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Complications following Total Temporo-Mandibular Joint Prosthetic Replacement

Borja Gonzalez-Perez-Somarriba; Gabriel Centeno; Carpóforo Vallellano; and

Luis Miguel Gonzalez-Perez*1Department of Mechanical and Manufacturing Engineering, Engineering School, University of

Seville, Spain.

*Corresponding to: Luis Miguel Gonzalez-Perez MD, DDS, PhD, Department of Maxillofacial Surgery,

Virgen del Rocio University Hospital. Av. Manuel Siurot s/n. 41013 Seville, Spain.

Email: [email protected]

Chapter 1

Oral and Craniofacial Diseases & Disorders

Abstract Prosthesesareartificialdevicesusedtoreplacehumanbodypartsduetode-generativediseases,accidenttraumaortumours.Fromthepointofviewofhealthcare,theprimaryfunctionofjointreplacementwithprosthesisistorelievepainandrestorefunction,whichincludestransmittingphysiologicalloadsandthepro-visionofaphysiological rangeofmovementandanarticulationwithminimumfrictionandwear.Ithasbeendemonstratedthattheuseofappropriatebiomaterialsanddesignparameterscandecreasematerialwearandincrease the longevityofjoint replacementdevices.Therefore,aswithany implanted functioningbiome-chanicaldevice,revisionsurgerymaybenecessarytoremoveorreplacethearticu-latingcomponentsduetomaterialwearorfailure.Thepurposeofthischapteristodescribethecomplicationsfollowingtotaltemporo-mandibularjointreplacementand,thereby,establisharationalefortheuseofthesedevicesinthelong-termman-agementofadvanced-stagetemporo-mandibularjointdisorders,withanemphasisonengineeringconceptsandfutureimprovements.

Keywords: Surgical implants; Biomaterials; Joint replacement; Prosthesis longevity;Temporomandibularjoint(TMJ);Temporomandibularjointreplacement(TMJR);FrictionandWear

1. Introduction

Temporomandibular joint (TMJ) isoneof themostcomplexhumanbody joints,be-ingtotalTMJreconstructionlimitedtopatientswhereremainingtherapieshavefailedorarenotindicated.Idealalloplasticorprostheticjointisthatwhichmimicsfunctionandshapeofreplacedjoint,beingabletosupportthesameforcesexperiencedbynormaljointandtorepro-

OralandCraniofacialDiseases&Disorders

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Gonzalez-PerezLM

duceitsfunctionalmovements.ThehistoryofTMJreconstructionwithalloplasticmaterialshasbeen characterizedbymultiple failuresbasedon inappropriate prosthesis design [1,2].TMJreplacement(TMJR)isabiomechanicalratherthanabiologicalsolutiontoadvanced-stageTMJdisease.TMJRhavebeenusedclinicallyforovertwentyyearsinitspresentform,and remainsoneof themost successful applicationsofprostheticTMJ surgery today.ThenumberofTMJRproceduresisincreasingatasignificantrate.Theincreasedlongevityofthepopulation,thedemandforincreasedqualityoflifeandmoreactivelifestyles,theearlieronsetanddiagnosisofdegenerativediseases,andthesuccessofthesurgicalproceduresmeanthatTMJRisnowundertakeninabroadage-rangeofpatients.Thishasplacedincreaseddemandsonboththedesignandperformanceoftheprostheses[1-6].

Theaimof this chapter is todescribeprocedures andcomplications associatedwithTMJR,withanemphasisonengineeringconceptsandfutureimprovements.Thisworkhasbeencarriedoutwithin theframeworkofacollaborativestudybetweentheDepartmentofMechanicalandManufacturingEngineeringattheSchoolofEngineeringandtheUniversityHospital“VirgendelRocío”,bothattheUniversityofSeville.

