Chuong, MD, DMD,a and Mark





A. Piper, MD, DLWD,~ St. Petersburg,



Severe bone erosion within the temporomandibular joint reconstructed with polytetrafluoroethylene implants is a well-recognized phenomenon. Although erosion into the middle cranial fossa has been reported, we know of no report of dural disruption with cerebrospinal fluid leakage. We report a case of cerebrospinal fluid leak noted at the time of PTFE implant removal and its subsequent management. Perforation of the contralateral glenoid fossa and its reconstruction is also reported. (ORAL SURG ORAL MED ORAL PATHOL 1992;74:422-5)

Polytetrafluoroethylene keted as Proplast-Teflon

(PTFE) implants, marinterpositional implants, were at one time widely usedfor reconstruction of the temporomandibular joint (TMJ) after meniscectomy. ‘32 The purpose of this alloplastic material was to interpose a stable material between the condyle and the fossato preservevertical dimensionand to provide a barrier to adhesionsand ankylosis. Since its widespreadusein the early and mid-1980s PTFE implants have beenremoved from the market becauseof severe bony erosion of both fossa and condyle.3 Multiple caseshave been reported that demonstrate the severity of the erosive responseas a result of an exuberant foreign body inflammatory reaction.2-7Perforation by the foreign body granuloma into the middle cranial fossa has been reported,7 although we are not aware of instancesof dural violation with cerebrospinal fluid (CSF) leak associatedwith the removal of a PTFE implant. This is a case report of the management of a GSF leak noted at the time of Proplast-Teflon removal from the TMJ at the site of perforation through the glenoid fossa.The contralateral joint also demonstrated a large perforation of the fossa but without dural violation. CASE REPORT A 65-year-old white woman had a long-standing history of chronic facial pain, TM3 pain, hypomobility, and chronic





headache. Four years before her evaluation in our practice, another surgeon had placed Proplast-Teflon implants in both TMJs after meniscectomy. Meniscal degeneration and perforation were noted at the time of initial surgery. Mild irregularity of the fossa and condyle was reported in the operative dictation. The patient came to us with complaints of severe burning pain around the face, jaw, and head. Complaints also included a feeling of weakness and malaise, although she was not aware of fever, chills, or significant changes in weight. The patient also complained of feelings of pressure around the eyes and teeth. She did not experience substantial relief of pain through the use of nonsteroida1 anti-inflammatory drugs of various types, muscle relaxants in a variety of combinations, antidepressant medica-

tions, and narcotic analgesics.She deniedproblemswith mouth opening, although she did complain of pain when she chewed. Clinical examination demonstrated slight lower facial asymmetry, with the chin and the mandibular dental midline, shifted approximately 2 mm to the left. The occlusion was correspondinglyasymmetrical,being ClassII on the left and Class I on the right. A 2 mm anterior open bite was noted with contact only on the first and second molars. There was 1+ tenderness around the TMJ capsules without palpable mass or crepitus. The neck was unremarkable to palpation with no adenopathy, mass, or tenderness. Mandibular range of opening was 41 mm interincisally and lateral excursions were 4 mm and 3 mm to the left and right, respectively. Plain radiography demonstrated marked erosion of the mandibular condyles and glenoid fossae. The condyles were miniature in overali size (Fig. 1). Glenoid fossa violation was clearly a concern. Magnetic resonance imaging was not available at the time of this evaluation.


Volume 74 Number 4

Fig. 1. Radiograph


shows condylar and fossa erosion of left TMJ.

Fig. 2. Temporalis muscle flap (M) is shown interposed between violation (arrow) of dura mater (0) and mandibular condyle (C). Gelfoam (G) is used to support flap and to minimize dead space, 13, eminence, EAC, external auditory canal. The medical history was significant for a previous appendectomy and hysterectomy in addition to the TMJ surgery. There was no history of significant medical illness. A preoperative physical exarnination was unremarkable except as noted in the maxillofacial examination. The patient was taken to the operating room several months later for bilateral TMJ arthroplasties to remove the Proplast-Teflon implants. Preoperative complete blood count, chemistry profile, urinalysis, chest radiograph, and electrocardiogram were unremarkable. The left joint was approached first. The previous preauricular incision was opened, and dissection was uneventful down to the joint capsule. The operating microscope was then used in accord with our routine for TMJ surgery.’ The implant was visualized as the capsule was reflected. In fact, the capsule was

