Piezoelectric osteoarthrectomy for management of ankylosis of the temporomandibular joint

Role of buccal fat pad to reduce the chances of re-ankylosis-A systematic review of literature

The role of buccal fat pad (BFP) as interpositional material in the temporomandibular joint ankylosis (TMJA) have been well documented. The purpose of the present systematic review is to reinforce the role of buccal fat pad as interpositional material in preventing re-ankylosis. A systematic search was conducted in PubMed, Google Scholar, Semantic scholar and Cochrane library database from 1980 to 2022 following the PRISMA guidelines. The studies using BFP as interpositional material in TMJA with more than 10 patients with atleast a follow-up of 6-months were included. All the human studies {prospective, retrospective, case reports/series (with more than 10 subjects), randomized or non-randomized trial) reporting the outcome of BFP as interpositional material were included. The present systematic review included 11 studies (prospective=7, Retrospective=3 and ambispective=1) using BFP as interpositional material. The total number of patients were 205. The number of unilateral TMJA and bilateral TMJA were 153 and 52 respectively, making a number of joint to 257. The distribution of gender was almost equal (few studies did not report the gender distribution). The minimum follow-up was 6-months and extended up to 5.3 years. Out of 205 patients, no re-ankylosis was reported in patients. The authors concluded that the BFP is nearly ideal and a preferred interpositional material to prevent re-ankylosis in temporomandibular joint ankylosis. Its vicinity to TMJ, ease of harvesting through the same surgical site and avoiding other scar makes it a preferred interpositional material in TMJA cases.

Total temporomandibular joint replacement in recurrent temporomandibular joint ankylosis: a case report

Total temporomandibular joint replacement (TMJR) is a surgical procedure in which end-stage temporomandibular joint disorders are replaced with an alloplastic prosthesis between the mandible and the base of the skull when autogenous grafts are inadvisable. These alloplastic prostheses may be available as stock or custom-made prostheses consisting of the mandibular condyle and glenoid fossa components. Although the first total temporomandibular joint prosthesis was used in the 1960s, we present the case of a 20-year-old female patient, probably the first case of total temporomandibular joint arthroplasty in Nepal, performed at Dhulikhel Hospital in Kavrepalanchok. The patient underwent bilateral TMJR with a custom joint prosthesis for recurrent TMJ ankylosis. Postoperatively, the patient noticed significant improvements in mouth opening, chewing ability, facial esthetics and, most importantly, her self-esteem and confidence.

Stylomandibular False Ankylosis: An Unusual Complication After Vascularized Iliac Crest Flap for Mandibular Reconstruction

Stylomandibular fusion is a poorly documented and rare complication of maxillofacial surgical procedures. This case report describes a patient presenting with stylomandibular false ankylosis following mandibular reconstruction. A 59-year-old female patient underwent segmental mandibular resection and reconstruction for a defect resulting from ameloblastoma surgery using an iliac crest free flap. A styloid fracture was detected postoperatively, and the patient was managed conservatively. In the third postoperative year, the patient presented with marked limitation of oral gape. A diagnosis of stylomandibular false ankylosis was made, and the patient underwent an ostectomy of the aberrant bone, with improved mouth opening. The abnormal union between the styloid process and the mandible is a previously unreported complication in the use of iliac crest free flaps. This case report emphasizes the importance of being vigilant for stylomandibular false ankylosis, especially when there is a restriction of oral aperture postoperatively following reconstructive procedures involving bone flaps.

Management of paediatric ankylosis

Temporomandibular joint ankylosis (TMJa) is one of the most crippling craniomaxillofacial pathological conditions characterized by replacement of normal architecture of temporomandibular joint (TMJ) with fibrous or bony tissue. The incidence of TMJa is most common in the paediatric population [first and second decades of life] and is commonly associated with maxillofacial trauma. Comprehensive management entails a thorough evaluation of the associated anatomy of the ankylotic mass and other pertinent details like the presence or absence of obstructive sleep apnoea. Categorizing patients based on these variables helps in selecting an appropriate surgical intervention. Various resective and reconstructive surgical techniques are discussed; along with their merits and demerits. Long-term physiotherapy, long-term clinical follow-up and appropriate family counselling are the essential pillars for success. In this review, the authors present an algorithmic approach to evaluation and management of paediatric TMJa. Appropriate recommendations are made based on evidence to select optimum surgical intervention.

Outcomes of total joint alloplastic reconstruction in TMJ ankylosis

OBJECTIVE

The purpose of this study was to evaluate subjective and objective outcomes in patients with temporomandibular joint (TMJ) ankylosis treated with TMJ alloplastic reconstruction (TMJR).

