oral surgery oral medicine oral pathology

With ECZ~O~S on oral and ITIBXiiiOfBCiBl radiology and endodontics

oral surgery

Editor: ROBERT B. SHIRA, DDS

School of Dental Medicine, Tufts University 1 Kneeland Street Boston, Massachusetts 0211 I

Osteoplasty of the mandibular condyle with preservation of the cover: Comparison sutures for fixation

articular soft tissue of fibrin sealant and of the articular soft l 1 tissue cover in rabbits

Kenichi Kurita, DDS, PhD,a Per-Lennart Westesson, DDS, PhD,b Lars Eriksson, DDS, PhD,” and Nils H. Sternby, MD, PhD,d Nagoya, Japan, Rochester, N.Y., and Lund and Malmii, Sweden

AICHI-GAKUIN UNIVERSITY, UNIVERSITY OF ROCHESTER, UNIVERSITY OF LUND, AND

UNIVERSITY HOSPITAL, LUND

Fibrin sealant and sutures were compared for fixation of the articular soft tissue cover after it had been

raised in association with osteoplasty of the mandibular condyle. Nine adult rabbits were operated on

bilaterally with the use of fibrin sealant on one joint and sutures on the other joint. The rabbits were killed after 3 months. Macroscopic and histologic evaluations of the condyles did not reveal any appreciable

differences between the two techniques. Fibrin sealant was, however, technically easier to apply than the sutures. It was concluded that fibrin sealant might be an alternative to sutures for fixation of the articular

soft tissue cover after it has been raised in association with osteoplasty of the mandibular condyle.

(ORAL SIJRC ORAL MED ORAL PATHOL 1990;69:661-7)

This study was supported by Immuno AB, Stockholm, Sweden; the Swedish Medical Research Council (project no. 675 1); and the Torsten and Ragnar Siiderbergs Foundations, Stockholm, Swe- den. aThe Second Department of Oral and Maxillofacial Surgery, Aichi-Gakuin University, Nagoya, Japan. bDepartment of Diagnostic Radiology, University of Rochester, School of Medicine and Dentistry, Rochester, N.Y. CDepartment of Oral Surgery, University Hospital, Lund, Swe- den. dDepartment of Pathology, University of Lund, General Hospital, Malm& Sweden. 7/12/11379

T he articular soft tissue cover is usually removed when osteoplasty or a high condylar shave of the mandibular condyle is performed. l-5 Experiments on rabbits have suggested that the articular surface would be smoother postoperatively if the articular soft tissue cover was raised and deflected forward before removal of bone and replaced after bone removal.6 However, in that study,6 an undesirable deformity was frequently seen at autopsy posteriorly on the condyles where the incision was made for the deflection of the articular soft tissue cover. Sutures

661

662 Kurita et al. ORALSURGORAL MEDORALPATHOL June 1990

Bone removal

Sutures

Fibrin sealant

Fig. 1. Schematic drawing of surgical techniques. A, Elevation of articular soft tissue cover and removal of bone. B, Fixation of articular soft tissue cover with sutures. C, Fixation of articular soft tissue cover with fi- brin sealant.

were placed in this incision line, and mechanical interference from the sutures during joint function might have contributed to the development of this undesirable deformity.

Fibrin sealant is a biologic substance that contains fibrinogen, plasma fibronectin, the coagulation factor XIII, and plasminogen. ’ In the presence of both thrombin and calcium, the fibrin sealant will act as a “surgical glue,” and it has been used as an alternative to sutures for fixation of soft tissues.* To investigate whether fibrin sealant could replace sutures, we raised the articular soft tissue cover6 bilaterally on rabbit temporomandibular joints, performed osteoplasty of the condyle, and used sutures for fixation of the artic- ,!nr en!? ?i:plz c~er or, one joint and fibrin sealant on the contralateral joint.

MATERIAL AND METHODS

Nine adult rabbits (Belgium giant) with an aver- age weight of 6 kg were operated on bilaterally. An intramuscular injection of Hypnorm (Janssen Phar- maceutica, Beerse, Belgium) (0.7 ml/kg body weight) was used for anesthesia. In addition, 0.5 ml of 2% lidocaine with 12.5 gg/ml of epinephrine was injected in the temporomandibular joint region. The surgery was carried out with the animal under an operation microscope.

