Autogenous grafts for condylar reconstruction in treatment of TMJ ankylosis: current concepts and considerations for the future

Growth Evaluation After Costochondral Graft Combined With Functional Appliance in Children With Temporomandibular Joint Ankylosis

The treatment of temporomandibular joint (TMJ) ankylosis in children is a great challenge for surgeons. Costochondral graft (CCG) is a common method of reconstructing the TMJ in children. However, the growth pattern of CCG is unpredictable. In this study, we introduced a surgical-orthodontic approach and evaluated the growth results of the mandible and maxilla in children with TMJ ankylosis through 3-dimensional computed tomography measurements. A prospective cohort study was conducted on child patients diagnosed as having TMJ ankylosis between September 1, 2018 and June 1, 2020. Computer-aided virtual mandibular position guided the CCG, and removable functional appliance was used after surgery. The maximal incisal opening (MIO), the maxilla height, and the length of mandibular ramus were determined. Paired t test was performed to analyze the differences among various stages. Six patients (3 females, 3 males; aged 6-9 y) were included in this study. MIO was 12.4 mm before surgery and improved to 36.8 mm after 42.8 months' follow-up. Mandible length increased by 5.1 mm in the affected side and by 5.3 mm in the unaffected side, without significant difference. The affected maxilla height increased by 6.7 mm, which was more than 5.0 mm in the unaffected side. In conclusion, continued growth of mandible and maxilla can be achieved through CCG combined with functional appliance treatment for children TMJ ankylosis.

Functional Outcomes After the Sacrifice of Mandibular Condyle Using Fibula Free Flap for Immediate Surgical Reconstruction

Introduction Head and neck cancer with mandibular invasion often necessitates composite resection, leading to defects requiring reconstruction. Microvascular fibula free flap (FFF) surgery is a common approach for this purpose. In this study, we focus on our experience with condyle sacrifice, emphasizing treatment outcomes and functional results. Additionally, we highlight a contemporary perspective by discussing surgical techniques and radiographic outcomes based on a 3D analysis of neo-condyle placement on CT imaging. Methods We studied 23 patients who had undergone segmental mandibulectomy requiring FFF reconstruction between 2009 and 2020. These were all performed by the same surgeon (M.M.) at an academic tertiary care center. Twenty-three reconstructions included condyle sacrifice. Retrospective chart review was performed with a focus on treatment, functional outcomes, and surgical technique. Results A total of 23 patients were included in the study group (13 females and 10 males) with a mean age of 58.1 years. The most common surgical indication was for oncologic purposes (n=9; 39.1%). Twenty (87%) patients required tracheostomy, and all were decannulated. In terms of surgical complications, two (8.7%) patients had a degree of arterial insufficiency and two (8.7%) developed delayed infections. The average inpatient stay was 5.61 days, with a subsequent average clinic follow-up after 16.9 days. CT or MRI imaging was available for 21 (91.3%) patients, showing 14 (66.7%) neo-condyles within the glenoid fossa. Fifteen (71.4%) patients had some element of anterior displacement (average=6.27 mm), and seven (33.3%) patients had a component of lateral displacement (average=2.23 mm). Three (13%) patients died during the follow-up period. Eighteen (90%) of the surviving patients returned to an oral diet within an average of 24.9 days. All patients returned to normal interincisal distance by 12 months. All FFFs, with and without complications, remained viable. Conclusion We achieved favorable oral function outcomes in the majority of our patients. Intriguingly, although radiographic evidence revealed anterior and/or lateral displacement of the neo-condyle, there was no observed correlation with the resumption of oral diet, trismus, or crossbite among these patients.

Surgical Treatment of Temporomandibular Joint Derangement: 30-Year Follow-Up of Temporomandibular Joint Discectomy, a Case Report and Literature Review

The improvement in diagnostic accuracy, improvement of the endoscopic equipment, better selection of patients for open TMJ surgery, and increased focus on research and education are promising for the treatment of the group of patients with TMJ derangements. In the future, prospective randomized clinical trials need to be performed to give the clinician guidelines as to which type of intervention should be chosen in a particular patient base on accepted criteria for diagnosis and treatment of TMJ derangement.

A bibliometric analysis of research on craniomaxillofacial distraction osteogenesis from 2000 to 2021

Objective

This study collected and summarized publications related to craniomaxillofacial distraction osteogenesis(DO) from 2000 to 2021, investigated trends in related research, and compared publications from different countries, institutions and journals. The aim is showcasing hotspots and frontiers in the field and providing a reference for future research.

Background

Craniomaxillofacial DO serves to treat different types of craniomaxillofacial dysplasia and bone defects and deformities. DO can significantly reduce surgical trauma, complications, and recurrence rate compared to conventional surgery. However, there is a lack of bibliometric analyses regarding Craniomaxillofacial DO.

Methods

CiteSpace and VOSviewer were used to analyze and visualize 3,141 articles and reviews searching through the Web of Science Core Collection(WOSCC) to obtain publications on craniomaxillofacial DO from 1 January 2000 to 31 December 2021.