STUDY DESIGN

All patients diagnosed with TMJ ankylosis that underwent TMJR at our institution between 2010 and 2019 were retrospectively reviewed. Patients were divided into 2 cohorts: bony and fibrous ankylosis. Subjective variables assessed were facial pain and headaches, TMJ pain, jaw function, diet, and disability. Objective variables assessed were maximum interincisal opening and lateral excursions. The Mann-Whitney test was employed to analyze subjective variables and an unpaired t-test was used to analyze the objective variables. P < .05 was considered statistically significant.

RESULTS

Twenty-eight patients met the inclusion criteria (21 female, 7 male). The mean age at the time of surgery was 42 years, and the mean number of prior TMJ surgeries was 3. A total of 52 TMJRs were performed in the 28 patients, and the mean follow-up time was 46 months. All subjective variables were significantly improved, and the mean maximum interincisal opening increased from 16.9 mm to 37.25 mm.

CONCLUSIONS

The results of the study demonstrate that TMJR is an effective and reliable method for the management of both fibrous and bony TMJ ankylosis.

Computer-assisted and navigated piezoelectric surgery: A new technology to improve precision and surgical safety in craniomaxillofacial surgery

Background

Computer-assisted navigated piezoelectric surgery (CANPS) is a surgical technique that combines the surgical navigation with a piezoelectric device. This association multiplies the advantages of both technologies, taking the best of each one providing a synergistic association.

Objective

To describe and assess the indications, advantages, disadvantages, and complications of this association of surgical techniques.

Methods

CANPS was used in 32 patients. The clinical diagnosis was facial trauma, tumors, orthognathic surgeries, temporomandibular joint ankylosis, pathology of the frontal sinus, and alveolar distraction. Nineteen patients were men and 13 were women. Planning software iPlan 3.05 of Brainlab, and Elements of Brainlab were used for planning and the Kolibri and Kurve of Brainlab for surgical navigation. The piezoelectric device used was a "Vercelotti" type in all patients.

Results

CAPNS could be performed successfully in all cases without complications and reduced the surgeon's uncertainty during the osteotomies. There is continuous control of the position of the surgical instrument. The use of the navigated piezoelectric device allowed the surgeon's uncertainty to be reduced during the performance of the osteotomies in depth, in poorly visible areas, with little access or reduced visibility. It also increases the safety of bone resections near important anatomical structures.

Conclusions

CANPS combines the advantages of piezoelectric surgery and navigation. CANPS affords real-time control of the position of the cutting tip and allows semiburied approaches. CANPS allows surgery to be precise, safer, and minimally invasive.

Transport distraction osteogenesis compared with autogenous grafts for ramus-condyle unit reconstruction in temporomandibular joint ankylosis: A systematic review and meta-analysis

This systematic review was planned to assess the clinical outcomes of transport distraction osteogenesis (TDO) compared with autogenous grafts for reconstruction of the ramus condyle unit (RCU). We searched Medline, Embase, Cochrane Library, Clinicaltrial.gov, and the references of included trials. The primary outcome was maximal incisal opening (MIO). Of the 148 studies retrieved, five were included (TDO = 49, autogenous grafts =123). The mean difference in MIO between TDO and autogenous graft RCU reconstruction, based on the random-effects model was 1.28 mm (95% CI 0.167 to 2.403) in favour of TDO. Re-ankyosis was observed in four cases in the costochondral graft group and none in the TDO group. Reconstruction of the RCU using TDO is comparable to autogenous grafts after the release of TMJ ankylosis, though the evidence is weak considering the small number of trials, high risk of bias, and absence of long-term results.

Total Alloplastic Temporomandibular Joint Replacement

Purpose

End-stage temporomandibular joint (TMJ) disease are not uncommon and affects quality of life. Multiple surgical procedures have been mentioned in literature for management of TMJ disease which ranges from conservative management to aggressive resection of involved joint and replacement with alloplastic total joint prosthesis. The purpose of the present paper was to provide an overview of the role of alloplastic total joint prosthesis in TMJ replacement.

Methods and results

Alloplastic total joint prosthesis is nowadays considered as a standard of care in the adult patients who require TMJ replacement. The requirement of alloplastic total prosthesis has increased in present era with the improvement in design and material of implants, surgical skills and reported victorious outcome along with improved quality of life after its use. It provides restoration of form and functions, improvement in quality of life, reduction in pain and maintenance of ramal height. Additionally, in TMJ ankylosis it reduces chances of re-ankylosis and allows facial asymmetry correction. Currently, enough evidence is however not available for replacement in skeletally immature patient.

Conclusion

The authors conclude that the total joint replacement is a standard procedure for end-stage TMJ disease. Every maxillofacial surgeon should be well-acquainted with TMJ replacement.

