Foreign body response around total prosthetic metal-on-metal replacements of the temporomandibular joint in the UK.

Replacements for the temporomandibular joint were developed in the early 1960s. Problems with various prostheses, notably the Kent VK1, led to detailed analysis of their risks and complications. In 1999 one type of prosthesis (the Christensen) was converted from an acrylic condyle on cobalt-chromium fossa to metal-on-metal cobalt-chrome condyle and fossa. This has been popular for the last 15 years in the UK, but since it was converted to the metal-on-metal variant there have been several cases of foreign body giant-cell reactions to the prosthesis. Of the 9 cases seen (out of 106 placed), 4 were found retrospectively to be sensitive to one of the metal components of the prosthesis; the others have not been tested to date. Other potential causes of this reaction are point contact, micromovement, or a lymphocyte-mediated response to the prosthesis.

Reconstruction of the temporomandibular joint autogenous compared with alloplastic.

The aims of and indications for temporomandibular joint (TMJ) reconstruction are well-established but the method of reconstruction is controversial. We describe a retrospective, two-centre audit of 49 patients treated with costochondral grafting and 50 patients treated with alloplastic joints. The characteristics of the patients were similar in both centres and the minimum follow-up period was 2 years. For each patient a number of variables were recorded including both subjective scores (pain and interference with eating) and objective data (interincisal distance). Patients in both groups showed an improvement in symptoms but more patients required reoperation in the autogenous group.

Temporomandibular joint replacement in rheumatoid-induced disease.

We report a series of seven patients with rheumatoid arthritis whose temporomandibular joints were replaced using the Christensen joint system. Patients were assessed before and after operation both subjectively (pain and dietary interference) and objectively (interincisal distance). Patient's satisfaction with the outcome of operation was also recorded. All patients showed improved visual analogue scores for pain and dietary interference after their operations and an improvement in interincisal distance was recorded in five of the patients (the remaining two having had the operation for anterior open bite). Overall satisfaction was high and no patient has rejected the prosthesis or had any substantial complications. The mean follow up period is 30 months (range 8-50). We suggest that patients with severe, rheumatoid-induced temporomandibular disease should be considered for arthroplasty as it is possible to restore some normal function and appearance.

Internal derangement of the temporomandibular joint treated by discectomy and hemi-arthroplasty with a Christensen fossa-eminence prosthesis.

Patients with internal derangement of the temporomandibular joint (TMJ) who have failed to respond to conservative treatment can be treated by discectomy and insertion of a Christensen fossa-eminence prosthesis, provided there is no clinical or radiological evidence of condylar disease (such as avascular necrosis). A total of 42 patients who had significant symptoms related to internal derangement of the TMJ, despite nonsurgical treatment, had discectomies and fossa-eminence prostheses inserted. Preoperative and postoperative measurements were recorded for Gape, Pain and restriction of feeding. All but one of the 34 patients showed improvements in their symptoms postoperatively. There were no serious postoperative complications.

Total prosthetic replacement of the TMJ: experience with two systems 1988-1997.

We report our experience with the Vitek VK II and the Christensen systems for total prosthetic replacement of the temporomandibular joint, in 62 patients treated between 1988 and 1997. Thirteen were treated in Birmingham and 49 in Gloucester. A total of 86 joints were replaced, of which 27 (31%) were Vitek VK II and 59 (69%) were Christensen prostheses. Just over half of the patients were treated for degenerative arthropathy or osteoarthritis, and the second most common diagnosis was rheumatoid arthritis. Twenty-five patients had had previous operations. The median follow-up was 14.5 months (range 1-120). Preoperatively only 14 patients (23%) could eat all types of food - and postoperatively this increased to 48 (77%). Thirty-nine patients (63%) reported severe pain preoperatively compared with three (5%) postoperatively. No prostheses were rejected, but four patients required replacement of Vitek VK II by Christensen prostheses; all four showed histological evidence of a foreign body giant cell reaction. The overall success rate was 58/62 patients and 81/86 joints replaced (94% in each case). However, for the Vitek VK II system alone the success rate was 14/17 patients (82%) and 24/27 joints replaced (89%).

Temporomandibular joint replacement.

Temporomandibular joint replacement is a small area in maxillofacial surgery but of great importance. The treatment of severe temporomandibular disease with prosthetic joints can produce enormous benefit to patients and the current status of this technique is discussed here.

Malignant melanoma of the parotid gland: a case report and literature review.

A case is reported of a malignant melanoma presenting in a parotid gland with no other primary lesion detectable. The pathological feasibility of primary malignant melanoma of the parotid is discussed together with a review of the literature.

The bony lid approach for the apical root resection of lower molars.

The apical root resection of mandibular molars is an operation seldom performed and then one limited primarily to the lower first molars. Although the first paper on this topic was published at the beginning of the 20th century, little progress has been observed since then. This is due to the thickness of the buccal bony plate in the lower molar region which makes surgery very difficult and leads to a substantial loss of bone. The resultant limitation of the operating field prevents good vision. The aim of our approach is to minimize or to eliminate these problems by opening a bony lid above the roots which are to be resected. This can be made large enough for the surgeon to have easy access and good vision during apical surgery. At the end of the operation the same lid is replaced in order to avoid a bony defect and to facilitate the healing process. Of the 75 patients treated using this technique during a 3-year period, only one post-operative complication has been observed. A complete healing of the bone was observed in the majority of cases within 6 months.

The versatility of the temporalis muscle flap in reconstructive surgery.

The temporalis muscle flap recently has become widely used in reconstructive surgery of the maxillo-facial region, although it was described around the turn of the century. We review the work which led to its development, and to illustrate its versatility, we describe some of its uses.

A modified hydroxylapatite implant material. A preliminary report.

Hydroxylapatite implants are becoming widely used, but this new material is not without its drawbacks. These mainly concern its physical characteristics, complicating and limiting its clinical applications. A method of altering these with fibrin adhesives is described and early laboratory and clinical experience is presented.

Extracranial surgery--intracerebral tumour.

A case is described in which localising neurological signs developed on the first day following general anaesthesia for insertion of a silastic implant over a frontal fracture. Despite prompt appropriate investigation seven weeks elapsed before the correct diagnosis was made. Aspects of the management of patients who develop a neurological deficit soon after general anaesthesia are discussed.

Actinomycosis of the parotid gland.

Primary parotid actinomycosis is extremely rare. Two patients are discussed in whom this disease presented quite differently. The literature is reviewed and the management described, with particular reference to antibiotic therapy.

Results of a program successfully combining live and killed polio vaccines.

Oral polio vaccine (OPV) has been used in the Gaza Strip since 1968. Although vaccine coverage had reached 80 to 90% of the infant population, the epidemiological pattern of the paralytic disease had not changed significantly as of the beginning of this study. The mean annual incidence continued to be around 10/100,000. Two outbreaks occurred, in 1974 and 1976, involving 75 and 77 children, respectively, an incidence of 18/100,000. In these two outbreaks, 34 and 50% of the affected children, respectively, received 3 to 4 doses of OPV. A serological survey done after a vaccination campaign with monovalent Type 1 vaccine showed an unexpectedly low percentage of seropositives. A parallel was found between the prevalence of diarrheal disease and vaccine failure, and a causal effect was postulated. To overcome this problem, a program of immunization was started early in 1978 combining both live and killed polio vaccines. Although cases of polio continue to appear, the incidence has been reduced to 2.4/100,000 population. In 1981, only one case was reported, in an unvaccinated child. Thus, it would seem that the new vaccination schedule combining live and killed vaccines makes eradication of polio a possibility.