A 2.0 cm skin incision was made between the lateral canthus of the eye and the external auditory meatus along the zygomatic arch. The joint capsule was explored, and the posterior attachment of the temporomandibular joint was incised to expose the condylar head. A mediolateral incision was made on

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Osteoplasty of mandibular condyle 663

Fig. 2. A and B, Lateral aspect of condyles from rabbit where sutures were used for fixation on one side (A) and fibrin sealant in other (B). Both condyles exhibit smooth articular surfaces and no postoperative defor-

mities. The operation sites (0~) are seen as slight depressions of the condyles (curved arrows). The locations of the incision lines are indicated by straight arrows. C and D, Histologic sections of joints shown in A and B demonstrating uninterrupted layer of subarticular cartilage cells both in operation areas (between curved arrows) and in areas of incision (straight arrows).

the posterior superior part of the condyle, and the articular soft tissue cover was elevated and deflected forward (Fig. 1, A). About 4 x 2 X 1.5 mm of the bone in the superior part of the condyle was removed by a 1 mm round bur (Fig. 1, A), and then the elevated articular soft tissue cover was replaced on the condyle. On one side, the articular soft tissue cover was sutured with 8-O polyglycolic acid suture (Dexon, Cyanamid of Great Britain Ltd, Gosport, Hampshire, Great Britain) (Fig. 1, B), and on the other side, it was fixed with fibrin sealant (Tissucol, Immuno AG, Vienna, Austria) (Fig. 1, C). When fi- brin sealant was used, the articular soft tissue cover was pressed down to have contact with the bone sur- face in the bottom of the defect (Fig. 1, c).

During the operation and for the next 4 days, the animals received a daily dose of 0.25 mg streptomy-

tin (Novo Industri A/S, Copenhagen, Denmark) and 0.2 mg benzylpenicillin (Novo Industri A/S) intra- muscularly. The animals’ diet was the same preoper- atively and postoperatively (pellets sized 5 X 12 mm, Evos Sweden Limited, SMertPlje, Sweden).

Three months after the operation, the rabbits were killed by an intravenous injection of pentobarbital. The condyles were dissected out, and the articular surface was macroscopically scrutinized for defects in the articular surface. The mediolateral dimension of the articular surface of the condyle, 3 mm anterior to the mediolateral incision line on the articular surface, was measured with a calliper.

The condyles were fixed in 10% neutral formalin and decalcified. The specimens were embedded in paraffin and sectioned in the sagittal plane. The sections were stained with hematoxylin and eosin and

664 Kurita et ai.

OP

ORALSURG ORAL MEDORALPATHOL June 1990

Fig. 2. E and F, Magnifications of areas indicated in C confirming uninterrupted layer of subarticular car- tilage cells (arrows). G and H, Magnifications of areas indicated in D confirming uninterrupted layer of sub- articular cartilage cells (arrows).

periodic acid-Schiff stains and examined under light microscopy.

RESULTS

All rabbits tolerated the surgery well and survived during the follow-up period. The day after surgery, +hP rabhi+c a+p their nnrmal diet and there were no indications that they had significant postoperative pain.

Macroscopic assessment of the condyles revealed that the operation sites in all joints were covered with soft tissue (Figs. 2 and 3). The soft tissue cover was smooth in all but three joints (two with sutures, one with fibrin sealant) (Table I). In these three joints, a deep mediolateral fissure (Fig. 3) was observed where the bone was removed. A deformity along the incision on the posterior part of the condyle was frequently seen (Fig. 3) (Table I). There was no

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Osteoplasty of mandibular condyle 665

Fig. 3. A and B, Superior aspect of condyles from rabbit where sutures were used for fixation on one side (A) and fibrin sealant in the other (B). Both condyles exhibit fissurelike deformities both in the area of bone removal (0~) and the area of the incision line (1~). C and D, Histological sections in sagittal plane of joints shown in A and B showing that subarticular layer of cartilage cells is interrupted in operation areas (between curved arrows) and also in area of incision (straight arrows) in joints where fibrin sealant was used,

statistically significant difference of the mediolateral width of the condyles operated on when sutures or fibrin sealant was used (Table I).

Histologically, the subarticular layer of cartilage cells was frequently interrupted both in the operation area and at the site of the incision in both joints operated on with sutures and with fibrin sealant (Fig. 3j (Table I). There was no inflammatory reaction.