Results

In the last 21 years, there has been a significant increase in the number of publications. The United States, the People's Republic of China, and Italy produce the vast majority of publications. University of Milan and University of Bologna are the most influential in this field. McCarthy JG is the most influential author. Obstructive sleep apnea, TMJ ankylosis and cleft lip and palate are potential research direction in this field.

Conclusion

Future research should focus on the precise indications and optimal timing of craniomaxillofacial DO and the evaluation of the long-term outcomes of various modified procedures. This study provides a relatively objective reference for related researchers, medical practitioners, and global health systems.

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.

3D printed gelatin-genipin scaffolds for temporomandibular joint cartilage regeneration

Gelatin has emerged as a biocompatible polymer with high printability in scaffold-based tissue engineering. The aim of the current study was to investigate the potential of genipin-crosslinked 3D printed gelatin scaffolds for temporomandibular joint (TMJ) cartilage regeneration. Crosslinking with genipin increased the stability and mechanical properties, without any cytotoxic effects. Chondrogenic differentiation of human bone marrow-derived mesenchymal stem cells (hBMSC) on the scaffolds were compared to cell pellets and spheres. Although hBMSC seeded scaffolds showed a lower expression of chondrogenesis-related genes compared to cell pellets and spheres, they demonstrated a significantly reduced expression of collagen (COL) 10, suggesting a decreased hypertrophic tendency. After 21 days, staining with Alcian blue and immunofluorescence for SOX9 and COL1 confirmed the chondrogenic differentiation of hBMSC on genipin-crosslinked gelatin scaffolds. In summary, 3D printed gelatin-genipin scaffolds supported the viability, attachment and chondrogenic differentiation of hBMSC, thus, demonstrating potential for TMJ cartilage regeneration applications.

Ankylosis management with autogenous grafts: A systematic review

A systematic review was performed to assess the clinical outcomes of the reconstructive methods using autogenous grafts for the management of temporomandibular joint (TMJ) ankylosis A comprehensive electronic and manual search of the literature without date or language restriction was performed in January 2021 to identify randomized controlled trials, prospective, and retrospective studies with the aim of comparing the various surgical modalities for TMJ ankylosis. Twenty-six publications were included: prospective (n ​= ​17), retrospective (n ​= ​7), randomised control trial (n ​= ​1) and ambispective study (n ​= ​1). Costochondral graft was the most common graft used followed by Coronoid process graft. Meta-analysis was not possible as most of studies were non-controlled in nature. Based on the available data, there was a strong evidence that autogenous grafts especially Costochondral grafts and coronoid grafts have remained one of the most favoured methods of reconstruction. Prospective and randomized control studies are recommended for the best stratification for the use of autogenous grafts for the management of TMJ ankylosis.

Temporomandibular joint reconstruction with costochondral graft: case series study

Various techniques have been used to reconstruct the temporomandibular joints, including autogenous transplants and alloplastic implants. Among autogenous grafts, costochondral grafts have mainly been used. A costochondral graft has many advantages over other autogenous grafts and alloplastic implants. Harvest is easy and has minimal impact on patients. The graft can bear functional load well and biocompatibility is excellent. A costochondral graft obviates foreign body reactions and further surgery for revision of alloplastic replacements if the graft takes well. Although long-term prognosis remains unclear, it appears that for autogenous condylar reconstruction, costochondral grafts can be used with few complications and acceptable results. This article describes cases and discusses surgical techniques and considerations related to costochondral grafts.

Reconstruction of Bilateral Mandibular Condyles Using a Single Vascularized Fibula

Patients with end-stage temporomandibular joint (TMJ) pathology present with loss of vertical ramus height with resulting retrognathia, anterior open bite, and restricted jaw function requiring joint reconstruction. Costochondral grafts, long considered the gold standard for TMJ reconstruction, carry risks of bony ankylosis and resorption. Custom-made alloplastic TMJ prostheses show excellent objective and subjective outcomes but are also associated with complications such as infection or metal sensitivity, and necessitate hardware explantation in some cases. Revision surgeries are rare but present a real challenge. We present the case of a 50-year-old woman with longstanding TMJ arthritis, having undergone many surgical procedures to her TMJ, including explantation of failed alloplastic replacement, who presented with bilateral facial weakness as well as difficulty chewing and swallowing food. She had class II malocclusion with retrodisplacement of her mandible and anterior open bite, and moderate trismus with an inter-incisal opening of only 15 mm, consistent with fibrous ankylosis. After weighing all the reconstructive options, bilateral mandibular condyle and ramus reconstruction with a single fibula free flap (FFF) was planned with the use of preoperative virtual surgical planning (VSP) and 3D-printing of osteotomy and repositioning guides. A 2-team approach increases efficiency of the procedure and decreases operative time. The procedure and postoperative recovery were uncomplicated, and at her 2-month follow-up, she had increased range of motion and maintained the planned position of her mandible. Her masticatory function and deglutition were also improved due to the correction of her malocclusion and repair of her anterior open bite.