2. Prosthesis Interface and Physical Environment

Thephysicalenvironmentintowhichthejointreplacementisimplantedisextremelychallenging.Notonlydoes ithaveparticularchemical,biochemical,biologicalandbiome-chanicalcharacteristics,butalsothefactthatthetissuesurroundingtheprostheticcomponentsremainslivingmeansthatthejointreplacementinterfaceandenvironmentcanundergocon-tinualchangewithtime.Thesechangesarenotonlyrelatedtothenaturalageingofthepatient,butalsocanoccurinresponsetothefunctionandpropertiesoftheprostheticdeviceitself.Thisresults inacomplex interactivebiomechanicalenvironment involving the living tissueandprostheticjointinthebodywhichcandeterminethelifetimeofthereplacementjoint.Overtheyearsithasprovenverydifficulttopredictpreclinicallymanyoftheseinteractions,andithasonlybeenasaresultofclinicalexperienceandresearchthatparticularclinicalfailureandsuc-cessscenarioshaveemerged[5-12].Despitetheboneresorptionandadversetissuereactionsinitiallyreportedin theearly1990swith thematerialfailureofProplast-Teflonin theTMJVitekprostheses,itbecameclearthatweardebriswasthemajorcauseofosteolysisandloos-eninginTMJR.Studiesofretrievedtissuesshowedanabundanceofmicronandsubmicron-sizedwearparticles,whichwerealsofoundinlaboratorywearstudies.Theseparticleswereshowntostimulatemacrophagestoreleaseosteolyticcytokines,whichleadtoosteolysisandboneresorption[6,12].

Althoughmanyof thesedevicesaresupportedbypre-clinicalsimulationtestswhichindicateimprovedperformancecomparedtotraditionaltechnologies,theultimatetestisthelong-termclinicalfollow-up.Untilthisisestablishedtherewillalwaysremainadegreeofun-


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certaintysurroundinganynewjointreplacementtechnology[13,14].

3. Prosthesis Longevity

TMJdiseaseisacommonprobleminourcountry,buttheresectionandreplacementofthediseasedTMJisnotcommon.ThecomplexityoftheanatomyoftheTMJpresentsaproblemwithitsreconstructionandmanyofthemovementsofthenormalTMJhavenotbeenreproducedintheartificialjointsavailable.

Two categories of prostheses havebeen approved for implantation: stock-prostheseswhich the surgeon must fit at implantation, and patient-fitted or custom-made prostheseswhicharemadespecificallyforeachcase(Table 1).ThenoveltyofthemodernTMJRlimitstheavailabilityoflong-termdataregardingmaterialwear,stability,andimplantfailure.ThelongevityoftheTMJRthusremainsunknown.Ithasbeendemonstratedthattheuseofappro-priatebiomaterialsanddesignparameterscanpostponefailureanddecreasewear,increasingthelongevityofgeneralcranio-maxillofacialprostheses[15],suchasTMJRdevices[16-18].Theobtainedresultswithprosthesesmanufacturedfromultra-high-molecular-weight-polyeth-ylene(UHMWPE)glenoidfossacomponentsandcastcobalt-chromium(Co-Cr)mandibularramus-condylecomponentshaveledthesematerialsbecomingthestandardforjointreplace-ment.

Inourstudies[19,20],therewerenocasesofUHMWPEwear-relatedosteolysis,butfewpatientshadinstabilityoftheprosthesisasaresultoflooseningofthescrews.AlthoughtheanatomicalfitofthefossaandmandibularcomponentsenhancesthestabilityofTMJR,thereisnoargumenttosupportthefactthatbecauseacustomprosthesisisbasedonanexactfittotheboneitwilllikelyoffergreaterlongevity.OpponentsofthestockTMJRsystemstatethatsuchprostheseshaveaninferiorfitowingtorepeatedtrying-inofprostheticcomponentstodeterminetheclosestfit,butestimatingtheidealsizepriortotheoperationbysimplyoverlay-ingthecomponentsofthestockjointsonplainradiographscandrasticallydecreasethis,aswedidforourpatients.ThedataanalysisfromourstudiesalsorevealedthattheneedforTMJRinvolvesarelativelyyoungerpatientpopulation.As38%ofourcaseswereundertheageof50yearsatthetimeofsurgery,thismeansthattheTMJRmusthavealonglifetimebecauseoncetheprosthesisisimplantedthereisnowaytoreturntothepreviousanatomy[19-22].ThelongevityofTMJRdevicesisbasedontheproperindicationforitsuse,thepropertiesandbio-compatibilityofthematerialsused,thecorrectplacementandstabilityoftheprosthesisinsitu,thepatient’sbiologicalacceptanceofthedevice,andthecapacityofthepatienttounderstandthelimitationsinvolvedwithhavingaprosthesisinplace[23-25].

