Int. J. Oral Maxillofac. Surg.

2009; 38: 301–307

doi:10.1016/j.ijom.2008.12.014, available online at http://www.sciencedirect.com

Review Paper
TMJ Disorders

Historical development of Oliver Driemel1, Tobias Ach1,

Urs Dietmar Achim Müller-Richter2,
Michael Behr3, Torsten Eugen
Reichert1, Martin Kunkel4,
alloplastic temporomandibular Rudolf Reich5
1
Department of Oral and Maxillofacial
Surgery, University of Regensburg, Germany;

joint replacement before 1945 2

Department of Oral and Maxillofacial Plastic
Surgery, University of Würzburg, Germany;
3
Department of Prosthetic Dentistry,
University of Regensburg, Germany;
4
Department of Oral and Maxillofacial
Oliver Driemel, Tobias Ach, Urs Dietmar Achim Müller-Richter, Michael Behr, Surgery, University of Bochum, Germany;
5
Torsten Eugen Reichert, Martin Kunkel, Rudolf Reich: Historical development of Department of Oral and Maxillofacial
alloplastic temporomandibular joint replacement before 1945. Int. J. Oral Surgery, University of Bonn, Germany
Maxillofac. Surg. 2009; 38: 301–307. # 2009 Published by Elsevier Ltd on behalf of
International Association of Oral and Maxillofacial Surgeons.

Abstract. Resections of the temporomandibular joint (TMJ) have been carried out for
about 150 years. This article reviews the beginning of TMJ surgery technique before
1945 by carrying out extensive inquiries in public and private libraries and
collections. Before 1945 the technique of alloplastic reconstruction of the TMJ was
mainly influenced by German and French surgeons. Reconstruction was limited to
replacement of the condyle. The role of the TMJ within the orofacial system was not
considered. Interposition of alloplastic implants, resection dressings and prostheses
Keywords: TMJ; condyle; alloplastic recon-
were the dominant technique. The main concerns were sterilisation, struction; mandible; historical review.
biocompatibility and implant fixation. No evidence-based data on outcomes are
available from that time. By 1945 reconstruction of the TMJ involved the close Accepted for publication 16 December 2008
cooperation of surgeons and dentists. Available online 23 February 2009

Resection surgery of the mandible can be
traced back to the early 19th century. The
first continuity resection of the mandible
without exarticulation has been ascribed to
Deadrik in 181041 and Dupuytren in
191251,58. The first hemimandibulectomy
including exarticulation was carried out by
Gräfe in 182147 rather than in 1793 by the
Austrian medical officer Fischer47 who
had only removed bone fragments result-
ing from a gunshot injury51. Signorini
performed the first total mandibulectomy
with exarticulation in 184341 (Table 1).
In view of their high mortality rates
these extensive and complicated interven-
tions were performed by only a few sur-
geons24. Weber, for instance, reported a
mortality rate of 30% (36 deaths in 153
exarticulations) in 186441. The range of
indications for temporomandibular joint
(TMJ) resection varied and included
pathologies that have lost their signifi-
cance (phosphorus necrosis) or where
therapeutic management has undergone
fundamental change (actinomycosis,
tuberculosis, luxations) (Table 2).
The grave functional and aesthetic con-
sequences of mandible resection with
exarticulation were recognized at an early
stage. SCHRÖDER differentiated complica-
tions developing during the first three
postoperative weeks (early sequelae) from
those based on scar contraction and occur-
ring from the fourth postoperative week
onward (late sequelae)52 (Table 3).
Attempts were made to control these
complications by implanting alloplastic
materials; in ankylosis patients several
alloplastic implants were used to prevent
recurrences35. In extensive bone resec-
tions defect reconstruction followed the
concepts of the German School6,16 or the
French School31.
This historical overview represents the
first part of two dealing with autogenous

0901-5027/040301 + 07 $36.00/0 # 2009 Published by Elsevier Ltd on behalf of International Association of Oral and Maxillofacial Surgeons.
302 Driemel et al.

