YIJOM-4230; No of Pages 6

Int. J. Oral Maxillofac. Surg. 2019; xxx: xxx–xxx

https://doi.org/10.1016/j.ijom.2019.06.021, available online at https://www.sciencedirect.com

Clinical Paper
TMJ Disorders

Endoscopically assisted fixation J.-S. Zheng1, X.-H. Liu1, A. Ahmed2,

M.-J. Chen1, S.-Y. Zhang1, C. Yang1
1
Department of Oral Surgery, Ninth People’s

of the custom-made total Hospital, Shanghai Jiao Tong University

School of Medicine, Shanghai Key Laboratory
of Stomatology & Shanghai Research
Institute of Stomatology, National Clinical

temporomandibular joint Research Center of Stomatology, Shanghai,

China; 2Department of Craniomaxillofacial
and Plastic Surgery, Faculty of Dentistry,
Alexandria University, Alexandria, Egypt

prosthesis in TMJ Yang’s

system through a modified
preauricular approach
J.-S. Zheng, X.-H. Liu, A. Ahmed, M.-J. Chen, S.-Y. Zhang, C. Yang: Endoscopically
assisted fixation of the custom-made total temporomandibular joint prosthesis in TMJ
Yang’s system through a modified preauricular approach. Int. J. Oral Maxillofac.
Surg. 2019; xxx: xxx–xxx. ã 2019 International Association of Oral and Maxillofacial
Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. This article describes the experience with the endoscopically assisted
fixation of the customized total temporomandibular joint (TMJ) prosthesis in TMJ
Yang’s system only through a modified preauricular approach. Twenty patients (23
joints) treated with the custom-made total TMJ prosthesis were retrospectively
recruited. An endoscopically assisted technique was used through a modified
preauricular approach to fix the mandibular component for all these patients. These
reconstructions were evaluated by surgical records, clinical examinations, and
radiographic observations. All patients had successful fixation of the prosthesis. No
patient had permanent weakness of the facial nerve and malocclusion or any
other severe complications. The mean operative time was 111 min per joint
(range, 85–133 min). The average surgical bleeding was 195 ml per side. The mean
follow-up period was 16.2 months (range, 5–32 months). The mean scores were 8.3
for surgical satisfaction and 9.2 for scar healing evaluation. All patients experienced
positive clinical outcomes, with a mean 75.2% reduction in pain and 53.7% increase
Key words: temporomandibular joint; custo-
in mouth opening with significant differences (P < 0.05). The endoscopically mized prosthesis; endoscope; minimally inva-
assisted TMJ reconstruction with the customized prosthesis in TMJ Yang’s system sive surgery.
through the modified preauricular approach could produce good aesthetic and
functional results. Accepted for publication 4 June 2019

0901-5027/000001+06 ã 2019 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Zheng JS, et al. Endoscopically assisted fixation of the custom-made total temporomandibular joint
prosthesis in TMJ Yang’s system through a modified preauricular approach, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/
YIJOM-4230; No of Pages 6