Analysis for different functional results of TMJ ankylosis management by comparing ramus-condyle unit reconstruction using vertical ramus osteotomy and interpositional gap arthroplasty

OBJECTIVE

The objective of the present study was to analyze the functional results of temporomandibular joint (TMJ) range; that is, trismus index, lateral excursion, protrusion, retrusion, occlusion, masticatory efficiency), reestablishment of the anatomic relationship of the TMJ, aesthetics to improve quality of life, and complications in terms of ramus shortening on the affected side, deviation, facial asymmetry, neurologic deficits, and reankylosis.

STUDY DESIGN

Sixteen patients with unilateral bony ankylosis were included and randomly divided into 2 groups with 8 patients in each group. Group I was treated with interpositional gap arthroplasty followed by reconstruction of the ramus-condyle unit using vertical ramus osteotomy. Group II was treated with interpositional gap arthroplasty. In both groups, a pedicled flap made up of fascia, temporalis muscle, and pericranium was used as an interpositional material. The functional range of the mandible was analyzed pre- and postoperatively.

RESULTS

Group I improved significantly more than group II in terms of TMJ range; that is, trismus index, lateral excursion, protrusion, retrusion, reestablishment of the normal anatomic relationship of the TMJ, aesthetics, and masticatory efficiency. The reestablishment of anatomic relationship showed better result in mastication significantly. No reankylosis was reported in any of the groups.

CONCLUSION

The functional results and aesthetics with TMJ reconstruction are significantly better.

DAPT inhibits titanium particle-induced osteolysis by suppressing the RANKL/Notch2 signaling pathway

Artificial prosthesis is wildly used in clinical medicine for degenerative disease such as osteoclast-related diseases. However, the material wear particles released from the surface of prostheses cause prosthetic loosening as a result of aseptic osteolysis in long-term use. Therefore, it is important to find an agent that inhibits the formation and function of osteoclast for therapeutic use. Notch signaling pathway plays a lot of roles in cell proliferation, differentiation, and apoptosis. However, the role of Notch signaling pathway in osteoclastogenesis remains unclear. The aim of this study is to assess the effects of γ-secretase inhibitor DAPT on osteoclastogenesis via Notch signaling pathway in vitro and titanium particle-induced osteolysis in vivo. In animal experiments, the inhibitory effect of DAPT on titanium particle-induced osteolysis in a mouse calvaria model was demonstrated. Interestingly, few resorption pits were observed following administration of DAPT and almost no osteoclasts formed at high concentration of DAPT. in vitro experiments revealed the mechanism of the effects of DAPT on osteoclastogenesis. DAPT inhibited the formation and function of osteoclast by blocking RANKL-induced Notch2-NF-κB complex signaling pathway. In conclusion, these results indicated that DAPT could prevent and cure titanium particle-induced prosthetic loosening and other osteoclast-related diseases.

Lemierre syndrome leading to ankylosis of the temporomandibular joint

Lemierre syndrome, also known as Lemierre's disease is a rare condition that was first described by Andre Lemierre in 1936. We present a case of a 3-year-old boy who presented with ankylosis of the right temporomandibular joint (TMJ) secondary to a mastoid infection as part of Lemierre syndrome. His ankylosis resulted in restricted mouth opening, which had a considerable impact on his speech and ability to eat. Surgical treatment comprising right coronoidectomy, gap arthroplasty of the TMJ, and interpositional fat grafting, enabled him to move his jaw and function has returned. This case report highlights the consequences of Lemierre syndrome and the need for clinicians to be aware of its features and the impact it may have on patients.

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.

Mandibular reconstruction with autogenous non-vascularised bone graft

Background

Reconstruction of mandibular defects can be challenging because an acceptable aesthetic and functional outcome must be achieved simultaneously.

Aim

To evaluate the pattern of mandibulectomy and reconstruction materials used in the reconstruction of mandibular defects.

Materials and methods

This was a retrospective study of mandibulectomies with reconstruction in Sokoto, Nigeria between 2012 and 2016. Data such as demographics, type of tumour, type of resection and type of reconstruction materials used were extracted and stored.

Results

Fifty-two cases of mandibulectomies were done comprising 24 males and 28 females (ratio 1:1.2). Age ranged 5–80 years with mean±SD (37.8±15). Most of the cases 30 (57.7%) were on the right. There are 35 (67.3%) benign and 17 (32.7%) malignant cases. Thirty (57.7%) lateral, 16 (30.8%) condylar, 1 (1.9%) central and 5 (9.6%) combined mandibular defects were seen. Reconstruction plate alone was used in 11 (21.2%) cases, reconstruction plate with rib and tibia grafts in 16 (30.8%) cases, reconstruction plate with Iliac crest and tibia grafts in 15 (28.8%) cases. Graft length ranged from 0–20cm. There was satisfactory outcome altogether in 32 (80.0%).

