FINDINGS:
This is a ***-year-old *** who presented with irretractable pain and limited range of motion the mandible due to restrictive function of bilateral temporomandibular joints (TMJ). The patient underwent cone beam CT evaluation which demonstrated arthritic changes and loss of intra-articular joint space. Degenerative joint disease was evident bilaterally. The patient with recurrent acute and chronic pain with limited functionality of the jaw. Case was discussed at length. Risks, benefits, and alternative therapies reviewed. Clinical indications for total prosthetic joint replacements were reviewed in detail. Risk of bleeding, infection, facial nerve injury, inferior alveolar nerve injury, potential hardware failure, and reoperation was reviewed, understood, and accepted by patient. Virtual surgical plan and imaging was reviewed in detail with the patient. Harvest of abdominal fat was discussed and understood. The patient is being taken to the operating room in an elective manner.
PROCEDURE:
The patient was taken to the OR and placed on the OR table in the supine position. The patient was induced under general anesthesia and maintained via nasotracheal intubation.
Under non-sterile conditions, 7 intermaxillary fixation pins were placed into the maxillary and mandibular arch forms for intra-operative closed reduction with intermaxillary fixation (CRIMF). After placement of the IMF pins, the patient was prepped and draped in a standard fashion for total joint reconstruction and harvest of abdominal fat.
Attention was directed to the right preauricular and retromandibular areas. Approximately 10 mL of a 1:100,000 dilution of epinephrine in normal saline was infiltrated into the proposed incision sites along the preauricular skin crease and retromandibular area. With the use of a marking pen, a preauricular fold incision was outlined from the hairline to the ear lobe. With the use of a #15 Bard-Parker blade, skin was incised and sharp dissection followed through the auricularis muscle to the temporalis fascia. Bovie and bipolar was used to control all bleeding points. Continued dissection anterior to the cartilaginous portions of the ear canal and extended inferiorly to the level of the ear lobe was completed. Good exposure of the temporal fascia was gained. The lateral lip of the glenoid fossa was palpated, with a #15 Bard-Parker blade a fascial incision was made 45 degrees off the Frankfort horizontal extending from the lateral lip of the glenoid Fossa anteriorly and superiorly. A subfascial dissection proceeded elevating tissue in anterior manner exposing the TMJ capsular ligaments and degloving the lateral rim of the glenoid fossa to the articular eminence. With full exposure of the articular eminence, the superior joint space was entered and good mobilization of the tissues within the joint space was noted. A large perforation of the discal complex was noted and the visualization of the condylar head was evident. An inverted-L type of incision was made over the condylar neck incised through the capsular ligaments allowing for the isolation of the condylar head and neck. Full exposure to the sigmoid notch was completed with soft tissue separation around the condylar head detaching the capsular ligaments. All bleeding points were controlled locally. FloSeal was placed into the surgical field, and the skin incision was stapled shut. Attention was directed to the retromandibular area.
A 4 cm skin incision was made approximately 1 fingerbreadth posterior and inferior to the right angle of the mandible. Sharp dissection through the skin and subcutaneous tissues to the level of the platysma muscle was completed. The platysma muscle was isolated and dissected in a layered manner exposing the deep cervical fascia. A nerve stimulator was used to denote branches of the facial nerve which were not encountered. Sharp and blunt dissection through the fascia to the masseteric sling was completed. The sling was isolated from the antegonial notch and extending along the posterior border of the mandible. With the use of a needle-tip Bovie, the muscle sling was incised along the inferolateral aspect of the inferior border, around the angle of the mandible and posterior border. Disinsertion of the masseteric muscle was done in a sharp manner exposing of the right lateral ramus to the level of the sigmoid notch.
A prefabricated surgical cutting guide with predictive hole placement for the prosthetic condylar stem was placed into the anatomic position, seated well and fixated with a single bicortical screw. All predictive holes were drilled as per surgical plan and the proposed subcondylar osteotomy was outlined with the use of an oscillating saw. The cutting guide was removed and full thickness separation of the condylar head was completed with the oscillating saw. The condyle was freed of all soft tissue through the submandibular and preauricular approaches and removed. The resected portion of the condyle matched the surgical plan and stereolytic medical model. Via the preauricular approach, all soft tissue within the glenoid fossa was isolated, total discectomy was completed in a sharp manner using a Bovie. All bleeding points were controlled locally. The recipient site was noted to be appropriately prepared, the area was packed with a ribbon gauze and both wounds were stapled.
Attention was directed to the contralateral side in which a similar preauricular and retromandibular incision and dissections were completed. On the left submandibular approach, facial nerve branches were encountered, isolated and elevated outside the sharp surgical approach through the masseteric sling. Once the isolation of the left lateral ramus was completed the condylar head, neck, glenoid fossa, discal complex was well visualized. A surgical cutting guide was positioned, fixated and predictive holes were pre-drilled and the left subcondylar osteotomy was outlined with an oscillating saw. The guide was removed, and the osteotomy was completed. The condylar head and neck component was resected, and the discectomy was completed in a similar manner.
At this time, the patient’s mouth was placed into intermaxillary fixation using 24-gauge wire and the IMF pins, appropriate dental cclusion was noted and stabilized. Under sterile conditions the fossa and condylar stems were placed accordingly on each side, fossa components were fitted into the recipient sites on the respective sides and the condylar stems were fixated with bicortical screwed as per surgical plan. Good adaptation and stable fixation was achieved on both condylar stems. The alignment of the fossa components confirmed as an appropriate position, each fossa component was fixated as per surgical plan with 4 individual screws on each side. With completion of the fixation, intermaxillary fixation was removed, and the patient demonstrated an appropriate arc of closure and stable dental occlusion with no evidence of condylar dislocation.
Attention was directed to the lower abdomen in which a dermal fat graft was harvested through a preexisting scar at the lower abdomen inferior to the umbilicus. A 4 x 2 ellipse was made with a #15 Bard-Parker blade. The skin was deepithelialized with a #15 Bard-Parker blade, the dermal fat graft was harvested with the use of a Bovie approximately 4 x 2 x 1.5 cm in size. All bleeding points were controlled locally. Closure was completed with the use of 3-0 Vicryl and 4-0 Monocryl.
The dermal-fat graft was trimmed to allow for placement anterior, posteriorly and medial to each prosthetic condylar head. A 23 gauge silastic drain was placed into each preauricular wound. Layered closure followed, the submandibular wounds were closed with reapproximation of the masseteric sling using 3-0 Vicryl suture. Fascia was closed with 3-0 Vicryl suture. Platysma with 3-0 chromic, subcutaneous tissues were reapproximated with 3-0 chromic, and the skin was closed with 4-0 Monocryl. The preauricular wounds were closed over the silastic drains with reapproximation of the capsular ligaments and fascia using of 4-0 Vicryl, subcutaneous tissues reapproximated with 4-0 chromic and skin closed with the use of 5-0 nylon.
IMF screws were removed and accounted for, this concluded the surgical portion of the case. The patient was extubated in the operating room and taken to the recovery room in stable condition.
