Simultaneous arthroplasty and distraction osteogenesis for the treatment of ankylosis of the temporomandibular joint and secondary mandibular deformities in children

Assessment of upper airway changes after interpositional arthroplasty: a cephalometric analysis

This prospective cohort study examined the changes in airway area and soft tissue parameters following interpositional arthroplasty for temporomandibular joint (TMJ) ankylosis. Ten patients with TMJ ankylosis underwent surgery, and preoperative and postoperative skeletal and soft tissue measurements were obtained. A significant rise in soft tissue parameters was observed following surgery, although only minor changes in skeletal parameters were seen. The nasoropharyngeal area, oral area, soft palate area, and tongue area were examined. After the surgery, increases in values were observed in the nasoropharyngeal area (from 3482.4 mm2 to 3618.7 mm2), the oral area (from 2731.8 mm2 to 2840.8 mm2), the soft palate area (from 204.9 mm2 to 217.3 mm2), and the tongue area (from 2577.5 mm2 to 2600.8 mm2). These findings suggest that interpositional arthroplasty can improve airway area and soft tissue dimensions, affecting the stomatognathic system's aesthetic and functional aspects. Further research is needed to validate these results and assess long-term stability.

How does changing the vector of transport disc distraction affect the outcomes of surgery in patients of temporomandibular joint ankylosis with obstructive sleep apnea?

PURPOSE

Temporomandibular joint ankylosis (TMJA) in children is associated with retrognathia, reduction in pharyngeal airway volume (PAV), and obstructive sleep apnea (OSA). Distraction-osteogenesis (DO) is the proven method in the management of OSA. There is paucity in literature about the effect of distraction vector on PAV. It can be expected that an oblique vector would improve PAV and relieve OSA. Thus, the study was designed to explore the feasibility, advantages, and disadvantages of this modified technique for managing TMJA and OSA simultaneously.

MATERIALS AND METHOD

The investigators designed a prospective study on patients of TMJA with retrognathia. Ethical approval was obtained (IECPG-547/14.11.2018). In all patients, simultaneous ankylosis release and mandibular distraction were performed. Primary outcome variables were improvement in 3-dimensional (3D) PAV and maximal interincisal opening (MIO). Secondary outcome variables were changed mandibular length, distraction relapse, and re-ankylosis. Paired t-test and multivariate ANOVA were used to assess all the parameters.

RESULT

The study included 13 joints in 8 patients of TMJA with retrognathia (2 unilateral and 6 bilateral ankylosis) with mean age of 14.25 ± 7.37 years. Mean distraction performed was 19 ± 4.0 mm. There was a statistically significant improvement of PAV by 225% (p = 0.002), a reduction in Epworth's scale (p = 0.017), an increase in MIO (p = 0.001), and an increase in mandibular length. Three patients had re-ankylosis at the 25-month follow-up.

CONCLUSION

The results of the present study conclude that modification of distraction vector improves 3D PAV and MIO in TMJA patients, with the added advantage of a reduction in overall treatment time and improved patient compliance.

Distraction osteogenesis promotes temporomandibular joint self-remodeling in the treatment of mandibular deviation caused by condylar ankylosis

Craniofacial deformity and malocclusion are primary concerns following temporomandibular joint ankylosis (TMJa) in growing patients, and they pose even greater challenges in adult patients. The treatment objectives always involve restoring proper jawbone structure, achieving stable occlusion, and attaining satisfactory joint mobility. This report presents a 4-year follow-up of an adult patient with TMJa-induced mandibular deviation, who underwent a combined treatment approach involving distraction osteogenesis (DO) and orthodontic-orthognathic surgery. Orthodontic treatment resulted in favorable occlusion and improved facial esthetics. A new condyle with a reconstructed glenoid fossa in a forward position was established after mandibular DO and the damaged TMJ experienced self-remodeling owing to functional improvement. Thus, this case demonstrates the efficacy of DO in promoting adaptive TMJ self-remodeling with long-term stability when treating mandibular deviation caused by condylar ankylosis in adult patients.