2 Zheng et al.

Total temporomandibular joint (TMJ) the use of the endoscope in the TMJ field9– Surgical procedure
12
prosthesis is an effective method to treat , the authors developed the idea of an
TMJ lesions, including the intermediate or endoscopy-assisted TMJ reconstruction The modified preauricular approach
end stage TMJ osteoarthritis, severe idio- with the prosthesis only through a modi-
pathic condylar resorption (ICR), TMJ fied preauricular approach. As described in previous reports, the
ankylosis, comminuted condylar frac- The purpose of the present study was to main approaches were performed as
tures, and some TMJ tumours1–3. Two introduce the experience regarding the use follows11,14–16:
types of total TMJ prosthesis have been of the endoscope in the replacement of
commercially and widely used in Europe total TMJ prosthesis in TMJ Yang’s sys- 1 A modified ‘L’-shaped incision about 5
and America for more than 30 years: the tem (TMJ Yang, Shanghai, China)13,14 cm long, entirely along the curvature of
Zimmer Biomet (Biomet microfixation, and to assess the outcomes obtained from the anterior border of the auricle or
Jacksonville, FL, USA)4 and the cus- patients implanted with TMJ prosthesis by partially behind the tragus, extending
tom-made TMJ Concepts (Ventura, CA, the endoscopic procedure. to the temporal region anteriosuperiorly
USA)2,3 prostheses. Following the clinical within the hairline, was used to expose
application of these prostheses, the surgi- Materials and methods the superficial musculoaponeurotic sys-
cal techniques have been modified based tem (SMAS) in the operative field.
Patients 2 The SMAS was incised along and just
on different purposes and indications5,6.
Currently, the common surgical approach This was a retrospective clinical study. ahead of the superficial temporal ves-
for the implantation of the total TMJ Consecutive patients, treated with the cus- sels to get access to the superficial
prosthesis comprises the preauricular tom-made total TMJ prosthesis in TMJ temporal deep fascia and the parotido-
and submandibular incisions, of which Yang’s system14 by the endoscopically masseteric fascia.
the latter incision may lead to an unfavour- assisted method conducted at Department 3 Both fascial layers were incised along
able scar in some cases after surgery2–6. of Oral Surgery, Shanghai Ninth People’s and in front of the middle temporal
Recently, more endoscopic procedures Hospital from November 2016 to May vessels to expose the zygomatic arch
are being advocated in the craniomaxillo- 2018, were included. and partial parotid gland with a blunt
facial region, such as the treatment of This study was approved by the Shang- dissection in order to protect the facial
craniomaxillofacial trauma, orthognathic hai Ninth People’s Hospital Human Re- nerve.
deformities, obstructive salivary gland search Ethics Committee. Moreover, the 4 With lifting the SMAS flap and partial
diseases, maxillary sinus disorders, tri- principles outlined in the Declaration of temporalis fascia anteriorly and well
geminal nerve injury, and TMJ disor- Helsinki were also followed in the study. preservation of the facial nerve within
ders7,8. The endoscope, which has been All patients were informed about the sur- the lifted flaps of soft tissue, the TMJ
described as an ‘extra set of eyes’ and a gical purpose, protocol, recovery period, can be clearly visualized directly
basis for minimally invasive surgery, may and possible complications. An informed (Fig. 1A).
be a better solution for this problem7. consent was obtained from all partici- 5 The condyle and the lesion were then
Based on the extensive experiences with pants. resected with the help of templates

Fig. 1. The modified preauricular approach. (A) Exposure of the joint and bony fusion after dissection. (B) Intraoperative view after resection of
the joint and lesion with the template guidance.

Please cite this article in press as: Zheng JS, et al. Endoscopically assisted fixation of the custom-made total temporomandibular joint
prosthesis in TMJ Yang’s system through a modified preauricular approach, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/
YIJOM-4230; No of Pages 6

Endoscopically assisted fixation 3

Fig. 2. The fixation of the total temporomandibular joint prosthesis. (A) Fixation of the fossa component. (B) Fixation of the mandibular
component with the upper two Ti-screws first.

according to the type of joint diseases 4 Adjusting the trocar with the transbuc- scale (VAS). The measurements of
(Fig. 1B), but non-involved normal cal retractor to match the hole in the the maximal interincisal opening (MIO)
structures, such as the disc, were pre- prosthesis, a long drill of about 10 cm were assessed directly in millimetres
served to obliterate the space in the was passed through the trocar to make a (mm). All quantitative measurements
medial side of the prosthesis as much bicortical hole (as carefully as possible) were performed by two oral and maxillo-
as possible. in the ramus with sufficient irrigation facial surgeons. In the case of a disagree-
(Fig. 3A). Then, a titanium screw was ment, a consensus was reached by
driven in to fix the mandibular compo- discussion2–4,14.
nent through the trocar (Fig. 3B).
Endoscopically assisted fixation of total 5 The remaining holes were fixed in the
same way as detailed above until the Statistical analysis
TMJ prosthesis
total number of screws was at least five Data were analysed using the Statistical
The customized total TMJ prosthesis in (Fig. 3C). Package for Social Sciences software, ver-
TMJ Yang’s system was used to repair the 6 A piece of the fat graft harvested from sion 17.0 (SPSS, Chicago, IL, USA). The
defect as a new ‘joint’. The detailed pro- the buccal fat pad was placed around the assessment indices of pain and MIO be-
cedure steps for the use of the endoscope condylar head, and the wound was fore and after surgery were compared
which is a 30 instrument of 10 cm length closed in layers with an 18-gauge drain using the paired t-test of one-way analysis
and 4 mm diameter (Stryker, San Jose, after double-checking the occlusion of variance. A P-value of less than 0.05
CA, USA), were as follows11,14: (Fig. 3D). was considered statistically significant (*
is P  0.05).
1 The fossa component was fixed with tita-
nium screws firstly (Stryker Fixation Sys-
tem, Kalamazoo, MI, USA) based on the Outcome evaluations of the endoscopic Results
matching situation with the bony anatomy assistance
Twenty consecutive patients (23 joints)
and the guidance of templates (Fig. 2A). The operative time and the bleeding volume were included in this study. There were
2 The mandibular component was prelim- were traced from the charts. The maxillo- 15 females and five males. Their mean age
inarily fixed by titanium screws in two facial general check-ups included (i) infec- was 49.4 years (range, 26–66 years). The
upper holes, which were drilled using tion, (ii) dental malocclusion, (iii) wound mean previous surgical number was 0.3
the template as a guide during the joint healing, (iv) facial nerve damage, and gland (range, 0–2 times). The left side was af-
resection procedure, through the modi- swelling, which were evaluated postopera- fected in 10 patients, the right side in
fied preauricular incision. The occlu- tively. The displacement, breakage, or loos- seven patients, and bilateral sides in three
sion was then checked and should be ening of the prosthesis components were patients. Twelve patients were finally di-
stable as in the preoperative relationship checked using postoperative computed to- agnosed as end stage TMJ osteoarthrosis,
(Fig. 2B). mography (CT) or orthopantomogram. while the remaining six patients had ICR
3 A small incision about 3–5 mm long, The outcome indices related to (i) pain (two patients), ankylosis (two patients),
located at the middle point of the man- in the preauricular region, (ii) the satisfac- and synovial chondroma (two patients),
dibular component on the parotideo- tion with the surgical outcomes, and (iii) based on the final histopathology. The
masseteric region, was made to insert the satisfaction with the scar healing, were mean follow-up period was 16.2 months
the trocar of the transbuccal retractor. obtained using a 10-length visual analog (range, 5 to 32 months).

