We have put together the following information on temporomandibular (jaw) implant devices. The TMJ Association, Ltd. does not endorse any device or manufacturer. We are presenting this for informational purposes only. We would urge extreme caution and careful consideration in making the decision to obtain a TMJ implant device.
Replacement of the temporomandibular joint with an artificial implant should be considered a last resort. When used in patients who have had multiple prior jaw surgeries, it may improve function, but studies have shown that it generally does not significantly reduce pain. Before undergoing such surgery on the jaw joint, it is extremely important to get other independent opinions and to fully understand the benefits and risks.
Select a TMJ manufacture/device from the list below for specific information pertaining to that implant device.
February 2005 In the Dow Corning litigation, the deadline for opt out claimants to complete their fact sheet discovery was February 28, 2005.
March 2003 Those who had Dow Corning Silicone products, as well as Vitek, implanted into the temporomandibular joint have been eligible to be included in the Dow Corning Bankruptcy Settlement. Mr. Mitchell Toups, representing many TMJ implant patients, informed us the claim process has begun. Clients should get all their medical records that will be needed for processing the claims. For further information, Mr. Toups can be reached at 1-800-835-0019.
August 2004 The TMJ Association contacted the FDA regarding the use of Silastic in the TMJ after learning that some doctors are still implanting this material in the TMJ. We were told by the FDA that if a surgeon implants any silicone material into a jaw joint the surgeon is using it "off label" and according the "practice of Medicine." This simply means, the surgeon is practicing without FDA or manufacturers recommendation for use.
In 1999 the FDA called for PMAs (pre-market approvals) on all TMJ devices. Pre-market approval documents contain testing and clinical data on safety and efficacy of a product. Not one silicone manufacturer submitted a PMA on Silastic sheeting to be used in the TMJoint. Therefore, FDA has not approved any company's silicone products for use in the TM joint.
As of January 1993, Dow Corning discontinued the sale of all Silastic TMJ implants. (Read letter from Dow Corning). Dow has since instructed customers to inform patients who received Silastic implants of the risks and benefits of removing the implant or leaving it in. If a patient decides to leave a Silastic disc in, he or she should be followed regularly with appropriate imaging and evaluation of symptoms. Dow further states that the temporary Silastic implant (Wilkes Design) should have been removed, and patients with silicone sheeting used in custom TMJ devices should be monitored regularly. Although Dow Corning has apparently bowed out of the TMJ device market, there are other silicone products manufacturers.
Dr. Lappe describes the development of Silastic and other implant materials for the TMJ as "marked by a pattern of haphazard development, entrepreneuralism, unverified assertions in the absence of animal testing, and a silent FDA. In 1992, he states, "we are left with no truly suitable implant material, in part because the most commonly used one - Silastic brand reinforced sheeting - was only belatedly subjected to testing. And then, it was found to be deficient for just the properties which were known to its manufacturer fully twenty years earlier."
In 1991, when sheep studies were conducted, severe bony destruction and foreign body giant cell reaction were found. Finally, after 20 years of use, it was decided that Silastic isn't appropriate for long-term use and that even short-term use is highly experimental.
As late as 1989, there was not one long-term study of the use of Silastic in animals or humans. As a matter of fact, a single study in 1965 "served as the principal impetus to encourage the marketing of Silastic sheeting for this new and untested purpose."
A 1986 article reported "fragmentation, perforation, and deterioration of the (Silastic) material." And another stated, "silicone may not be a totally inert material and that its biomechanical properties are not ideal for use in the TMJ." By the end of the 1980s, enough failures had occurred for some researchers to call for strict limits on the use of Silastic.
The Wilkes Design, marketed in 1985, had "tabs" to allow for easy removal.
A 1982 study warned doctors that particle migration meant they should be alerted to possible systemic reactions and foreign body synovitis, speeding failure.
Short-term studies in the early Seventies looked good. Reports after one to five years, however, showed substantial problems, including ankylosis, arthritis, and lymph node swelling.
Introduced in the mid-Sixties, was a Silastic block, or silicone rubber, carved to shape. Another was Silastic HP Sheeting, which was reinforced with Dacron. Although designed for temporary use, many surgeons leave these implants in the joints for an indefinite period of time.
July 2003 The FDA has issued a warning letter to Dr. James Yanney, a Hoffman-Pappas TMJ implant clinical investigator.
The Endotec or Hoffman-Pappas Temporomandibular Joint Replacement System is a custom TMJ prosthesis being used at approximately ten hospital centers in this country for clinical trials. The FDA has given the company an Investigational Device Exemption #G97OO92, as part of the approval process.
