Puricelli biconvex arthroplasty as an alternative for temporomandibular joint reconstruction: description of the technique and long-term case report

Abstract

Background There are several indications for partial or total replacement of the temporomandibular joint (TMJ), including neoplasms and severe bone resorptions. In this regard, several techniques have been suggested to increase the functionality and longevity of these prosthetic devices. This case report describes the treatment of a TMJ ankylosis patient with the Puricelli biconvex arthroplasty (ABiP) technique, with a long-term follow-up. Case presentation In 1978, a 33-year-old male polytraumatised patient developed painful symptoms in the right preauricular region, associated with restricted movement of the ipsilateral TMJ. Due to subcondylar fracture, an elastic maxillomandibular immobilisation (EMMI) was applied. Subsequently, the patient was referred for treatment when limitations of the interincisal opening (10 mm) and the presence of spontaneous pain that increased on palpation were confirmed. Imaging exams confirmed the fracture, with anteromedial displacement and bony ankylosis of the joint. Exeresis of the compromised tissues and their replacement through ABiP was indicated. The method uses conservative access (i.e., preauricular incision), partial resection of the ankylosed mass, and tissue replacement using two poly(methyl methacrylate) components, with minimal and stable contact between the convex surfaces. At the end of the procedure, joint stability and dental occlusion were tested. The patient showed significant improvement at the postoperative 6-month follow-up, with no pain and increased mouth opening range (30 mm). At the 43-year follow-up, no joint noises, pain or movement restrictions were reported (mouth opening of 36 mm). Imaging exams did not indicate tissue degeneration and showed the integrity of prosthetic components. Conclusions The present case report indicates that ABiP enables joint movements of the TMJ, allowing the remission of signs and symptoms over more than 40 years of follow-up. These data suggest that this technique is a simple and effective alternative when there is an indication for TMJ reconstruction in adult patients with ankylosis.

Puricelli biconvex arthroplasty: an experimental study in sheep

“…In our study, the 45-day period was adopted based on the data from an experimental study in rabbits [ 31 ], which involved the reorientation of the force vector of the jaw to the base of the skull, a principle similar to that on which the biconvex arthroplasty technique is based [ 24 , 32 ]. The histomorphometric analysis of the temporal bone of the animals suggested increased bone remodelling rates during the evaluated period, which is consistent with our clinical observations in humans [ 16 – 18 , 24 ].…”

“…Puricelli biconvex arthroplasty technique enables the reconstruction of this joint using two PMMA convex surfaces. The technique has been successfully used for over 20 years, with long-term positive results [ 16 – 18 , 24 ]. In the present study, we investigated the functional outcome of the procedure as well as maintenance of physical properties of the material in a sheep model of the ABiP method.…”

“…PMMA is also used in the Puricelli biconvex arthroplasty (ABiP) technique, employed in temporomandibular joint reconstruction in adult and paediatric patients [ 16 , 17 ] and recently described in greater detail [ 18 ]. In ABiP, two PMMA components with minimal, stable contact between the convex surfaces are used for TMJ replacement.…”

“…In ABiP, two PMMA components with minimal, stable contact between the convex surfaces are used for TMJ replacement. This low-cost, more conservative surgery, with single access and limited ostectomy, results in adequate joint stability and dental occlusion, and long-term follow-up (up to 43 years) [ 18 ] has shown no joint noises, pain or movement restrictions in patients. Despite excellent clinical results, there is a lack of experimental studies for the investigation of biological and histological parameters of ABiP.…”

Effect of changing the direction of the force vector of the mandible in relation to the skull base: study in rabbits

“…Puricelli Biconvex Arthroplasty technique proposes TMJ reconstruction by interposition of two polymethyl methacrylate (PMMA) semi-spheres. The great particularity of this technique, reproduced in this study, is the possibility of changing the direction of the force vector from the condyle, which occurs in an approach contrary to normal anatomy-physiology, since its direction turns in the sagittal inferior-superior and anterior-posterior planes [12–13].…”