IMPLANT FOR RECONSTRUCTION OF TEMPOROMANDIBULAR JOINT

Abstract: A surgical TM joint implant is described having two parts: a first part (14) for covering or replacing the natural glenoid fos­ sa of a natural TM joint, and a second part (30) for replacing the natural condylar head of the joint. The first part (14) includes a plate (13) having a fossa cavity (15) defined by a relatively deep concave portion (23) and an anteriorly located concavo­ planar portion (23a). The second part (39) has a condylar head engaging the concavo-planar surface (23a) and establishing therewith a planar contact area (49) which minimizes the unit stress transmitted between the first and second parts, thereby providing for an even load distribution between their engaged planar surfaces.

Description: IMPLANT FOR RECONSTRUCTION OF TEMPOROMANDIBULAR JOINT This invention relates, in general, to prostheses for the reconstruction of the natural temporo-mandibular (TM) joint, which consists of the glenoid fossa, the condyle head, the mandibular disc, and muscle attachments, and, more particularly, to improved fossa and condyle head prostheses. When severe functional impairment of the TM joint anatomy takes place, as from rheumatoid arthritis, osteoarthritis, tumors, and trauma, surgical TM joint reconstruction is required. Such impairment is believed to have a strong biomechanical etiology in that forces through the TM joint can become excessively large and destructive, due to abnormal muscle tension or grinding of teeth. In U.S.A patent 3,178,728, Christensen discloses a metallic fossa prosthesis adapted to cover or replace the natural glenoid fossa as well as the adjoining articular eminence. During the operation, to best fit within a particular patient's natural fossa and articular eminence, the surgeon had to select one from about 20 fossa prostheses of differing sizes and contours. In U.S.A patent 3,579,643, Morgan states that a Christensen type fossa prosthesis is needlessly oversized and may even be dangerous because it is likely (1) to disturb the normal relationship between the articular surfaces in the TM joint between the natural or artificial condyle head and the fossa prosthesis, and (2) to alter the normal bite. Morgan's proposed solution is for the prosthesis to cover only the articular eminence and not the natural fossa cavity. Morgan claims that in reducing the size of Christensen's fossa prosthesis, he requires only one right prosthesis and one left prosthesis to fit most patients. The metallic prostheses of Christensen and of Morgan were secured by screws to the zygion. But, this fixation was found to be inadequate, because such single-sided fixation allows a fossa prosthesis to become loose due to the large loads that become exerted in the TM joint. Previously, the present applicant has developed a tissue-ingrowthpromoting porous polymer sold under the trademark PROP LAST and which is described in detail in US-A-3,992,725. Subsequently the applicant developed a first type polymer fossa prosthesis which employed PROPLAST for postoperative permanent fixation due to tissue ingrowth. Using this fossa prosthesis and an available metallic condylar head prosthesis made it possible for a surgeon to accomplish a total reconstruction of the TM joint. This first type polymer fossa prosthesis was custom made for each patient based mostly on prior X-rays obtained from the patient's TM joint. It consisted of 3 layers: a superior layer of PROPLAST I (PTFE-graphite) implant material, a middle layer of TEFLON FEP (fluorinated ethylene propylene) polymer with an embedded polyamide or metal mesh, and a most inferior layer of fused TEFLON PTFE (polytetrafluoroethylene) polymer reinforced with graphite fiber. But, this first type polymer fossa prosthesis (1) did not extend fully over the articular eminence, (2) did not adequately protect the external auditory canal, and (3) was too complex and costly to manufacture. Subsequently, the first type polymer fossa prosthesis has been slightly modified to produce a second type fossa prosthesis which was also custom made for each patient. This slightly improved second type fossa prosthesis consisted of only 2 layers: a superior layer made of a PROPLAST II (polytetrafluoroethylene polymer with aluminium oxide) porous implant material, and of an inferior layer made of TEFLON FEP (fluorinated ethylene propylene) polymer having an embedded polyamide mesh reinforcement. However, after using this second type implant in the reconstructed TM joint, it was found