protocol for concomitant temporomandibular joint … · article presents a new treatment protocol...

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Protocol for ConcomitantTemporomandibular Joint

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Custom-fitted Total JointReconstruction andOrthognathic Surgery UsingComputer-assisted SurgicalSimulation

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Reza Movahed, DMDa,*, Larry Wolford, DMDb,c
KEYWORDS

� Temporomandibular joint � Total joint reconstruction � Orthognathic surgery� Computer-assisted surgical simulation

KEY POINTS

� Combined orthognathic and total joint reconstruction cases can be predictably performed in 1stage.

� Use of virtual surgical planning can eliminate a significant time requirement in preparation ofconcomitant orthognathic and temporomandibular joint (TMJ) prostheses cases.

� The concomitant TMJ and orthognathic surgery–computer-assisted surgical simulation techniqueincreases the accuracy of combined cases.

� In order to have flexibility in positioning of the total joint prosthesis, recontouring of the lateralaspect of the rami is advantageous.

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INTRODUCTION

Clinicians who address temporomandibular joint(TMJ) disorders and dentofacial deformities surgi-cally can perform the surgery in 1 stage or 2 sepa-rate stages. The 2-stage approach requires thepatient to undergo 2 separate operations andanesthesia, significantly prolonging the overalltreatment. However, performing concomitantTMJ and orthognathic surgery (CTOS) in these

a Orthodontics, Saint Louis University, 40 North Kingsh63108, USA; b Department of Oral and Maxillofacial SurgHealth Science Center, 3409 Worth Street, Suite 400, DaBaylor College of Dentistry, Texas A&M University HealthTX 75246, USA* Corresponding author.E-mail address: [email protected]

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Oral Maxillofacial Surg Clin N Am - (2014) -–-http://dx.doi.org/10.1016/j.coms.2014.09.0041042-3699/14/$ – see front matter � 2014 Published by E

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cases requires careful treatment planning and sur-gical proficiency in the two surgical areas. Thisarticle presents a new treatment protocol for theapplication of computer-assisted surgical simula-tion (CASS) in CTOS cases requiring reconstruc-tion with patient-fitted total joint prostheses. Thetraditional and new CTOS protocols are describedand compared. The new CTOS protocol helpsdecrease the preoperative work-up time and in-crease the accuracy of model surgery.

ighway Boulevard, Apartment 16A, Saint Louis, MOery, Baylor College of Dentistry, Texas A&M Universityllas, TX 75246, USA; c Department of Orthodontics,Science Center, 3409 Worth Street, Suite 400, Dallas,

October 2014 ■ 3:07 pm

lsevier Inc. oralmaxsurgery.theclinics.co

mailto:[email protected]

http://dx.doi.org/10.1016/j.coms.2014.09.004

http://oralmaxsurgery.theclinics.com

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INDICATIONS

TMJ disorders and dentofacial deformitiescommonly coexist. The TMJ disorders may bethe causative factor of the jaw deformity, ordevelop as a result of the jaw deformity, or thetwo entities may develop independently of eachother. The most common TMJ disorders that canadversely affect jaw position, occlusion, and or-thognathic surgical outcomes include (1) articulardisc dislocation, (2) adolescent internal condylarresorption, (3) reactive arthritis, (4) condylar hyper-plasia, (5) ankylosis, (6) congenital deformation orabsence of the TMJ, (7) connective tissue andautoimmune diseases, (8) trauma, and (9) otherend-stage TMJ disorders.1 These TMJ conditionsare often associated with dentofacial deformities,malocclusion, TMJ pain, headaches, myofascialpain, TMJ and jaw functional impairment, earsymptoms, and sleep apnea. Patients with theseconditions may benefit from corrective surgicalintervention, including TMJ and orthognathic sur-gery. Some of the aforementioned TMJ disordersmay have the best outcome prognosis usingcustom-fitted total joint prostheses for TMJreconstruction.Many clinicians choose to ignore the TMJ disor-

ders and perform only orthognathic surgery forthese types of cases. Clinicians who address theTMJ disorders and dentofacial deformities surgi-cally can perform the surgery in 1 stage or 2 sepa-rate stages. The 2-stage approach requires thepatient to undergo 2 separate operations andanesthesia, significantly prolonging the overalltreatment. However, performing CTOS in thesecases requires careful treatment planning and sur-gical proficiency in the two surgical areas. Usingtraditional model surgery and treatment planningtechniques exposes the outcome to its own

