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Total Temporomandibular Joint Replacement and Simultaneous Orthognathic Surgery Using Computer- Assisted Surgery

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Total Temporomandibular Joint Replacement and Simultaneous Orthognathic Surgery Using Computer- Assisted Surgery Total Temporomandibular Joint Replacement and Simultaneous Orthognathic Surgery Using Computer- Assisted Surgery Natalia Lucia Gomez, Luis Alejandro Boccalatte, Águeda Lopez Ruiz, María Gabriela Nassif, Marcelo Fernando Figari, et al. Journal of Maxillofacial and Oral Surgery ISSN 0972-8279 J. Maxillofac. Oral Surg. DOI 10.1007/s12663-020-01422-y 1 23 Your article is protected by copyright and all rights are held exclusively by The Association of Oral and Maxillofacial Surgeons of India. This e-offprint is for personal use only and shall not be self-archived in electronic repositories. If you wish to self-archive your article, please use the accepted manuscript version for posting on your own website. You may further deposit the accepted manuscript version in any repository, provided it is only made publicly available 12 months after official publication or later and provided acknowledgement is given to the original source of publication and a link is inserted to the published article on Springer's website. The link must be accompanied by the following text: "The final publication is available at link.springer.com”. 1 23 Author's personal copy J. Maxillofac. Oral Surg. https://doi.org/10.1007/s12663-020-01422-y CLINICAL PAPER Total Temporomandibular Joint Replacement and Simultaneous Orthognathic Surgery Using Computer-Assisted Surgery 1 1 2 Natalia Lucia Gomez • Luis Alejandro Boccalatte • A´ gueda Lopez Ruiz • 1 1 3,4 Marı´a Gabriela Nassif • Marcelo Fernando Figari • Lucas Ritacco Received: 6 April 2020 / Accepted: 10 July 2020 Ó The Association of Oral and Maxillofacial Surgeons of India 2020 Abstract Materials and methods We present two cases to illustrate Background Disorders of the temporomandibular joint our protocol and its results. (TMJ) are frequent and are usually associated with other Results In the first case, the difference in millimeters disorders of the facial skeleton. Surgery might be needed to between planning and surgical outcomes was 1.72 mm for correct TMJ anatomy and function and, in cases where the glenoid component and 2.16 mm for the condylar pathologies coexist, a two-stage corrective surgery might prosthesis; for the second case, differences in the right side be needed. However, the current fashion of single-stage were 2.59 mm for the glenoid component and 2.06 mm for procedures is feasible with the aid of new technologies the ramus, and in the left side, due to the anatomy the such as computer-assisted surgery (CAS). This is a step difference was a little greater, without clinical significance forward toward performing complex procedures such as a Conclusion Combined surgery of the midface and mand- TMJ replacement with simultaneous orthognathic surgery. ible with total TMJ replacement is feasible and beneficial CAS allows designing patient-fitted prosthesis and more for the patient. CAS facilitates the planning and design of predictable and accurate surgeries. Moreover, intraopera- custom-fit prosthesis and execution of these procedures. tive development can be controlled in real time with intraoperative navigation, and postoperative results can be Keywords Temporomandibular joint Á Computer-assisted measured and compared afterwards. surgery Á Intraoperative navigation Á Orthognathic surgery Aims The primary purpose of this article is to present the protocol used in our institution for orthognathic surgery associated with unilateral and bilateral TMJ replacement Introduction with patient-fitted prostheses guided with CAS. Disorders of the temporomandibular joint (TMJ) are fre- quent and generally coexist with other abnormalities of the maxillofacial skeleton [1–3]. When surgical correction is & Natalia Lucia Gomez required, single-stage procedures are feasible and benefi- [email protected]; cial for patients [1, 4–7]. Surgical corrective goals may be [email protected] achieved with adequate planning and surgical execution, preoperative virtual planning (PVP), 3D model printing 1 Head and Neck Surgery Section, General Surgery Department, Hospital Italiano de Buenos Aires, Peron 4190, and intraoperative virtual navigation (IVN) which are 1181 Buenos Aires, Argentina useful tools that facilitate treatment of complex disorders. 