J Oral Maxillofac 4%348-353.
Surg
1990
The Use of Autologous Auricular Cartilage for Temporomandibular Joint Disc Replacement: A Preliminary VICTOR
J. MATUKAS,
DDS,
PHD,
MD,*
Report
AND
JOACHIM
LACHNER,
DDS,
MDt
The technique of harvesting auricular cartilage and its use in 22 patients (35 joints) is described. Follow-up was from 3 to 24 months. Pain relief was achieved in 90% of the cases. Function was equal or better to the preoperative situation in all cases.
Materials and Methods
A variety of techniques have been used to surgically correct internal derangements of the temporomandibular joint (TMJ). Most clinicians recognize that pain from muscle spasm is different from internal derangement and treat the former by conservative biteplate therapy and/or occlusal manipulation. However, as progressive internal derangement occurs with pain and dysfunction, surgical therapy is often indicated. Most surgeons choose to repair the disc, if possible. If the disc is not repairable, the decision to replace the disc must be made. The use of Proplast-Teflon (Vitek, Inc, Houston, TX) and Silastic (Dow Corning/Wright Inc. Arlington, TN) for this purpose has produced widespread concern because of both the bone resorption and infIammatory reactions reported.’ Due to the complications related to alloplastic reconstruction of the TMJ, a replacement material has been sought that is autogenous, space occupying, viable, and easy to harvest. Auricular cartilage with perichondrium, meets many of these requirements. The use of auricular cartilage for this purpose was reported by Witsenburg and Freihofer in 1984’ and followed by a longer follow-up of the same patients in 1988.3 This report details our experience with this material.
Thirty-three patients underwent surgery for a total of 51 joints. Twenty-two patients (35 joints) with a follow-up period of 3 months or greater were included in this study. Two patients were followed for more than 24 months, 8 between 18 and 24 months, 4 between 12 and 18 months, and 8 less than 1 year. The mean age was 39 years (21 to 65 years). Thirteen patients had bilateral surgery, 6 had right unilateral surgery, and 3 had left unilateral surgery. The primary indication for surgery was intolerable pain following either previous surgery or conservative treatment. The patients were evaluated preoperatively for amount of mouth opening, and localization and severity of the pain. Pain severity was subjectively assessed. The placement of patients into categories of no complaints, minimal complaints, and severe complaints was based on the need for narcotics or other pain medications. Routine screening radiographs, arthrograms, or nuclear magnetic resonance images were obtained as indicated. The decision to remove the disc was made intraoperatively when it could not be repaired. Auricular cartilage was placed in every joint.
Received from the University of Alabama at Birmingham. * Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry and Medicine. t Fellow, Department of Oral and Maxillofacial Surgery. Address correspondence and reprint requests to Dr Matukas: Department of Oral and Maxillofacial Surgery, School of Dentistry and Medicine, University of Alabama at Birmingham, UAB Station, Birmingham. AL 35294. 0 1990 geons
American
Association
of Oral and Maxillofacial
SURGICAL TECHNIQUE
In the first 16 patients, an anterior skin incision to approach the joint and a posterior auricular incision to harvest the graft were used. The joint was exposed and the disc tissue removed. The condyle was firmly seated to maintain hemostasis while the graft was harvested. A second incision was then made on the posterior aspect of the concha, and the
Sur-
0278-2391/90/4804-0003$3.00/O
348
MATUKAS AND LACHNER
349
perichondrium FIGURE 3. Cartilage graft showing anterior convex surface. This surface will be placed on the condyle and sutured to the capsule.
