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Fig.4.Exampleofadeterioratedsiliconesheetremovedfromapatientthathad undergoneprevioussurgeryinanotherstructurewithoutfixationofthesheet. Thereisaperforationatitsinnerpart.