Growth Outcome and Jaw Functions Are Better After Gap Arthroplasty Plus Costochondral Graft Reconstruction Than Gap Arthroplasty Alone in Pediatric Temporomandibular Joint Ankylosis Patients: A Cluster Randomized Controlled Trial

PURPOSE

It is not known if the muscle matrix that becomes functional after gap arthroplasty (GA) in temporomandibular joint ankylosis (TMJA), induces growth of the mandible or the reconstructive arthroplasty with costochondral graft (CCG) is responsible for growth. The study aimed to evaluate the mandibular growth and functional outcome with the use of CCG/GA in the management of pediatric TMJA.

METHODS

The investigators designed a cluster randomized controlled trial on pediatric (3 to 16 years) TMJA patients. Treatment applied (CCG and GA), was the primary predictor variable. Patients were divided into CCG and GA groups. The primary outcome variable was growth. Secondary outcome variables included etiology and duration of ankylosis, maximal incisal opening (MIO), reankylosis, occlusion, laterotrusion, chin deviation, facial asymmetry, occlusal tilt, and complications. The distance condylion (Co) to gnathion (Gn) was used to measure mandibular length. Ramal height was measured from Co- gonion (Go). Lower facial height was measured from the anterior nasal spine to Gn. Generalized estimating equations were used to calculate the regression coefficient adjusted for the cluster. The patient was considered as a cluster and the unit of analysis was joint.

RESULTS

Fifty-six {n = 28 in each group, (n = 33 joint in the CCG group and n = 31 joints in GA group)} patients were analyzed. The median follow-up was 33-months (31.93 ± 15.24) in CCG and 32-months (32.85 ± 17.84) in the GA group. Intergroup comparison between the CCG and GA group showed a statistically significant difference in mandibular length (CCG = 77.51 ± 9.31 and GA = 66.66 ± 8.32 mm, P < .001), ramal height (CCG = 44.21 ± 7.3 and GA = 31.87 ± 8.4 mm, P < .001), and statistically insignificant difference in lower facial height (CCG = 52.53 ± 6.1 and GA = 50.19 ± 6.3 mm, P = 0.14) at follow-up. Statistically, significant improvement was seen in MIO in both groups (<.001).

CONCLUSIONS

The results of the present study concluded that growth and jaw functions were better in reconstructive arthroplasty with CCG than GA in pediatric TMJA.

Alloplastic total joint replacement in management of temporomandibular joint ankylosis

Both autogenous and alloplastic material have been used in management of temporomandibular joint (TMJ) ankylosis. Second surgical site, donor site morbidity, possibility of over/undergrowth, graft fracture or resorption and increased surgical time are the disadvantages of autogenous graft. Alloplastic total joint replacement (TJR) has become a promising technique in management of adult temporomandibular joint ankylosis (TMJA). This paper intends to present the role of alloplastic TJR in management of TMJA. There is significant current evidence of the role of alloplastic TJR in the management of TMJA. Results in TMJA are excellent with sustained improvement in pain free mouth opening, correction of facial asymmetry, reduction in recurrence and improved quality of life. TMJ TJR is becoming the gold standard of care in the management of TMJA, although costs can sometime preclude access to this mode of therapy.

Strategies to reduce re-ankylosis in temporomandibular joint ankylosis patients

The purpose of the study was to define a protocol for the prevention of re-ankylosis after surgical management of temporomandibular joint ankylosis (TMJA). The investigators designed a retrospective study on all TMJA patients treated with different treatment modalities from 2013 to 2019. The investigators observed that complete removal of the ankylotic mass particularly on the medial side; use of a piezoelectric scalpel for a clean and smooth osteotomy with copious irrigation to remove bone chips and slurry; less trauma to the local tissue; osteotomy design parallel and inferior osteotomy at the narrowest part, which mostly corresponds to the condylar neck; performance of a coronoidectomy (if mouth opening is <30mm), fat interposition; no intraoperative correction of any pre-existing chin deviation when treated with costochondral graft; patient motivation; and aggressive physiotherapy, and use of a vacuum drain are all important to prevent re-ankylosis, irrespective of the treatment modality. A total of 114 patients (n=152 joints), [bilateral (n=38), unilateral (n=76)] were evaluated retrospectively. Interpositional arthroplasty with fat was performed in n=43, CCG was used for reconstruction in n=30 and total joint replacement (TJR) was done in n=41 patients. Re-ankylosis was seen in n=3 (2.6%) patients (2 in CCG and 1 patient in interpositional arthroplasty). The follow-up ranged from 12-80 months. The results conclude that following the suggested best practice protocol is effective in reducing re-ankylosis.

Does Bilateral Gap Arthroplasty Increase the Severity of Obstructive Sleep Apnea in Patients With Temporomandibular Joint Ankylosis?

PURPOSE

Obstructive sleep apnea (OSA) is common in patients with bilateral temporomandibular joint ankylosis (TMJA). The purpose of this study was to compare the preoperative and postoperative apnea-hypopnea index (AHI) in patients with TMJA undergoing bilateral gap arthroplasty (BGA).