Characterization of Upper Airway and Analysis of Potential Risk Factor Associated with OSA in Patients with Unilateral Temporomandibular Ankylosis and Micrognathia Deformities

OBJECTIVE

To ascertain the airway characteristics in patients with unilateral temporomandibular joint ankylosis and maxilla-mandibular deformities (UTMAMD) and investigate the potential risk factors associated with obstructive sleep apnea (OSA) among UTMAMD patients.

METHODS

Authors conducted a retrospective single-center study to assess and compare study group consisting of a cohort of 32 patients diagnosed with UTMAMD between January 2011 and July 2022 with control group including 54 participants. The study group was further divided into two subgroups based on the presence or absence of OSA in patients. Parameters related to the upper airway were measured and analyzed using three-dimensional reconstruction of computed tomographic scans. The measurements of airway parameters were compared between study group and control group and between two subgroups. Pearson correlation analysis was used to identify the factors associated with the presence of OSA, and a multiple variable regression model was used to identify risk factors for OSA.

RESULTS

Airway volume (VOL), Minimum cross-section area (min CSA), mean CSA, tilt in sagittal plane (TS), and tilt in sagittal plane (TC) in velopharynx; VOL, airway length (AL), min CSA, mean CSA, TS, TC, and airway deviation (AD) in glossopharynx; min CSA, TS, and AD in hypopharynx were found difference with significance between study group and control group. Lateral dimension/anterior-posterior dimension (LAT/AP) ratio in velopharynx and min CSA, TC, and LAT/AP ratio in glossopharynx were significant different between patients with UTMAMD with OSA and without OSA.

CONCLUSIONS

The upper airway of patients with UTMAMD exhibits significant narrowing and distortion, rendering them susceptible to suffer from OSA. Patients with UTMAMD and OSA demonstrate more elliptical airways, and the glossopharyngeal LAT/AP ratio is a predictive indicator for the occurrence of OSA.

A systematic review on the outcome of distraction osteogenesis in TMJ ankylosis

Introduction

TMJ ankylosis (TMJa) management by arthroplasty alone fails to address the deformity and the compromised airway. Distraction osteogenesis (DO) can offer a pragmatic solution to TMJa. The aim of the study was to generate evidence towards the role of DO in TMJa, evaluate its efficiency and develop an algorithm for use of DO in TMJa.

Material and methods

The research question was formulated using the PICOS statement for reporting guidelines in systematic reviews, where the efficiency of DO was evaluated in terms of mouth opening, correction of facial deformity and asymmetry, airway correction, and its long term effects.

Results

1130 articles reported DO as a treatment modality for TMJ ankylosis, of which 32 prospective studies, 16 retrospective and 2 RCTs were included in the study. DO was used for mandibular distraction in 45 studies and for simultaneous maxillamandibular distraction in only five studies. An algorithm for use of DO in TMJa was developed.

Conclusion

Although DO has proven its application in TMJ ankylosis cases, its best use is for correction of obstructive sleep apnoea. Relapse causing loss of posterior ramal height is a concern after transport DO. Prearthroplastic DO appears to best correct mandibular deformity. A maxillomandibular deformity requires simultaneous maxillomandibular distraction. However, a metanalysis is still awaited for effectiveness of DO in TMJ ankylosis.

Classification and surgical management of temporomandibular joint ankylosis: a review