Improvements indesigncanhaveconsiderable impacton function, andfluoroscopicinvestigationsarenowprovidingrealinsightsintotheeffectofdifferentdesignsonkinematicfunction in theTMJ.Designandmaterialwearcharacteristics related to longevitymustbe


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consideredinrelationtofactorsastheprostheticmaterialsmustbeanatomicalinshape,besecurelyfixed to the surroundingbone, and remain securelyfixed throughout thepatient’slifetimewithoutlooseningofscrews[26-28].Increasedloadingpost-surgeryoccursuntiltheTMJRs,muscles,softtissuesandocclusionreachastateofequilibriumandadaptationtothenewposition,whichcouldtakeseveralmonths.Assuch,weconsidertheinitiationofpostop-erativephysiotherapytobeveryimportant,aswasdonewithourpatients.

4. Problems associated with Joint Replacement

ThemainproblemsassociatedwithTMJRarerelatedtowearatthearticularsurfaces,foreignbody reaction, andmobilityof the implantwithdisplacement and implant fracturecausedbytheuseofinappropriatealloplasticmaterials[16,21,29,30].Anumberofdifferentprostheseswereavailableforthisprocedure,includingTMJImplants,TMJConcepts,andtheBiometMicrofixationTMJReplacement System; nevertheless, since early 2006 nearly allTMJprosthesesimplantedinourdepartmenthavehadaUHMWPEglenoidfossacup.Tothisend,whilemetal-on-metalstockTMJRswereintroducedalongtimeagoandhavebeenusedinourunitoverthelast15years,withsimilaroutcomestotheUHMWPE-on-metalprosthesis,thenumbersusedaretoolowtoenableacomparativeanalysistobeperformed.

Thedebatein theliteraturerelatingto theefficacyof total jointreplacementappearstoindicatethatjointsmadefromcobalt-chromiumalloyarticulatingwithUMWPEfulfilltherequirementsorthopaedicsurgeonshaveusedforartificialjointreplacementsinthehip,kneeandshoulder[27-30].StudiesbyotherauthorsshowthatTMJRhasbeensuccessfullyem-ployedinthe20yearstheyhavebeenfollowingtheirpatients[31].

Hypersensitivitycanalsopresentaproblem,withnickel,cobaltandchromiumbeingthemostcommonsensitizingagents.Thishypersensitivitymaybethetriggerforunfavour-ableoutcomeswithtotaljointsurgery[32].Forthisreason,ametalallergytestpatchhasbeenincludedinthepreoperativestudiesforTMJRpatientsatourinstitution[19,20,32].

5. Planning Joint Replacement

OnedeficiencyinplanningTMJRsurgeryistheinabilitytopredictablyproducecom-plextemporo-mandibularcontoursusingcommerciallyavailablestockTMJRdevices,whicharesuppliedasgenericsizesandshapesdesignedonthebasisoftheaveragepatient[23-27].In themost complex and difficult cases, the surgeonmay spend considerable time duringsurgeryshapingtheTMJRtofitthecontourofthepatient’sbone,andtheserepeatedmanipu-lationstoadaptthemtodifficultanatomicalconfinesmightmaketheprosthesissusceptibletofatiguefractures[21,31].Onesolutiontothisproblemistousecomputer-guidedsurgicalplanningtechnologiestoproduceapassivefittingTMJprosthesisdesignedforspecificana-tomicalneedsofpatients.Progressinmedicalimagingandcontinuedadvancesincomputer-


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processingpowerforthree-dimensionaldataacquisitionofpatientparametersandsubsequentimageprocessingmakeitpossibleforclinicianstodiagnose,moreaccuratelyplan,simulateandtreatadvanced-stageTMJpatients.Tothepresenttime,themostcommonuseofadditivemanufacturinghasbeenthefabricationofpatientspecificskullmodels,whicharefabricatedforpreoperativeplanningusingpatient-specificimagingdatainDigitalImagingandCommu-nicationsinMedicine(DICOM)files,whicharethenconvertedintostereolithography(SLT)files,thestandardmanufacturingformatusedtoprintpatientspecificskullmodels[20].Theuseofsuchthree-dimensionalmedicalmodelshelpssurgeonstoplan,simulatetheplannedoperationandmanuallypre-shapecommerciallyavailablecranio-maxillofacial replacementdevices(Figure 1).Recentdevelopmentsintheareaofadditivemanufacturingallowthepre-fabricationofpatientspecific,custom-madeprosthesesusingthepatient’sDICOMdata.TheadvantagesofrapidprototypingindesigningandmanufacturingcustomizedTMJprosthesesare that theydonot require intraoperativemodificationsandoffer improvedpassivefitting[15].