Fig. 1. (A) Measurement of the cephalometric predictionsecond molar after counterclockwise rotation of the mandsurement obtained from the prediction tracing to the finfixating the mandible to the maxilla with methylmethacrytocol for concomitant temporomandibular joint custom-fgery utilizing computer-assisted surgical simulation. J Oral

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subset of error margin. As a result, CTOS requiresexperience and expertise.Over the past decade, CASS technology has

been integrated into many maxillofacial surgicalapplications,2,3 including dentofacial deformities,congenital deformities, defects after tumor abla-tion, posttraumatic defects, reconstruction of cra-nial defects,4 and reconstruction of the TMJ.5

CASS technology can improve surgical accuracy,provide intermediate and final surgical splints,and decrease surgeons’ time input for presurgicalpreparation compared with traditional methods ofcase preparation.6

PROTOCOL FOR TRADITIONALCONCOMITANT TEMPOROMANDIBULARJOINT AND ORTHOGNATHIC SURGERY

Treatment planning for CTOS cases is based onprediction tracing, clinical evaluation, and dentalmodels, which provide the template for move-ments of the upper and lower jaws to establishoptimal treatment outcome in relation to function,facial harmony, occlusion, and oropharyngealairway dimensions. For patients who require totaljoint prostheses, a computed tomography (CT)scan is acquired of the maxillofacial region that in-cludes the TMJs, maxilla, andmandible with 1-mmoverlapping cuts. Using these CT scan data, astereolithic model is fabricated, with the mandibleas a separate piece.Using the original cephalometric tracing and

prediction tracing (Fig. 1A), the mandible onthe stereolithic model is placed into its futurepredetermined position using the planned mea-surements for correction of mandibular anteropos-terior and vertical positions, pitch, yaw, and roll(see Fig. 1). The mandible is stabilized to themaxilla with quick-cure acrylic. Many patients

tracing for the amount of open bite produced at theible into its final position. (B) Duplication of the mea-al mandibular position on the stereolithic model andlate. (From Movahed R, Teschke M, Wolford LM. Pro-itted total joint reconstruction and orthognathic sur-Maxillofac Surg 2013;71(12):2123–9; with permission.)

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with temporomandibular disorders requiringconcomitant orthognathic surgery benefit fromcounterclockwise rotation of the maxillomandibu-lar complex, which requires the development ofposterior open bites on the model (see Fig. 1B).Because the mandibular position on the stereo-lithic models is established using hands-on mea-surements, the operator’s manual dexterity andthree-dimensional perspective play critical rolesin setting the mandible in its proper and final posi-tion. This step can predispose the planning pro-cess to a certain margin of error.

The next step requires the preparation of thelateral aspect of the rami and fossae (Fig 2A, B)for fabrication of the patient-fitted total joint pros-theses. The goal of this step is to recontour thelateral ramus to a flat surface in the area wherethe mandibular component will be placed. Thefossa requires recontouring only if heterotopicbone or unusual anatomy is present. The recon-touring areas are marked in red for duplication ofbone removal at surgery. Because most patientswith TMJ problems requiring CTOS can benefitfrom counterclockwise rotation of the maxilloman-dibular complex, the stereolithic model is likely tobe set with posterior open bites, because themaxilla is maintained in its original position.