Please cite this article in press as: Zheng JS, et al. Endoscopically assisted fixation of the custom-made total temporomandibular joint
prosthesis in TMJ Yang’s system through a modified preauricular approach, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/
YIJOM-4230; No of Pages 6

4 Zheng et al.

Fig. 3. The operation of endoscopically assisted fixation of total temporomandibular joint prosthesis. (A) Schematic view for the whole procedure.
(B) Endoscopic view of the preparation of the hole. (C). Endoscopic view of the implant of the bi-cortical Ti-screw. (C) Intraoperative view after
suturing.

The mean operative time was 111 min purpose. With the assistance of the endo- assistance. After 2 years of follow-up,
per joint (range, 85–133 min). The aver- scope, the whole procedure could be oper- quality of life improved significantly be-
age surgical bleeding volume for one side ated within 2 h with less than 200 mL of cause of the suspension of the chronic
was 195 mL (range, 140–400 mL). There surgical bleeding per side. Patients showed opioid therapy, no masticatory complica-
were no severe complications, such as high satisfaction with surgical outcomes tions, 40 mm of mouth opening compared
wound infection, permanent facial nerve (no complications, 75.2% reduction in pain, with 15 mm preoperatively, and no scar
damage, serious swelling and haematocele and 53.7% increase in mouth opening) and appeared in the submandibular region.
in gland field, in any patients after surgery. inconspicuous scars (the modified preauri- Compared with the approach in the current
All patients had a stable occlusion the cular incision and no submandibular inci- study, there was still an additional incision
same as preoperatively. The surgical sion) after surgery. Accordingly, the in the oral cavity to insert the endoscope
wounds of all patients healed well. There implantation of the total TMJ prosthesis into the ramus area, and the major problem
was no displacement, breakage, or loos- has become more minimally invasive. was the high risk of cross-infection be-
ening of the prosthesis components in The endoscopic technique has been cause the oral cavity was interconnected
postoperative CT or orthopantomogram widely applied to the diagnosis and treat- with the prosthesis and TMJ region. The
during the study period (Fig. 4). ment of TMJ diseases8–10,12,17, in particu- technique of the endoscopic application
The mean scores were 8.3 (range, 6–10) lar for TMJ disc repositioning and for the implantation of the total TMJ
for surgical outcome satisfaction and 9.2 intracapsular lesion removal, such as sy- prosthesis in this study was just through
(range, 8–10) for scar healing satisfaction novial chondromatosis. However, only a the modified preauricular incision and on-
(including the preauricular and cheek in- few maxillofacial surgeons had tried to use ly a 3- to 5-mm-long incision on the
cision). There was a mean of 75.2% re- the endoscope to assist in TMJ replace- parotideomasseteric region for transbuc-
duction from 5.7  2.7 to 1.4  1.56 in ment rather than following the conven- cal retractor; thus it seems to have prime
pain level, 53.7% improvement from 22.8 tionally open surgical approaches, which results due to no submandibular incision
 10.6 to 35.1  5.4 mm in MIO with included the preauricular and submandib- and no risk of cross-infection between the
significant differences (P < 0.05) (Fig. 5). ular incisions to fix the fossa and mandib- intraoral and preauricualr incisions.
ular components separately11,18. Qiu Therefore, this approach may be a better
et al.11 described the endoscopically option compared with its open or other
Discussion assisted reconstruction of the condyle with endoscopic counterparts.
During the past decades, craniomaxillofa- a costochondral graft through a modified Similarly to other endoscopic techni-
cial surgeons have been exploring new preauricular approach for more than 122 ques, the endoscopically assisted recon-
applications of the endoscopically assisted patients. The outcomes of good aesthetic struction of total TMJ prosthesis requires a
surgical procedures, which could decrease and functional results resulting from re- detailed understanding of the use of an
the occurrence of complications, increase ducing the operative time and tissue dam- endoscope and strict indications for the
the success rates, and promote earlier age have been showed during 5-year inclusion of patients8,11. Firstly, the endo-
postoperative function recovery7,8. In the follow-ups. Later, Belli et al.18 reported scopic assistance could just apply to the
current study, the authors investigated a case treated with a modified approach for customized total TMJ prosthesis, because
the total TMJ prosthesis replacement in the TMJ replacement with a stock Biomet it is necessary for a stock TMJ prosthesis,
combination with the endoscope for this prosthesis under an intraoral endoscopic such as Zimmer Biomet, to carry out

