I'm probably the only one who finds it fascinating....so feel free not to read on if you don't want to!!
Here's the letter:
As you know, Tiffany fell while running on August 12, 2014. She sustained severe injuries to her maxilla and mandible with a dentoalveolar fracture (fracture of the teeth & bone in which they reside) in the anterior maxilla. There was a body fracture in the anterior mandible as well as bilateral condylar fractures. Apparently, there was minimal condylar displasia initially so she was treated with arch bars to stabilize the segmental fractures and a soft diet. A month later it became apparent there had been displacement of the condylar segments. She was, therefore, taken to hospital and, under general anaesthesia, closed reduction was carried out. She was kept wired for two weeks and then wore tight elastic fixation for another two weeks followed by light elastic fixation. When the arch bars were removed there was a persistent malocclusion with anterior open bite and deviation of the mandible to the left.
Tiffany has severe pain affecting both temporomandibular joints as well as the temporalis and masseteric regions (the muscles of chewing, that go up to your temples and down under your jaw). This pain limits her range of motion as well as her ability to chew. She has quite a bit of dental pain. She has received a number of root canals and dental restorations and there are more planned.
Clinical examination showed the patient to be normo-cephalic (see that?? I'm normal in the head!) with normal eyes, ears, nose and throat. Cranial nerves II through XII are grossly intact. She had mild facial asymmetry with deviation of the chin to the left. The was a healed scar in the chin region.
Palpation of the muscles of mastication elicited two plus pain. She had three plus pain in both TMJs. Her range of motion was markedly limited at 20 millimetres. I could detect no clicking or crepitus (grinding) with this opening.
Intraorally she had a crowded, Class II malocclusion with deviation to the left and crossbite and anterior open bite. The only teeth in occlusion were the first and second molars. The oral mucosa and periodontal status were grossly normal. I did manipulate the mandible as well as the anterior maxillary teeth. There was no mobility, suggesting bony union of the anterior mandibular and maxillary fractures.
I had a chance to review the cone beam CT scan, which shows malunion of a right condylar fracture with loss of vertical dimension of the ramus condyle unit. On the left side there is a non-union a condylar neck fracture with malposition. I also noted the body fracture of the mandible, which did go through the cuspid region on the left side. External resorption of the 33 is evident.
DIAGNOSIS:
Previous bilateral condylar fracture with right-sided malunion and left-sided non-union. Multiple dental trauma. Secondary TMJ fibrosis and probable disc damage with secondary hypo mobility and anterior open bite.
I reviewed these findings today with Tiffany. I explained my concerns about the biological predictability of condylar stability for her over the long run. I am concerned that these condyles have been severely damaged and there is now fibrosis in both joints. I think the probability of getting predictable adaptive changes with good joint function is poor. Any attempt to correct her malocclusion with surgical movement of the mandible would have a high degree of unpredictability over the long run because of the unpredictable behaviour of the condyles. To this end, I think the most predictable thing we can do for her is to plan on replacing the TMJs with alloplastic, custom temporomandibular joint total joint replacements. I explained to Tiffany that these custom implants could be designed to allow simultaneous repositioning of the mandible into an optimal occlusal relationship.
I have recommended proceeding with completion of the necessary dental repair work as quickly as possible. I have also recommended simultaneous orthodontic treatment to level and align the arches. I stressed that the purpose of orthodontics is not to correct the malocclusion, but rather to align the teeth to prepare for surgical repositioning of the mandible. The mandible will be shifted to close the open bite and also to correct the asymmetry. This will be done at the same time as removal of the damaged TMJs. The new, custom, alloplastic total TMJ implants will be designed to hold the mandible in this new, corrected position. Tiffany understands there will be some finishing orthodontics following this surgical procedure. Definitive prosthodontics can be carried out at this time.
I agree that the 33 should be removed. Please let me know when you would like to have this done and we will arrange to do it for Tiffany.
The details of the TMJ alloplastic total joint reconstructive surgery were reviewed today with Tiffany. In particular, I discussed the placement of facial incisions, surgical technique, postoperative healing and sequelae and potential complications. Risks and benefits were reviewed. Rare, though possible, complications were discussed, including bleeding, transfusion, infection, temporary or permanent numbness or facial weakness and foreign body reaction. Websites were given to Tiffany for her review. Costs were discussed.
I have given Tiffany a referral for an MRI scan of the TMJs. I have also given her a prescription for Vimovo for NSAID therapy and Flexural as a nighttime muscle relaxant. I will see her in a couple of months to see how the preparatory work is coming along. Together, Dr O and I will determine a surgical date for her, which will likely occur in about one year.
Thanks again for the opportunity to assess and treat this very pleasant lady. Your confidence in my surgical practice is deeply appreciated.