Table 1. Chronology of mandibular resection surgery.

Year of -surgery Surgeon Type of intervention Source
1793 Fischer Removal of bone fragments Schlössmann (1905) [51]
1810* Deadrik Continuity resection without exarticulation Perthes (1907) [41]
1812* Dupuytren Continuity resection without exarticulation Tilmann (1903) [58],
Schlössmann (1905) [51],
Sigron (1991) [55]
1821 Gräfe Hemimandibulectomy with exarticulation Rothmund (1853) [47],
Sigron (1991) [55]
1843 Signorini Total mandibulectomy with exarticulation Perthes (1907) [41],
Sigron (1991) [55]
1854 Humphry Isolated resection of the condylar process Humphry (1856) [20],
Abbe (1880) [1],
Orlow (1903) [35]
*
Reported in the literature.

Table 2. Overview of indications for TMJ resections as described until 1945. and alloplastic TMJ replacement and
Indications for TMJ resection Number of cases Source aims to: outline the development of allo-
plastic TMJ replacement up to 1945;
Ankyloses document the origin of the interposition
Acquired (posttraumatic) 1 Helferich (1894) [19],
of alloplastic material in the context of
2 Orlow (1903) [35],
17 Blair (1914) [5], ankylosis treatment; pinpoint the differ-
2 Murphy (1914) [33], ences between the German and the
n. g. Ridson (1934) [45], French Schools in their reconstruction
n. g. Dingman (1946) [8] concepts following jaw resection with
Acquired (postinflammatory) 2 König (1878) [23], exarticulation; and outline the problems
27 Blair (1914) [5], of alloplastic TMJ replacement for their
3 Murphy (1914) [33], present relevance.
5 Orlow (1903) [35],
n. g. Ridson (1934) [45],
n. g. Dingman (1946) [8] Material and methods
Congenital n. g. Orlow (1903) [35],
2 Blair (1914) [5], The online database ‘Oldmedline’ goes
2 Murphy (1914) [33] back to 1950, therefore no information
n. g. Dingman (1946) [8] on alloplastic TMJ replacement before
1945 could be obtained from it. The lit-
Neoplasias
Benign 1 Berndt (1898) [3],
erature was obtained from interlibrary
1 König (1908) [25] lending or copies of contributions from
Malignant 1 Keller (1853) [21], various European libraries, museum
1 BÖNNECKEN (1893) [6], archives and private collections. Further
1 BERNDT (1898) [3], articles were found with the help of refer-
1 TILMANN (1903) [58], ences in the literature retrieved and were
1 KÜHNS (1904) [28], integrated in this overview.
1 SCHLÖSSMANN (1905) [51],
2 KÖNIG (1908) [25],
1 KOHEN-BARANOWA (1908) [27], Interposition of alloplastic material
1 LEXER (1908) [30],
1 RIEGNER (1911) [46], Rosner introduced the interposition of
3 EISELSBERG and PICHLER (1923) [11] alloplastic material in 1898 after anky-
losis-related resection of the TMJ con-
Inflammatory Changes dyle. He implanted a gold plate to
Phosphorous Necrosis 3 KELLER (1853) [21],
prevent recurrence. This method was
3 WOOD (1856) [60],
1 LANGENBECK VON (1878) [29], modified by Orlow who attached gold-
1 SCHLENKER 1883 [50] coated aluminium plates to the exposed
Actinomycosis n. g. VORSCHÜTZ (1912) [59] bone ends35,45. The favourable func-
Tuberculosis 1 RIEGNER (1911) [46] tional outcomes reported by Orlow (inci-
sal jaw opening about 2.5 cm) for the
Trauma
War Injuries n. g. BÖNNECKEN (1893) [6], first postoperative weeks35 led to the
n. g. HASHIMOTO (1908) [18], wide acceptance of this therapeutic con-
12 KLAPP (1917) [22] cept, despite the fistulation that occurred
Occupational Injuries n. g. BONATESTA (2000) [7] in one patient and resulted in the
removal of the interpositioned alloplas-
Luxations that cannot be repositioned n. g. FINK (1910) [13],
n. g. AXHAUSEN (1925) [2] tic material35. Early postoperative func-
tional TMJ exercise9, today considered
Total (without n. g.) 100 an essential therapeutic element, played
n. g. not given. no role in this treatment35. Modifications