DISCUSSION

This study did not reveal any appreciable macro- scopic or histologic difference between condyles in which fibrin sealant or sutures were used for fixation of the articular soft tissue cover after it had been raised in association with osteoplasty of the mandib- ular condyle. This observation supports other studies on the use of fibrin sealant8 and suggests that fibrin sealant might be an alternative to sutures. Fibrin

sealant was technically easier to apply than the sutures, which was valuable for this specific applica- tion since it sometimes can be difficult to suture on the condyle, especially in the medial part of the joint.

According to a previous study, preservation of the articular soft tissue cover will result in a smoother articular surface postoperatively compared with removal of both the soft tissue layer and the bone.6 This observation was supported by the findings in the present study and suggests that preservation of the articular soft tissue cover might be one way to improve the postoperative condition after osteoplasty. The technique has, however, in its present form, significant drawbacks that should be eliminated before it is clinically applied. Thus, a fissurelike deformity was frequently seen at autopsy along the incision that was made in the articular surface

666 Kurita et al. ORAL. SLIRG ORAL MED ORAL PATHOI

June 1990

OP Suture

Fig. 3. E and F, Magnifications of areas indicated in C showing interrupted layer of subarticular cartilage cells (arrows) in operation area (E) but not in area of incision (F). G and H, Magnification of areas indicated in D showing interrupted layer of subarticular cartilage cells (arrows).

posteriorly on the condyle. This deformity was ini- tially suspected to be associated with the sutures in the incision line, but the macroscopic and histologic results of the present study disproved this suspicion since similar deformities occurred also when fibrin sealant was used instead of sutures. Other ways snoula oe attempted to eiiminate this defect; piac- ing the incision outside the articulating area might

be one of the ways to reduce this undesirable de- formity.

In summary, 3 months after surgery there were no appreciable macroscopic or histologic differences between the condyles in which fibrin sealant or sutures were used for fixation of the articular soft tissue cover. Fibrin sealant might therefore represent an alternative to sutures in this application.

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Table I. Comparison of fibrin sealant and sutures for fixation of the articular soft tissue cover after osteo- plasty of the mandibular condyle (n = 9 rabbits)

.Iy.cl-

Mean and range (mm) 4.4; 3.1-6.9 4.6; 3.9-6.3 of mediolateral width of condyle

Deep fissure in articular 1 joint 2 joints surface in area operated on

Interrupted subarticular 7 joints 6 joints layer of cartilage cells in area operated on

Irregular articular 7 joints 8 joints surface in area of incision

Absence of subarticular 8 joints 7 joints layer of cartilage cells beneath incision line

REFERENCES

1. McCarty WL, Farrar WP. Surgery for internal derangements of the temporomandibular joint. J Prosthet Dent 1979;42: 191-6.

2.

3.

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6.

Osteoplasty of mandibular condyle 667

Henny FA. Treatment of the painful temporomandibular joint. J Oral Surg 1957;15:214-22. Henny FA. Surgical treatment of the painful temporoman- dibular joint. J Am Dent Assoc 1969;79:171-7. Henny FA, Baldridge OL. Condylectomy for the persistently painful temporomandibular joint. J Oral Surg 1957; 15:24- 31. Dingman RO, Grabb WC. lntracapsular temporomandibular joint arthroplasty. Plast Reconstr Surg 1966;38:179-85. Kurita K, Westesson P-L, Eriksson L, Sternby NH. High con- dylar shave of the temporomandibular joint with preservation of the articular soft tissue cover. An experimental study on rabbits. ORAL SURC ORAL MED ORAL PATHOL 1990;69: 1 O-4. Farrari Parabita G, Derada Troletti G, Vinci R. Use of tissucol (Tisseel) in maxillofacial surgery. In: Schag G, Red1 H, eds. Fibrin sealant in operative medicine. Vol 4. Plastic surgery-maxillofacial and dental surgery. Berlin: Springer- Verlag, 1986: 13 5-40. Schag G, Red1 H, eds. Fibrin sealant in operative medicine. Vol 4, Plastic surgery-maxillofacial and dental surgery. Berlin: Springer-Verlag 1986:1-194.

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Dr. Per-Lennart Westesson School of Medicine and Dentistry Department of Diagnostic Radiology University of Rochester Box 694 601 Elmwood Ave. Rochester. NY 14642