Please cite this article in press as: Zheng JS, et al. Endoscopically assisted fixation of the custom-made total temporomandibular joint
prosthesis in TMJ Yang’s system through a modified preauricular approach, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/
YIJOM-4230; No of Pages 6

Endoscopically assisted fixation 5

Fig. 4. Postoperative radiographic examination. (A) Orthopantomogram. (B) Three-dimensional computed tomography image.

Fig. 5. The pre- and postoperative outcomes of pain level and maximal interincisal opening (MIO).

trimming and osteotomy of the bone on who have extensive experience in the use thesis could lead to improved aesthetic
the ramus surface from the submandibular of the endoscope in TMJ were to perform and functional outcomes, with greater sur-
approach to match the prosthesis for more this technique. The more experience the geon and patient satisfaction.
stability and accuracy5,6. Secondly, sever- surgeons have, the better the outcome of
al special instruments, including a 30 this technique11. However, this technique
endoscope (10 cm in length), a transbuccal still needs a higher level of skills and
Funding
retractor, and a drill (10 cm in length), training in order to have enough experi-
have been prepared as completely as pos- ence to perform such delicate procedures. Funding was provided by the national key
sible11. Meanwhile, it is very important to In conclusion, the endoscopically research and development plan
implant the upper two Ti-screws with a assisted technique offers many advantages (2016YFC1100600), Clinical Research
stable occlusion relationship prior to the including fewer incisions and avoiding the Program of Shanghai ninth People’s Hos-
use of the endoscope. The position of the esthetically unaccepted mandibular inci- pital (JYLJ003), Youth Fund of Medicine
prosthesis would be more similar with the sion, minor tissue damage, and direct vi- and Engineering of Shanghai Jiao Tong
location during design and more stable sualization of a magnified and illuminated University (YG2017QN05), Seed fund of
during fixation of the remaining Ti-screws operative field for the surgeon. With its Shanghai Ninth People’s Hospital
by endoscope14. In addition, it would be wide range of indications, the endoscopi- (JYZZ019) and Shanghai Shenkang Proj-
preferable if two maxillofacial surgeons cally assisted fixation of total TMJ pros- ect (16CR3104B).

Please cite this article in press as: Zheng JS, et al. Endoscopically assisted fixation of the custom-made total temporomandibular joint
prosthesis in TMJ Yang’s system through a modified preauricular approach, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/
YIJOM-4230; No of Pages 6