cartilage was harvested, (Figs 1 and 2) leaving the perichondrium attached. The graft is large enough to cover the condyle, and the concave side fits this area anatomically (Fig 3). The graft was inserted (Fig 4) and attached to the surrounding tissue with 4-O Vicryl suture (Ethicon, Inc. Summerville, NJ). The preauricular incision was closed in layers. The postauricular incision was closed with a 6-O chromic suture in one layer after a Petite suction drain was placed. When using the posterior approach, 1% lidocaine with l:lOO,OOOepinephrine was first infiltrated in the posterior ear. An incision was made halfway between the base of the auricle and the outer rim of the ear (Fig 5). Blunt supraperichondral dissection was carried down to the root of the cartilage along
the mastoid fascia, after identifying the external auditory canal. A no. 10 scalpel blade was used to transect the canal just where it begins to diverge (Fig 6). The incision was extended over the superficial temporal fascia. A separate flap was then made in the fascia, exposing the joint capsule (Fig 7). After opening the upper and lower joint spaces (Fig 8), the damaged disc or previous implant was removed. The auricular cartilage was exposed posteriorly as previously described with the anterior approach to the joint (Fig 3). The perichondrium on the convex surface of the concha was retained. The graft was mobilized, leaving 3 to 4 mm of cartilage between the transected external auditory canal and the graft area. This resulted in a 3.5 x 2 cm ovalshaped graft covered on one side by perichondrium. After the joint was irrigated, the cartilage was positioned and fixed to the capsule with 4-O Vicryl sutures (Fig 9). Dead space was eliminated in a routine fashion and a small drain was placed (Fig 10). The postauricular incision was closed in one layer,
FIGURE 2. Clinical appearance of cartilage dissection. Note the clean subperichondral plane on the anterior surface of future graft.
FIGURE 4. Graft (arrow) being positioned. It is important to properly place the graft medially to completely cover the condyle.
FIGURE 1. Diagram illustrating incision on posterior part of the ear. with dissection leaving perichondrium on convex surface. Note the incision through cartilage and subperichondral dissection on anterior surface.
350
AURICULAR
FOR JOINT REPLACEMENT
with, CT) for 1 day. The drain, which nected to a Corvac blood tube (Monoject, MO), adapted the skin and remaining drium of the ear. The drain was removed day before the patient was discharged.
skin incision
posterior
CARTILAGE
ear
was conSt Louis, perichonthe next
Results Thirty-five joints were reevaluated 3 to 24 months after surgery. AI1 patients had been previously treated conservatively, and some had been treated surgically (Table 1). Their chief complaint, besides TMJ pain, was unilateral or bilateral temporal and/ or occipital headaches. In 75% of the patients, symptoms increased during chewing or speaking. Mouth opening averaged 28 mm (6 to 45 mm) interincisal distance.
FIGURE 5. Skin incision on posterior part of the ear. It is made equidistant from the face and the rim.
using a running 6-O chromic suture. The skin of the outer ear canal was reapproximated with four 4-O chromic sutures, and the canal was packed with Xeroform gauze (Cheesebrough-Ponds, lnc, Green-
outer ear canal
temporal
fascia
ear canal transected
temporal
temporal fascia
bone
transectlon temporal muscle .A[ -
i
mastoid process
==5 ‘d
5_
-s-I 3
B
‘C p=
\
L
skin
canal
w temporal fascia
FIGURE 6. A, Dissection is made down to the mastoid fascia and carried contiguously to the temporal fascia. The ear canal is then transected. B, Cross section showing the correct anatomic plane.
MATUKAS AND LACHNER
fascia
/
\
outer ear canal sutured
FIGURE 7. A separate incision is made through the temporal fascia to the capsule of the joint. The ear canal is sutured and the ear is retracted from the field.
Significant amounts of granulation tissue and scar tissue were found surrounding the Proplast-Teflon implants. Six implants were perforated. The removed discs were either perforated or showed severe histologic changes (Table 2). After surgery, all patients reported immediate pain relief, and mouth opening increased to 33 mm (18 to 45 mm) within 3 months of surgery. In 39%, clicking of the affected joint was noted postsurgically, which was not related to pain. Twenty-five joints were free of symptoms with the patient having no restrictions in chewing or speaking. Seven joints were still sore on palpation, with minimal spontaneous pain. Two patients (three joints) were dependent on narcotics. However, none of these patients considered the pain severe enough to undergo further surgery.