Inourexperience,improvementsindesigncanhaveconsiderableimpactonfunction.Designandmaterialwearcharacteristicsrelatedtolongevitymustbeconsideredinrelationtothefourfollowingfactors:

5.1. Stability of prosthesis components in situ at implantation

The prostheticmaterialsmust be anatomical in shape, be securely fixed to the sur-roundingbone, and remain securelyfixed throughout thepatient’s lifespan.Preferably, theprosthetic components shouldbe implantedwithminimumbone resection.TheTMJRhasfunctionalmovements that are unconstrained. Stresses and strains directly or eccentricallyvectoredagainstanincompleteorinadequatecomponenttohost-boneinterfaceduringTMJRcreatewear.Unstable,thin,castCo–Crfossacyclicallyloadedbythemetalcondylarheadcanleadtolocalplasticdeformation,micromotion,galling,frettingcorrosion,componentscrewlooseningand/orthincastmetalfossacomponentfatigue,leadingtothefinalfailureofthede-vice(Figure 2).ColdflowisthepropertywhichallowsUHMWPEunderloadingtodevelopalterationofshaperather thanparticulation. InTMJR, thispropertydictates that thestablecomponentofaTMJRarticulation(i.e.theglenoidfossa)isheldinpositionandstabilizedbyastrongermaterial(metal).

CustomTMJRfossacomponentsaredesignedandmanufacturedtomaterialspecifica-tions.Further,themetalliccomponentofacustomfossaofferssolidstructurethroughwhichthezygomaticarchfixationscrewspass.StockTMJRdeviceswithanUHMWPEflangescrewfixationdesignhavethepotentialtodevelopmaterialcoldflowaroundthescrewholesorfrac-tureshouldmicromotionoccurifthesurgeoncannotordoesnotmakethefossacomponentfitproperly.Coldflowoftheresultantscrewfixationholecanleadtolooseningofthestockfossa


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fixationscrewsandincreasedmicromotionunderrepetitiveloading,resultingindevicefailure[31].

5.2. Materials biocompatibility to withstand the forces of mandibular function

Thebiomaterialsfromwhichtheimplantismademustbebiocompatible,andanywearparticlesproducedmustalsobecompatiblewiththebodyandnotcauseadversebiologicalreactions.Thejointreplacementshavetobecompatiblewitharangeofdifferentpatientanato-miesandgeometriesandtypicallyarangeofdifferentsizesisnecessary.Similarly,thebonequalityofpatientsisquitevariableandthemethodsoffixationhavetobeabletoaccommodatedifferentboneinterfaceconditions(Figures 3&4).

EmployingthemostadvantageousphysicalcharacteristicsofbiocompatiblematerialsisanessentialconsiderationinthedesignandmanufactureofanyTMJRdevice.Co-Cr,withitsrelativelyhighcarboncontent,contributestoitsstrength,polishability,andbiocompatibility.ItsexcellentwearcharacteristicswhenarticulatedagainstanUHMWPEpresentlymakeitthestandardforthenon-moveablearticulatingsurfaceofmostorthopaedictotaljointreplacementdevices[31].

Cobalt-basedalloyswereinitiallyusedasanorthopedicbiomaterialbecausetheyweremorecorrosion-resistantthanstainlesssteel.CastCo–Cr,oftenemployedinthemanufactureofstockTMJRdevices,isbiomechanicallyinferiortoanywroughtalloy.MetallurgicalflawssuchasinclusionsandporosityfoundincastCo–Crcomponentshavebeenassociatedwiththefatiguefailureofmetal-on-metalprostheses.TheseflawsmayalsoleadtothefailureofCo–CrTMJRcomponents,resultinginnoxiousmetallicdebris(metalosis)foundinadjacenttissues(Figure 2).

UHMWPEisalinearunbranchedpolyethylenechainwithamolecularweightofmorethanonemillion.TestingoveronedecadeofuseinTMJRhasledtotheconclusionthatUH-MWPEisconsideredtohaveexcellentwearandfatigueresistanceforapolymericmaterial(Figure 4)[10,16,28,31].

5.3. Design to withstand loads over the full range of function of the joint to be replaced

ThedesignofTMJRisahighlyinterdisciplinaryactivity,callingforadetailedunder-standingoftheTMJanatomy,knowledgeofMaterialScienceandEngineering,andsurgicalexperience[3,5,7,11].

StockfossacomponentsaredesignedwithoutaposteriorstoptopreventtheTMJRde-vicecondylefromdisplacingposteriorly.Shouldthestockcondylenotbeperfectlyalignedinthecentreofthestockfossamedio-laterallyand/orantero-posteriorly,thecondylecandisplaceposteriorly,andimpingeonthetympanicplateand/ortheauditorycanal.Thiscanresultin


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painandmandibulardysfunctionandfacialdeformity.