that an uneven and concentrated transfer of stresses took place between the engaging portions of the oppositely articular surfaces of the condylar head and of the fossa prostheses. Such poor load transfers can lead to great pain, bone resorption, fibrous encapsulation, loosening, extrusion, failure of the artificial fossa's material, and dislocation of the fossa and condyle prostheses within the TM joint. It is a primary object of this invention to minimize high stress concentrations within a reconstructed TM joint. Reduction of stress concentration is critically important to the long term success of the TM joint reconstruction, because the clinical tendency of such patients is to overload the TM joint by abnormal muscle tension and/or grinding of teeth. The surgical TM joint implant has two-parts: a first part for covering or replacing the natural glenoid fossa of a natural TM joint, and a second part for replacing the natural condylar head of the joint. The first part includes a plate having a fossa cavity defined by. a relatively deep concave portion and an anteriorly located concavo-planar portion. The second part has a condylar head defining a convexo-planar, articular face for engaging the concavo-planar surface and establishing therewith a planar contact area which minimizes the unit stress transmitted between the first and second parts, thereby providing for an even load distribution between their engaged planar surfaces. The plate is preferably shaped to fully cover the articular eminence and to protect the external acoustic meatus against external pressure. The invention is further described in connection with the accompanying drawings, wherein: FIG. 1 is an exploded perspective view of the preferred forms of the fossa and condyle head prostheses in accordance with the invention; FIG. 2 is a side elevational view of a human skull carrying the artificial prostheses of FIG. 1; FIG. 3 is a side view of the fossa prosthesis shown in FIG. 1; FIGS. 4-7 are views taken on lines 4-4 through 7-7 on FIGS. 3, 4, 5 and 3, respectively; FIG. 8 is a side plan view of the condyle head prosthesis shown in FIG.1; FIG. 9 is an elevational view taken on line 9-9 of FIG. 8; FIG. 10 is a top view taken on line 10-10 of FIG. 8; FIGS. 11 and 12 show a partial side elevational view of the condyle prosthesis and a sectional view of the fossa prosthesis; FIG. 11 shows the condyle head near closed bite closure, and FIG. 12 shows the condyle head when the jaws are fully engaged; FIG. 13 is a view taken on line 13-13 of FIG. 11; FIG. 14 is a view taken on line 14-14 of FIG. IS, which shows applicant's above-mentioned, already-known, second type of fossa prosthesis in engagement with the prior condyle head prosthesis when it is in a position similar to that of FIG. 11; FIG. 15 is a view taken on line 15-15 of FIG. 14; FIG. 16 is an enlarged perspective view, similar to FIG. 2, showing the novel condyle head prosthesis in engagement with the novel fossa prosthesis; ; FIG. 17 shows the planar contact surface between the novel condyle head when it is near full engagement with the novel fossa prosthesis, as shown in FIG. 11; and FIG. 18 is a plan view of the concentrated load-transfer lines between the known condyle head prosthesis when it is in engagement with the known fossa prosthesis, as shown in FIG. 15. The invention will be described with general reference to FIGS. 1-13 and 16-17. In FIGS. 14-15 and 18, which illustrate applicant's prior fossa and condylar head prostheses, the same numerals followed by the letter "A" are used to designate corresponding parts of FIGS. 1-13 and 16. The novel composite prosthesis 10 (FIGS. 1-2,16) of this invention consists of a condyle prosthesis 30 and of a glenoid fossa prosthesis 14, which respectively constitute the ball and socket portions of a reconstructed TM joint. The condyle head prosthesis 30 (FIGS. 8-9, 11-14) is made of a surgical, chrome-cobalt-molybdenum alloy and comprises a condyle head 31 which is provided with a critical load-transmitting, convexo-planar, articular face 32 (FIG. 11). A heel 34 extends backwardly and a toe 36 extends forwardly from face 32. An oval sole 35 (FIGS. 1,9) follows and extends rearwardly from face 32 and smoothly blends at its opposite ends with the heel and toe. A bridge part 40 spans between face 32, heel 34, and toe 36. A neck 42 couples bridge 40 to shank 44. Fossa prosthesis 14 is made of a superior layer 46 of PROPLAST II (polytetrafluoroethylene polymer with aluminum oxide) porous implant material, and