Once the stereolithic model is finalized, themodel is sent to TMJ Concepts (Ventura, CA) toperform the design, blueprint, and wax-up of the

Fig. 2. (A) Marking the condylectomy osteotomy and theafter condylectomy and recontouring of the fossae and ramses wax-up for approval by the surgeon. (From Movahedtemporomandibular joint custom-fitted total joint reconsassisted surgical simulation. J Oral Maxillofac Surg 2013;7

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custom-fitted total joint prostheses (see Fig. 2C),with the design and wax-up sent to the surgeonfor approval before manufacture of the prosthe-ses. The period from CT acquisition to themanufacturer’s completion of the custom-fittedprostheses is approximately 8 weeks. Thesurgical procedures are then performed onarticulator-mounted dental models. The mandibleis repositioned on the articulator, duplicating themovements performed on the stereolithic model,and the intermediate splint is constructed. Themaxillary model is repositioned, segmented if indi-cated, and placed into the maximal occlusal fit.Then, the palatal splint is constructed.

PROTOCOL FOR TRADITIONALCONCOMITANT TEMPOROMANDIBULARJOINT AND ORTHOGNATHIC SURGERY

1. CT scan including the entire mandible, maxilla,and TMJs

2. Fabrication of stereolithic model with themandible separated

3. Surgeon positions the mandible in its final posi-tion and fixates it

4. Removal of condyles and recontouring thelateral aspect of the rami and fossae if indicated

5. Model sent to TMJ Concepts for prosthesesdesign, blueprint, and wax-up

irregularities of the fossa. (B) The stereolithic modeli (marked in red). (C) Stereolithic model with prosthe-R, Teschke M, Wolford LM. Protocol for concomitanttruction and orthognathic surgery utilizing computer-1(12):2123–9; with permission.)


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6. Approval of total joint prostheses blueprint andwax-up by the surgeon

7. Manufacture of custom-fitted total jointprostheses

8. Prostheses sent to hospital for surgicalimplantation

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STEPS IN TRADITION ORTHOGNATHICSURGERY, AND INTERMEDIATE AND PALATALSPLINT FABRICATION FOR CONCOMITANTTEMPOROMANDIBULAR JOINT ANDORTHOGNATHIC SURGERY

1. Acquisition of dental models2. Mounting maxillary and mandibular dental

models on an articulator3. Repositioning the mandibular dental model,

duplicating the positional changes acquiredon the stereolithic model

4. Fabrication of intermediate splint5. Repositioning maxillary dental models with

segmentation if indicated6. Construction of palatal splint7. Ready for surgery

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PROTOCOL FOR CONCOMITANTTEMPOROMANDIBULAR JOINT ANDORTHOGNATHIC SURGERY USINGCOMPUTER-ASSISTED SURGICALSIMULATION

For CTOS cases, the orthognathic surgery isplanned using Medical Modeling (Golden, CO)CASS technology and moving the maxilla andmandible into their final position in a computer-simulated environment (Fig. 3A, B). Using thecomputer simulation, the anteroposterior and ver-tical positions, pitch, yaw, and roll are accuratelyfinalized for the maxilla and mandible based onclinical evaluation, dental models, predictiontracing, and computer-simulation analysis.Using Digital Imaging and Communications in

Medicine (DICOM) data, the stereolithic model isproduced with the maxilla and mandible in the finalposition and provided to the surgeon for removalof the condyle and recontouring of the lateralrami and fossae if indicated (Fig. 4A). The stereo-lithic model is sent to TMJ Concepts for thedesign, blueprint, and wax-up of the prostheses.Using the Internet, the design is sent to the sur-geon for approval. The custom-fitted total jointprostheses are then manufactured (see Fig. 4B).It takes approximately 8 weeks to manufacturethe total joint custom-fitted prostheses.Approximately 2 weeks before surgery, the final

dental models are produced, including 2 maxillarymodels if the maxilla is to be segmented or dental


equilibration is required. One of the maxillarymodels is segmented if indicated, dental equilibra-tion is performed, and the segments are placed inthe best occlusion fit with the mandibular dentitionand maxillary segments fixed to each other. Thedental models do not require mounting on an artic-ulator. The 3 or 4 models (2 maxillary and 1mandibular, or 2 mandibular models if equilibra-tions are done) are sent to Medical Modeling forscanning and simulation into the computer model.Because the authors routinely perform the TMJreconstruction and mandibular advancementwith the TMJ Concepts total joint prosthesis first,the unsegmented maxillary model is simulatedinto the original maxillary position and themandible is maintained in the final position. The in-termediate splint is constructed (see Fig. 3B), andthen the segmented maxillary model is simulatedinto the computer model in its final position, withthe maxilla and mandible placed into the bestocclusal fit, and the palatal splint is fabricated.The dental models, splints, and images of thecomputer-simulated surgery are sent to the sur-geon for implementation during surgery.