FIGURE 8. Access to the disc is from a posterior approach. Care is taken to isolate the disc by freeing both the superior and inferior joint space.
FIGURE 9. The graft is taken as previously described and sutured laterally to the remaining joint capsule.
Discussion Surgical treatment remains the last modality in the cascade of treatments for internal derangements of the TMJ. Plication and other repair procedures are probably adequate if the disc is anteriormedially displaced, reducible, and not deformed. If the disc is distorted or worn, it must be removed. The problem is compounded by reoperations or previously removed discs. Reports of discectomies date back to the beginning of the century.4 According to the literature, both short- and long-term pain control have been good with this procedure.5 However, bony resorption of both condyle and glenoid fossa are de-
FIGURE 10. A small suction drain, as well as a pressure dressing, is used to prevent hematoma formation in the ear.
352
Table 1.
AURICULAR
Previously Treated Joints
Surgical treatment* Proplast-Teflon implants Silicone implants Plication of joints Eminectomy Functional treatment Biteplate therapy Orthodontics Orthognathic surgery
17 joints 2 joints 5 joints I joints I6 patients 6 patients 5 patients
* Three joints had more than one surgical procedure.
scribed, which leads to an open bite secondary to loss of posterior ramus height.6 Thus, replacement of the damaged discs seems desirable to provide a gliding surface and to protect adjacent bony surfaces from further resorption. Alloplastic materials (Proplast-Teflon and Silastic) enjoyed a certain popularity for a time. However, both materials have resulted in a high incidence of postoperative pain and have shown poor wear characteristics by breaking down under a masticatory load.7-9 Marked inflammatory reactions as well as shredding of the implant also have been reported. Giant cell reactions have been demonstrated, with particles of both Proplast and Silastic being noted in lymph nodes adjacent to the operative site.‘” ProplastTeflon especially evoked bone resorption that necessitated early removal in some cases. There has also been an interest in the use of autogenous materials for disc replacement. Dermal grafts have been used both as a disc replacement and for repair of perforations.““’ Fascia lata has also been reported for the same purposes, and case reports also suggest its use in ankylosis.‘3 In both these techniques, a thin sheet of collagen is placed, as it offers no bulk or real possibility of survival. Also, the donor site is remote from the operative site and morbidity is relatively high. There has been renewed interest in the use of temporal muscle flaps as an interpositional graft. I4 This technique has been used in the past and has been reexamined recently. There is some concern that trauma to the muscle will either cause necrosis
Table 2.
CARTILAGE FOR JOINT REPLACEMENT
or contribute to ongoing pain. There is also concern over maintenance of the vascular pedicle. Auricular cartilage was first reported for use in disc replacement in 1973.15 There have since been two reports of a limited number of cases.2.3 In these reports, the technique was not addressed, nor were the indications for surgery. In theory, auricular cartilage may fulfill many of the demands of an ideal disc replacement. It is biologically inert and, when the perichondrium is left, presumably viable. It has some bulk and thus can partially compensate for loss of posterior ramus height. It is easy to harvest and is in the same operative field. The final graft is well contoured to fit the anatomic needs of a disc replacement (Fig 3). All patients operated on had a long history of pain and dysfunction. They also had undergone previous operations which had failed, primarily as measured by return of pain, or they had undergone intensive conservative treatment consisting of biteplates, medications, and occlusal adjustments. In every case, there was an element of dysfunction, but pain was the common indication for surgical intervention. Subjectively, relief of pain was immediate. Some postsurgical pain was noted, but not to the same extent as with our previous experience with Proplast-Teflon. Ninety-one percent were no longer taking narcotics for pain, whereas 100% had done so before surgery. Two patients (three joints) are still