Thereisalsothepotentialforinfectionshouldtherebeapressure-relatedperforationassociatedwith theauditorycanal.This isofspecialconcernwhenusingastockTMJRincombinationwithanothersurgicalprocedure.ThecustomTMJRfossahasaposteriorstop,al-leviatingthisconcern[31].SincethecomponentsofacustomTMJRinterfacesowellwiththehostboneandthescrewfixationisstablefromimplantation,mandibularfunctioncanbeginimmediatelyafterimplantation[19,20].

5.4. Established criteria for successful joint replacement

There are two categories of TMJR devices approved for implantation: off-the-shelf(stock)deviceswhichthesurgeonhasto‘makefit’atimplantation,andpatient-fitted(custom)deviceswhichare‘madetofit’ineachspecificpatient[4,14,21,22].StockTMJRsystemswithmultiple‘makefit’choices,designedandmanufacturedfromeitherthincastCo–CrfossaorallUHMWPEfossacomponents,utilizingcastCr–Coramus/condylecomponents,canposemultipledesignandmaterialissues(Table 2).TriedandtestedstabilizedUHMWPEbearingsarticulatingagainstpolishedmetalcondylarcomponentshaveaveryhighprobabilityofpro-vidingmorethan10years’successfulclinicaluse.

Afterselectingthepropersize, theprostheticmaterialsmustbesecurelyfixedto thesurroundingbone,beanatomicalinshape,andremainsecurelyfixedthroughoutthepatient’slifetime.Theflangedirectionofthecondylarprosthesisisgenerallyidealwhenitparallelstheposteriormarginof themandibular ramus.Theproperplacementof theprostheticcondylarheadintothefossa-eminenceprosthesisassuresthattheheaddoesnotcontactanyscrewheadsduringfunction.Itisimportanttofixthecondylarprosthesistotheramusofthemandiblewithasmanyscrewsaspossible.Cautionshouldbeusedsoasnottoforcethescrewinplacewithtoomuchpressureasthescrewheadcouldfracture(Figure 1, and Figure 5).

ThemainproblemsassociatedwithTMJRarerelatedtoforeignbodyreaction,wearatthearticularsurfaces,andmobilityoftheimplantwithdisplacementandimplantfracturecausedbytheuseofinappropriatebiomaterials.Radiologicalstudyisusefultoexcludepatho-logicalprocessesafterimplantationsuchasmarkedosteolysisorafractureafterTMJR.Therearenospecificfeaturesrelatingtoinfectioninandaroundprostheticjoints.Ordinaryradio-graphsarenot sufficiently sensitiveor specific,whilecomputed tomographyandmagneticresonanceimagingarebothlimitedbyartifactsinducedbytheimplantedmaterials.

From2010onwards,nearlyallTMJprostheses implanted inourcountryhavepoly-ethyleneglenoidfossacups(Figure 5).Thispromptedconsiderableresearchintofactorsthatcausedaccelerationofthewearofpolyethyleneaswellasthedevelopmentofalternativebear-ingsurfacesandnewtechnologiestoreducewearandosteolysis.Duringthefirstdecadeof


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largejoint(hip,knee)replacement,themajorityofpolyethylenecomponentsweresterilizedusinggammairradiationinthepresenceofair.Duringtheearly1990sitemergedthattheirra-diation,whichcauseschainscissionandfreeradicals,rendersthematerialunstableandsubjecttooxidativedegradationcausingareductioninitsmechanicalpropertiesandanincreaseinthewearrate.Aswellasahigherwearrate,theoxidizedmaterialsalsoproducesmallparticleswithgreaterosteolyticpotential.Themajorityofcondylarheadswasconstructedfrompolishedmetalalloyswhichwereshowntobecomescratchedanddamaged,resultinginacceleratedwear(Figure 5).Thewidespreadrecognitionoftheroleofpolyethyleneweardebris-inducedosteolysisinthelong-termfailureofTMJprostheseshasledtoanewgenerationofdesignsandbearingmaterialsforTMJR[28-30].