Table 3. Overview of the complications of mandibular resection including exarticulation.
Complications of mandibular resection with exarticulation
Early complications
Chewing disorders
Dysphagia
Insufficient fixation of the tongue
causing it to sink back
Speech disorders
Increased flow of saliva from the corners of
the mouth (oral continence compromised)
Mild aesthetic impairment
Late Complications
Opening of the mouth severely restricted
High-grade dislocation of mandible
Pain in the residual TMJ
Impaction of the tongue
Ulcers of the palate and gingival
Maxillary deformation
Severe aesthetic impairment
of the implant material (magnesium45,
gutta-percha5, ivory38) as well as body
tissues such as myofascial flaps obtained
from the temporal muscle33,38 and fatty
tissue33 were used to minimize potential
TMJ Replacement before 1945 303
tion of tantalum foil for the prevention
Source of relapses after ankylosis-related resec-
tion of the TMJ condyle in children 10
BÖNNECKEN (1893) [6] (Table 4). Dingman abandoned all lining
SCHRÖDER (1901) [52] of the joint socket and favoured the idea
SCHLÖSSMANN (1905) [51] of inducing a large blood clot on account
PERTHES (1907) [41] of its connective tissue structure8.
HASHIMOTO (1908) [18] The literature is confined largely
BILLING (1910) [4] to individual case reports with short
NYSTRÖM (1912) [34] follow-ups. Functional outcomes after
BÖNNECKEN (1893) [6] interposition of alloplastic material
SCHRÖDER (1901) [52]
obtained at that time cannot be assessed
SCHLÖSSMANN (1905) [51]
PERTHES (1907) [41] reliably. Interpositional arthroplasty,
HASHIMOTO (1908) [18] introduced more than 100 years ago in
BILLING (1910) [4] surgical ankylosis management, is still
NYSTRÖM (1912) [34] recommended for the prevention of rean-
SCHRÖDER (1901) [52] kylosation, in major and medially
SCHLÖSSMANN (1905) [51] located disc perforation, in rheumatoid
PERTHES (1907) [41] arthritis and in the context of painful
BÖNNECKEN (1893) [6] chronic synovitis associated with treat-
SCHRÖDER (1901) [52] ment refractory chronic rheumatoid
SCHLÖSSMANN (1905) [51]
arthritis43,44.
PERTHES (1907) [41]
HASHIMOTO (1908) [18]
BILLING (1910) [4] Resection dressing
NYSTRÖM (1912) [34]
BÖNNECKEN (1893) [6] Resection dressings were introduced in the
SCHRÖDER (1901) [52] late 19th century by the German or Berlin