Fig. 3. Bone graft (BG) is stabilized against fossa at site of erosion (arrow) to intact dura mater (D). Gelfoam (G) helps to support graft and to minimize dead space. C, Mandibular condyle, E, eminence, EAC, external auditory canal. distended by the underlying inflammatory tissue that was grossly consistent with granulation and fibrous tissue. Marked erosion of the zygomatic arch was evident. The implant was removed by gentle curettage along the fossa. The inflammatory soft tissue mass encapsulated the condyle, which necessitated sharp and blunt dissection to free the head of the condyle. The condyle was markedly eroded and miniaturized. Condyloplasty was performed with a bur. No frank bleeding was noted from the bone surface. Gentle curettage of the inflammatory tissue was completed along the fossa surface. A bony perforation that measured approximately 10 mm X 6 mm along the midfossa medially was noted. Reactive tissue was noted to extend into the perforation. Gentle dissection allowed retrieval of this tissue. However, it was then noted that clear cerebrospinal fluid (CSF) was leaking from the perforation. The actual defect in the dura mater could not be visualized. After consulta-


Chuong and Piper

tion with a neurosurgeon, the decision was made to rotate a temporalis myofascial flap into the defect. Such a flap was mobilized and turned lateral to what little remained of the zygomatic arch. Within thejoint, stabilization was achieved by suturing the flap to the lateral pterygoid muscle and by packing a resorbable gelatin sponge (Gelfoam) inferior to the flap and superior to the condyle (Fig. 2). Intravenous cefuroxime was administered intraoperatively. The wound was closed in layers. No surgical drain was placed. The right TMJ was approached in similar fashion. Although marked bone erosion was noted along the fossa and condyle, no CSF leak was noted in spite of a very large perforation through the roof of the fossa that measured approximately 10 mm in the mediolateral dimension and 12 mm in anteroposterior dimension. Marked condylar erosion was noted and managed by condyloplasty. As for the left side, no surface bleeding was evident. A corticocancellous bone graft that had been harvested from the iliac crest was placed against the fossa. The graft was secured to the lateral fossa with a resorbable suture, the cortical portion was directed inferiorly. Additional curettings of the cancellous bone were packed into the fossa defect, between the dura mater and the main graft. A resorbable gelatin sponge was placed between the condyle and the bone graft for additional support (Fig. 3). Once again, the wound closure was performed in a standard fashion. The postoperative course was marked by low-grade fevers that ranged from 100” to 100.8” F rectally. The patient’s temperature normalized by the fifth postoperative day. Cefuroxime was continued throughout this period. There was no evidence of drainage from the TMJ wounds. Neurologic examination was unremarkable throughout the postoperative period. Range of jaw-opening exercises were initiated on the second postoperative day with the gentle assistance of tongue depressors. The patient was discharged from the hospital on the fifth day after surgery. Analgesics and antiinflammatory medications were prescribed. The patient has been followed for more than 3% years. Maxillary and mandibular osteotomies were completed 2% years later for correction of apertognathia and mandibular asymmetry. The range of jaw opening has stabilized at 32 mm. No neurologic problems have occurred. The patient’s chronic facial pain continues although less intensely since the TMJ implant removals. DISCUSS10 The marked foreign-body inflammatory response to PTFE implants in the TM.J has been widely reported. 2-7 These reports have also included perfora-

tion through the glenoid fossa into the middle cranial cavity.6 None has discussed actual CSF leakage because of dural violation, This article discusses our management of this unusual circumstance. Maxillofacial surgeons must be prepared to reconstruct the TMJ at the time of removal of the implant material and the surrounding

reactive tissue. As discussed in

this article, the surgeon must be prepared to carry out







October 1992 bony reconstruction with autogenous bone as weli as to manage violation of the dura mater of the temporal lobe. Neurosurgical consultation is appropriate. Dural violations may, in general, be managed by direct repair by oversewing if visualization and access are adequate. If access is inadequate or if the tissues do not allow direct reapproximation, resorbable gelatin film, a muscle or pericranial flap, or a combination of the two may be used. In the case reported here, a gelatin sponge was used to help support the tempo-

ralis flap against the dural defect and to minimize dead space within the joint. Although we commonly use closed-suction surgical drains for TMJ arthroplasty procedures, their use was contraindicated because of the CSF leak. Use of resorbable gelatin film against dural violations is a recognized application that seems to facilitate dural regeneration with the gelatin serving as a scaffold.g A CSF leak in setting midfacial fractures will typically resolve with the reduction and stabilization of the fracture. In all settings of CSF leaks, there must be adequate control of factors that may increase intracranial pressure, such as alveolar hypoventilation, the Valsalva maneuver, fluid overload, agitation, and coughing. lo Assessment of respiratory function, careful fluid balance, bedrest, possible lumbar puncture to reduce CSF pressure, elevation of the head of the bed, acetazolamide to reduce CSF production, the use of stool softeners, and possibly judicious sedation should be considered. Bone defects associated with a CSF leak may be closed with fat, muscle, cartilage, bone, or some combination. A persistent CSF leak may require continuous lumbar CSF drainage or possibly a ventriculoperitoneal shunt, if elevated intracranial pressure can be demonstrated.“O Cefuroxime is a semisynthetic, broad-spectrum antibiotic for parenteral administration. It was used in this setting because of its penetration into the CSF. It is typically effective against group A and B streptococci, pneumococci, and Streptococcus viridans. Although generally effective against staphylococci, other cephalosporins such as cefazolin and cefalothin are usually more effective.‘l In retrospect, the case reported here might best have been imaged more aggressively preoperatively. Although reliable magnetic resonance imaging was not available at the time, computerized tomography may have been of help. However, the preoperative plain radiographs clearly raised the likelihood of glenoid fossa perforation. At present we routinely use plain sagittal and coronal tomography and sagittal and coronal magnetic resonance imaging scans in this setting, with selective use of computerized