The Hoffman-Pappas prosthesis ("joint") has been co-developed by an oral and maxillofacial surgeon, Dr. David Hoffman, and a well-known biomedical engineer, Dr. Michael Pappas. Dr. Pappas is responsible for the development of a number of other prosthetic joint replacement systems for the hips and knees used throughout the world.
The Hoffman-Pappas joint is a custom-made prosthesis that is built from data obtained from a CAT Scan of a patient's skull. The joint is designed and fabricated on CAD CAM Systems and is fitted to a replica of the patient's skull. Any changes in the patient's occlusion, jaw position or abnormal anatomy can be accommodated at the design level and can be checked at the construction level.
The three basic materials used are titanium, high molecular weight polyethylene and titanium-nitride (a thin layer ceramic). These are the same materials used for prosthetic joints made for other parts of the body. The prosthesis is divided into three components as follows:
The condyle is made of titanium. Its outer surface is chemically changed to a coating of titanium nitride, a material that is extremely hard and has been tested extensively for its wear properties in prosthetic joints. The high molecular weight polyethylene insert is a standard material used in all articulating surfaces for joint reconstruction. The metal fossa is made of pure titanium.
The fossa and condylar components are screwed into position against the skull and the lateral side of the mandible respectively. The fossa component obtains most of its stability through its custom fit and is secured in place using three or four small 2mm screws. The condylar component obtains its stability from two types of screws, three of which are specialized microlocking screws that avoids any type of micromovement of the prosthesis or movement of the screw against the metal. This is a unique feature of this joint. The screw holes are all designed to be placed in the maximum amount of bone avoiding contact of underlying structures, such as nerves or blood vessels.
The prosthesis is placed through two incisions, one in front of the ear approximately one and a half to two inches long and the second incision along the lateral side of the neck below the angle of the jaw, approximately two inches long. The standard hospitalization for the procedure is usually two days.
Patients are seen on a routine outpatient basis after surgery and may regain function of their jaw within a short period of time after surgery. There is no intermaxillary fixation or wiring of the teeth together after surgery. Patients should allow approximately two weeks of nonworking and a two to three month period of continuous passive motion machines and/or physical therapy.
The study has been ongoing for one year. Long-term follow up studies lasting up to three years have been conducted with prototypes. Overall results are very promising. There have been no surgical failures to date.
Indications for this prosthesis follows guidelines presented by the American Association of Oral and Maxillofacial Surgeons and the American Academy of Orofacial Pain. The indications generally consist of previous failed surgeries, underlying rheumatological or severe osteoarthritic diseases, significant traumatic injuries or failed alloplastic implants.
May 2006 To date we are unaware of any FDA warning letters issued to TMJ Concepts Inc.
December 2000 We have received a letter from Dr. Louis Mercuri, clinical scientist for TMJ Concepts, asking our assistance in contacting patients who have received the Techmedica total joint device. (The Techmedica Company manufactured TMJ total joint devices from January 1989 through September 1993 and TMJ Concepts has been producing them since December 1997.) Dr. Mercuri is attempting to contact as many Techmedica patients as possible, which have not reported for follow-up, in order to collect long-term data. If you are one of these patients, Dr. Mercuri asks that you contact your surgeon, TMJ Concepts (formerly Techmedica) at 800-504-9527 - www.tmjconcepts.com, or Dr. Mercuri at 708-216-6907.
The TMJ Association is encouraged that TMJ Concepts is making an effort to retrieve the Techmedica patients lost to follow-up. It is only through information provided from a comprehensive database that current and future TMJ implant patients can make informed health care decisions. The Association will cooperate with other TMJ manufacturers in their attempts to contact patients who have been lost to follow-up.
The FDA has posted the May 10, 1999 Dental Products Panel meeting transcript on their website, http://www.fda.gov/ohrms/dockets/ac/99/transcpt/3514t1.rtf.
January 31, 2012 - 180-Day TMJ Fossa-Eminence Prosthesis SystemTMJ Medical, Golden, CO. Approval for labeling changes to update the owner and company name, manufacturing suite, standardization of the product names, and adverse events section related to completion of the post-approval study.
September 30, 2010 TMJ Implants, Inc is acquired by Crocker Ventures.
October 27, 2009 FDA Wins Court Case Against TMJ Implants, Inc. — Manufacturer to Pay $340,000 in Civil Money Penalties
The United States Court of Appeals Tenth Circuit ruled in favor of the FDA in a civil money penalties case against TMJ implant device manufacturer, TMJ Implants, Inc. and President, Dr. Robert W. Christensen, for failure to submit 17 medical device reports. Click here to read the article that appeared in FDA Law Blog.