Conclusion

This study has shown the types of mandibulectomies and reconstruction materials used in our centre.

Ankylosis of the Temporomandibular Joint in Pediatric Patients

INTRODUCTION

While surgical interventions for temporomandibular joint (TMJ) ankylosis are well-documented, there is lack of consensus regarding the ideal approach in pediatric patients. Surgical interventions include gap arthroplasty, interpositional arthroplasty, or total joint reconstruction.

METHODS

A systematic review of PubMed (Jan 1, 1990-Jan 1, 2017) and Scopus (Jan 1, 1990-Jan 1, 2017) was performed and included studies in English with at least one patient under the age of 18 diagnosed with TMJ ankylosis who underwent surgical correction. Primary outcomes of interest included surgical modality, preoperative maximum interincisal opening (MIO) (MIOpreop), postoperative MIO (MIOpostop), ΔMIO (ΔMIO = MIOpostop - MIOpreop), and complications.

RESULTS

Twenty-four case series/reports with 176 patients and 227 joints were included. By independent sample t tests MIOpostop (mm) was greater for gap arthroplasty (30.18) compared to reconstruction (27.47) (t = 4.9, P = 0.043), interpositional arthroplasty (32.87) compared to reconstruction (t = 3.25, P = 0.002), but not for gap compared to interpositional (t = -1.9, P = 0.054). ΔMIO (mm) was greater for gap arthroplasty (28.67) compared to reconstruction (22.24) (t = 4.2, P = 0.001), interpositional arthroplasty (28.33) compared to reconstruction (t = 3.27, P = 0.002), but not for interpositional compared to gap (t = 0.29, P = 0.33). Weighted-average follow-up time was 28.37 months (N = 164). 4 of 176 (2.27%) patients reported development of re-ankylosis. There was no significant difference in occurrence of re-ankylosis between interventions.

CONCLUSIONS

Given the technical ease of gap arthroplasty and nonsignificant differences in ΔMIO, MIOpostop, or occurrence of re-ankylosis between gap and interpositional arthroplasty, gap arthroplasty should be considered for primary ankylosis repair in pediatric patients, with emphasis on postoperative physiotherapy to prevent recurrent-ankylosis.

The Inverted Coronoid-Ramus Graft for Condylar Reconstruction

The purpose of this article is to describe a creative, versatile technique for condylar reconstruction using autogenous mandibular bone. The technique has been used for reconstruction of small condyle and/or ramus defects (approximately 35 to 40 mm in length) typically associated with condylar hyperplasia, condylar tumors, idiopathic condylar resorption, and failed reconstruction attempts. The technique involves excision of the ipsilateral coronoid process-mandibular ramus, inverting it and rotating the segment 180° along its horizontal axis to replace the excised condyle. The resultant graft simulates the morphology of the posterior aspects of the ramus and condyle and has been shown to resist resorption typical of endochondral bone grafts harvested from the rib or iliac crest. Grafting is carried out via vestibular and preauricular or endaural incisions. Four cases followed over a period of 3 to 40 months (average, 21 months) are presented. No adverse functional results, including ankylosis, removal of hardware or adverse remodeling, have occurred. A period of intermaxillary fixation is used because it is considered beneficial for intra-articular scarring of the subglenoid fossa pad (disc or retrodiscal tissue and fibrocartilage) and initial healing. Physical therapy has not been prescribed. The inverted coronoid graft is a versatile technique when virtual surgical planning is used to assess feasibility, as well as defect and graft dimensions; fabricate custom bone plate and drilling guides; and determine screw osteosynthesis sites. In general terms, a post-reconstruction opening of 35 mm allows for adequate function and guards from contralateral symptomatic hypermobility given disparate right- and left-sided joint mechanics. In the cases described, a mean of 40.5 mm was achieved; however, in 2 of these cases, this was measured with undesirable asymptomatic (preoperative) deviation to the ipsilateral side by greater than 4 mm and by 6 mm. The inverted coronoid graft technique reduces operative time, can be executed with few external scars, and reduces the number of operative fields.

Considerations for Temporomandibular Joint Procurement in Vascularized Composite Allotransplantation

Methods for harvest of the temporomandibular joint (TMJ) for transplantation may involve several anatomic levels. The authors aim to assess the feasibility and identify challenges with 2 such methods, resuspending the donor condyles from the recipient glenoid fossae and en bloc harvest of the joint and surrounding temporal bone with plate-fixation to the recipient skull base. Two mock face transplantations were carried out using 4 fresh cadavers. Computed tomography imaging was obtained before and after the procedures to assess the technical success of each method. Both techniques were technically successful, allowing for full passive jaw range of motion following graft transfer and appropriate condyle positioning as assessed by computed tomography. En bloc TMJ harvest allowed for transfer of the entire joint without violating its capsule or altering its biomechanics. The authors found this technique better able to avoid issues with size mismatch between the donor mandible and recipient skull base width. When no such mismatch exists, graft harvest at the level of the mandibular condyle is technically easier and less time consuming. Although both methods of TMJ harvest are technically feasible with acceptable immediate postoperative jaw position and range of motion, the en bloc technique allows for more natural jaw function with less risk of postoperative joint immobility by preserving the joint capsule and its ligamentous support.

