Complications associated with different surgical modalities for management of temporomandibular ankylosis in a series of 791 cases

Can growing patients with end-stage TMJ pathology be successfully treated with alloplastic temporomandibular joint reconstruction? - A systematic review

INTRODUCTION

The use of alloplastic total temporomandibular joint reconstruction (TMJR) in growing patients is controversial, mainly due to immature elements of the craniomaxillofacial skeleton. The aim of this systematic review was to evaluate the use of alloplastic TMJR in growing patients, focusing on the patient's clinical presentation, surgical and medical history and efficacy of alloplastic TMJR implantation.

MATERIALS AND METHODS

The literature search strategy was based on the Population, Intervention, Comparator, Outcomes and Study type (PICOS) framework. We searched Pubmed, Google Scholar, Dimension, Web of Science, X-mol, Semantic Scholar and Embase to January 2023, without any restriction on the type of publication reporting alloplastic TMJR in growing patients (age ≤ 18 years for boys and age ≤ 15 years for girls).

RESULTS

A total of 15 studies (case reports: 09, case series: 02, cohort studies: 04) met the inclusion criteria, documenting 73 patients of growing age from 07 countries. Thirty-eight (~ 52%) cases were female. The mean ± SD (range) age and follow-up of patients in all studies was 13.1 ± 3.2 (0-17) years and 34.3 ± 21.5 (7-96) months, respectively. A total of 22 (30%) patients were implanted with bilateral alloplastic TMJR. Over half of the studies (n = 10) were published in the last 3 years. All patients underwent multiple surgeries prior to implantation of alloplastic TMJR. In extreme cases, patients underwent a total of 17 surgeries. Different types of studies reporting inconsistent variables restricted our ability to perform quality assessment measures for evidence building.

CONCLUSIONS

Clinical experience with alloplastic TMJR in growing patients is limited to cases showing poor prognosis with other types of reconstruction. Nevertheless, studies show promising results for the use of alloplastic TMJR in growing patients, highlighting the need for well-controlled prospective studies with long-term follow-up.

Bilateral Lateral Arthroplasty in a Growing Patient for Type III TMJ Ankylosis

A 10 year old male patient reported with a chief complaint of inability to open mouth since 4 years. There was a history of fall from height, following which there was progressive limitation in mouth opening and jaw movements. Clinically there was maximal mouth opening (MMO) of 1-2 mm with restricted protrusive and laterotrusive jaw movements. On radiographic evaluation, there was a bifid condyle appearance which showed a medially displaced condyle along with complete lateral fusion of joint components bilaterally. With a diagnosis of Sawhney's type III ankylosis, lateral arthroplasty was planned under G.A. for both sides. On 2 years follow-up MMO of 30-34 mm was maintained along with unrestricted protrusive and bilateral laterotrusive movements. In this case, we show that the comparatively less invasive treatment plan of lateral arthroplasty involving preservation of medial condylar stump is adequate for the return of TMJ movements to near normalcy.

Autogenous grafts for reconstruction arthroplasty in temporomandibular joint ankylosis: A systematic review and meta-analysis

Autogenous methods for reconstruction arthroplasty (RA) for the surgical management of the temporomandibular joint (TMJ) have been extensively reported. The present review was aimed to systematically review and pool data on clinical outcomes of autogenous grafts for RA in subjects with TMJ ankylosis. Major electronic databases and prominent subject-specific journals were searched up to December 2020. Randomised controlled trials (RCT), cohort studies, and retrospective studies reporting outcomes of autogenous grafts for RA in TMJ ankylosis were included. A total of 35 studies with 700 subjects was included. The most commonly employed grafts were costochondral grafts (CCG) and coronoid process grafts. Postoperative change in maximum incisor opening (MIO) was comparable amongst all grafts and was in the clinically acceptable range (27.21-31.38 mm). The recurrence rate was comparable for all grafts and was ≈ 8% except for coronoid grafts, where the recurrence rate was 2.98%. Growth assessment for CCG revealed that 55.89%, 30.89%, and 13.24% of subjects depicted optimal growth, overgrowth, and undergrowth, respectively. Within the limitations of the present review, the recurrence rate for all grafts was comparable except for coronoid graft, which depicted least recurrence rate and resultant postoperative change in MIO was in the clinically acceptable range.

Sternoclavicular Graft Versus Costochondral Graft In Reconstruction of Ankylosed Temporomandibular Joint

Introduction

The temporo-mandibular joint (TMJ) is a complex anatomical structure that is concerned with mastication, deglutition, and speech. Ankylosis of the TMJ occurs when the condyle gets fused to glenoid fossa by bony or fibrous tissue. It is an incapacitating problem, commonly occurring in children and is usually associated with trauma or infection.