2 Vicente Lo´pez, Buenos Aires, Argentina Such tools, generically called ‘‘computer-assisted surgery’’ (CAS); primary endpoint is achieving more predictable and 3 Computer Assisted Surgery Unit (CAS Unit), Hospital Italiano de Buenos Aires, Buenos Aires, Argentina precise postoperative results [8, 9]. They facilitate simple procedures, like removal of a foreign body, as well as 4 Instituto de Medicina Traslacional e Ingenierı´a Biome´dica (IMTIB), Hospital Italiano de Buenos Aires, Buenos Aires, complex ones such as those performed for facial trauma, Argentina correction of craniomaxillary dysmorphisms, orthognathic 123 Author's personal copy J. Maxillofac. Oral Surg. surgery, oncological resections or TMJ replacements (IRB). We have read and followed the guidelines stated in [10–12]. the Helsinki Declaration when treating these patients and PVP allows to virtually design osteotomies and pros- preparing this article. The IRB stated no need of informed theses, while INV is useful for implementing decisions consent for the developing of this paper. made during PVP and guiding the surgeon during surgery by providing continuous imaging assessment of the anat- omy. Additionally, 3D printing is used to make splints, Case 1 prostheses and 3D models [11]. The goal of this study is to present the protocol used in The patient is a 49-year-old lady with a history of recurred our institution for orthognathic surgery associated to uni- condylar hyperplasia, referred due to progressive occlusion lateral and bilateral TMJ replacement with customized dysfunction and lateral deviation of the mandible. On prostheses, performed in a single stage procedure with physical examination, her skeletal class was type I, with a computer assistance; we present two cases to illustrate this slight occlusion overjet and lateral deviation. Metabolic protocol and its results. As secondary aim, we wish to condylar activity was assessed in three bone SPECT exams assess the accuracy of the procedure and postoperative at 8-month intervals, which showed a 16% difference clinical course. between both condyles and a CT of the facial skeleton with a 16.3 9 13.6 mm bone lesion, associated to arthrosis of the TMJ and no condyle excursion with open mouth Protocol Presentation technique. Orthodontic treatment was implemented for presurgical alignment and leveling of dental arches and In both patients, the general treatment aims were to achieve subsequently perform a total TMJ replacement associated harmony in the mid- and lower thirds of the face, adequate to a sagittal osteotomy of both ramuses. For orthodontic vertical dimension and facial projection, and general planning, VTO (visual treatment objective) and 3D images functional rehabilitation, including TMJ (Table 1). were used (PVP). Orthognathic surgery and total TMJ replacement, unilat- The VTO and PVP showed a maxillary canted occlusal eral and bilateral, were performed in a single surgical stage. plane that limited transverse rotation of the mandible Preoperative planning was performed with a 64 slice-high (Fig. 1a); therefore, it was decided to combine the bilateral resolution computed tomography (CT) of the craniofacial mandibular osteotomies with a type I Le Fort osteotomy. skeleton and neck, without contrast enhancement (Multislice The surgical objectives were: 64, Aquilion, Toshiba Medical Solutions, Erlangen, Ger- • A 3 mm advancement in the maxilla with a 2 mm many); the CT scan protocol includes 1-mm sections, impaction in the right side and no impaction in the left obtained with the patient in occlusion and a wax up model in side. centric relation to determine the condylar location. • Bilateral sagittal osteotomy of the mandible for trans- Despite the retrospective nature of this study, it was verse rotation approved by the hospital’s institutional review board Table 1 Surgical protocol summary 1. Retromandibular and preauricular approach, uni- or bilateral 2. Intermaxillary fixation without splints 3. Installation of registration pins or skull post 4. First registration for placing the condylar componenta 5. The osteotomies for the condyle and the coronoid process are traced but not yet performed 6. Also, eight holes are delineate. The regristrator is not removed 7. Bilateral Le fort I osteotomy and bilateral SSOs; fixation with intermediate and final splints, respectively 8. TMJ is exposed with resection of capsule and ligaments 9. Second registration for placing the condylar componentb. The registrator’s position is not changed 10. Skull based drilling aided with IVN 11. Placing and fixation (six screws) of the glenoid component with IVN 12. Placing and fixation (eight screws) of the condylar component with IVN, according to the first registration SSO sagittal split osteotomy; IVN intraoperative virtual navigation a,bRegistration implies: primary registration and surface or secondary registration 123 Author's personal copy J. Maxillofac. Oral Surg. Fig. 1 A 3D reconstruction of the patient’s facial skeleton. a The VTO movements were applied to the 3D model; notice that the lines show the maxillary canted plane. b Virtual planning of the inferior dental nerve is colored in yellow mandibular osteotomies. The referral lines are also shown. c The • Centralization of the lower midline. built in titanium, and at least 8, 2.4-mm screws were
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