6 Zheng et al.

Competing interests total joint prosthesis. Int J Oral Maxillofac Biomechanical evaluation of Chinese cus-
Surg 2010;39(10):951–5. tomized three-dimensionally printed total
The authors have stated explicitly that 5. ShanYong Z, Liu H, Yang C, Zhang X, temporomandibular joint prostheses: a finite
there are no conflicts of interest in con- Abdelrehem A, Zheng J, Jiao Z, Chen M, element analysis. J Craniomaxillofac Surg
nection with this article. Qiu Y. Modified surgical techniques for total 2018;46(9):1561–8.
alloplastic temporomandibular joint replace- 14. Zheng JS, Chen XZ, Jiang WB, Zhang SY,
Ethical approval ment: one institution’s experience. J Cranio- Chen MJ, Yang C. An innovative total
maxillofac Surg 2015;43(6):934–9. temporomandibular joint prosthesis with
This study was approved by the Shanghai 6. Bai G, He D, Yang C, Chen M, Yuan J, customized design and 3D printing additive
Ninth People’s Hospital Human Research Wilson JJ. Application of digital templates fabrication: a prospective clinical study. J
Ethics Committee no. Hu Jiuyuan Lun- to guide total alloplastic joint replacement Transl Med 2019;17:4. http://dx.doi.org/
shen [2015]18. All patients were informed surgery with Biomet standard replacement 10.1186/s12967-018-1759-1.
about the surgical purpose, surgical proto- system. J Oral Maxillofac Surg 2014;72 15. He D, Yang C, Zhang S, Wilson JJ. Modified
col, recovery period, and possible compli- (12):2440–52. temporomandibular joint disc repositioning
cations. An informed consent was 7. Pedroletti F, Johnson BS, McCain JP. Endo- with miniscrew anchor: part I—surgical
obtained from all participants. scopic techniques in oral and maxillofacial technique. J Oral Maxillofac Surg 2015;73
surgery. Oral Maxillofac Surg Clin North Am (1). 47.e1–9.
2010;22(1):169–82. 16. Zhang S, Liu X, Yang X, Yang C, Chen M,
Patient consent 8. McCain JP, Williams L. Principles and prac- Haddad MS, Chen Z. Temporomandibular
tice of temporomandibular joint arthroscopy. joint disc repositioning using bone anchors:
Patient consent for publication, including
St Louis: Mosby; 1996. P1–11. an immediate postsurgical evaluation by
any individual details, images or videos,
9. Liu X, Zheng J, Cai X, Abdelrehem A, Yang magnetic resonance imaging. BMC Muscu-
was obtained with our institutional con- C. Techniques of Yang’s arthroscopic disco- loskelet Disord 2010;12(11):262.
sent forms. pexy for temporomandibular joint rotational 17. Troulis MJ, Kaban LB. Endoscopic approach
anterior disc displacement. Int J Oral Max- to the ramus/condyle unit: clinical applica-
References illofac Surg 2019;48:769–78. tions. J Oral Maxillofac Surg 2001;59
10. Yang C, Cai XY, Chen MJ, Zhang SY. New (5):503–9.
1. Mercuri LG. Alloplastic TMJ replacement. arthroscopic disc repositioning and suturing 18. Belli E, Mici E, Mazzone N, Catalfamo L,
Rationale for custom devices. Int J Oral technique for treating an anteriorly displaced Fini G, Liberatore GM. A monolateral TMJ
Maxillofac Surg 2012;41(1):1033–40. disc of the temporomandibular joint: part I- replacement under intraoral endoscopic as-
2. Mercuri LG, Wolford LM, Sanders B, White technique introduction. Int J Oral Maxillofac sistance for jaw osteomielitis: a modified
RD, Giobbie-Hurder A. Long-term follow- Surg 2012;41(9):1058–63. approach. G Chir 2015;36(1):36–9.
up of the CAD/CAM patient fitted total 11. Qiu YT, Yang C, Chen MJ. Endoscopically
temporomandibular joint reconstruction sys- assisted reconstruction of the mandibular Address:
tem. J Oral Maxillofac Surg 2002;60 condyle with a costochondral graft through Chi Yang
(12):1440–8. a modified preauricular approach. Br J Oral Department of Oral Surgery
3. Wolford LM, Mercuri LG, Schneiderman Maxillofac Surg 2010;48(6):443–7. Ninth People’s Hospital
ED, Movahed R, Allen W. Twenty-year fol- 12. Cai XY, Yang C, Chen MJ, Jiang B, Wang Shanghai Jiao Tong University School of
low-up study on a patient-fitted temporo- BL. Arthroscopically guided removal of Medicine
mandibular joint prosthesis: the large solitary synovial chondromatosis from No. 639 Zhi Zao Ju Road
Techmedica/TMJ Concepts device. J Oral 200011 Shanghai
the temporomandibular joint. Int J Oral
Maxillofac Surg 2015;73(5):952–60. China
Maxillofac Surg 2010;39(12):1236–9.
4. Westermark A. Total reconstruction of the E-mail: [email protected]
13. Chen X, Wang Y, Mao Y, Zhou Z, Zheng J,
temporomandibular joint. Up to 8 years of Zhen J, Qiu Y, Zhang S, Qin H, Yang C.
follow-up of patients treated with Biomet1

Please cite this article in press as: Zheng JS, et al. Endoscopically assisted fixation of the custom-made total temporomandibular joint
prosthesis in TMJ Yang’s system through a modified preauricular approach, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/