One thing I certainly didn't expect from this injury is the limitations that have been placed on me physically. It makes me uncomfortable to say it, but I don't feel like I'm one to accept limitations without pushing them a little bit first. I wouldn't say that I'm someone who pushes through anything super human to achieve a goal, but I'm not one to say "I can't do that" without trying it first. Maybe I'll try it secretly...without announcing the results...but I'll give it a go.
This injury has been a source of almost constant discomfort. I say almost because there are good drugs and bottles of wine (not to be combined!) that can take it away but neither of these are perfect. Hangovers and side effects need to be managed! Whether it's neck, shoulder, head, jaw or tooth pain, it always seems to be something. I find that often times I'm taken aback by how unrelenting it is, and how places that I thought could never hurt, do. Like your head muscles. How many of you have asked to have your head muscles massaged? Did you even know you HAD head muscles? The ones that cover your skull and barely move? I get them massaged every other week....and it never makes the pain go away completely. (Actually, if you're reading this you probably have TMJ and totally get it. Sorry.)
Anyways, I'm not writing this to whine about my aches (ok, maybe a little bit), but to talk about accepting, and sometimes pushing, your limitations.
There are a lot of things that I want to be able to do without ending up in a pain crisis, or fully exhausted for a week, or without crying because I've over done it. Like go out for a night on the town. Or train for a competition. Or stay up past 10 pm on a weeknight. Or deal with a cold. Or go out in the cold for a day. Or make multiple plans on a weekend (with associated eating/drinking) and function like normal the following week.
You get it.
I'm whiny.
But really, all of these things end up sort of crushing me at some point. And I don't mean like "oh boy, I'm extra tired on Monday." This past weekend I went out to a late dinner Friday night, cleaned my house on Saturday, went to a friends house in the afternoon and then walked around Toronto watching my sister run a marathon on Sunday. By Monday I was exhausted, had a splitting headache and a nasty sore throat, which I really felt was set off by my lack of energy and ability to bounce back after some busy times. My jaw muscles were aching and I felt the vice-like grip around my temples that comes after a lot of talking, eating socially and maneuvering my jaw around trying to make my braces presentable after just taking a bite. Maybe it's just cold/flu season, but I'm really tired of this!
I used to just push through busy things, over-schedule myself and rebound alright....now I'm like a ticking time bomb. I have another late night, busy weekend coming up and I'm already dreading the "recovery time" from that. My sister went to work the day after the marathon, damn it!! Why can't I??
If this whole situation has taught me anything, it's got to be patience. The funny thing is, there's patience with life and then patience with yourself. Having patience with yourself (and self-care) is the hardest thing to practice. I would rather just push through my plans and obligations and deal with the tiredness later. It's just that now, it's not just being tired. It's pain, it's exhaustion, and it's the "me" that I put forth and give to my family that I have to be concerned with. Sigh.
Or here is this question to ponder....
How bad is this situation? You know when you hear about people doing incredible things, like, oh...say EVERY paralympian, EVER? Who am I to whine?
Time to feed that courage wolf...
Tuesday, October 20, 2015
Current TMJ Implant Options
The world of alloplastic implant options is small you might say. There are three options on the market for your surgeon to choose from:
1. TMJ Implants
2. TMJ Concepts
3. Biomet/Lorenz
To start, there are several criteria that are considered when designing an implant for use in the TMJ. This is done to ensure that a situation like the Vitek implant disaster does not happen again, and takes into account what was learned with that experience, as well as what can be applied from hip and knee replacement implants that have been around for decades. I found an excellent review article in the McGill Journal of Medicine that explains implant design in detail.
(Sinno H, Youssef T, Giladino M, Bobyn D. Engineering Alloplastic Temporomandibular Joint Replacements. MJM 2010 13(1): 63-72.
The following is a summary of the key factors in implant design.
1. Biocompatibility.
The implant has to affix well to the bone to which it is attached, while causing the least amount of damage to the surrounding tissues as possible.
2. Modulus, or stiffness of the material.
The more flexible the implant material, the more it can share the load with the bone it is affixed to. When bone is stressed with a load, the more bone density and strength are preserved in the long run.
