The sequential treatment of temporomandibular joint ankylosis with secondary deformities by distraction osteogenesis and arthroplasty or TMJ reconstruction

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.

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.

Combination of double-sliding advancement genioplasty and prearthroplastic distraction osteogenesis in cases of TMJ ankylosis with severe mandibular atrophy

The aim of this study is to present a case of facial asymmetry secondary to unilateral long-standing temporomandibular joint (TMJ) ankylosis managed by a staged treatment protocol. Treatment for facial asymmetry secondary to unilateral TMJ ankylosis can have varied approaches followed by different workers according to their experiences. This predistraction arthroplasty versus prearthroplastic distraction debate has been at the center stage in literature for quite some time. Hereby, we present a case followed by the latter approach along with double-sliding genioplasty to correct chin asymmetry. A 25-year-old male patient with a history of facial trauma 15 years ago reported a complaint of inability to open mouth and gradually developing facial asymmetry. The patient was thoroughly evaluated using radiographs and cephalometric analysis to establish the diagnosis of TMJ ankylosis with facial asymmetry and suspected sleep apnea. The patient was treated according to our institutional protocol of prearthroplastic asymmetry correction followed by ankylosis release along with double-sliding genioplasty to correct residual deformity at a later date. Correction of facial asymmetry before ankylosis release provides a more evidence-based approach as supported by the current literature. Plus, any residual deformity can be rectified using orthomorphic procedures such as genioplasty. Since there is an ongoing debate in the current literature about sequencing in the treatment of facial asymmetry cases, the presented case adds to the argument that the approach followed herein provides for more favorable outcome.

Bilateral Biplanar Distraction Osteogenesis in Facial Deformity Secondary to Temporomandibular Ankylosis

Background

The purpose of this single-centre prospective clinical study was to evaluate the correction of severe facial deformity and Obstructive sleep apnoea hypopnoea syndrome (OSAHS) in 22 patients aged from 9 to 42 years (mean 20.09) of bilateral Temporomandibular joint ankylosis.

Materials and Methodology

Patients underwent multisegment distraction using external bilateral bidirectional distractors. Facial deformity was evaluated clinically in terms of mouth opening and neck chin angle and cephalometrically in terms of corpus length (gonion-pogonion), ramal height (articulare-gonion), chin deficiency (N perpendicular to Pog and SNB). OSAHS was evaluated through Epworth sleepiness scale, Berlin's questionnaire, pharyngeal airway space, apnoeic hypoapnoeic index, oxygen desaturation index, average arterial oxygen saturation and minimal fall in O2 saturation. Patients were followed up for a period of 13-74 months (mean 28.68).

Results

Statistically highly significant results were obtained in all parameters. Complications encountered were pin infection (13.63%), loosening of pins (4.5%), wound dehiscence (9.09%), tooth fracture (4.5%) and parotid fistula (9.09%). Intermediate segment necrosis and vector loss were not observed.

Conclusion

This study is a large case series using two corticotomy cuts for external bilateral bidirectional distracters with concomitant neo callous moulding in patients both pre- and post-ankylosis release. It is extremely efficient in correcting mandibular corpal and ramal deficiency as well as improving OSAHS.

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.

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.

A Bibliometric Analysis of International Publication Trends in Total Temporomandibular Joint Replacement Research (1986-2020)

PURPOSE

To conduct a bibliometric analysis that systematically characterizes publications on temporomandibular joint temporomandibular joint replacement from 1986 to 2020.

MATERIALS AND METHODS

The articles were retrieved on the same day from the Web of Science Core Collection database of the Web of Science on December 31, 2020 to prevent bias due to daily database updates. Excel 2016, CiteSpace IV, and VOSviewer v1.6.16 were used for analysis.

RESULTS

A sum of 610 publications from 1986 to 2020 were analyzed. The highest number of publications were identified and published in the Journal of Oral and Maxillofacial Surgery. The United States had the highest number of publications and the highest H-index. The highest co-citations were from Mercuri.

CONCLUSIONS

In this study, developments, the most influential publications, journals, and countries in the field of temporomandibular joint temporomandibular joint replacement were determined based on evidence through bibliometric analysis.