receiving psychiatric and drug rehabilitation, but they admitted to marked relief of subjective pain. Function was also clearly improved and has been maintained for the period of this study. There was an 8-mm average increase in opening after surgery, and 43% had good translatory movements. Because most of the patients were reoperations, these data are difficult to analyze. However, with the exception of the two patients, normal unrestricted masticatory function was present in all patients. There have been no relapse or failures necessitating removal of the grafts. No objective ear deformities resulted from graft harvest. Our recent experience with using a single poste-
Pain Relief Correlated With Preoperative Pathology Previous Implant
Preoperative pathology No complaints (no medications) Minimal complaints (aspirin or other nonsteroidal anti-inflammatory medications) Severe pain (narcotics)
Scarring/Anterior Dislocation Without Reduction
Disc Perforation
Distorted Disc
19 14
10 8
3
3
1
I
5 0
0 2
2 0
0
I
MATUKAS AND LACHNER
rior incision for graft harvesting and joint approach (six patients) has been gratifying. It avoids two incisions and lessens the possibility of compromised vascular supply to the ear. It also makes the procedure more efficient and esthetic. The postoperative morbidity is also reduced with this approach. We can only speculate about the long-term success of this procedure. The graft offers the possibility of a self-perpetuating disc replacement not subjected to the normal wear and tear of a self-perpetuating disc replacement not subjected to the normal wear and tear of alloplastic materials. Clearly, larger numbers and longer follow-ups are necessary before more definitive recommendations can be made. References I. Florine BL. Gatto DJ. Wade ML, et al: Tomographic evaluation of joints following discoplasty or placement of polytetratluoroethylene implants. J Oral Maxillofac Surg 48:!83, 1988 2. Witsenburg B. Freihofer HPM: Replacement of the pathological temporomandibular articular disc using autogenous cartilage of the external ear. Int J Oral Surg !3:40!, 1984 3. loannides C. Freihofer HPM: Replacement of the damaged interarticular disc of the TMJ. J Craniomaxillofac Surg !6:273. 1988 4. Lantz A Discitis Mandibularis. Zentralb! Chir 36:289, 1909 5. Eriksson L. Westesson PL: Long term evaluation of menis-
353 cectomy of the temporomandibular joint. J Oral Maxillofat Surg 43:263, 1985 6. Brown WA: Internal derangement of the temporomandibular joint: Review of 214 patients following meniscectomy. Can .I Surg 23:30, 1980 7. Gallagher DM, Wolford LM: Comparison of Silastic and Proplast implants in the temporomandibular joint after condylectomy for osteoarthritis. .I Oral Maxillofac Surg 40:627, 1982 8. Bronstein SL: Retained alloplastic temporomandibular joint disc implants: A retrospective study. Oral Surg Oral Med Oral Patho! 59:449, 1985 9. Westesson PL, Eriksson L. Lindstrom C: Destructive lesions of the mandibular condyle following discectomy with temporary Silicone implants. Oral Surg Oral Med Oral Pathol 63: 143, 1988 IO. Dolwick MF, Aufdemorte TB: Silicone-induced foreign body reaction and lymphadenopathy after temporomandibular joint arthroplasty. Oral Surg Oral Med Oral Patho! 59:449, 1985 11. Georgiade NC: The surgical correction of temporomandibular joint dysfunction by means of autogenous derma! grafts. Plast Reconstr Surg 30:68, 1962 12. Tucker MR. Jacoway JR, White RK: Autogenous derma! grafts for repair of temporomandibular joint disc perforations. J Oral Maxillofac Surg 44:78!, 1986 13. Narang R. Dixon RA: Temporomandibularjoint arthroplasty with fascia lata. Oral Surg 39:45, 1975 14. Feinberg SE, Larsen PE. The use of pedicled temporalis muscle-pericranial flap for replacement of the TMJ disc. J Oral Maxillofac Surg 47: 142, 1989 15. Perko M: lndikationen und Kontraindikationen fur chirurgische Eingriffe am Kiefergelenk. Schweiz Msch Zahnheilk 83:73. 1973
Surg
1990
The Use of Autologous Auricular Cartilage for Temporomandibular Joint Disc Replacement: A Preliminary VICTOR
J. MATUKAS,
DDS,
PHD,
MD,*
Report
AND
JOACHIM
LACHNER,
DDS,
MDt
The technique of harvesting auricular cartilage and its use in 22 patients (35 joints) is described. Follow-up was from 3 to 24 months. Pain relief was achieved in 90% of the cases. Function was equal or better to the preoperative situation in all cases.