The following information is taken from the October 27, 2009 United States Court of Appeals document:
Dr. Christensen offered to file the required MDRs if FDA promised to drop the Civil Money Penalties of $340,000. The judges state:
December 20, 2006 The FDA issued a warning letter to TMJ Implants, Inc. concerning the promotion of hemi and full mandibles without premarket clearance or approval from the FDA. TMJ Implants, Inc.'s response to the warning letter is also posted on the FDA's site.
July 14, 2005 The Food and Drug Administration (FDA), along with the Center for Devices and Radiological Health (CDRH) and the United States Department of Health and Human Services, has filed an administrative complaint against TMJ Implants, Inc., manufacturer of the Christensen implant. Also named in the complaint are Robert Christensen, President of TMJ Implants, Inc., and Maureen Mooney, Regulatory Affairs and Quality Assurance Manager of TMJ Implants, Inc. The complaint alleges that TMJ Implants, Inc., violated an FDA regulation that requires "a medical device manufacturer file a medical device report (MDR) whenever the manufacturer becomes aware of deaths and serious injuries which the manufacturer's device has caused or may have caused or to which the device has contributed or may have contributed." According to the FDA, TMJ Implants, Inc., failed to file MDRs between October 22, 2002 and July 10, 2003. "[The] FDA routinely inspects medical device manufacturers to determine their compliance with Food, Drug and Cosmetic Act requirements and monitors adverse event reporting systems such as MedWatch, through which consumers and physicians report deaths, serious injuries, or other adverse effects which a medical device has caused or may have caused or to which the device has contributed or may have contributed." During an inspection in July and August of 2003, the FDA collected complaint reports received by TMJ Implants, Inc., which "describe MDR reportable events." The FDA is seeking a civil penalty of $10,000 for each of the twenty-one MDR violations listed in the complaint, $210,000 for TMJ Implants, Inc., and $210,000 each for Robert Christensen and Maureen Mooney. The complaint is currently in the discovery stage. The following is a Web link to the FDA complaint, FDA Docket No: 2005H-0271.
March 2001 TMJ Implants, Inc. is asking our assistance in contacting patients lost to follow-up. It is only through information derived from a comprehensive database, that current and future TMJ implant patients can make informed health care decisions. If you have been lost to follow-up, please contact TMJ Implants, Inc., Registry/IDE Study, 17301 West Colfax Avenue, Suite 135, Golden, CO 80401. E-mail: email@example.com Telephone: 1-800-825-4TMJ.
February 27, 2001 The FDA approved the Christensen Fossa-Eminence partial temporomandibular joint. The FDA included product labeling which the patient and the surgeon will share the risk responsibility. This single step has led to the joints return to the market. According to Dickinson FDAWebview "… this approval is the first in 25 years where the agency (The FDA) stepped back from its "appropriate use" worries and left them to physicians and patients to decide, based on full disclosure in labeling of the device's real-world limitations - including the availability of no-device alternative therapies". An Editorial in the Journal of Oral Maxilofacial Surgery written by Dr. Daniel Laskin entitled "Shifting the Responsibility for Medical Decisions" references the February article posted on Dickinson's FDA Webview. The FDA issued the Approval Order, Summary of Safety and Effectiveness, and Labeling for TMJ Implant Inc.'s (Christensen) Fossa-Eminence partial temporomandibular joint. Please view the FDA's Web site to view these documents. http://www.accessdata.fda.gov/cdrh_docs/pdf/P000035b.pdf.
January 5, 2001 The FDA issued the Approval Order, Summary of Safety and Effectiveness, and Labeling for TMJ Implant Inc.'s (Christensen) all metal total joint device.
September 2000 The FDA has issued a warning letter to TMJ implants, Inc.
On October 6, 2000 at a meeting of the Dental Products Advisory Panel to the FDA, Panel members voted unanimously to "not approve" the partial joint prosthesis. The Panel believed that the safety and effectiveness data for the device were inadequate. In addition, the panel believed that the indications for use needed to be clarified. (See p. 17)
As stated on p.18, "The FDA considered and concurred with the Panel's concerns about the prospective and retrospective studies…. [The] FDA balanced the scientific concerns related to the limited clinical data with the knowledge that there appears to be a group of patients, albeit poorly defined, for whom this device seems to provide a reasonable treatment option."
The following was presented by The TMJ Association at the October 6 2000 panel hearing. FDA Dental Products Meeting of the Medical Device Advisory Committee - Open Session .