Interpositional arthroplasty of post-traumatic temporomandibular joint ankylosis: A modified method

The purpose of this study was to evaluate a modified method of interpositional arthroplasty for post-traumatic temporomandibular joint ankylosis. All patients were treated with a modified interpositional arthroplasty that included: navigation-assisted accurate bone dissection with minimal removal of only 5 mm of the ankylosed bony mass, novel application of bone wax and porcine acellular dermal matrix to prevent re-ankylosis, and a unique 3D-printed splint for occlusal stabilization and gap maintaining. The pre- and post-operative physical and radiological examinations of patients were recorded during routine follow-up visits. Postoperative follow-up visits lasted at least 12 months. Twelve patients, seven males and five females, ranging from 21 years to 59 years, were enrolled in this retrospective case series. All of the twelve patients with eighteen bony ankylosed temporomandibular joints were treated by our new method. The post-operative follow-up periods ranged from 1 year to 4 years. During the follow-up visits within at least 1 year, no one manifested re-ankylosis. The mean maximum incisor opening changed from 7.4 ± 5.3 mm (p < 0.001, before surgery) to 37.6 ± 3.9 mm (p < 0.001, last follow-up visit). No sign of post-operative infection or foreign body rejection was observed during the follow-up visits. The post-operative occlusal relationship was sound and stable. It is suggested that the modified method of interpositional arthroplasty provides favorable clinical and radiographic outcomes after a short-term follow up.

Temporomandibular Joint Ankylosis among Patients at Saint Paul's Hospital Millennium Medical College, Ethiopia: A 9-Year Retrospective Study

Background

Temporomandibular joint ankylosis (TMJA) is a gradually developing pathological condition manifested by a limited mouth opening. It can result in an extremely disabling deformity that may affect mastication, swallowing, speech, oral hygiene, and facial cosmetic appearance. The present study aimed to determine the pattern of TMJA at St. Paul's Hospital millennium medical college (SPHMMC), Addis Ababa, Ethiopia.

Methods

A retrospective descriptive study design was conducted at SPHMMC. All medical records of patients with the diagnosis of TMJA that visited the Maxillofacial Surgery unit from September 2010 through August 2019 were reviewed. Sociodemographic and clinical data including age, sex, place of residency, duration of TMJA cases, etiology, clinical presentations, imaging results, type of surgical operation, and complications after surgery were collected and analyzed using IBM SPSS software version 20 for Windows (Armonk, NY, USA: IBM Corp) computer program.

Results

A total of 130 patients' medical records were reviewed. Out of this, 95 were included in the study. Forty-two (44.2%) of the TMJA cases were males, while the remaining 53 (55.8%) were females with a male to female ratio of 0.79 : 1. 20-29-year-old patients were the most affected, 36 (37.9%), followed by the 30 to 39 years age group, 33 (34.7%). Trauma (77.9%) was identified as the most common cause of TMJA. Notably, bilateral ankylosis (72.6%) was more common than unilateral (27.3%), and micrognathia was the most common (23.0%) deformity observed. The majority 52 (54.7%) of TMJA patients were treated with gap arthroplasty.

Conclusions

TMJA was predominant among females than their male counterparts. Of note, 20-29-year-old patients were the most affected group. The majority of TMJA cases were treated by gap arthroplasty with almost no postoperative complications. Early detection and intervention to release the ankylosed joint is needed to improve patients' quality of life.

Controversies in the management of temporomandibular joint ankylosis using distraction osteogenesis - A systematic review

Background:

The three commonly employed sequences of distraction osteogenesis (DO) in the management of temporomandibular joint (TMJ) ankylosis with dentofacial deformities include post-arthroplastic distraction osteogenesis (PAD), simultaneous arthroplastic distraction osteogenesis (SAD), and pre-arthroplastic distraction osteogenesis (PrAD).

Objective:

The aim of this systematic review is to compare the effectiveness of various sequences of DO in the management of TMJ ankylosis with micrognathia/and obstructive sleep apnea syndrome (OSAS).

Data Sources:

A comprehensive online and manual search of English language literature with no date restrictions was done on March 2020.

Eligibility Criteria:

Inclusion criteria were case series and prospective and retrospective studies involving adult/paediatric human subjects with unilateral/bilateral TMJ ankylosis and micrognathia/OSAS treated with DO.

Study Appraisal and Synthesis Methods:

Of 73 studies identified, only 10 were included in the qualitative synthesis. The outcomes assessed were as follows: maximum mouth opening (MMO), posterior airway space (PAS), polysomnography variables, reankylosis, mandibular length, and chin and mandible position.

Results:

All the included studies showed high risk of bias. MMO and mandibular length increased, chin and mandibular position improved by the end of treatment in all the three sequences, and polysomnography variables and PAS significantly improved in PrAD compared to PAD and improved in SAD compared to baseline. Reankylosis was significantly less in PrAD.

Conclusion:

More well-designed studies comparing the three sequences of DO should be carried out to arrive at a consensus.