3. Stiffness.
This depends on both the flexibility of the material and the shape and thickness of the implant. The thicker the implant, even if it is made of a flexible material, the stiffer it will be. This is the reason why, when you look at pictures of the implants, they show little notches in the metal parts. Putting these notches in, or making it hollow, or very porous, helps to reduce the stiffness of the implant.
4. Stress Shielding.
Similar to, and perhaps a summary of modulus and stiffness, when 2 materials have a uniform load applied to both, the stiffer material will absorb most of that load. So when an implant is attached to bone, it will absorb the loading and shield bone from the stress. As mentioned above, this will cause the bone to lose density and strength in the long term.
5. Notch Sensitivity.
This was the hardest for to me to understand, but when an implant is made with notches in it to reduce it's stiffness, or perhaps to encourage the bone to grow into the notches and rigidly fix the implant, those notches are a point of weakness. So notch sensitivity is is how sensitive the material is to fracture due to the presence of the notches.
6. Modularity.
This enables the use of different materials for different parts of the implant. Materials that are best for wear resistance can be used for bearing components. Materials that are less stiff can be used for load carrying and fixation to reduce the stress shielding and bone resorption that results.
7. Materials.
The same materials that are used in hip/knee replacements are what are used in TMJ implants. Cobalt-Chromium (Co-Cr) and titanium alloys are useful in the stems and bodies of the implants. There are also a variety of options for porous fixation surfaces. A new development is the use of highly cross-linked polyethylene, which is a very wear resistant plastic - ultra high molecular weight polyethylene (UHMWPE) that is also being used widely in hip and knee replacements.
Stainless steel is not used, because it can corrode - so it's not biocompatible for the TMJ.
A few notes on Co-Cr, titanium alloys and UHMWPE:
Co-Cr is very hard and abrasion resistant, but can cause significant stress sheilding.
Titanium alloys are more flexible than Co-Cr, but does not have good wear properties. It is also notch sensitive, so it can't be impregnated with beads or wire to promote bony ingrowth. It can, however, be roughened at the surface, or coated.
UHMWPE has had long term success in orthopaedic surgery, but is subject to wear after repeated loading.
Comparison of current implants:
The condylar portion of all implants is made with Co-Cr alloy. The Biomet/Lorenz implants have a plasma spray titanium coating on the bone-contacting surface to help bone fixation. The Co-Cr bearing has high hardness and strength.
Attached to the condyle is the ramus (below the condyle on the jaw). In TMJ Implant and Biomet, the ramus is made of Co-Cr alloy. TMJ concepts uses titanium alloy. The authors of the study thought that since the ramus is a thinner bone, using a titanium alloy would distribute the load better, and reduce stress sheilding.
The ball and socket portion of the implant is the fossa. The TMJ implants uses metal-on-metal bearings made of Co-Cr. Both TMJ Concepts and Biomet use UHMWPE.
Overall, the study suggests that Alloplastic TMJ reconstruction devices have shown a lot of predictability and reliability. Choosing Alloplastic over Autogenous reconstruction provides a few benefits, including custom made implants that allow for immediate jaw function (in most cases, no wiring shut) after surgery.
Of course, everyone in this "business" knows that these implants are not meant to last forever, and will need replacement at some point in time. The current suggestion is about 20 years of life, since they are relatively new and every year that goes by, another one lasts another year longer.
It's sure no picnic to sift through all of this information...so I hope it's somewhat helpful in learning more about TMJ implants!
1. TMJ Implants
2. TMJ Concepts
3. Biomet/Lorenz
To start, there are several criteria that are considered when designing an implant for use in the TMJ. This is done to ensure that a situation like the Vitek implant disaster does not happen again, and takes into account what was learned with that experience, as well as what can be applied from hip and knee replacement implants that have been around for decades. I found an excellent review article in the McGill Journal of Medicine that explains implant design in detail.
(Sinno H, Youssef T, Giladino M, Bobyn D. Engineering Alloplastic Temporomandibular Joint Replacements. MJM 2010 13(1): 63-72.
The following is a summary of the key factors in implant design.
1. Biocompatibility.
The implant has to affix well to the bone to which it is attached, while causing the least amount of damage to the surrounding tissues as possible.