PROTOCOL OF CONCOMITANTTEMPOROMANDIBULAR JOINT ANDORTHOGNATHIC SURGERY USINGCOMPUTER-ASSISTED SURGICALSIMULATION

1. CT scan of entire mandible, maxilla, and TMJs(1-mm overlapping cuts)

2. Processing of DICOM data to create a com-puter model in the CASS environment

3. Correction of dentofacial deformity, includingfinal positioning of the maxilla and mandible,with computer-simulated surgery

4. Stereolithic model constructed with jaws infinal position and sent to surgeon for condy-lectomy and rami and fossae recontouring ifindicated

5. Model sent to TMJ Concepts for prosthesesdesign, blueprint, and wax-up

6. Surgeon evaluation and approval using theInternet

7. TMJ prostheses manufactured and sent tohospital for surgical implantation

8. Two weeks before surgery, acquisition of finaldental models (2 maxillary, 1 or 2 mandibularmodels if dental equilibrations are required);1 maxillary model is segmented and modelsequilibrated if indicated to maximize theocclusal fit; models sent to Medical Modeling

9. Models incorporated into computer-simulatedsurgery for construction of intermediate andfinal palatal splints

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Fig. 3. Staged computer-aided surgical simulation surgical report. (A) Simulated preoperative position of themaxilla and mandible. (B) The maxilla and mandible in the simulated intermediate position, with the maxillain its original position, but the mandible in its final position with the mandibular surgery performed first forfabrication of the intermediate splint. (C) The final position of maxilla and mandible, after advancement ofmandible and segmental osteotomy of the maxilla, for the production of a palatal splint. (From Movahed R,Teschke M, Wolford LM. Protocol for concomitant temporomandibular joint custom-fitted total joint reconstruc-tion and orthognathic surgery utilizing computer-assisted surgical simulation. J Oral Maxillofac Surg2013;71(12):2123–9; with permission.)

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10. Models, splints, and printouts of computer-simulated surgery sent to surgeon

Using CASS technology for CTOS cases elimi-nates the ‘traditional’ steps requiring the surgeon

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to manually set the mandible into its new final po-sition on the stereolithic model, thus saving timeand improving surgical accuracy. Although dentalmodel surgery is necessary only if the maxilla re-quires segmentation, the models do not require


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Fig. 4. (A) Stereolithic model fabricated after simulated maxillary and mandibular advancement to the final po-sition. Condylectomy and recontouring of the lateral rami and fossae were performed (red) and sent to TMJ Con-cepts for construction of the prostheses. (B) Constructed patient-fitted TMJ prosthesis using the computer-aidedsurgical simulation fabricated stereolithic model. (From Movahed R, Teschke M, Wolford LM. Protocol forconcomitant temporomandibular joint custom-fitted total joint reconstruction and orthognathic surgery utiliz-ing computer-assisted surgical simulation. J Oral Maxillofac Surg 2013;71(12):2123–9; with permission.)

Pearls

1. Combined orthognathic and total jointreconstruction cases can be predictably per-formed in 1 stage.

2. Use of virtual surgical planning can eliminatea significant time requirement in prepara-tion of concomitant orthognathic and TMJ

Movahed & Wolford6

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mounting on an articulator, which saves consid-erable time by eliminating the time required tomount the models, prepare the model basesfor model surgery, reposition the mandible,construct the intermediate occlusal splint, andmake the final palatal splint. With CASS technol-ogy, the splints are manufactured by MedicalModeling.

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prostheses cases.

3. The CTOS-CASS technique increases the accu-racy of combined cases.

4. In order to have flexibility in positioning ofthe total joint prosthesis, recontouring ofthe lateral aspect of the rami is advanta-geous.