phy imaging. In all cases of PTFE implant



Volume 74 Number 4

the surgeon must be prepared to deal with large fossa perforations with or without dural disruption. The patient must be prepared for bony reconstruction with a possible graft dono’r site. Although the unilateral fossa perforation reported in the literature7 was not reconstructed, in the setting of very large bilateral perforations, bony reconstruction is probably indicated to minimize the likelihood for impingement on the dura mater and to help maintain the posterior vertical dimension of mandibular position. We have managed 19 other examples of glenoid fossa perforation caused by PTFE implant erosion, all but three were relatively small and were not grafted with bone. The remaining six were reconstructed with bone grafts for dural protection and for maintenance of vertical dimension. One case of fossa perforation that was related to metal condyle prosthesis reconstruction has been managed by prosthesis removal and autogenous grafts to the fossa. All have healed well without complications related to the reconstruction. Recurrent PTFE implant reaction has been observed in one case that was not reconstructed.12 CONCLUSION

A case of bilateral, large glenoid fossa perforations secondary to a chronic inflammatory reaction to PTFE (Proplast-Teflon) implants in TMJs is reported. On one side, a CSF leak was encountered. Management of it with a temporalis myofascial flap and resorbable gelatin sponge is reported. The contralateral perforation was managed by autogenous bone grafts of the fossa. The surgeon and the patient must be prepared for the possibility of such problems associated with removal of these implants and for the reconstruction of soft tissue as well as bone that may be necessary.


REFERENCES 1. Kent JN, Block MS, Homsy CA, et al. Experience with a polymer glenoid fossa prosthesis for partial or total temporomandibular joint reconstruction. J Oral Maxillofac Surg 1986;44:520-33. 2. Estabrooks LN, Fairbanks CE, Collett RJ, Miller L. A retrospective evaluation of 301 TMJ Proplast-Teflon implants. ORALSURG ORAL MED ORALPATHOL 1990;70:381-6. 3. Public Health Advisory on Vitek Proplast Temporomandibular Joint Implants, Department of Health & Human Services, Food and Drug Administration, September 1991. 4. Florine BL, Gatto DJ, Wade ML, Waite DE. Tomographic evaluation of temporomandibular joints following discoplasty or placement of polytetrafluoroethylene implants. J Oral Maxillofac Surg 1988;48:183-8. 5. Wagner JD, Mosby EL. Assessment of Proplast-Teflon disc replacements. J Oral Maxillofac Surg 1990;48:1140-4. 6. Bronstein SL. Retained alloplastic temporomandibular joint disk implants: a retrospective study. ORAL SURG ORAL MED ORAL PATHOL 1987;64:135-45. 7. Berarducci JP, Thompson DA, Scheffer RB. Perforation into middle cranial fossa as a sequel to use of a Proplast-Teflon implant for temporomandibular joint reconstruction. J Oral Maxillofac Surg 1990;48:496-8. 8. Piper MA. Microscopic disc preservation surgery of the temporomandibular joint. In: Merrill RG, ed. Disorders of the TMJ II: arthrotomy. Philadelphia: WB Saunders, 1989:279301. 9. Jenkins HP, Janda R, Clarke J. Clinical and experimental observations on the use of gelatin sponge or foam. Surgery 1946;20:124-32. 10. Teasdale GM, Miller JD, eds. Current neurosurgery. New York: Churchill Livingstone, 1992. Il. The Medical Letter 1984;26:15-6. 12. Chuong R, Piper MA, Boland TB. Recurrent giant-cell reaction due to residual Proplast in the temporomandibular joint. In preparation. Reprint


Robert Chuong, MD, DMD Maxillofacial Surgery Institute of Florida 111 Second Ave., NE Suite 1006 St. Petersburg, Florida 33701

Cerebrospinal fluid leak associated with proplast implant removal from the temporomandibular joint.

Severe bone erosion within the temporomandibular joint reconstructed with polytetrafluoroethylene implants is a well-recognized phenomenon. Although e...
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