Materials and Methods
A variety of techniques have been used to surgically correct internal derangements of the temporomandibular joint (TMJ). Most clinicians recognize that pain from muscle spasm is different from internal derangement and treat the former by conservative biteplate therapy and/or occlusal manipulation. However, as progressive internal derangement occurs with pain and dysfunction, surgical therapy is often indicated. Most surgeons choose to repair the disc, if possible. If the disc is not repairable, the decision to replace the disc must be made. The use of Proplast-Teflon (Vitek, Inc, Houston, TX) and Silastic (Dow Corning/Wright Inc. Arlington, TN) for this purpose has produced widespread concern because of both the bone resorption and infIammatory reactions reported.’ Due to the complications related to alloplastic reconstruction of the TMJ, a replacement material has been sought that is autogenous, space occupying, viable, and easy to harvest. Auricular cartilage with perichondrium, meets many of these requirements. The use of auricular cartilage for this purpose was reported by Witsenburg and Freihofer in 1984’ and followed by a longer follow-up of the same patients in 1988.3 This report details our experience with this material.
Thirty-three patients underwent surgery for a total of 51 joints. Twenty-two patients (35 joints) with a follow-up period of 3 months or greater were included in this study. Two patients were followed for more than 24 months, 8 between 18 and 24 months, 4 between 12 and 18 months, and 8 less than 1 year. The mean age was 39 years (21 to 65 years). Thirteen patients had bilateral surgery, 6 had right unilateral surgery, and 3 had left unilateral surgery. The primary indication for surgery was intolerable pain following either previous surgery or conservative treatment. The patients were evaluated preoperatively for amount of mouth opening, and localization and severity of the pain. Pain severity was subjectively assessed. The placement of patients into categories of no complaints, minimal complaints, and severe complaints was based on the need for narcotics or other pain medications. Routine screening radiographs, arthrograms, or nuclear magnetic resonance images were obtained as indicated. The decision to remove the disc was made intraoperatively when it could not be repaired. Auricular cartilage was placed in every joint.
Received from the University of Alabama at Birmingham. * Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry and Medicine. t Fellow, Department of Oral and Maxillofacial Surgery. Address correspondence and reprint requests to Dr Matukas: Department of Oral and Maxillofacial Surgery, School of Dentistry and Medicine, University of Alabama at Birmingham, UAB Station, Birmingham. AL 35294. 0 1990 geons
American
Association
of Oral and Maxillofacial
SURGICAL TECHNIQUE
In the first 16 patients, an anterior skin incision to approach the joint and a posterior auricular incision to harvest the graft were used. The joint was exposed and the disc tissue removed. The condyle was firmly seated to maintain hemostasis while the graft was harvested. A second incision was then made on the posterior aspect of the concha, and the
Sur-
0278-2391/90/4804-0003$3.00/O
348
MATUKAS AND LACHNER
349
perichondrium FIGURE 3. Cartilage graft showing anterior convex surface. This surface will be placed on the condyle and sutured to the capsule.