The TMJ Association is sufficiently concerned about the FDA's approval of the device in spite of the unanimous opinion of its advisory panel that we have petitioned the agency to hold a public hearing to reconsider the FDA decision. On August 12, 2002, we received a letter from the FDA, denying the petition of The TMJ Association. Though disappointed, we were not surprised by FDA's decision. We will continue to press for scientific evidence of safety and effectiveness of TMJ devices and other treatments that are recommended to TMJ patients.
On Friday, October 6, 2000 the Food and Drug Administration (FDA) Dental Products Panel voted unanimously that the TMJ Implants, Inc. (also known as the Christensen) fossa eminence prosthesis was not approvable. Concerns were raised regarding the indications for use. The applicant's clinical study included over 81% of the patients with a diagnosis of internal derangement. The panel expressed concerns about this clinical study and requested further data to substantiate safety and efficacy. The sponsors did not provide any testing data demonstrating the effect of the metal eminence on the natural mandibular condyle. Final disposition of the recommendation awaits FDA's decision.
The FDA has posted the October 6, 2000 Dental Products Panel Meeting transcript on their Web site, http://www.fda.gov/ohrms/dockets/ac/00/transcripts/3655t1.pdf.
The FDA is proceeding with approval of the metal on metal total joint replacement system. Of interest is the fact that labeling states that the fatigue-limit is 130 pounds. Labeling further states that, surgeons who recommend this device should take into consideration the patient's oral habits such as bruxing or grinding which may increase the joint loads.
We have been advised that as of May 8, 2000 there is no Pre-Market Approval document (PMA) on any device manufactured by TMJ Implants, Inc. (commonly referred to as the Christensen) under active review by the Food and Drug Administration. The devices include the stock or "off the self" TMJ condylar prosthesis with, either a cast cobalt chromium head or polymethylmethacrylate (PMMA) condylar head, the patient-specific all metal custom device and the fossa eminence prosthesis. These devices are not legally marketable. Some of these devices may be utilized under the rules of an investigational device exemption application.
On May 11, 1999 the Dental Products Advisory Panel evaluated the Pre-Market Approval Application (PMA) for temporomandibular joint implants manufactured by TMJ Implants, Inc. On August 10, 1999 the agency granted the company a public health need status for the TMJ Implants Inc. fossa eminence prosthesis for meniscal perforation only. This means the company may continue to market the fossa eminence prosthesis for this indication. At the present time, the portion of the PMA concerning the fossa eminence for the above indication remains under review. The FDA has posted the May 11, 1999 Dental Products Panel meeting transcript on their Web site, http://www.fda.gov/ohrms/dockets/ac/99/transcpt/3514t2.pdf.
Further information from FDA regarding the status of TMJ Implants Inc.'s PMA is considered confidential.
The other devices included in TMJ Implants, Inc.'s PMA are: The TMJ Condylar prosthesis available with either a cast cobalt chromium head or a polymethylmethacrylate (PMMA) condylar head and a patient-specific (all metal custom) device.
According to FDA law when a PMA is past 180 days the device cannot be legally marketed.
No information has been received from this organization. The Temporomandibular Research Foundation did not respond to the 1999 FDA request for Pre-market Approvals (PMA) for all TMJ devices. These devices have not been evaluated by the FDA and are not being marketed.
September 12, 2007 An Ontario Superior Court judge allowed a class-action lawsuit to go-ahead against the Canadian federal government over jaw implants. The lawsuit specifically alleges the Health Canada employees negligently approved the Vitek TMJ Implants under the Food and Drugs Act, and that they failed to warn doctors and patients of the potential risks. The class action was certified by the Kathryn Taylor case.
January, 2006 The U.S. Environmental Protection Agency (EPA) plans to list a toxic chemical, PFOA, used to make Teflon to its list of well-known pollutants. Over the years TMJ implant patients have received Vitek implants which contain Teflon and have reported many health problems to us. The TMJ Association is in communication with the EPA about this issue and will continue to keep patients updated via our website.
June, 2005 The Food and Drug Administration (FDA) released a CD-ROM with over 800 pages of Vitek, Inc. implant-related documents, including FDA correspondence. You may request a copy of the CD-ROM through the Freedom of Information (FOI) Act by writing to: Mr. Patrick Kaelin, Food and Drug Administration, 4040 N. Central Expressway, Dallas, TX 75204. Please note there is a charge of $9.00 + shipping and handling.
2004 In the LSU/Kent litigation involving the Vitek, INc. TMJ implant, the Court ruled in late 2004 that the class action could not proceed under various legal defenses raised by the defendants. Therefore, it appears that a class action approach is no longer a viable option for anyone who did not file an individual claim before 2001.