METHODS

The investigators implemented a prospective cohort study on patients with bilateral TMJA treated with BGA. The primary predictor variable was time (before and after BGA). The primary outcome variable was AHI and secondary outcome variable included posterior airway space, skeletal changes, Epworth sleepiness scale, minimum oxygen_, average oxygen saturation, and maximal incisal opening at preoperative time (T0), 1 month (T1), and at 6 months (T2). The statistical test used were Greenhouse-Geisser test, repeated measure ANOVA (1 way), followed by post hoc Bonferroni test. The P-value was taken significant when <0.05 at a confidence interval of 95%.

RESULTS

The study sample included 12 (m:f = 1:2) patients of bilateral TMJA with a mean age of 14.9 ± 4.8 years and mean follow-up of 6 months. Mean duration of ankylosis was 10.5 ± 6.9 years (median = 12). Trauma was the main etiological factor in 11 (91.7%) patients followed by infection in 1 (8.3%) patient. The mean increase in AHI was 8.6 (T0 to T1) with P-value = .002 and 23.4 (T1 to T2) and was statistically significant (P = .001). The mean decrease in posterior airway space was 4.5 ± 1.0 to 3.5 ± 0.5 (T0 to T2) and was statistically significant (P = .02). Mean difference in minimum oxygen was 6.8 (P-value = .015). Skeletal changes are consistent with clockwise rotation of the mandible and statistically significant changes in horizontal and vertical dimension. The mean change in average oxygen was statistically insignificant (P = 1.0).

CONCLUSIONS

The present study concludes that gap arthroplasty in patients with bilateral TMJA can lead to development or worsening of pre-existing mild to moderate OSA. Ramus-condyle reconstruction should be performed to prevent the retropositioning of mandible and worsening of OSA.

Piezoelectric Cutting Devices for Osteotomy in Temporomandibular Joint Condylectomy

Condylar hyperplasia is an alteration in mandibular growth that can cause facial asymmetry and occlusal changes that usually affect the aesthetics and function of patients. To date, condylectomy for its part remains a key part of the treatment. Although there are still controversies regarding the amount of bone to remove and the surgical approach, there are still other concerns, such as finding the benefit in terms of intraoperative safety and postoperative results with different cutting devices, including the use of piezoelectric, which is increasing its use in the maxillofacial field. This is why the main objective of this study is to compare the results found in medical records and databases of condylectomy procedures performed between 2017 and 2019 with different cutting devices.

Efficacy of Local Anesthetic Wound Infiltration in Temporomandibular Joint Ankylosis Surgery for Control of Postoperative Pain: A Prospective, Randomized Controlled, and Double-Blinded Trial

PURPOSE

This study aimed to compare the analgesic efficacy of wound infiltration with ropivacaine alone or with adjuvants clonidine or dexamethasone for postoperative pain in temporomandibular joint ankylosis (TMJA) surgery.

MATERIALS AND METHODS

The investigators implemented a randomized controlled trial with 3 parallel groups, among the patients of bilateral TMJA visiting the maxillofacial surgery unit between March 12, 2015 and February 5, 2017. At the completion of surgery, wound infiltration was done with 0.25% of ropivacaine (R group), 0.25% of ropivacaine with 0.5 mcg/kg of clonidine (RC group), 0.25% of ropivacaine with 0.1 mg/kg of dexamethasone (RD group), and 0.2 mL/kg of drug volume on each side. The primary outcome variables were total opioid consumption (fentanyl in micrograms/kilogram) and visual analog scale for pain at rest and movement for 24 hours after surgery. The secondary outcome variables were time (minutes) to first rescue analgesic requirement and patient satisfaction scores. The patients, surgeons, and anesthesiologists collecting the data were blinded to the group allocation. Continuous and qualitative data were summarized using mean (standard deviation) and frequency distribution, respectively.

RESULTS

About 45 patients were randomized into 3 equal groups. Mean age of the sample was 17.6 ± 8.04 years (males = 24 [53%]; females = 21 [47%]). Surgery for TMJA included gap arthroplasty (n = 17), interpositional arthroplasty (n = 24), and total TMJ replacement (n = 4). Total fentanyl (micrograms) consumption during 24 hours was comparable between all the 3 groups and statistically not significant (P = .40). The pain scores (visual analog scale at rest and movement) were comparable at all time points. No significant difference was noted for time to first rescue analgesic requirement (P = .31). Patient satisfaction was higher in RC group as compared with R group (P = .009). No adverse effects were noted in any group.

CONCLUSIONS

Within the confines of the sample size and the absence of power calculation, the study implies that wound infiltration with ropivacaine was as efficacious as when mixed with adjuvants, either clonidine or dexamethasone, for control of postoperative pain for 24 hours.