Materials and Methods

A total of ten patients with written informed consent having TMJ ankylosis (unilateral/bilateral) fulfilling the inclusion criteria were selected for the study and were operated under general anaesthesia with arthrectomy followed by reconstruction of ramal condylar unit with SCG (Group I) or CCG (Group II). Pre-operative and post-operative evaluation assessments were done at regular intervals for maximum mouth opening, range of mandibular movements, and height of ramus.

Results

Statistical analysis shows that the increase in maximum mouth opening was found 1.1% higher in Group II (75.9%) as compared to Group I (74.9%). The increase in lateral excursion at affected side was found 1.3% higher in Group I (84.6%) as compared to Group II (83.3%). The increase in lateral excursion at non-affected side was found 10.3% higher in Group I (76.9%) as compared to Group II (66.7%). The increase in protrusive movement was found 17.5% higher in Group II (88.9%) as compared to Group I (71.4%). Six months post-operative height of ramus was found 10.5% higher in Group II as compared to Group I.

Conclusion

The present study concludes the superiority of costochondral graft over sternoclavicular graft in terms of growth and function. Continued deliberation between the two grafts with larger sample size and a longer follow-up with multicentric consensus will be required to draw definitive indications of the two grafts.

Technique of Dual Distraction for Correction of Unilateral Temporomandibular Joint Ankylosis With Facial Asymmetry: A Case Series

PURPOSE

Temporomandibular joint (TMJ) ankylosis, not only results in joint hypomobility, but also causes considerable facial deformity. Its unilateral variant can cause facial asymmetry, leading to major psychosocial effects on the individual.

PATIENTS AND METHODS

We present the cases of 7 patients with unilateral TMJ ankylosis and facial asymmetry of various grades who have been treated using gap arthroplasty and simultaneous dual distraction. Considerable debate has surrounded the sequencing of TMJ release and distraction osteogenesis; however, the simultaneous approach has recently become popular. The use of a single distractor simultaneously with TMJ release has been widely reported. However, one disadvantage with this technique is that the proximal condylar segment remains unstable. Dual distraction is a newer technique which we have proposed as a single-stage approach for the correction of TMJ ankylosis and facial asymmetry and to address the problems resulting from the use of a single distractor.

RESULTS

After treatment, all the patients showed a mouth opening ranging from 35 to 50 mm and satisfactory facial symmetry.

CONCLUSIONS

Dual distraction is a promising technique in the correction of facial asymmetry. However, further studies with adequate statistical analysis and larger sample size are required.

Lateral arthroplasty along with buccal fat pad inter-positioning in the management of Sawhney type III temporomandibular joint ankylosis

Objectives

The objective of this study was to highlight the role of lateral arthroplasty along with interposition of the buccal fat pad (BFP) in the management of Sawhney type III temporomandibular joint (TMJ) ankylosis.

Materials and Methods

Ten patients with TMJ ankylosis (7 unilateral and 3 bilateral, total of 13 joints) were treated with lateral arthroplasty and BFP interposition. The bony bridge of the ankylotic mass on the lateral aspect was resected, leaving a distance of 1.5 to 2.0 cm from the base of the skull to the neck of the condyle. The condyle was left intact. Coronoidectomy was performed on the ipsilateral side via the same approach in all cases. The inter-incisal opening was measured at that time, and if it was less than 35 mm, contralateral coronoidectomy was performed by using the intra-oral approach. After satisfactory inter-incisal mouth opening (≥35 mm) was achieved, the TMJ surgical site was revisited, and BFP was retrieved and used to cover the lateral aspect of the medially placed condyle.

Results

With lateral arthroplasty, the medially displaced condyle can be left in-situ to maintain the mandibular ramal height and function and to act as a growth center in children. Interposition of the BFP prevents reformation of the lateral bony bridge that was removed.

Conclusion

Lateral arthroplasty along with interpositioning of the BFP is a novel technique for managing Sawhney type III ankylosis that achieves management goals while avoiding complex and advanced reconstructive surgical procedures.

Surgical treatment of type III temporomandibular joint ankylosis with a lateral arthroplasty while retaining the medially displaced condyle

INTRODUCTION

We discuss our findings on the retention of the medially displaced residual condyle during the treatment of type III temporomandibular joint ankylosis, as well as the postoperative results observed during follow-up.

MATERIALS AND METHODS

Thirty-two patients with type III temporomandibular joint ankylosis that met the inclusion criteria of the study were included as subjects. The morphological integrity of the medially displaced residual condyle was verified in all of the participating patients through the use of cone beam computed tomography. The duration of the ankylosis ranged from 2 to 12 years. The maximum length that patients were able to open their mouths ranged from 6 mm to 14 mm. The surgical treatments used in this report included the separation of bony fusions between the condyle and the glenoid fossa, resection of the ankylosed sites, preservation of the displaced condyles in their medial position and suturing the remains of the disc to its typical position or taking the temporalis myofascial flap instead. The long-term results were evaluated by computed tomography and clinical follow-up examinations.

