First in Romanian medicine and surgery. Bilateral temporomandibular joint reconstruction in a patient with bilateral post-traumatic temporomandibular ankylosis

Recently, in a first for Romanian military medicine, and probably for national surgery, in the operating room of the Clinical Department of Oral and Maxillofacial Surgery of the Central Military University Emergency Hospital „Dr. Carol Davila” the surgical intervention for bilateral reconstruction of the temporomandibular joint with full bicomponent joint prostheses (titanium and UHMWPE – polyethylene with very high molecular weight) made specifically for this case, operation performed in the case of a patient diagnosed with temporomandibular ankylosis bilateral post-traumatic.

What is the temporomandibular joint

„The temporomandibular joint (TMJ) is the structure that joins the skull to the mandible, it allows the closing and opening of the mouth, but also the lateral movements of the mandible. Within this joint, complex movements of coordinated and balanced sliding and rotation are carried out – rocking left-right (taking into account that a single bone, the mandible, articulates at 2 points with the base of the skull in a manner similar to a see-saw).

The joint consists of the articular bone ends covered by cartilage, the articular disc and numerous ligaments. This joint opens and closes approximately 2000 times a day, contributing to the process of mastication, phonation and swallowing, thus being the most active in the body.

Pathological processes that affect the joints in the human body (inflammatory, degenerative, traumatic, congenital diseases, etc.) can also affect the temporomandibular joint, resulting in a specific clinical picture.

Among these, TMJ ankylosis is defined as bony or fibrous adhesion between anatomical articular components, accompanied by limitation of mouth opening. The unilateral form is more common than the bilateral one.

The frequency of this condition is higher in children than in adults, and the main causes are (in order of importance): direct traumas affecting this area and indirect ones (hits, falls on benton), loco-regional infections, rheumatoid arthritis and inflammation of the joint produced of general factors.

Sometimes, when a stroke occurs during childhood, it is overlooked, because the effects do not appear immediately but at a distance (through left-right asymmetric development). Most of the time, the patient does not even remember having hit himself at the time when he is diagnosed with ankylosis.

Ankylosis, symptoms

As symptomatology, in adults, the limitation or even the absence of mandibular movements is observed, which induces: dental and periodontal lesions (determined by oral hygiene that is difficult to achieve), functional disorders (mastication, swallowing, phonation), as well as changes in physiognomy, but without developmental changes of the jaw bones.

In children, the consequences of ankylosis are more severe and easy to identify because in addition to the symptoms mentioned in adults, there is also the defective development of the dento-maxillary apparatus, with more important functional and aesthetic implications.

The first in Romanian medicine and surgery, the bilateral reconstruction of the temporomandibular joint

Initially, the patient presented himself in the department of Oral and Maxillofacial Surgery for facial asymmetry due to retrusion of the mandible and the permanent impossibility of opening the mouth, accompanied by mastication and phonation disorders. From the analysis of the patient’s medical documents, it emerged that approximately 3 years ago he suffered a work accident resulting in a triple fracture of the mandible (bilateral condyle and symphysis) for which incomplete surgical treatment was instituted.

After the clinical examination, it was decided to perform a CBCT type computerized tomography (cone beam computed tomography) of the entire skull, an investigation that revealed the presence of bone blocks at the level of the temporo-mandibular joints bilaterally, with the disappearance of the joint space bilaterally .

Based on the clinical examination and the imaging scan, the diagnosis of bilateral post-traumatic temporomandibular ankylosis was established and the need for surgical intervention was decided: complete bilateral temporomandibular arthroplasty with bi-component titanium and UHMWPE „patient specific” (customized) joint prostheses. .

Consequently, the medical team, with the logistical support of the hospital and in collaboration with a private economic partner, carried out the virtual surgical planning based on the images obtained after performing the CBCT. In this way, the surgical guides and the „patient specific” (personalized) articular prostheses could be generated.

During the eight hours that the operation lasted, several operating times were achieved, among which we mention: the necessary tracheostomy intubation, the resection of temporo-mandibular ankylosing blocks bilaterally with the help of 3D printed surgical guides and the bilateral reconstruction of the TMJ with titanium articular prostheses „patient specific” (customized).

The surgical intervention was carried out under the coordination of Doctor Major Dr. Adrian Gabără and supervised by the Head of the Section, Doctor Colonel Dr. Cătălin Dumitru, with Mr. Doctor Dr. Ioana Bratu, ATI specialist doctor. The team was completed by maxillofacial surgery resident doctors – Sergiu Sitaru, Mirela Radu, Victor Burloiu, Radu Todosi, Mihnea Popescu, Lorena Burlacu and Adela Ceau; Robert Mistrianu, ATI resident doctor, operating theater nurses – Preda Camelia, Ilie Viorela and nurse Pătrașcu Cătălina.

At the end of the surgical intervention, the patient was transferred, for 48 hours, to the ATI Department, for the monitoring of vital functions. Postoperative evolution was favorable under anti-algesic, anti-inflammatory, antibiotic, anti-secretory and injectable anticoagulant treatment.

Upon returning to the Oral and Maxillofacial Surgery Clinic, the following were removed: the tracheostomy, the central venous catheter, the drain tubes and the urinary catheter. After another three days, the patient was discharged in good general condition, afebrile and healing surgical wounds.

Later, i.e. after 14 days, the patient returned for reevaluation and occlusal rebalancing, but also to start the medical recovery and physiotherapy procedures, procedures that were carried out in the Medical Recovery Department II, by Dr. Chiriac Ovidiu. In the following period, the patient continued his medical gymnastics and will follow a prosthetic rehabilitation plan.

Currently, the general condition of the patient is good, the surgical wounds are healed and most importantly the functionality has been resumed”, says the „Dr. Carol Davila” Central Military Emergency University Hospital. (PHOTO HERE).

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