cartilage was harvested, (Figs 1 and 2) leaving the perichondrium attached. The graft is large enough to cover the condyle, and the concave side fits this area anatomically (Fig 3). The graft was inserted (Fig 4) and attached to the surrounding tissue with 4-O Vicryl suture (Ethicon, Inc. Summerville, NJ). The preauricular incision was closed in layers. The postauricular incision was closed with a 6-O chromic suture in one layer after a Petite suction drain was placed. When using the posterior approach, 1% lidocaine with l:lOO,OOOepinephrine was first infiltrated in the posterior ear. An incision was made halfway between the base of the auricle and the outer rim of the ear (Fig 5). Blunt supraperichondral dissection was carried down to the root of the cartilage along
the mastoid fascia, after identifying the external auditory canal. A no. 10 scalpel blade was used to transect the canal just where it begins to diverge (Fig 6). The incision was extended over the superficial temporal fascia. A separate flap was then made in the fascia, exposing the joint capsule (Fig 7). After opening the upper and lower joint spaces (Fig 8), the damaged disc or previous implant was removed. The auricular cartilage was exposed posteriorly as previously described with the anterior approach to the joint (Fig 3). The perichondrium on the convex surface of the concha was retained. The graft was mobilized, leaving 3 to 4 mm of cartilage between the transected external auditory canal and the graft area. This resulted in a 3.5 x 2 cm ovalshaped graft covered on one side by perichondrium. After the joint was irrigated, the cartilage was positioned and fixed to the capsule with 4-O Vicryl sutures (Fig 9). Dead space was eliminated in a routine fashion and a small drain was placed (Fig 10). The postauricular incision was closed in one layer,
FIGURE 2. Clinical appearance of cartilage dissection. Note the clean subperichondral plane on the anterior surface of future graft.
FIGURE 4. Graft (arrow) being positioned. It is important to properly place the graft medially to completely cover the condyle.
FIGURE 1. Diagram illustrating incision on posterior part of the ear. with dissection leaving perichondrium on convex surface. Note the incision through cartilage and subperichondral dissection on anterior surface.
350
AURICULAR
FOR JOINT REPLACEMENT
with, CT) for 1 day. The drain, which nected to a Corvac blood tube (Monoject, MO), adapted the skin and remaining drium of the ear. The drain was removed day before the patient was discharged.
skin incision
posterior
CARTILAGE
ear
was conSt Louis, perichonthe next
Results Thirty-five joints were reevaluated 3 to 24 months after surgery. AI1 patients had been previously treated conservatively, and some had been treated surgically (Table 1). Their chief complaint, besides TMJ pain, was unilateral or bilateral temporal and/ or occipital headaches. In 75% of the patients, symptoms increased during chewing or speaking. Mouth opening averaged 28 mm (6 to 45 mm) interincisal distance.
FIGURE 5. Skin incision on posterior part of the ear. It is made equidistant from the face and the rim.
using a running 6-O chromic suture. The skin of the outer ear canal was reapproximated with four 4-O chromic sutures, and the canal was packed with Xeroform gauze (Cheesebrough-Ponds, lnc, Green-
outer ear canal
temporal
fascia
ear canal transected
temporal
temporal fascia
bone
transectlon temporal muscle .A[ -
i
mastoid process
==5 ‘d
5_
-s-I 3
B
‘C p=
\
L
skin
canal
w temporal fascia
FIGURE 6. A, Dissection is made down to the mastoid fascia and carried contiguously to the temporal fascia. The ear canal is then transected. B, Cross section showing the correct anatomic plane.
MATUKAS AND LACHNER
fascia
/
\
outer ear canal sutured
FIGURE 7. A separate incision is made through the temporal fascia to the capsule of the joint. The ear canal is sutured and the ear is retracted from the field.
Significant amounts of granulation tissue and scar tissue were found surrounding the Proplast-Teflon implants. Six implants were perforated. The removed discs were either perforated or showed severe histologic changes (Table 2). After surgery, all patients reported immediate pain relief, and mouth opening increased to 33 mm (18 to 45 mm) within 3 months of surgery. In 39%, clicking of the affected joint was noted postsurgically, which was not related to pain. Twenty-five joints were free of symptoms with the patient having no restrictions in chewing or speaking. Seven joints were still sore on palpation, with minimal spontaneous pain. Two patients (three joints) were dependent on narcotics. However, none of these patients considered the pain severe enough to undergo further surgery.