2. Modulus, or stiffness of the material.
The more flexible the implant material, the more it can share the load with the bone it is affixed to. When bone is stressed with a load, the more bone density and strength are preserved in the long run.
3. Stiffness.
This depends on both the flexibility of the material and the shape and thickness of the implant. The thicker the implant, even if it is made of a flexible material, the stiffer it will be. This is the reason why, when you look at pictures of the implants, they show little notches in the metal parts. Putting these notches in, or making it hollow, or very porous, helps to reduce the stiffness of the implant.
4. Stress Shielding.
Similar to, and perhaps a summary of modulus and stiffness, when 2 materials have a uniform load applied to both, the stiffer material will absorb most of that load. So when an implant is attached to bone, it will absorb the loading and shield bone from the stress. As mentioned above, this will cause the bone to lose density and strength in the long term.
5. Notch Sensitivity.
This was the hardest for to me to understand, but when an implant is made with notches in it to reduce it's stiffness, or perhaps to encourage the bone to grow into the notches and rigidly fix the implant, those notches are a point of weakness. So notch sensitivity is is how sensitive the material is to fracture due to the presence of the notches.
6. Modularity.
This enables the use of different materials for different parts of the implant. Materials that are best for wear resistance can be used for bearing components. Materials that are less stiff can be used for load carrying and fixation to reduce the stress shielding and bone resorption that results.
7. Materials.
The same materials that are used in hip/knee replacements are what are used in TMJ implants. Cobalt-Chromium (Co-Cr) and titanium alloys are useful in the stems and bodies of the implants. There are also a variety of options for porous fixation surfaces. A new development is the use of highly cross-linked polyethylene, which is a very wear resistant plastic - ultra high molecular weight polyethylene (UHMWPE) that is also being used widely in hip and knee replacements.
Stainless steel is not used, because it can corrode - so it's not biocompatible for the TMJ.
A few notes on Co-Cr, titanium alloys and UHMWPE:
Co-Cr is very hard and abrasion resistant, but can cause significant stress sheilding.
Titanium alloys are more flexible than Co-Cr, but does not have good wear properties. It is also notch sensitive, so it can't be impregnated with beads or wire to promote bony ingrowth. It can, however, be roughened at the surface, or coated.
UHMWPE has had long term success in orthopaedic surgery, but is subject to wear after repeated loading.
Comparison of current implants:
The condylar portion of all implants is made with Co-Cr alloy. The Biomet/Lorenz implants have a plasma spray titanium coating on the bone-contacting surface to help bone fixation. The Co-Cr bearing has high hardness and strength.
Attached to the condyle is the ramus (below the condyle on the jaw). In TMJ Implant and Biomet, the ramus is made of Co-Cr alloy. TMJ concepts uses titanium alloy. The authors of the study thought that since the ramus is a thinner bone, using a titanium alloy would distribute the load better, and reduce stress sheilding.
The ball and socket portion of the implant is the fossa. The TMJ implants uses metal-on-metal bearings made of Co-Cr. Both TMJ Concepts and Biomet use UHMWPE.
Overall, the study suggests that Alloplastic TMJ reconstruction devices have shown a lot of predictability and reliability. Choosing Alloplastic over Autogenous reconstruction provides a few benefits, including custom made implants that allow for immediate jaw function (in most cases, no wiring shut) after surgery.
Of course, everyone in this "business" knows that these implants are not meant to last forever, and will need replacement at some point in time. The current suggestion is about 20 years of life, since they are relatively new and every year that goes by, another one lasts another year longer.
It's sure no picnic to sift through all of this information...so I hope it's somewhat helpful in learning more about TMJ implants!
Saturday, October 10, 2015
TMJ Replacement Options
I was recently asked the question: are you getting TMJ Concepts custom made implant or Biomet custom implant? Do you know by any chance what is the difference and which one may be a better one?
This is a question that I've thought a lot about myself, but just sort of trusted my surgeon to recommend what's best. And I still feel that way - whatever he is most comfortable "installing" in my face has got to give the best outcome. Some might feel differently, but allow me to explain myself. This is a very uncommon and relatively new surgery. There are fewer surgeons who actually perform the TMJ replacements, so they are on the leading edge of what is being developed and seeing the results of themselves with their patients. However, having a solid Biology background (as in, an undergrad degree), I am keenly interested in the implants that I'm getting and why.