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DISCUSSION

Using CASS technology for CTOS cases, the sur-geon superimposes the orthognathic computer-simulated surgery into the production of thestereolithic model, hence decreasing the marginof error that can occur with hands-on positioningof the mandible on the stereolithic model. Further-more, this technique decreases the time taken bythe surgeon in the laboratory, by TMJ Conceptsfor the fabrication of prostheses, and for settingthe stereolithic model with increased accuracy inthe process.The remaining areas in which improvement can

be made in CASS technology include performingrecontouring of the rami and fossae in the simu-lated environment in an accurate fashion, elimi-nating the requirement for the acquisition ofdental models by using laser scanning technol-ogy, and performing accurate maxillary segmen-tation and equilibration using CASS technology.Further research is necessary to achieve thisgoal and to move the workflow directly from theCASS environment to the fabrication of custom-fitted TMJ Concepts prostheses, without requiringthe surgeon to have ‘hands-on’ involvement in theprocess.


CASE

A 32-year-old woman was diagnosed with juvenileidiopathic arthritis in grade school, had orthodon-tics from 15 to 17 years of age with maxillary firstbicuspids extractions, and developed an openbite at age 28 years Q(Figs. 5–9). Over the yearsshe was treated conservatively with occlusalsplints and arthroscopic surgeries. Her myofascialpain persisted over the years and worsenedbefore her initial consultation. The maximal incisalopening measured with pain was 36 mm andwithout pain was 14 mm. Excursion movementsto the right were 9 mm and to the left were10 mm. Her surgery was planned using CTOS-CASS technology:

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Fig. 5. Frontal view, before surgery (A) and 1 year after surgery (B).Q17

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1. Bilateral TMJ reconstruction and counter-clockwise rotation of the mandible withTMJ Concepts patient-fitted total jointprostheses

Fig. 6. Frontal view, smiling, before surgery (A) and 1 yea

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2. Bilateral TMJ fat grafts packed around the ar-ticulating area of the prostheses, harvestedfrom the abdomen

3. Bilateral coronoidectomies

r after surgery (B).


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Fig. 7. Profile view, before surgery (A) and 1 year after surgery(B).

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4. Multiple maxillary osteotomies for counter-clockwise rotation and advancement

5. Bilateral partial inferior turbinectomies

One-year after surgery she reported nomyofascial, TMJ, or headache pain and her

Fig. 8. Prediction analysis before surgery (A) and after sur


incisal opening improved to 50 mm. Excursionmovements were 4 mm to the right and2 mm to the left. A class I occlusion wasobtained and better facial harmony wasachieved.

gery (B).

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Fig. 9. Presurgery occlusion (A–C) and postsurgery occlusion 1 year after surgery (D–F).


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REFERENCES

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TMJ disorders: orthodontic and surgical manage-

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ries, vol. 6. Ann Arbor (MI): University of Michigan;

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dod 2002;93:382–93.

3. Xia J, Ip HH, Samman N, et al. Computer-assisted

three-dimensional surgical planning and simulation:

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3D virtual osteotomy. Int J Oral Maxillofac Surg

2000;29:11–7.

4. Rotaru H, Stan H, Florian I, et al. Cranioplasty with

custom-made implants: analyzing the cases of 10 pa-

tients. J Oral Maxillofac Surg 2012;70:e169.

5. Gateno J, Xia J, Teichgraeber J, et al. Clinical feasi-

bility of computer-aided surgical simulation (CASS)

in the treatment of complex cranio-maxillofacial defor-

mities. J Oral Maxillofac Surg 2007;65:728.

6. Movahed R, Teschke M, Wolford LM. Protocol for

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REZA MOVAHED, DMD, Clinical Assistant Professor, Orthodontics, Saint Louis University, Saint

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LARRY WOLFORD, DMD, Clinical Professor, Departments of Oral and Maxillofacial Surgery and

Orthodontics, Baylor College of Dentistry, Texas A&M University Health Science Center, Dallas, Texas

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cases. The concomitant TMJ and orthognathic surgeryecomputer-assisted surgical simulation technique

increases the accuracy of combined cases. In order to have flexibility in positioning of the total joint

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