Management of Temporomandibular Joint Ankylosis With Dentofacial Deformities in Children

This retrospective study described the authors' experience in the treatment of temporomandibular joint (TMJ) ankylosis with dentofacial deformities in 18 pediatric patients during a 4-year period. These patients underwent different types of arthroplasty with condylar reconstruction, simultaneously with treatment of dentofacial deformities. Re-ankylosis was confirmed if maximal incisal opening (MIO) was <20 mm. Clinical outcomes were evaluated in terms of oral function, radiography, and medical photography. Patients were followed up for a mean time of 24.8 months. No infections, re-ankylosis, or permanent facial nerve damage were found during the hospitalization or follow-up period. All patients achieved significant improvements in MIO and oral function. The dentofacial deformities in most patients were improved to varying degrees. The results provided more useful information for the management of the pediatric patients with TMJ ankylosis and secondary dentofacial deformities. Early treatment and close follow-up play an important role in the management of these patients.

Interpositional Arthroplasty by Temporalis Fascia Flap and Galea Aponeurotica Combined With Distraction Osteogenesis: a Modified Method in Treatment of Adult Patients With Temporomandibular Joint Ankylosis and Mandibular Dysplasia

BACKGROUND

Interpositional arthroplasty (IPA) with temporalis fascia flap has been one of the most frequently performed procedures to treat temporomandibular joint (TMJ) ankylosis. However, recurrence often occurs when the flap lacks bulk or atrophies. Whether to perform IPA or distraction osteogenesis (DO) first has long been a controversial issue when patients presented mandibular dysplasia (MD). This study provided IPA a new graft material sufficient to prevent recurrence, combined the modified protocol of performing DO 6 months after IPA, and evaluated its efficacy in treating TMJ ankylosis patients with MD.

METHODS

Six patients with unilateral TMJ ankylosis and MD were treated in the authors' study. The temporalis fascia flap and part of adjacent galea aponeurotica were filled the space after surgical release. Mouth-opening exercises started immediately post-IPA. Distraction osteogenesis was performed 6 months after IPA and had a 4-month consolidation. The maximum interincisal distance at preoperative, immediately post-IPA and the latest follow-up were recorded, as was the distraction length. The body mass index was measured at each patient's postoperative visit.

RESULT

All patients had significant improvements in facial aesthetic, mouth-opening, and occlusion. No major complication or recurrence was observed at 3 to 4 years' follow-up. The mean maximum interincisal distance was 4.83 ± 2.79 mm preoperative and 35.67 ± 3.39 mm at the latest follow-up. The mean distraction distance was 16.17 ± 5.98 mm. The body mass index improved from 17.33 ± 0.64 kg/m preoperative to 18.75 ± 0.60 kg/m before DO.

CONCLUSIONS

Temporalis fascia flap and adjacent galea aponeurotica as new graft materials are recommended for IPA. The modified staged treatment proved to be reliable and effective to prevent recurrence, improve mandibular length and final occlusion.

Skull Base Erosion Resulting From Primary Tumors of the Temporomandibular Joint and Skull Base Region: Our Classification and Reconstruction Experience

PURPOSE

We sought to introduce our classification and reconstruction protocol for skull base erosions in the temporomandibular joint and skull base region.

PATIENTS AND METHODS

Patients with neoplasms in the temporomandibular joint and skull base region treated from January 2006 to March 2017 were reviewed. Skull base erosion was classified into 3 types according to the size of the defect.

RESULTS

We included 33 patients, of whom 5 (15.2%) had type I defects (including 3 in whom free fat grafts were placed and 2 in whom deep temporal fascial fat flaps were placed). There were 8 patients (24.2%) with type II defects, all of whom received deep temporal fascial fat flaps. A total of 20 patients (60.6%) had type III defects, including 17 in whom autogenous bone grafts were placed, 1 in whom titanium mesh was placed, and 2 who received total alloplastic joints. The mean follow-up period was 50 months. All of the patients exhibited stable occlusion and good facial symmetry. No recurrence was noted.

CONCLUSIONS

Our classification and reconstruction principles allowed reliable morpho-functional skull base reconstruction.