Longitudinal electromyographic changes in masseter and anterior temporalis muscle before and after temporomandibular joint arthroplasty in ankylosis patients

PURPOSE

The literature lacks evidence about activity of masseter and anterior temporalis muscles in temporomandibular joint ankylosis (TMJA) patients. The purpose of this study was to evaluate longitudinal electromyography (EMG) changes in masseter and anterior temporalis muscle before and after gap arthroplasty in unilateral TMJA patients. Specific aim was to investigate the EMG activity restoration to the level of non-ankylosed side after arthroplasty.

METHODS

The investigator implemented a prospective longitudinal study amongst TMJA patients treated with gap arthroplasty. EMG of masseter and anterior temporalis were recorded bilaterally on ankylosed and non-ankylosed side. EMG signals of masseter and anterior temporalis were recorded preoperatively and 1 week, 3 month and 6 month postoperatively at rest and at maximum voluntary clench (MVC).

RESULTS

The study sample was composed of 16 (male:female = 1:1.28) unilateral TMJA patients. The mean duration of ankylosis was 3.25 ± 1.18 years. The difference in EMG root-mean-square (RMS) values of ankylosed side when compared to the preoperative values of non-ankylosed side was found to be statistically significant (p < 0.001) preoperatively, 1 week and 3 month postoperatively, while it was statistically not significant (p > 0.99) at 6-month postoperatively.

CONCLUSION

The present study concludes that the TMJA patients have hyperactivity of masseter and anterior temporalis muscle. Restoring the function causes the muscle activity to progress to the values of normal side. EMG activity as measured on follow-up may be one of the predicting factor for re-ankylosis.

Outcome of Stock Total Joint Replacement With Fat Grafting in Adult Temporomandibular Joint Ankylosis Patients

PURPOSE

Adult temporomandibular joint ankylosis (TMJA) lacks a uniform management protocol. The purpose of the study was to evaluate the outcome of stock total joint replacement (TJR) along with fat grafting around the joint in adult TMJA patients. Specific aim was to find out whether TJR can be a definitive management for adult TMJA.

METHODS

The investigators implemented a prospective study on adult TMJA patients treated with ostearthrectomy of ankylosis and stock temporomandibular joint (TMJ) TJR with fat grafting. Concomitant orthognathic correction of facial asymmetry was performed in some unilateral cases. Follow-up was carried out at regular intervals for assessing primary outcome variable of maximal incisal opening (MIO) and reankylosis. Secondary outcome variable included demographic data, etiology, duration of ankylosis (DOA), correlation between DOA and preoperative and postoperative MIO, occlusion and complications of hemorrhage, facial nerve paresis, periprosthetic joint infection, dislocation, and implant failure.

RESULTS

The study sample was composed of 41 patients (54 joints) (bilateral, n = 13; unilateral, n = 28 [right side, n = 12; left side, n = 16]). The number of recurrent cases was 15. Trauma as etiology of ankylosis was seen in n = 30 (73.2%), infection in n = 7 (17.1%), unknown in n = 3 (7.3%), and ankylosing spondylitis in n = 1 (2.4%) cases. Mean DOA was 11.95 years. Paired t test revealed a statistically significant difference between preoperative and follow-up MIO (P < .001). None of the cases showed reankylosis in the follow-up period. Pearson correlation revealed statistically negative correlation between DOA and postoperative MIO.

CONCLUSIONS

The result of this study suggests that stock TMJ TJR along with fat grafting around the joints provides adequate mouth opening without any sign and symptoms of reankylosis. Stock TMJ TJR with fat grafting can be considered as a definitive treatment modality in adult TMJA with minimum comorbidity.

Evaluation of Success of Transport Disc Distraction Osteogenesis and Costochondral Graft for Ramus Condyle Unit Reconstruction in Pediatric Temporomandibular Joint Ankylosis

PURPOSE

The costochondral graft (CCG) is considered the reference standard for pediatric temporomandibular joint reconstruction. It has the disadvantages of unpredictable growth, donor site morbidity, and the need for intermaxillary fixation. It has been reported that transport disk distraction osteogenesis (TDDO) can result in the formation of a neocondyle and disc. We performed a randomized trial to measure and compare clinically relevant outcomes of ramus-condyle unit (RCU) reconstruction using CCG and TDDO for pediatric temporomandibular joint ankylosis (TMJA).

MATERIALS AND METHODS

In the present randomized controlled trial (block randomization with a variable block size), pediatric patients with unilateral, nonrecurrent TMJA aged 3 to 16 years who had presented to our unit from December 2015 to June 2017 were enrolled. Instead of temporalis myofascial flap interposition, a buccal fat pad was used to fill the gap created by osteoarthrectomy. The primary outcome parameter was mouth opening. A mouth opening of at least 25 mm at the median follow-up point was considered success. The secondary outcome parameters were occlusion, laterotrusion, protrusion, reankylosis, neocondyle, chin deviation, facial asymmetry, midline shift, and neo-disc formation. Data were analyzed using the independent t test and rank sum test.