SCHLÖSSMANN (1905) [51] School and were mainly affected by BÖN-
PERTHES (1907) [41] 27
NECKEN, HAHL and SAUER . These dres-
HASHIMOTO (1908) [18] sings should counter scar contraction
BILLING (1910) [4]
following partial jaw resection and fix
NYSTRÖM (1912) [34]
SCHRÖDER (1901) [52] the remaining jaw in its physiological
SCHLÖSSMANN (1905) [51] position. After successful wound healing
the resection dressing was replaced or
supplemented by a definite prosthesis6,48.
HASHIMOTO (1908) [18]
In many cases this did not include the
BÖNNECKEN (1893) [6]
SCHRÖDER (1901) [52] restoration of the ascending mandibular
PECKERT (1905) [40] ramus32 to prevent any contact of fresh
SCHLÖSSMANN (1905) [51] wounds with an immediately implanted
PERTHES (1907) [41] foreign body32.
HASHIMOTO (1908) [18] In 1883 Sauer combined resection dres-
NYSTRÖM (1912) [34] sings with a metal plate at an inclined
NYSTRÖM (1912) [34] plane (Fig. 1a), which was fixed to the
BÖNNECKEN (1893) [6] teeth of the residual jaw17. This inclined
SCHRÖDER (1901) [52] plane would slide along the maxillary
SCHLÖSSMANN (1905) [51]
teeth during occlusion movements guiding
PERTHES (1907) [41]
HASHIMOTO (1908) [18] the residual jaw into its anatomically cor-
BÖNNECKEN (1893) [6] rect position16 (Table 4). In an edentulous
SCHRÖDER (1901) [52] jaw, the inclined plane was anchored in the
PERTHES (1907) [41] bone itself6,17. Trying to preserve the peri-
BÖNNECKEN (1893) [6] osteum, if possible31, the bony mandibular
SCHRÖDER (1901) [52] defect was regularly packed with iodo-
SCHLÖSSMANN (1905) [51] form gauze over a period of several
PERTHES (1907) [41] months. The wire splint allowed regular
HASHIMOTO (1908) [18]
wound hygiene, but was unable to support
NYSTRÖM (1912) [34]
soft tissues41,54.
HAHL replaced the wire splint of
SAUER’s resection dressing by natural rub-
ber in which the remaining teeth were
foreign body reactions (Table 4). Apart embedded in a perfect fit for retentive
from the material used, the volume of anchoring and which conveyed the outer
the inserted alloplastic implant became shape of the alveolar process (Fig. 1b).
an issue in the middle of the 20th cen- The free-ending cupped rubber base was
tury. Eggers recommended the interposi- designed to provide support to the cheeks
304 Driemel et al.