Kaempferide Prevents Titanium Particle Induced Osteolysis by Suppressing JNK Activation during Osteoclast Formation

Kaempferide (KF) is an O-methylated flavonol, a natural plant extract, which is often found in Kaempferia galanga. It has a variety of effects including anti-carcinogenic, anti-inflammatory, anti-oxidant, anti-bacterial and anti-viral properties. In this study, we aimed to investigate whether KF effectively inhibits titanium particle induced calvarial bone loss via down regulation of the JNK signaling pathway. In the mice with titanium particle induced calvarial osteolysis, the Low dose of KF mildly reduced the resorption pits while in the high dose group, fewer scattered pits were observed on the surface of calvarium. Histological examination showed fewer osteoclasts formation in the KF group. In mouse bone marrow macrophages (BMMs) and RAW264.7 cells, KF significantly inhibited the osteoclast formation and bone resorption at 12.5 μM. However, KF does not affect the mature osteoclast F-actin ring formation. But when being co-treated with KF and anisomycin, BMMs differentiated into mature osteoclasts. At the molecular levels, the JNK phosphorylation was inhibited and the osteoclastogenesis-related specific gene expression including V-ATPase d2, TRAP, calcitonin receptor (CTR), c-Fos and NFATc1 was markedly suppressed. In conclusion, these results indicated that KF is a promising agent in the treatment of osteoclast-related diseases.

The autogenous graft versus transport distraction osteogenesis for reconstruction of the ramus-condyle unit: a prospective comparative study

This study aimed to compare the joint function and morphology achieved following condylar reconstruction using sternoclavicular grafts (SCG) versus transport distraction osteogenesis (TDO) in temporomandibular joint (TMJ) ankylosis patients. Twenty-two patients with TMJ ankylosis underwent TMJ reconstruction with SCG or TDO (n=11 each). Radiographic and clinical evaluations were performed at 1 week and at 1, 3, and 6 months post-surgery. Clinical criteria examined included the duration of surgery, mean postoperative mouth opening, excursive jaw movements, and pain scores. The radiographic evaluation 6 months postoperatively (computed tomography) included subjective assessment of joint morphology and measurements of the mean condylar height, width achieved, and amount of condylar resorption. The χ² test and Student t-test were used to compare qualitative and quantitative variables, respectively. Similar mean mouth opening (SCG=31.8mm, TDO=32.1mm at 6 months), excursive movements, and pain scores were observed in the two groups throughout follow-up. Mean condylar resorption was significantly greater in the TDO group (TDO=7.0mm, SCG=2.7mm; P=0.005). The duration of reconstruction surgery was greater in the SCG group (P=0.035). A greater incidence of complications was observed with TDO. In conclusion, based on the protocols used in this study, SCGs are superior to TDO in terms of condylar morphology, stability, and surgical safety.

Transport distraction osteogenesis combined with orthodontic treatment in a patient with unilateral temporomandibular joint ankylosis

Temporomandibular joint ankylosis manifests a range of clinical characteristics dependent upon the age of onset, the affected side, and the severity. When it occurs during development, mandibular growth is affected, resulting in severe retrusion or asymmetry as well as limitation of mandibular movements. Progressive asymmetric mandibular growth in unilateral ankylosis causes canting of the occlusal plane. In this case report, we present a successful temporomandibular joint reconstruction using transport distraction osteogenesis combined with camouflage orthodontic treatment for occlusal canting correction of a patient with unilateral temporomandibular joint ankylosis and severe facial asymmetry.

Novel technique for harvesting the sternoclavicular graft

PURPOSE

Originally introduced for mandibular reconstruction more than 40 years ago, the sternoclavicular graft (SCG) has gained widespread popularity for the reconstruction of the ramus-condyle unit (RCU) owing to its anatomic and histological likeness to the normal mandibular condyle. Conventional longitudinal osteotomy design for its harvest has been fraught with considerable complications at the donor site including fracture clavicle and major neurovascular injury. In an attempt to alleviate these ill effects, a new technique for procuring the sternoclavicular graft is presented.

MATERIAL AND METHODS

A split-thickness cortico-cancellous graft was harvested form the sternal end of the clavicle along with the articular disk with the osteotomy cut oriented parallel to the coronal plane, with limited soft tissue dissection. Donor site complications were assessed in terms of incidence of clavicle fracture, neurovascular injury, pleural tear and radiographic healing as seen in the six-month postoperative chest radiograph.

RESULTS

17 patients suffering from unilateral temporomandibular joint ankylosis underwent SCG harvesting for RCU reconstruction following osteoarthrectomy. No adverse events were seen in the intra- and post-operative period in any patient and satisfactory radiographic osseous healing was observed after six months.

CONCLUSION

The proposed harvest technique for SCG results in reduced donor site morbidity and favourable healing and greater patient comfort.