The paper reviews various classifications and surgical techniques for the treatment of temporomandibular joint ankylosis. PubMed, EBSCO, Web of Science, and Google Scholar were searched using a combination of keywords. Articles related to classification, resection-reconstruction of the temporomandibular joint, and management of airway obstruction were considered and categorized based on the objectives. Seventy-nine articles were selected, which included randomized clinical trials, non-randomized controlled cohort studies, and case series. Though several classifications exist, most classifications are centered on the radiographic extent of the ankylotic mass and do not include the clinical and functional parameters. Hence there is a need for a comprehensive staging system that takes into consideration the age of the patient, severity of the disease, clinical, functional, and radiographic findings. Staging the disease will help the clinician to adopt a holistic approach in treating these patients. Interpositional arthroplasty (IA) results in better maximal incisal opening compared with gap arthroplasty, with no significant difference in recurrent rates. Distraction osteogenesis (DO) is emerging as a popular technique for the restoration of symmetry and function as well as for relieving airway obstruction. IA, with a costochondral graft, is recommended in growing patients and may be combined with or preceded by DO in cases of severe airway obstruction. Alloplastic total joint replacement combined with fat grafts and simultaneous osteotomy procedures are gaining popularity. A custom-made total joint prosthesis using CAD/CAM can efficiently overcome the shortcomings of stock prostheses.

Clinical outcomes of open treatment of old condylar head fractures in adults

The aim of this study was to classify the clinical feasibility and outcomes of open reduction treatment of old condylar head fractures (CHFs). This was a retrospective case series study of patients with old CHFs that were treated with open reduction and internal fixation, with anatomic reduction and sutured fixation of the articular disc. Preoperative and postoperative examinations were recorded and analyzed, including temporomandibular joint (TMJ) symptoms, occlusion, maximum interincisal opening (MIO), and mandibular deviation. Computed tomography (CT) was used to assess condylar morphology and position. Eleven patients with old CHFs were included (nine unilateral and two bilateral). The mean period from condylar fracture to operation was 8.9 months (ranging from 6 to 14 months). The mean follow-up period after surgery was 16.1 months (ranging from 12 to 22 months). At the end of follow-up period, no malocclusion was found, and the MIO had expanded considerably to 37.4 ± 3.8 mm. Postoperative CT showed that all fragments were properly reduced and the condyles were in the normal position. All patients showed apparently improved TMJ function, occlusion, and facial appearance. Our results showed that open reduction treatment could be an effective method for the treatment of old CHFs.

A single-stage computer-guided gap arthroplasty with simultaneous patient-specific total joint replacement with a novel flat fossa design: A case report

INTRODUCTION AND IMPORTANCE

The computer-guided approach for the patient-specific TMJ replacement is considered an ultimate reliable option in advanced cases. However, dislocation of the condylar head could happen with the concave fossa design. A flat design was described and used in this case.

CASE PRESENTATION

A 15 years old male patient with mandibular asymmetry and class IV recurrent ankylosis of the right TMJ received a patient-specific artificial joint with computer-guided gap arthroplasty and orthognathic corrective mandibular surgery for the left side. The fossa component was made entirely flat, and the patient was followed up over the next year.

CLINICAL DISCUSSION

Customized TMJ prosthetic solutions are reliable in advanced cases, especially when facial corrections are indicated; however, the commonly used concave design showed reported dislocations requiring some design modifications as proposed in the presented case.

CONCLUSION

The flat fossa design of the artificial TMJ secures the same results as the anatomical fossa design without the incidence of dislocation.

Bilateral temporomandibular joint reconstructions with stock alloplastic prostheses on a distracted mandible - A case report

Background: The management of patients with a triad of temporomandibular joint (TMJ) ankylosis, retrognathia, and obstructive sleep apnea (OSA) has long been a matter of debate. Even though consensus favors distraction osteogenesis (DO) in the 1st phase of treatment to relieve the OSA, various treatment approaches for TMJ reconstruction after ankylosis release have been put forth. Most of the reconstructive modality has been focused on autogenous materials or customized TMJ prostheses after mandibular distraction.Case Presentation: The authors present a case of a patient with the triad of TMJ ankylosis, retrognathia, and OSA who underwent DO for correction of his OSA. This was followed by bilateral TMJ reconstruction with stock alloplastic prostheses on the distracted mandible, along with genioplasty to correct retrogenia.Conclusion: In this case, stock TMJ total joint prostheses were used successfully to treat bilateral TMJ ankylosis following previous surgery for mandibular distraction.