6. Conclusion

Joint replacement has been one of themajor successes in temporo-mandibular jointsurgeryoverthelastdecade.Thesurgicalplacementofaprosthesissignificantlyreducespainanddysfunctionsecondarytoadvancedtemporo-mandibularjointdisease.Clinicalsuccess,long-termresults,andincreasedexpectationandlifetimesofpatientshavedriventheneedforimprovedmaterials,bearingsurfaces,anddesigns.Ithasbeendemonstratedthattheuseofappropriatebiomaterialsanddesignparameterscandecreasematerialwearandincreasethelongevityofjointreplacementdevices.Differentdesigns,materialsandbearingsareavailableforclinicaluseinlargejoints,suchasthehipandknee;however,whenusedinthetemporo-mandibular joint, the potential long-term uncertainties outweigh the benefits, and the newtechnologicalsolutionsrequirerigorousandeffectiveclinicalfollow-up.Inourexperience,themostcommoncomplicationsincludedislocation,needforrevisionduetomalocclusion,materialhypersensitivity,persistentpain,heterotopicboneformationandperiprostheticjointinfection.

Theuseofappropriatebiomaterialsanddesignparameterscandecreasematerialwearandincreasethelongevityoftemporo-mandibularjointreplacementdevices.Anunderstand-ingofbioengineeringconceptsandmechanics,theuseofbettermaterialsandsuperiordesigns,andlong-termstudiescanimproveoutcomesforourpatients.


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Figure 1:Theprocessassociatedwithfabricatingacustom-madeprosthesisbasedonCAD/CAMinassociationwiththree-dimensionalcomputed-tomographyishighlypromising.Suchanapproachpermitsthefabricationofacustomizedprosthesisthatprovidesaperfectfitforthepatient(customBiomet-Lorenzprosthesis).

Figure 2:Metal-on-metalTMJprosthesis(stockChristensenprosthesis)aftersurgicalremovalfromoneofourpatients.Acloseinspectionbymicroscopeofthearticulatingcomponents(right:glenoidfossarod;left:condyleplate)revealsplasticdeformationthatcombinedbydegradationand/orwear.

Figure 3:Balancebetweenwear,oxidationandmechanicalpropertiesandstructuralintegrityofaprostheticimplantmaterial.

7.Figures


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Figure 4: Featurestoconsiderwhenyouuseamaterialinaprostheticimplant.

Figure 5: Thedesignanddevelopmentofprosthesesisahighlyinterdisciplinaryactivity,callingforanunderstandingofmechanicalengineeringprinciples,adetailedknowledgeofanatomy,andsurgicalexperience.Itisthereforesurgicalteamstobeaidedbymaterialsengineeringexpertssothatthedesignandperformanceofprosthesescanbepredictedwithaccuracyandprecision.Theuseofthree-dimensionalmedicalmodelshelpssurgeonstoplan,simulatetheplannedoperationandmanuallypre-shapecommerciallyavailablereplacementdevices(customCGAprosthesis).


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Stock TMJ prosthesis Customized TMJ prosthesis

Makefitatimplantation Madetofit

Fossacomponentof3sizes(S,M,L),madecompletelyofUHMWPE

ComputerAidedDesign-ComputerAidedManufac-turing(CAD/CAMsystem)forcustomizeddesign

Mandibularcomponentin3differentlengths,and2dif-ferentwidths(standardandnarrow).

Stereolithographicmodelisstudiedtodetermineos-teotomiesandplacementoftheprostheticparts

Lowercost Highercost

Shortertreatmenttimeframes Longertreatmenttimeframes

Longersurgicaltime Reducedsurgicaltimes

Removalofbone Minimalremovalofbone

Moredifficulttoobtainprimarystability Easiertoobtainprimarystability

Potentialmicromovement Nomicromovement

Placementversatility Lessplacementversatility

LimiteduseforlargeordifficultanatomicdefectsExcellentforpatientswith lossofa largeportionorwithasignificantdeformityofthemandibularramus

Table 2:Establishedcriteriaforsuccessfuljointreplacement.

1.Theprostheticmaterialsmustbeanatomicalinshape,besecurelyfixedtothe surrounding bone, and remain securelyfixed throughout the patient’s

lifespan.

2. Thecomponentsofanyprosthesismustbestableinsituatimplantation.

3. ThematerialsfromwhichTMJprosthesesaremanufacturedmustbebio-compatibleandabletowithstandtheforcesofmandibularfunction.

4. Prostheticdevicesmustbedesignedtowithstandtheloadsdeliveredoverthefullrangeoffunctionofthejointtobereplaced.

5. Theuseofappropriatematerialsanddesignparameterscandecreasemate-rialwearandincreaselong-termstabilityandthelongevityofprostheses.

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Table 1:Differencesbetweenstockandcustom-madeTMJprostheses

8. Tables


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