Zurich pediatric distractor for ramal condylar unit distraction in temporomandibular joint ankylosis

Temporomandibular joint (TMJ) Ankylosis is an extremely disabling condition characterized by difficulty or inability to open the mouth resulting in facial asymmetry, malocclusion and dental problems. Surgical excision of the ankylosed mass is the only treatment option available to gain mouth opening. The loss in vertical height of ramus following release of ankylosis is difficult to manage in both unilateral and bilateral TMJ ankylosis. Out of all the methods to restore this height Distraction Osteogenesis (DO) is gaining popularity because of predictable gain in the length without any associated morbidity. Recurrent bilateral TMJ ankylosis in a 32 year old male was treated by osteoarthrectomy and temporal fascia interpositioning arthroplasty. Bilateral reconstruction of ramal condylar unit (RCU) was carried out by Zurich paediatric distractor (KLS Martin, Tuttlingen Germany). Following a latency period of 7 days distraction was carried out at a rate of 1mm/day for 8 days. Distractors were removed after 12 weeks of consolidation period. The case was followed up for 12 months during which the mouth opening was maintained at 38 mm and there was no anterior open bite.

Coronoid process and residual ankylotic mass as an autograft in the management of ankylosis of the temporomandibular joint in young adolescent patients: a retrospective clinical investigation

The aim of this non-randomised investigation was to assess the feasibility of using autogenous grafts (such as coronoid process and the resected ankylotic mass) in reconstruction of the condyle after gap arthroplasty for ankylosis of the temporomandibular joint (TMJ). Sixteen patients (23 joints) operated on between 2007 and 2009 were studied and postoperative measurements of maximum interincisal opening, bite force, range of movement, and infection were recorded. After a mean (SD) follow up of 55 (2.25) months mouth opening improved from 3 (3.84) mm to 33 (1.66) mm in patients treated with coronoid graft, while in patients treated with an ankylotic mass after a mean (SD) follow up of 58 (1.58) months it increased from 4 (2.64) mm to 26 (8.04) mm. Bite force six months postoperatively ranged from 18.25kg/cm(2) - 27.5kg/cm(2) after reconstruction with the coronoid process and 18.5kg/cm(2) - 23.25kg/cm(2) after reconstruction with the ankylotic mass. One patient developed reankylosis postoperatively and another developed infection, in both of which the ankylotic mass had been used. Both were managed successfully. Both the ankylotic mass and the coronoid process gave satisfactory results and seem to be options for reconstruction. However, the coronoid process graft was better than residual ankylotic mass in terms of masticatory efficiency, bite force, and range of movement.

Computer-aided resection and reconstruction in a case of aneurysmal bone cyst of the mandibular condylar head

A case is presented of a 16-year-old girl with an aneurysmal bone cyst (ABC) of the mandibular condyle of the temporomandibular joint (TMJ). This lesion rarely involves the mandibular condyle, and involvement of condylar head is even rarer. To our knowledge, only 12 cases have been reported in the literature so far. This is the first case of ABC of the mandibular condyle with 3D planning of costochondral graft reconstruction described in the literature.

Ramus Condyle Unit Reconstruction Using Vertical Ramus Osteotomy in Temporomandibular Joint Ankylosis

INTRODUCTION

Treatment of bony Temporomandibular Joint (TMJ) Ankylosis includes release of the ankylosis and creation of a gap with or without insertion of interposing material and complete reconstruction of the joint using e.g. costochondral, autogenous coronoid/ankylosed mass, sternoclavicular, clavicular bone grafts etc. As these are non-pedicled grafts, there is eventual resorption with subsequent decrease in height of the ramus, facial asymmetry, deviated mouth opening and reankylosis. The authors have applied the method of vertical ramus osteotomy (VRO) on the posterior border of the mandibular ramus for reconstruction of the ramus condyle unit (RCU) as a pedicled graft along with Myofascial Temporalis Interposition for the correction of TMJ Ankylosis.

MATERIALS AND METHODS

Ten patients of TMJ Ankylosis were included in this study. All ten patients were treated using VRO for the RCU reconstruction with posterior border of mandibular ramus after Gap Arthroplasty. Temporalis myofascial flap was used as an interpositional material in all patients. Patients were followed from 20 to 30 months (mean 24 months).

RESULTS

As a result of successful procedure the post-operative maximal mouth opening of 32-45 mm (mean 37 mm) was achieved. No patient experienced pain and infection at surgical site. None of the patients had graft rejection and reankylosis at follow-up.

CONCLUSION

The results showed that VRO on the posterior border of the mandibular ramus seems to be an alternative and promising method for RCU reconstruction in patients with TMJ Ankylosis.

Preliminary clinic study on computer assisted mandibular reconstruction: the positive role of surgical navigation technique

Background

The objectives of the present study were to investigate the reliability and outcomes of computer-assisted techniques in mandibular reconstruction with a fibula flap and verify whether the surgical navigation system was feasible in mandible reconstructive surgery.

Methods

Eight cases were enrolled in the computer assisted surgery (CAS) group and 14 cases in the traditional group. The shaping and fixation of the fibula grafts were guided by computer assisted techniques, which could be monitored with the BrainLAB surgical navigation system. The variation of mandible configuration was evaluated by CT measurement in the Mimics software, including the variation of length, width, height and gonial angle of the mandible. The 3D facial soft tissue alteration was also analyzed in 3D chromatogram by Geomagic software.