Sequential treatment of unilateral temporo-mandibular joint ankylosis with distraction osteogenesis - a case report

Temporo-mandibular joint (TMJ) ankylosis is a common cause of acquired mandibular deformity in children and adults. It causes reduced mouth opening and limitation of functional movements resulting in mandibular growth impairment leading to mandibular retrognathism and facial asymmetry. The treatment of TMJ ankylosis is challenging, not only due to the complexities involved and the risk of relapse but also because it requires a high degree of patient cooperation. The treatment may be performed in 1 or 2 phases consisting of the initial release of ankylosis with or without condylar reconstruction, followed by a correction of mandibular hypoplasia and of facial asymmetry by orthognathic surgery. Distraction osteogenesis has been proposed to treat cases with severe deformity due to its inherent advantages of generating new bone and soft tissue. This case report describes the staged treatment of a patient with unilateral TMJ ankylosis. The patient presented with significant facial deformity due to mandibular retrognathism and facial asymmetry as a consequence of impaired growth. The treatment objectives included releasing ankylosis to establish mouth opening, addressing the dentofacial deformity and achieving a normal occlusion. The patient was treated with a combined surgical-orthodontic approach including distraction osteogenesis. The case was treated with a rigid external distractor and CBCT generated facial models were used to plan and execute adjunctive surgeries. The staged treatment approach resulted in a significant improvement of facial aesthetics.

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.

Protocol for the management of ankylosis of the temporomandibular joint

Ankylosis of the temporomandibular joint (TMJ) is a severely deforming, disabling condition as a result of craniomandibular fusion caused mainly by condylar fractures with displacement of the meniscus. Ankylosis may be fibrous, fibro-osseous, or bony, and unilateral or bilateral. The severity of the deformity is based on the onset, duration, and type of ankylosis. Various surgical techniques have been described for treatment, but no single treatment is recommended because of inconsistent results and the high rate of failure. While our total experience extends to 300 cases, we have developed a protocol using the most recent 193 patients to address our earlier high failure rate. The onset was during childhood in 168 patients, and 25 were adults. We describe the protocol that we developed for these two groups. Our management included gap arthroplasty, costochondral grafting, temporalis flaps, ramus osteotomies, and transport distraction.

Temporomandibular Joint Ankylosis Leading to Obstructive Sleep Apnea

Temporomandibular joint ankylosis in children commonly lead to difficulty in feeding, poor oral hygiene, retrognathic mandible and obstructive sleep apnea. Surgical release of the ankylosis has always been the standard treatment. The authors report a 12 year old boy with unilateral temporomandibular joint ankylosis and obstructive sleep apnea underwent surgical release of the ankylosis with successful gain in mouth opening. However, he continued to suffer from obstructive sleep apnea as confirmed by post-operative polysomnography. Orthognathic surgery for mandibular advancement is not favorable due to his young age and mandibular distraction osteogenesis was not a choice. A mandibular advancement device similar to orthodontic myofunctional appliance was the preferred choice in the post-operative period while waiting for definitive retrognathia surgical treatment after skeletal maturity. Surgical release of temporomandibular joint ankylosis corrects the oral problem but does not adequately address the narrow pharyngeal airway space. Assessment of pharyngeal airway with a high suspicion of obstructive sleep apnea is mandatory in the management of TMJ ankylosis.

Staged therapeutic approach for rehabilitation of severe asymmetric Class II dentofacial deformity secondary to long standing unilateral temporomandibular joint ankylosis

Despite being one of the most pervasive debilitating skeletal problems in the craniofacial region, surgical-orthodontic management of long-standing asymmetric Class II dentofacial deformities is often a unique challenge posed to the clinicians. This case report describes the encouraging results of systematically sequenced and staged therapeutic approach adopted for successful rehabilitation of an adult patient with asymmetric Class II dentofacial deformity with mandibular micrognathia secondary to unilateral TMJ ankylosis. Concurrent gap arthroplasty and bilateral distraction of mandibular body were performed during the first operation for functional restoration of mandibular movements and correction of mandibular micrognathia and associated asymmetry. After 13 months of post-distraction orthodontic treatment, Le Fort I osteotomy for inferior repositioning and sagittal advancement of maxilla was performed during the second operation, in conjunction with adjunctive alloplastic reconstruction of inferior border of mandible for optimization of facial aesthetics. Postsurgical orthodontic detailing facilitated achievement of stable, balanced interdigitation. The total active treatment period was 29 months. After treatment, both the skeletal disharmony and the functional stability were significantly improved with establishment of functional occlusion. The morphological and functionally acceptable results were reasonably well-maintained during three-year follow-up. The merits of mandibular osteodistraction vs. conventional mandibular orthognathic surgery and the potential advantages of staged surgical approach are discussed.