FIGURE 8. Access to the disc is from a posterior approach. Care is taken to isolate the disc by freeing both the superior and inferior joint space.
FIGURE 9. The graft is taken as previously described and sutured laterally to the remaining joint capsule.
Discussion Surgical treatment remains the last modality in the cascade of treatments for internal derangements of the TMJ. Plication and other repair procedures are probably adequate if the disc is anteriormedially displaced, reducible, and not deformed. If the disc is distorted or worn, it must be removed. The problem is compounded by reoperations or previously removed discs. Reports of discectomies date back to the beginning of the century.4 According to the literature, both short- and long-term pain control have been good with this procedure.5 However, bony resorption of both condyle and glenoid fossa are de-
FIGURE 10. A small suction drain, as well as a pressure dressing, is used to prevent hematoma formation in the ear.
352
Table 1.
AURICULAR
Previously Treated Joints
Surgical treatment* Proplast-Teflon implants Silicone implants Plication of joints Eminectomy Functional treatment Biteplate therapy Orthodontics Orthognathic surgery
17 joints 2 joints 5 joints I joints I6 patients 6 patients 5 patients
* Three joints had more than one surgical procedure.
scribed, which leads to an open bite secondary to loss of posterior ramus height.6 Thus, replacement of the damaged discs seems desirable to provide a gliding surface and to protect adjacent bony surfaces from further resorption. Alloplastic materials (Proplast-Teflon and Silastic) enjoyed a certain popularity for a time. However, both materials have resulted in a high incidence of postoperative pain and have shown poor wear characteristics by breaking down under a masticatory load.7-9 Marked inflammatory reactions as well as shredding of the implant also have been reported. Giant cell reactions have been demonstrated, with particles of both Proplast and Silastic being noted in lymph nodes adjacent to the operative site.‘” ProplastTeflon especially evoked bone resorption that necessitated early removal in some cases. There has also been an interest in the use of autogenous materials for disc replacement. Dermal grafts have been used both as a disc replacement and for repair of perforations.““’ Fascia lata has also been reported for the same purposes, and case reports also suggest its use in ankylosis.‘3 In both these techniques, a thin sheet of collagen is placed, as it offers no bulk or real possibility of survival. Also, the donor site is remote from the operative site and morbidity is relatively high. There has been renewed interest in the use of temporal muscle flaps as an interpositional graft. I4 This technique has been used in the past and has been reexamined recently. There is some concern that trauma to the muscle will either cause necrosis
Table 2.
CARTILAGE FOR JOINT REPLACEMENT
or contribute to ongoing pain. There is also concern over maintenance of the vascular pedicle. Auricular cartilage was first reported for use in disc replacement in 1973.15 There have since been two reports of a limited number of cases.2.3 In these reports, the technique was not addressed, nor were the indications for surgery. In theory, auricular cartilage may fulfill many of the demands of an ideal disc replacement. It is biologically inert and, when the perichondrium is left, presumably viable. It has some bulk and thus can partially compensate for loss of posterior ramus height. It is easy to harvest and is in the same operative field. The final graft is well contoured to fit the anatomic needs of a disc replacement (Fig 3). All patients operated on had a long history of pain and dysfunction. They also had undergone previous operations which had failed, primarily as measured by return of pain, or they had undergone intensive conservative treatment consisting of biteplates, medications, and occlusal adjustments. In every case, there was an element of dysfunction, but pain was the common indication for surgical intervention. Subjectively, relief of pain was immediate. Some postsurgical pain was noted, but