RESULTS

A total of 24 patients were enrolled in the CCG and TDDO groups (n = 12 in each group). Trauma (40.9%) was the most common etiology with a slight male preponderance (59.09%). The mean age was 10.32 ± 2.85 years. The average distraction achieved in the TDDO group was 10.42 mm. The median follow-up duration was 31.5 months (range, 24 to 39 months). The mean preoperative maximal incisal opening had improved from 8.5 ± 4.1 and 9.5 ± 7.1 mm in the CCG and TDDO groups preoperatively to 35.7 ± 2.7 and 34.4 ± 8.9 mm, respectively, at the median follow-up point (P < .005). RCU reconstruction with both modalities resulted in improvement in all the parameters; however, the intergroup comparison showed statistically non-significant differences. No reankylosis or open bite was found. The 3-hour delayed gadolinium-enhanced magnetic resonance imaging scan showed successful neo-disc formation.

CONCLUSIONS

Similar success can be achieved in RCU reconstruction using either CCG or TDDO for pediatric TMJA. Both techniques have some advantages and disadvantages. RCU reconstruction using CCG or TDDO results in formation of a neocondyle, maintenance of occlusion, and correction of facial asymmetry.

Ultrasonic versus conventional gap arthroplasty for the release of ankylosis of temporomandibular joint: a prospective cohort study

The purpose of this study was to compare the clinical outcomes of ultrasonic surgery to the conventional bone cutting technique using bur and saw for the release of ankylosis of temporomandibular joint. We conducted a prospective cohort study on 25 patients with 38 ankylotic joints at Chinese PLA General Hospital from March 01, 2012 to March 01, 2016. Patients were followed up at least 2 years postoperatively. The primary outcome was the intraoperative blood loss per joint. The secondary outcome was the long-term (≥2 years) improvement of maximum mouth opening. The blood loss was significantly reduced in the ultrasonic group compared to the conventional group (107.3 ± 62.3 ml vs. 186.3 ± 92.6 ml, P = 0.019). The long-term improvements of maximum mouth opening were substantial and stable in both groups (33.5 ± 4.8 mm in the ultrasonic group vs. 29.2 ± 6 mm in the conventional group, P = 0.06). Multivariate linear regression analysis showed a significant association between blood loss and technique used (coefficient: 66.3, 95% confidence interval: 22.1,110.4, P = 0.006). The ultrasonic surgery was associated with less intraoperative blood loss when compared to the conventional method for the release of ankylosis of temporomandibular joint while providing a stable and comparable long-term improvement of maximum mouth opening.

Piezoelectric harvest of osteo-odonto-lamina in modified osteo-odonto keratoprosthesis: A maxillofacial perspective

Purpose:

We describe the piezo-osteotomy feasibility in rehabilitation and harvesting of osteo-odonto lamina in modified osteo-odonto keratoprosthesis (MOOKP) surgery. Surgery was evaluated regarding operative technique and success of the keratoprosthesis (KPros) in terms of perception to light (+ve) to finger counting (+ve).

Materials and Methods:

This retrospective cohort study included 12 patients undergone MOOKP surgery procedures. Harvesting of osteo-odonto-lamina was performed using piezosurgical osteotomy during 2007–2012.

Results:

The mean follow up was 34 months (range 24–48 months). Of the 12 patients six patients had vision ≥6/12, four patients had vision <6/12, but >6/60 and one patients had vision ≤6/60. KPros was retained and functional in all the eyes after a minimum follow up of 24 months. There was mucosal overgrowth over the optical cylinder occurred in two cases over 4 years follow up which was corrected with trimming. Postoperative complication at donor site was seen in three cases, two cases with exposure of root of adjacent teeth and oro antral fistula in one.

Conclusions:

This study suggests that piezoelectric harvest of osteo-odonto-lamina is a valuable surgical option in patients undergoing MOOKP surgery, resulting in high success rate with less complication.

Management of the Bilateral Chronic Temporomandibular Joint Dislocation

Temporomandibular jaw dislocation is an uncontrolled anterior movement of the condyle beyond the articular eminence. It can occur mostly in young adults, and the symptoms are mouth opening disturbance, preauricular skin depression, tense masticatory muscles, and pain. The main purpose of the eminectomy procedure is removal of a part of the articular eminence to maintain free movement of the condyle. The surgical procedure may be performed by conventional surgery or piezosurgery. The present case report describes the management of a recurrent mandibular dislocation in a 28-year-old patient who had also treated conservatively with autologous blood injection. In this report, bilateral eminectomy was performed by piezosurgery to provide soft-tissue protection, precise cut, and optimal view of the surgical area. The management technique is discussed within the current literature.