Results

All 22 fibula flaps survived. The mandibular configurations and facial contours had a better clinic result in the CAS group. The length, width, height and gonial angle of the reconstructive mandible were more similar to the original one. The Wilcoxon rank sum test analysis suggested significant differences in the measurements. The chromatographic analysis also visually showed superiority over the traditional group.

Conclusions

The computer assisted surgical navigation method used in mandibular reconstruction is feasible and precise for clinical application. The contour of the reconstructed mandible and facial symmetry are improved with computer techniques.

Use of oral mucoperiosteal and pterygo-masseteric muscle flaps as interposition material in surgery of temporomandibular joint ankylosis: a comparative study

Background:

The most common complication of surgery for the release of temporomandibular joint (TMJ) ankylosis is relapse of the ankylosis. To prevent re-ankylosis, a variety of interpositional materials have been used.

Aim:

The aim was to compare the surgical outcome of oral mucoperiosteal flap, not hitherto used as interpositional material, with pterygo-masseteric muscles flap after surgical release of TMJ ankylosis.

Subjects and Methods:

This was a prospective randomized study of all consecutive patients treated for the release of complete TMJ bony ankylosis, from January 2003 to December 2012, at the Oral and Maxillofacial unit of our institution. The patients were randomized into two groups: The pterygo-masseteric group comprises 22 patients while the oral mucoperiosteal group had 23 patients. Information on demographics, clinical characteristics, and postoperative complications over a 5 year follow-up period were obtained, and analyzed using the statistical package for social sciences (Statistical Package for the Social Sciences version 13, Chicago, IL, USA). A P < 0.05 was considered significant.

Results:

The age of the patients ranged from 15 to 28 mean 20.3 (3.35) years while the duration of ankylosis ranged from 2 to 16 mean 5.1 (3.4) years. The baseline demographic (gender; P = 0.92; side; P = 0.58) and clinical characteristics in terms of etiology (P = 0.60) and age (P = 0.52) were comparable in both treatment groups. All the patients presented with complete bony TMJ ankylosis with a preoperative inter-incisal distance of <0.5 cm. The intraoperative mouth opening achieved ranged from 4 cm to 5 cm, mean 4.6 (0.27) cm and this was not different for either group (P = 0.51). The patients were followed up postoperatively for a period ranging from 3 to 5 years, mean 3.4 (0.62) years. The mouth opening decreased, over the period of postoperative review, from the initial range of 4–5 cm to 2.9–3.6 cm, and this was not different in both groups (P = 0.18).

Conclusion:

This study suggests that oral mucoperiosteal flap could be an option in the choice of interpositional materials in surgery of TMJ ankylosis.

Retrospective comparison of autogenous cosotochondral graft and coronoid process graft in the management of unilateral ankylosis of the temporomandibular joint in adults

We retrospectively compared the clinical outcomes of autogenous coronoid process grafts (n=32) and costochondral grafts (n=28) in condylar reconstruction for the treatment of unilateral ankylosis of the temporomandibular joint (TMJ) in adults. Preoperative and postoperative assessments included diet scores, cone-beam computed tomography (CT), maximal interincisal opening, lateral excursion, and mandibular deviation on opening the mouth. There were no significant differences between the 2 groups in the measurements before and after the operation with respect to incisal opening, lateral excursion, mandibular deviation, diet scores, or recurrence rate, but in both the postoperative incisal opening, lateral excursion, and diet scores had improved significantly compared with preoperatively. After costochondral graft 3 patients developed intraoperative plural tears, and 6 had temporary pain at the donor site. The frontal branch of the facial nerve was temporarily affected in 5 patients after costochondral graft and 3 after coronoid process grafts, all of which recovered in 3-6 months. There was no recurrence after coronoid process grafting, and one after costochondral grafting. The clinical outcomes in both groups were satisfactory and comparable. Autogenous coronoid process grafting may therefore be a good alternative for condylar reconstruction in patients with ankylosis of the TMJ.

Comparison of Costochondral Graft and Customized Total Joint Reconstruction for Treatments of Temporomandibular Joint Replacement

Purpose:

We review published research on temporomandibular joint (TMJ) total replacement that compares costochondral graft and customized total joint reconstruction (especially TMJ concepts), focusing on effectiveness.

Methods:

We searched PubMed databases, including prospective, retrospective, case-control or longitudinal studies and significant statistical analysis. In data analysis, we divided outcomes into ‘Acceptable’ or ‘Non-acceptable’.

Results:

There were seven articles found dealing with costochondral graft and 180 patients. The majority of patients had satisfactory treatment outcomes (n=109, 61%). There were six articles including 275 patients using the alloplastic material TMJ concepts. Almost all patients had satisfactory treatment outcomes (n=261, 95%).

Conclusion:

Comparing customized total joint reconstruction with costochondral graft, use of TMJ concepts resulted in increased quality of life and fewer complications. In conclusion, we judged that alloplastic material such as TMJ concepts is more effective device in total joint replacement than costochondral graft.