not to the same extent as with our previous experience with Proplast-Teflon. Ninety-one percent were no longer taking narcotics for pain, whereas 100% had done so before surgery. Two patients (three joints) are still receiving psychiatric and drug rehabilitation, but they admitted to marked relief of subjective pain. Function was also clearly improved and has been maintained for the period of this study. There was an 8-mm average increase in opening after surgery, and 43% had good translatory movements. Because most of the patients were reoperations, these data are difficult to analyze. However, with the exception of the two patients, normal unrestricted masticatory function was present in all patients. There have been no relapse or failures necessitating removal of the grafts. No objective ear deformities resulted from graft harvest. Our recent experience with using a single poste-
Pain Relief Correlated With Preoperative Pathology Previous Implant
Preoperative pathology No complaints (no medications) Minimal complaints (aspirin or other nonsteroidal anti-inflammatory medications) Severe pain (narcotics)
Scarring/Anterior Dislocation Without Reduction
Disc Perforation
Distorted Disc
19 14
10 8
3
3
1
I
5 0
0 2
2 0
0
I
MATUKAS AND LACHNER
rior incision for graft harvesting and joint approach (six patients) has been gratifying. It avoids two incisions and lessens the possibility of compromised vascular supply to the ear. It also makes the procedure more efficient and esthetic. The postoperative morbidity is also reduced with this approach. We can only speculate about the long-term success of this procedure. The graft offers the possibility of a self-perpetuating disc replacement not subjected to the normal wear and tear of a self-perpetuating disc replacement not subjected to the normal wear and tear of alloplastic materials. Clearly, larger numbers and longer follow-ups are necessary before more definitive recommendations can be made. References I. Florine BL. Gatto DJ. Wade ML, et al: Tomographic evaluation of joints following discoplasty or placement of polytetratluoroethylene implants. J Oral Maxillofac Surg 48:!83, 1988 2. Witsenburg B. Freihofer HPM: Replacement of the pathological temporomandibular articular disc using autogenous cartilage of the external ear. Int J Oral Surg !3:40!, 1984 3. loannides C. Freihofer HPM: Replacement of the damaged interarticular disc of the TMJ. J Craniomaxillofac Surg !6:273. 1988 4. Lantz A Discitis Mandibularis. Zentralb! Chir 36:289, 1909 5. Eriksson L. Westesson PL: Long term evaluation of menis-
353 cectomy of the temporomandibular joint. J Oral Maxillofat Surg 43:263, 1985 6. Brown WA: Internal derangement of the temporomandibular joint: Review of 214 patients following meniscectomy. Can .I Surg 23:30, 1980 7. Gallagher DM, Wolford LM: Comparison of Silastic and Proplast implants in the temporomandibular joint after condylectomy for osteoarthritis. .I Oral Maxillofac Surg 40:627, 1982 8. Bronstein SL: Retained alloplastic temporomandibular joint disc implants: A retrospective study. Oral Surg Oral Med Oral Patho! 59:449, 1985 9. Westesson PL, Eriksson L. Lindstrom C: Destructive lesions of the mandibular condyle following discectomy with temporary Silicone implants. Oral Surg Oral Med Oral Pathol 63: 143, 1988 IO. Dolwick MF, Aufdemorte TB: Silicone-induced foreign body reaction and lymphadenopathy after temporomandibular joint arthroplasty. Oral Surg Oral Med Oral Patho! 59:449, 1985 11. Georgiade NC: The surgical correction of temporomandibular joint dysfunction by means of autogenous derma! grafts. Plast Reconstr Surg 30:68, 1962 12. Tucker MR. Jacoway JR, White RK: Autogenous derma! grafts for repair of temporomandibular joint disc perforations. J Oral Maxillofac Surg 44:78!, 1986 13. Narang R. Dixon RA: Temporomandibularjoint arthroplasty with fascia lata. Oral Surg 39:45, 1975 14. Feinberg SE, Larsen PE. The use of pedicled temporalis muscle-pericranial flap for replacement of the TMJ disc. J Oral Maxillofac Surg 47: 142, 1989 15. Perko M: lndikationen und Kontraindikationen fur chirurgische Eingriffe am Kiefergelenk. Schweiz Msch Zahnheilk 83:73. 1973