Without disrespecting anyone who has dealt with this longer than I have, and certainly that's almost anyone who is facing this as a result of a systemic issue rather than a recent trauma (like me), I'm writing this from the perspective that your surgeon has recommended a TJR (total jaw replacement) and a certain type of implant and you're wondering why they might be recommending that type and the history behind it. In my particular case, I know that this is my only option going forward - foregoing TJR of any type is not an option. I know that there are some folks out there who believe surgery should be avoided at all costs, and certainly there are cases where this should not be jumped into. However, I've done enough research and know my own situation well enough to know that this is something that I need and there is no other option.
That being said, here are the options for complete TMJ reconstruction surgery:
Pros:
Alloplastic Replacement is the replacement of the whole joint (fossa/"socket", condyle/"ball" and ramus - what you think of as the jaw bone) with a manufactured joint. These implants can be conceptualized as the same as a hip or a knee replacement implant.
The reasons you might get an alloplastic implant are:
Some of the benefits of alloplastic joints over autogenous grafting are:
This is a question that I've thought a lot about myself, but just sort of trusted my surgeon to recommend what's best. And I still feel that way - whatever he is most comfortable "installing" in my face has got to give the best outcome. Some might feel differently, but allow me to explain myself. This is a very uncommon and relatively new surgery. There are fewer surgeons who actually perform the TMJ replacements, so they are on the leading edge of what is being developed and seeing the results of themselves with their patients. However, having a solid Biology background (as in, an undergrad degree), I am keenly interested in the implants that I'm getting and why.
Without disrespecting anyone who has dealt with this longer than I have, and certainly that's almost anyone who is facing this as a result of a systemic issue rather than a recent trauma (like me), I'm writing this from the perspective that your surgeon has recommended a TJR (total jaw replacement) and a certain type of implant and you're wondering why they might be recommending that type and the history behind it. In my particular case, I know that this is my only option going forward - foregoing TJR of any type is not an option. I know that there are some folks out there who believe surgery should be avoided at all costs, and certainly there are cases where this should not be jumped into. However, I've done enough research and know my own situation well enough to know that this is something that I need and there is no other option.
That being said, here are the options for complete TMJ reconstruction surgery:
- Autogenous Replacement (rib graft most often)
- Alloplastic Replacement (manufactured implant)
- TMJ Implant
- TMJ Concepts
- Biomet/Lorenz
Pros:
- Cost - since no manufactured parts are required, the cost is lower for this surgery. However, since there is another surgical site and associated pain, the hospital stay is longer, and the recovery may be longer. This may offset the cost savings to the patient.
- Growth potential - in children, this is the only option for reconstruction, since they will continue growing and a manufactured implant will not.
- Recovery time is long
- Only reconstructs the "ball" and not the "socket" part of the joint
- Often requires re-operation, which may ultimately include a manufactured implant
Alloplastic Replacement is the replacement of the whole joint (fossa/"socket", condyle/"ball" and ramus - what you think of as the jaw bone) with a manufactured joint. These implants can be conceptualized as the same as a hip or a knee replacement implant.
The reasons you might get an alloplastic implant are:
- Ankylosis of the TMJ with severe anatomic abnormalities
- Failure of autogenous grafts
- Failure of Proplast-Teflon or Vitek-Kent or partial joint implants
- Severe inflammatory joint disease resulting in joint mutilation and functional disability
Some of the benefits of alloplastic joints over autogenous grafting are:
- Immediate jaw function, allowing for physiotherapy to begin on Day 1 of recovery
- No need for a secondary donor site (rib sectioning, etc)
- Custom implant availability
Surgeons seem to see that immediate movement of the joints contributes to a much shorter healing time, and better outcomes. Of course, one of the deciding factors in the relative success of the surgery is dependant on how many prior surgeries a patient has had. The more surgeries, the lesser the degree of success.
I hope that this helps to understand the differences between grafting-type TMJ reconstruction and manufactured implants. In my next post, I will share what I've learned are the subtle differences between TMJ Concepts and Biomet/Lorenz manufactured implants.
Keep feeding the courage wolf!!
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