RESULTS

Three-year postoperative follow-up examinations were performed for all of the patients included in this study. No recurrences were observed in the patients who adhered to the postoperative therapeutic advice. Patients had an average maximal mouth opening distance of 34.50 ± 5.75 mm as recorded during the final follow-up examination.

CONCLUSIONS

The released medially residual condyle can still function normally in temporomandibular joint movement and without reankylosis after a bone fusion resection. The displaced condyle should thus be preserved instead of being removed during the treatment of type III temporomandibular joint ankylosis.

Silicone vs temporalis fascia interposition in TMJ ankylosis: A comparison

OBJECTIVE

Temporomandibular joint ankylosis (TMJa) is a distressing condition, but can be surgically managed by gap or interpositional arthroplasty, with an aim to restore joint function and prevent re-ankylosis. The aim of this paper is to compare two interposition materials used in management of TMJ ankylosis.

METHODS

15 patients with TMJa were randomly allocated to two groups: group A (n = 6), interposition material used was medical-grade silicon elastomer, and group B (n = 9) where the interposition material used was temporalis fascia. Patients were followed up at regular intervals of 1 and 2 weeks, 1 month, 3 months, and 6 months and were assessed on following parameters: pain by VAS Scale, maximal mouth opening (MMO), implant rejection, and recurrence.

RESULTS

The results showed a loss of 4.6% and 7.9% in maximal interincisal mouth opening at 3rd and 6th months in Group A while Group B had a mean loss of 9% and 10% at 3rd and 6th months respectively without any significant difference. None of our cases showed recurrence or implant rejection.

CONCLUSION

We conclude that silicone is comparable to temporalis fascia in terms of stability, surgical ease, and adaptability. It not only restores the function of mandible and ensures good maximum interincisal opening but also maintains the vertical ramal height. Also, it requires less operating time and is easy to handle but is not economical. It might be an effective way to restore function and prevent re-ankylosis.

Outcome of amniotic membrane as an interpositional arthroplasty of TMJ ankylosis

PURPOSE

Temporomandibular joint ankylosis is a major disorder, mainly due to trauma and other reasons, which is responsible for the restriction of mandibular functional activities. The scope of the successful surgical correction of temporomandibular joint ankylosis with amniotic membrane is on the membrane's being an interpositional material which we found not to elicit any host reaction, is capable of functional adaptation, and is very economical. Our purpose is to show the amniotic membrane as a suitable, biocompatible, and interpositional material alternative to the other materials, thereby reducing donor site morbidity.

METHODS

A study was conducted in 13 patients with an age range of 10 to 35 years with unilateral and bilateral bony TMJ ankylosis confirmed by clinical and radiological evaluations. Preoperative and postoperative clinical assessments of TMJ functions were done. Amniotic membranes were collected from the tissue bank, sterilized by gamma radiation, and freeze-dried. Then, the prepared amniotic cap (10-15 layers of amniotic membrane) was placed over the condylar head and anchored loosely to the neck and the surrounding tissues with a 3/0 Vicryl suture.

RESULTS

Measurements of postoperative maximum interincisal opening was taken with scale among the 13 patients. Preoperative interincisal distances ranged from 0 to 15 mm, and preoperative and immediate postoperative were 33-45 and 25-32 mm, respectively. Postoperative follow-up of interincisal opening after 1-, 6-, and 12-month intervals was found from 32 to 35 mm. Lateral excursions (left and right), protrusive movements, and functional recovery were all satisfactory.

CONCLUSION

Amniotic membrane graft as an interpositional material in temporomandibular joint ankylosis can be a good alternative as to prevent reankylosis and recover functionality.

Management of temporomandibular joint ankylosis type III: lateral arthroplasty as a treatment of choice

Many surgical techniques for the management of temporomandibular joint (TMJ) ankylosis have been described in the literature. The purpose of this study was to report our experience using a lateral arthroplasty technique in the management of type III ankylosis. The records of 15 patients treated for TMJ ankylosis at our institution between 2007 and 2011 were reviewed. Pre- and postoperative information collected included age, gender, aetiology, ankylosis type/classification, existing facial asymmetry, maximum pre- and postoperative mouth opening, complications, and recurrence of ankylosis. The mean maximum inter-incisal opening in the preoperative period was 12.9 mm and in the postoperative period was 36.2mm. No major complication was observed in any patient. No recurrence was noted in any patient. Our working hypothesis was that for patients with ankylosis type III, the medially displaced condyle and disc can fulfil their role in mandibular function and growth after extirpation of the ankylozed mass. Although they are located in an awkward medial position, they should function exactly as they would after a properly treated, displaced condylar fracture.