of an inferior plate 13 of TEFLON FEP (fluorinated ethylene propylene) polymer having an embedded polyamide mesh reinforcement therein. Plate 13 is shaped to (1) fully cover the natural fossa cavity including the adjoining natural articular eminence, (2) give the surgeon one left fossa prosthesis and one right fossa prosthesis generally fitting the TM joints of most patients, and (3) protect the external acoustic meatus 12 (Fig. 2) against external pressure, and inhibit meatus 12 from post-operatively adhering to condyle head 31. By using a single left and a single right fossa prostheses, the surgeon requires less operative time, while the implant manufacturer is relieved from the burden and expense; of making custom fossa and condylar prostheses based on X-rays. Plate 13 (FIG. 1) has a fossa cavity 15 which is defined by posterior rim 16, medial rim 17, lateral rim 18, and anterior rim 19. The posterior rim 16 sufficiently projects inferiorly of fossa cavity 15 to protect the external acoustic meatus 12. The protective rim 16 is moved slightly anteriorly to avoid impingement of soft tissue over the external auditory canal. Medial rim 17 smoothly joins the posterior rim 16 and likewise projects inferiorly to cover the medial aspect of the natural glenoid fossa and the adjoining articular eminence. The anterior rim 19 has an apex 19a and projects anteriorly and obliquely superiorly to cover the articular eminence. Rim 19 is relieved at 19b to conform to the junction between the natural zygion 18' and the natural articular eminence. Lateral rim 18 extends superiorly to and is shaped to fit along the lateral extension of zygion 18' (Fig. 2). Fossa cavity 15, anterior ridge 15a (FIGS. 4-5), anterior rim 19, medial rim 17, and posterior rim 16 are shaped to offer minimum friction to the complex movements of condyle head 31 over fossa cavity 15. Rim 18 usually receives one or more screws 22 by means of which prosthesis 14 is initially attached to zygion 18', whereas the tissue-ingrowth-promoting porous PROPLAST II material provides permanent postoperative fixation for fossa prosthesis 14 within the TM joint. There are three unique features which make the TM joint very complex: it is a non-stress and stress bearing joint, depending on the spacing between condyle head 31 and fossa cavity 15; it is a sliding hinge; and it is a bilateral joint, i.e., both the right and left sides of the joint should act in symmetry. Therefore, fossa cavity 15 (FIGS. 11-12) is provided with a stress-bearing, articular surface defined by a relatively deep concave portion 23, followed by an anteriorly located concavo-planar portion 23a, and then by a convex portion 23b. When the TM joint is near closed bite position (FIG. 11), the articular, load-transfer, convexo-planar face 32 of condylar head 31 engages the articular, load-receiving, concavo-planar surface 23a of fossa cavity 15 and establishes therewith a relatively wide planar contact area 49 (FIG. 17) which minimizes the unit stress (kg/cm2) transmitted between prostheses 14 and 30 and provides for an even load distribution between their engaged planar sliding surfaces. In articulating the mandible from closed bite position (FIG. 12) to nearly open bite position (FIG. 11), convexo-planar, load-transfer face 32 of condyle head 31 moves forwardly on deep concave surface 23, then the planar portion of face 32 slides, while exerting very strong pressure, over the planar portion of surface 23a, and then face 32 moves over convex surface 23b. The convexo-planar articular face 32 and the concavo-planar surface 23a are shaped to maximize the extent of the planar contact area 49 and minimize wear, as condylar head 31 translates and rotates within fossa cavity 15. It has been unexpectedly found that minimal stress concentration at the critically near closed bite position of the mandible (FIG. 11) is provided by maximizing the extent of planar contact area 49 between the planar portion of convexo-planar face 32 and the planar portion of concavo-planar surface 23a. As an additional benefit, fossa cavity 15 optimally distributes the significant lateral pressures to which it becomes subjected during jaw movements. In sum, the engaging articular concavo-planar and convexo-planar surfaces 23a and 32, respectively, are shaped so as to better protect the auditory canal 12 (FIG. 2) from pressure, and to more evenly and efficiently distribute the forces transmitted through the planar contact area 49, especially near closed bite position (FIG. 11), which is