Best personal regards,
Dr. P
As you know, Tiffany fell while running on August 12, 2014. She sustained severe injuries to her maxilla and mandible with a dentoalveolar fracture (fracture of the teeth & bone in which they reside) in the anterior maxilla. There was a body fracture in the anterior mandible as well as bilateral condylar fractures. Apparently, there was minimal condylar displasia initially so she was treated with arch bars to stabilize the segmental fractures and a soft diet. A month later it became apparent there had been displacement of the condylar segments. She was, therefore, taken to hospital and, under general anaesthesia, closed reduction was carried out. She was kept wired for two weeks and then wore tight elastic fixation for another two weeks followed by light elastic fixation. When the arch bars were removed there was a persistent malocclusion with anterior open bite and deviation of the mandible to the left.
Tiffany has severe pain affecting both temporomandibular joints as well as the temporalis and masseteric regions (the muscles of chewing, that go up to your temples and down under your jaw). This pain limits her range of motion as well as her ability to chew. She has quite a bit of dental pain. She has received a number of root canals and dental restorations and there are more planned.
Clinical examination showed the patient to be normo-cephalic (see that?? I'm normal in the head!) with normal eyes, ears, nose and throat. Cranial nerves II through XII are grossly intact. She had mild facial asymmetry with deviation of the chin to the left. The was a healed scar in the chin region.
Palpation of the muscles of mastication elicited two plus pain. She had three plus pain in both TMJs. Her range of motion was markedly limited at 20 millimetres. I could detect no clicking or crepitus (grinding) with this opening.
Intraorally she had a crowded, Class II malocclusion with deviation to the left and crossbite and anterior open bite. The only teeth in occlusion were the first and second molars. The oral mucosa and periodontal status were grossly normal. I did manipulate the mandible as well as the anterior maxillary teeth. There was no mobility, suggesting bony union of the anterior mandibular and maxillary fractures.
I had a chance to review the cone beam CT scan, which shows malunion of a right condylar fracture with loss of vertical dimension of the ramus condyle unit. On the left side there is a non-union a condylar neck fracture with malposition. I also noted the body fracture of the mandible, which did go through the cuspid region on the left side. External resorption of the 33 is evident.
DIAGNOSIS:
Previous bilateral condylar fracture with right-sided malunion and left-sided non-union. Multiple dental trauma. Secondary TMJ fibrosis and probable disc damage with secondary hypo mobility and anterior open bite.
I reviewed these findings today with Tiffany. I explained my concerns about the biological predictability of condylar stability for her over the long run. I am concerned that these condyles have been severely damaged and there is now fibrosis in both joints. I think the probability of getting predictable adaptive changes with good joint function is poor. Any attempt to correct her malocclusion with surgical movement of the mandible would have a high degree of unpredictability over the long run because of the unpredictable behaviour of the condyles. To this end, I think the most predictable thing we can do for her is to plan on replacing the TMJs with alloplastic, custom temporomandibular joint total joint replacements. I explained to Tiffany that these custom implants could be designed to allow simultaneous repositioning of the mandible into an optimal occlusal relationship.
I have recommended proceeding with completion of the necessary dental repair work as quickly as possible. I have also recommended simultaneous orthodontic treatment to level and align the arches. I stressed that the purpose of orthodontics is not to correct the malocclusion, but rather to align the teeth to prepare for surgical repositioning of the mandible. The mandible will be shifted to close the open bite and also to correct the asymmetry. This will be done at the same time as removal of the damaged TMJs. The new, custom, alloplastic total TMJ implants will be designed to hold the mandible in this new, corrected position. Tiffany understands there will be some finishing orthodontics following this surgical procedure. Definitive prosthodontics can be carried out at this time.
I agree that the 33 should be removed. Please let me know when you would like to have this done and we will arrange to do it for Tiffany.
The details of the TMJ alloplastic total joint reconstructive surgery were reviewed today with Tiffany. In particular, I discussed the placement of facial incisions, surgical technique, postoperative healing and sequelae and potential complications. Risks and benefits were reviewed. Rare, though possible, complications were discussed, including bleeding, transfusion, infection, temporary or permanent numbness or facial weakness and foreign body reaction. Websites were given to Tiffany for her review. Costs were discussed.
I have given Tiffany a referral for an MRI scan of the TMJs. I have also given her a prescription for Vimovo for NSAID therapy and Flexural as a nighttime muscle relaxant. I will see her in a couple of months to see how the preparatory work is coming along. Together, Dr O and I will determine a surgical date for her, which will likely occur in about one year.
Thanks again for the opportunity to assess and treat this very pleasant lady. Your confidence in my surgical practice is deeply appreciated.
Best personal regards,
Dr. P
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