A review of temporomandibular joint-related papers published between 2014-2015

We conducted a retrospective study and reviewed the temporomandibular joint (TMJ)-related papers published in a leading international journal, Journal of Oral and Maxillofacial Surgery, between January 2014 and December 2015. The study was conducted to ascertain and compare the trends of articles being published in the years 2014 and 2015. A total of 28 articles were reviewed, of which most of the full-length articles were on clinical management and outcomes and the role of radiology. The bulk of the studies were prospective, and less interest was shown in experimental research. A thorough review and analysis thus gives the impression that there is a great need for well-designed clinical studies on TMJ.

Benefits of using the ultrasonic BoneScalpel™ in temporomandibular joint reconstruction

PURPOSE

The main objective of this retrospective study is to analyze and report on our operative experiences and outcomes using the ultrasonic BoneScalpel™ (BoneScalpel) versus a conventional reciprocating saw (RecipSaw) for the purpose of completing the osteotomies in total temporomandibular joint reconstruction (TJR) surgery.

MATERIALS AND METHODS

23 consecutive patients presented with a diagnosis of either degenerative joint disease (n = 23), a failing autogenous TJR (n = 1), heterotrophic bone formation (n = 1) or a subcondylar fracture (n = 1) for a total of 26 joints that received a TJR. 13 unique TJR surgeries employed the use of the BoneScalpel to perform the osteotomies and 13 used the RecipSaw.

RESULTS

There was a 49% reduction in the average volume of blood loss in the BoneScalpel group compared to the RecipSaw group (130cc vs. 268cc, p ≤ 0.004), unpaired t-test). For the other variables it was observed that there were more favorable clinical results using the BoneScalpel but without statistically significant differences given the small sample size relative to the prevalence of the outcome that was being measured.

CONCLUSIONS

Use of the BoneScalpel in TMJ reconstruction is overall safer and results in less blood loss compared to surgeries employing the use of the conventional RecipSaw for completing osteotomies.

Surgical management of ankyloses of the temporomandibular joint by a piezoelectric device

INTRODUCTION

Piezosurgery is commonly used in different field of craniomaxillofacial surgery; since its introduction it has become one of the widely adopted technique for performing osteotomies in orthognathic surgery, distraction osteogenesis and dentoalveolar surgery. Little has been written regarding ultrasonic system for temporomandibular joint surgery (TMJ). In this prospective study we describe the use of piezoelectric device for ankylosis of the TMJ.

MATERIALS AND METHODS

We enrolled in this study 19 patients, 10 males and 9 females, mean (SD) age 24.6 (7.6) years, affected by unilateral ankylosis of TMJ who were surgically managed between January 2009 and December 2014 by interpositional arthroplasty with temporomyofascial muscle flap. We adopted in all cases a preauricular approach with temporal extension. The ankylotic block was removed with piezoelectric device in 9 patients and using traditional rotary bur in 10 cases. We investigated and compared the following parameters as surgical outcomes: intraoperative bleeding, duration of operation, incidence of infection, postoperative swelling and hematoma, mouth opening, nerve impairment and rate of recurrence.

RESULTS

We noticed a substantial reduction in bleeding with the piezoelectric bone cutter when compared to traditional mechanical surgery (103 ml versus 117 ml; p < 0.05); however, we did not report any severe bleeding from the pterygoid plexus or maxillary artery. Operating time was longer in the piezo group (101 min versus 88 min; p < 0.05). There was a lower incidence of postoperative hematoma and swelling following piezoosteotomy. However, regarding postoperative nerve impairment and infection we did not observe any differences between the two groups. At one year follow-up mean (SD) mouth opening was 34 (4.3) mm. We did not report recurrence of the disease.

CONCLUSION

Piezoelectric bone removal for the release of ankylosis of the TMJ is associated with minimal bleeding and few postoperative complications. We believe that piezosurgery allows surgeons to achieve better results compared to a traditional surgery. It is a possible alternative due to the clinical benefits demonstrated.

Single-stage temporomandibular joint arthroplasty in a patient with complete bony ankylosis and previous extradural haematoma

We present a case of a man aged 20 years who was referred with the inability to open his mouth as a consequence of severe ankylosis of his temporomandibular joint. He had previously undergone an attempt to release the ankylosis at the referring institution; however, this was complicated by an extradural haematoma as a result of iatrogenic injury. We describe a one-stage procedure which provided safe excision of the ankylotic mass along with immediate total joint replacement with a custom implant. We advocate the use of preoperative vascular imaging along with the use of custom-made cutting guides to minimise vascular injury.

Stylomandibular fusion complicating recurrent bilateral temporomandibular joint ankylosis

Ankylosis of the temporomandibular joint (TMJ) is debilitating, and difficult to manage because it recurs. Recurrent bilateral ankylosis is further complicated by the fusion of the styloid process and the mandible. We report such a case, and to our knowledge no similar case has been reported previously.