the critical position corresponding to maximum load transmission through the reconstructed TM joint. This is in contrast to what one would obtain from applicant's prior glenoid fossa prosthesis 14A and condyle prosthesis 30A (FIGS. 14-15). It will be readily seen that the external articular surface 52 of condyle head prosthesis 30A engages its opposite fossa plate 13A only along a pair of single-dimensional parallel lines 50 and 51 (FIG. 18), while the remainder of surface 52 between lines 50 and 51 is out of contact with plate 13A. As condyle head 30A translates and rotates over the fossa cavity defined by plate 13A, these parallel lines 50-51 also rotate, and for some positions of condyle head 30A lines 50-51 actually merge. Consequently, uneven and concentrated transfers of stress take place between condylar head prosthesis 30A and fossa prosthesis 14A. Such concentrated stresses are largest especially at near biting closure (FIG. 15) and can lead to great pain, bone resorption, fibrous encapsulation, loosening, extrusion, failure of the artificial fossa's material, and dislocation of the fossa and condyle prostheses within the TM joint. It will be also noted that the overall size of the novel glenoid fossa prosthesis 14 is reduced as compared to prior fossa prosthesis 14A. Hence the trimming time required from the surgeon of fossa prosthesis 14 is minimized. Long term stabilization, favorable distribution of articular forces without slippage are obtained with the two-part prosthesis 10 of this invention. In one embodiment, the maximum used thickness "tl" (Fig. 12) of the PROPLAST II coating 46 (Fig. 5) was within a range of 3-lOmm with preferred values of 4m and 7m, and the depth "d" of fossa cavity 15 had a range of Im to 9mm with preferred values of 3m and 6mm. The thickness "t2" of plate 13 had a range between Imm and 4mm with a preferred value of 2mm. From the foregoing description, it will be apparent that the invention resides primarily in the geometry of the two parts of the TM joint, not the materials used in the construction of the joint. The particular materials described, i.e. PROPLAST II, the TEFLON FEP polymer reinforced with a polyamide mesh, and the surgical, chrome-cobalt-molybdenum alloy, are merely the currently preferred materials. For a further description of PROPLAST II, reference may be had to US-A-3,992,725. TEFLON FEP is a conventional, commercially available fluorinated ethylene/propylene polymer which needs no further description.

Claims: CLAIMS 1. A surgical TM joint implant having two-parts: a first part for covering or replacing the natural glenoid fossa of a natural TM joint, and a second part for replacing the natural condylar head of said joint, characterized in that said first part (14) includes a plate (13) having a fossa cavity (15) defined by a ----------- deep concave portion (23) and an anteriorly located concavo-planar portion (23a); and said second part (30) having a condylar head (31) defining a convexo-planar, articular face (32) for engaging said concavo-planar surface (23a) and establishing therewith a planar contact area (49) which minimizes the unit stress transmitted between said first and second parts, thereby providing for an even load distribution between their engaged planar surfaces. 2. An implant according to Claim 1, characterized in that said plate (13) is shaped to fully cover the natural fossa cavity including the adjoining natural articular eminence, and said fossa cavity (15) being followed by a convex portion (23b). 3, An implant according to claim 1 or 2, characterised in that said head (31) has a heel (34) extending backwardly and a toe (36) extending forwardly from said face (32), an oval sole (35) following and extending rearwardly from face (32) and smoothly blending at its opposite ends with said toe and heel. 4. An implant according to claim 1, 2 or 3, characterised in that said plate (13) is shaped to protect the external acoustic meatus (12) against external pressure. 5. An implant according to any one of claims 1-4, characterised in that the frist part (14) comprises a superior layer (46) constructed of a porous, tissue ingrowth promoting material comprising polytetrafluoroethylene and aluminium oxide, and an inferior layer (13) constructed of a fluorinated ethylene/propylene polymer hving a reinforcing polyamide mesh embedded therein.

Inventors: HOMSY, CHARLES ALBERT, KENT, JOHN N., TELLKAMP, JOHN WILLIAM
Applicants: VITEK INC.
Application year: 1986
Main classification: A61F2
IPC codes: A61F2