Table 4. Overview of alloplastic implants following TMJ resection. and preclude direct contact between the
Implantation of foreign material Number alloplastic material and the wound. The
after TMJ resection of cases Source teeth of the resected mandible were
Interposition of foreign material moulded from white natural rubber17,24,32.
Metal plate n. g. RIDSON (1934) [45] Cooperation between surgeons and den-
Gold-coated metal plate 3 ORLOW (1903) [35] tists for optimal rehabilitation41 could be
Magnesium n. g. RIDSON (1934) [45] so problematic that it was sometimes
Gutta-percha n. g. BLAIR (1914) [5] avoided. Garré introduced a piano wire
Ivory plate n. g. PARTSCH (1932) [38] loop, the bent section of which rested in
Tantalum foil 1 EGGERS (1946) [10] the fossa while its two ends were attached
Resection dressings to the resected mandible; it was designed
Resection dressing after Sauer 2 BÖNNECKEN (1893) [6] to allow surgeons to work independently
1 KÖRNER (1894) [26] from dentists27.
n. g. SCHLATTER (1895) [49]
n. g. HAHL (1897) [16]
n. g. FRITZSCHE (1901) [14]
1 HAHL (1901) [17] Prostheses for the reconstruction of
n. g. SCHLÖSSMANN (1905) [51] the mandible including the condyle
n. g. KÖNIG (1907) [24]
n. g. PERTHES (1907) [41] Towards the end of the 19th century and
3 KOHEN-BARANOWA at the turn of the century, the French
(1908) [27] School or ‘Lyon School’ founded by
n. g. MÖHRING (1915) [32] Martin was considered to be (together
n. g. PARTSCH (1917) [37] with the German School) the world lea-
n. g. SCHRÖDER (1921) [54] der in alloplastic TMJ replacement. Its
Resection dressing after Hahl n. g. HAHL (1901) [17] protagonists favoured primary recon-
n. g. KÖNIG (1907) [24] struction with prostheses made from nat-
n. g. KOHEN-BARANOWA (1908) [27]
ural rubber, which were fitted by dentists
1 MÖHRING (1915) [32]
n. g. SCHRÖDER (1921) [54] on a patient-by-patient basis, and were
Piano wiring after Garré n. g. KÖNIG (1907) [24] attached to the teeth using clips or were
n. g. KOHEN-BARANOWA screwed to the resection stump16,27,31,32
(1908) [27] (Fig. 2a). This so-called immediate
n. g. PARTSCH (1917) [37] prosthesis, first implanted by Martin in
Prostheses for mandibular reconstruction including the condyle 187814, was designed to support the
Prosthesis after Martin n. g. BÖNNECKEN (1893) [6] adjacent soft tissue immediately on
1 MARTIN (1893) [31] resection and counter postoperative scar
n. g. SCHLATTER (1895) [49] contraction and deformation of the
n. g. PARTSCH (1897) [36] wound area32. Cleansing of wound sur-
n. g. FRITZSCHE (1901) [14] faces was achieved by an integrated tube
n. g. SCHRÖDER (1901) [52] system that was flushed with antiseptic
n. g. SCHLÖSSMANN (1905) [51] irrigation solutions at 1–2-hour inter-
n. g. KÖNIG (1907) [24]
vals51.
n. g. PERTHES (1907) [41]
2 KOHEN-BARANOWA (1908) [27] In Germany, SCHRÖDER was considered
n. g. MÖHRING (1915) [32] the pioneer of immediate prostheses12.
n. g. PARTSCH (1917) [37] Natural rubber turns porous when sub-
n. g. SCHRÖDER (1921) [54] jected to sterilisation, so he used hard
Prosthesis after Schröder n. g. PECKERT (1905) [40] rubber for the immediate prosthesis he
n. g. SCHRÖDER (1905) [53] designed and reduced its weight by mak-
1 KÖNIG (1907) [24] ing it hollow54 (Fig. 2b and c). In view of
2 KÖNIG (1908) [25] the frequently observed granulating
n. g. KOHEN-BARANOWA inflammation in the joint fossa region,
(1908) [27]
Partsch substituted the hard rubber con-
2 RIEGNER (1911) [46]
3 MÖHRING (1915) [32] dyle of SCHRÖDER’s immediate prosthesis
n. g. PARTSCH (1917) [37] with a glass body37.
n. g. SCHRÖDER (1921) [54] The immediate prosthesis, according to
Prosthesis after Stoppany 1 FRITZSCHE (1901) [14] Stoppany, initially served as a replace-
n. g. PECKERT (1905) [40] ment for the body of the mandible. It
n. g. SCHLÖSSMANN (1905) [51] consisted of an aluminium splint that only
n. g. KÖNIG (1907) [24] reconstructed the vestibular part of the
n. g. PERTHES (1907) [41] resected jaw and was packed lingually
1 KOHEN-BARANOWA
with iodoform gauze56. Additional recon-
(1908) [27]
n. g. MÖHRING (1915) [32] struction of the TMJ condyle became pos-
n. g. PARTSCH (1917) [37] sible when SCHRÖDER succeeded in
n. g. SCHRÖDER (1921) [54] soldering a tin condyle to the aluminium
splint32.
 TMJ Replacement before 1945 305