Piezosurgery in implant dentistry

Piezosurgery, or the use of piezoelectric devices, is being applied increasingly in oral and maxillofacial surgery. The main advantages of this technique are precise and selective cuttings, the avoidance of thermal damage, and the preservation of soft-tissue structures. Through the application of piezoelectric surgery, implant-site preparation, bone grafting, sinus-floor elevation, edentulous ridge splitting or the lateralization of the inferior alveolar nerve are very technically feasible. This clinical overview gives a short summary of the current literature and outlines the advantages and disadvantages of piezoelectric bone surgery in implant dentistry. Overall, piezoelectric surgery is superior to other methods that utilize mechanical instruments. Handling of delicate or compromised hard- and soft-tissue conditions can be performed with less risk for the patient. With respect to current and future innovative surgical concepts, piezoelectric surgery offers a wide range of new possibilities to perform customized and minimally invasive osteotomies.

Temperature and time variations during osteotomies performed with different piezosurgical devices: an in vitro study

AIM

The aim of this experimental in vitro study was to evaluate the effects of the piezoelectric device in temperature and time variations in standardized osteotomies performed with similar tip inserts in bovine bone blocks.

METHODS

Two different piezosurgical devices were used the OE-F15(®) (Osada Inc., Los Angeles, California, USA) and the Surgybone(®) (Silfradent Inc., Sofia, Forli Cesena, Italy). Serrated inserts with similar geometry were coupled with each device (ST94 insert/test A and P0700 insert/test B). Osteotomies 10 mm long and 3 mm deep were performed in bone blocks resembling type II (dense) and type IV (soft) bone densities with and without irrigation. Thermal changes and time variations were recorded. The effects of bone density, irrigation, and device on temperature changes and time necessary to accomplish the osteotomies were analyzed.

RESULTS

Thermal analysis showed significant higher temperatures during piezosurgery osteotomies in hard bone without irrigation (P < 0.05). The type of piezosurgical device did not influence thermal variations (P > 0.05). Time analysis showed that the mean time values necessary to perform osteotomies were shorter in soft bone than in dense bone (P < 0.05).

CONCLUSIONS

Within the limitations of this in vitro study, it may be concluded that the temperature increases more in piezosurgery osteotomies in dense bone without irrigation; the time to perform the osteotomy with piezosurgery is shorter in soft bone compared to hard bone; and the piezosurgical device have a minimal influence in the temperature and time variations when a similar tip design is used during piezosurgery osteotomies.

Can piezoelectric ultrasound osteotomies result in serious noise trauma?

The use of ultrasound to cut bone in oral and craniofacial surgery has increased. There is concern that the application of ultrasound to the craniofacial skeleton might represent a potential hazard to the inner ear because of sound transmission by bone conduction resulting in hearing trauma. Conventional and ultrasound osteotomies were performed on human specimens of temporal bone containing an intact middle and inner ear. The equivalent sound pressure was measured with a microphone at the round window, which had been calibrated with a bone conduction audiometer. Conventional osteotomy with a rose burr resulted in maximum sound pressures of 125dB(A) consisting of major frequency components at 2100, 7600, and 9300Hz. Ultrasound osteotomy resulted in maximum sound pressures of 122dB(A) and exhibited major frequency components at around 10kHz, 20kHz, and 26.5kHz. Ultrasound osteotomies have no acoustic advantage over conventional osteotomies. Both osteotomy techniques can produce noise-induced hearing trauma, especially when applied over longer durations of time. This appears to be more relevant for ultrasound osteotomies, because the bone cutting efficiency is usually poorer than in conventional osteotomies. Surgeons should consider the risk of noise-induced potential damage to the inner ear when selecting the method of osteotomy.

Piezoelectric Bone Surgery: A Review of the Literature and Potential Applications in Veterinary Oromaxillofacial Surgery

Piezoelectric bone surgery is a recent and innovative technology, permitting a selective cut of mineralized tissue while sparing soft tissue. Similar to a dental scaler, a high frequency vibration, in the range of 25-35 kHz, is transmitted to a metallic tip. However, the power of the piezosurgical instrument is three to six times higher than that of a dental scaler. The major advantages of this technology include high precision, a design that increases ease of curvilinear osteotomy, less trauma to soft tissue, preservation of neurological and vascular structures, reduced hemorrhage, minimal thermal damage to the bone, as well as overall improvement of healing. The handpiece of the instrument is equipped with a sterile irrigation system and light-emitting diode (LED) light, which improves visibility and overall safety. Piezoelectric surgery is particularly useful when performing delicate bone procedures such as periodontal or endodontic surgery. It is also indicated when performing more invasive bone surgery such as maxillectomy, mandibulectomy, and condylectomy, where preservation of neurovascular structures is important. Piezoelectric instruments are different from rotary instrumentation or oscillating saws, they require light pressure with constant motion of the tip. Training is required to master the technique.