September, 1991 the FDA publishes the following safety alert letters:
In January 7, 1991 the FDA issued a class one recall of jaw implants manufactured by Vitek, Inc.
In December 1990 the FDA issued a "Public Health Advisory on Vitek Proplast TMJ Implants" to oral & maxiofacial surgeons warning of complications associated with Proplast-Teflon. The surgeons were advised to examine their patients every 6 months with an appropriate radiographic (imaging) exam, for as long as the implants remained in place. They were told that if the exam shows signs of deterioration, the implant should be removed as soon as possible.
In March 1990, because of an increasing number of reports of implant failure, the Food & Drug Administration (FDA) recalled Vitek's Interpositional Implants (IPIs). Several months later Vitek declared bankruptcy. Subsequently, Dr. Charles Homsy, the president of Vitek, Inc. fled the United States. Vitek continued to market their TMJ implants under subsidiary companies. Surgeons still used them until eventually the FDA seized all products from Vitek as well as its subsidiaries.
At the 1986 meeting of the American Association of Oral and Maxillofacial Surgeons (AAOMS), several surgeons reported catastrophic biomechanical failure of the IPI that caused a giant cell reaction, leading to bone resorption and pain. A summary of the literature from 1986 to 1991 reported a failure rate of 10 to 25 percent. By 1992, a success rate of less than 20 percent was being reported.
Only after reports of failure began appearing in 1984, were animal studies conducted on dogs. The results were "essentially catastrophic," according to a 1990 deposition that Dr. Jack Kent, a Vitek consultant who owned 21,000 shares in the company, gave in an Arizona court case against Vitek. After just a few months, the Teflon layer was "completely worn," and Teflon particles had triggered bone erosion in the dogs. Dr. Kent wrote a letter to Dr. Homsy in early 1984 expressing his concern that, based on his experience with one of his patients, Vitek might have a "calamity of unbelievable proportions on our hands. "This did not, however, deter Dr. Kent from continuing to write articles praising the Vitek implants, and it certainly did not stop him from collecting his royalties.
In 1983 the FDA allowed Vitek to market a pre-cut disc. Under the law, the company's president, Charles Homsy, merely had to convince the Food and Drug Administration (FDA) that the device was "substantially equivalent" to Dow Corning's Silastic disc, marketed years earlier.
In the 70's, Vitek developed and sold Proplast Sheeting (Teflon FEP film, laminated to a porous composite material made from polytetrafluoroethylene (PTFE) and carbon). The implant was modified in the early 80's, and Teflon film was then laminated to PTFE and aluminum oxide. These implants, usually no larger than a thumbnail, were manufactured individually or custom cut from sheets in the operating room by the surgeon and then sutured to the fossa or condyle. Many people with Silastic and Proplast-Teflon implants experienced problems shortly after implantation.
January 2003 The FDA has issued a warning letter to Dr. Douglas Sinn, a Walter Lorenz TMJ implant clinical investigator.
August 22, 2002 dental products panel hearing on August 22, 2002 to vote on a pre-market approval application for the Walter Lorenz Surgical device. The Panel unanimously voted that P020016 be found approvable with conditions.
The FDA has posted the August 22, 2002 Dental Products Panel meeting transcript on their website, http://www.fda.gov/ohrms/dockets/ac/02/transcripts/3889t1.pdf.
June of 1995 an FDA-approved (IDE #G940177) clinical study utilizing a total temporomandibular joint prosthesis developed by Biomet-Lorenz began. The first patient was enrolled in June of 1995 at the Hospital of the University of Pennsylvania. Peter D. Quinn, DMD, MD, Chairman of Oral and Maxillofacial Surgery at the University of Pennsylvania served as the clinical investigator. In April of 1998, a second clinical site for this study was initiated at the University of Texas Southwestern Medical School with Douglas Sinn, DDS, Chairman of the Department of Oral and Maxillofacial Surgery serving as the clinical investigator at that institution.
To date, approximately 112 cases are being followed at intervals of one month, three months, six months, one year, 1.5 years, and annually thereafter. The prosthesis is a stock prosthesis with a fossa component of ultra-high weight polyethylene and a condylar prosthesis made of cobalt-chrome alloy.
The most current three-year data on the implants placed at the University of Pennsylvania has been recently published in the February 2000 issue of the Oral and Maxillofacial Surgery Clinics of North America (pages 93-103).
The TMJ Association, Ltd. again states this is presented solely as an informational guide. We are presenting this information in response to the many questions we receive asking us for the specifications of the available devices. The TMJ Association does not endorse any specific prosthetic device for use in the TM joint. The TMJ Association does not endorse any of the devices of the companies listed.
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