Table 4 (Continued ) The difficult wound and relapse control

Implantation of foreign material
after TMJ resection
Tin splinting after Fritzsche
Celluloid prosthesis after Berndt
Ivory prosthesis
Total number (without n. g.)
Fig. 1. Resection dressings. (a) Resection dressing, after Sauer, made from metal with inclined
plane. (b) Resection dressing, after Hahl, made from natural rubber in two colours, with inclined
plane.
Number that was criticized by advocates of resec-
of cases Source tion dressings6 inspired FRITZSCHE to
n. g. FRITZSCHE (1901) [14] develop a removable immediate prosthe-
1 KÜHNS (1904) [28] sis. Prior to surgery, the surgeon defined
2 SCHLÖSSMANN (1905) [51] on a model jaw the mandibular section to
n. g. KÖNIG (1907) [24] be resected and a dentist cast this section
n. g. PERTHES (1907) [41] in tin. The immediate prosthesis was fixed
n. g. KOHEN-BARANOWA (1908) [27]
n. g. PARTSCH (1917) [37]
to the residual jaw with splint support that
4 BERNDT (1898) [3] permitted removal of the immediate pros-
n. g FRITZSCHE (1901) [14] thesis for wound cleansing14,15 (Fig. 2d).
n. g. SCHLÖSSMANN (1905) [51] All immediate prostheses were intended
n. g. KÖNIG (1907) [24] to be replaced by a definite prosthesis after
n. g. PERTHES (1907) [41] wound healing14,39. These prostheses took
n. g. MÖHRING (1915) [32] into consideration intraoral aesthetic
n. g. PARTSCH (1917) [37] aspects and could be inserted or removed
1 KÖNIG (1908) [25] by the patient41.
1 SUDECK (1909) [57]
Unlike immediate prostheses, the
n. g. MÖHRING (1915) [32]
n. g. PARTSCH (1917) [37] rarely used implant prostheses provided
immediate definite reconstruction of the
34 mandible including the condyle and no
subsequent replacement by a definite
prostheses was required41. BERNDT was
an early supporter of implant prostheses.
Because of its good sterilisation proper-
ties, its light weight and easy handling in
the restoration of bony defects he
implanted a celluloid ring after exarticu-
lation3. The main criticisms of it were the
absence of fixation to the residual jaw25,41
and foreign body reactions involving fis-
tulation32,41,51. These points led KÖNIG
and ROLOFF to design an implant prosthe-
sis made from ivory, which was anchored
in the spongy bone of the mandibular
stump with a spike (Fig. 2e). Despite
the good initial stability of this junction
of bone and ivory spike25, stability was
lost later on and the prostheses were
removed frequently42.

Fig. 2. Immediate prostheses for the primary reconstruction of the mandible including the condyle. (a) Immediate prosthesis, after Martin, made from
natural rubber with integrated tube system for postoperative irrigation of wound surfaces. (b) Immediate hard rubber prosthesis, after Schröder, for
surgical management after hemimandibulectomy. (c) Fluted immediate prosthesis, after Schröder, made from hard rubber for prosthetic care after total
mandibulectomy. (d) Tin splinting, after Fritzsche, with splint support alowing the removal of the immediate prosthesis for wound cleansing. (e) Ivory
implant prosthesis, after König and Roloff, with a spike to allow the prosthesis to be anchored in the spongy bone of the residual mandible.
306 Driemel et al.
Conclusions
 Up to 1945 improvement of alloplastic
TMJ reconstruction was mainly
achieved by scientific curiosity and
the creativity of several German and
French physicians
 The different regimes concentrated on
condyle replacement only
 The replaced condyle countered the
functional and aesthetic impairments
the patients experienced due to scar
contraction. The functional role of the
TMJ in the orofacial system was
neglected
 Sterilisation, biocompatibility and fixa-
tion of the implants were the main
issues in alloplastic replacement
 Interpositioning of alloplastic implants
was introduced more than 100 years ago
for the treatment and prevention of
recurrent ankylosis, and is still advo-
cated for this reason.
 Surgical resection dressings and
immediate, implant or definite pros-
theses were used in ablative tumour
surgery, for the management of war
and occupational diseases, and in the
pre-antibiotic age after extensive resec-
tion of the mandible due to acute
inflammatory changes
 Alloplastic TMJ replacement was
described mainly in individual case
reports. Follow-ups were short and
did not include standardized parameters
for functional and aesthetic results.
Actual outcomes of reconstruction at
that time can only be presumed
 Close cooperation between surgeons
and dentists in TMJ reconstruction
was preferred and underlines the impor-
tance of oromaxillofacial surgery as a
link between those disciplines
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Corresponding author. Address:
Oliver Driemel
Klinik und Poliklinik für Mund-
Kiefer- und Gesichtschirurgie
Klinikum der Universität Regensburg
Franz-Josef-Strauß-Allee 11
D-93053 Regensburg
Germany
Tel. +49 941 9446337
Fax: +49 941 9446302
E-mail: oliver.driemel@klinik.uni-regens-
burg.de