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

Analysis of the Use of Sample Size and Effect Size Calculations in a Temporomandibular Disorders Randomised Controlled Trial-Short Narrative Review

BACKGROUND/OBJECTIVES

Temporomandibular disorder (TMD) is the term used to describe a pathology (dysfunction and pain) in the masticatory muscles and temporomandibular joint (TMJ). There is an apparent upward trend in the publication of dental research and a need to continually improve the quality of research. Therefore, this study was conducted to analyse the use of sample size and effect size calculations in a TMD randomised controlled trial.

METHODS

The period was restricted to the full 5 years, i.e., papers published in 2019, 2020, 2021, 2022, and 2023. The filter article type-"Randomized Controlled Trial" was used. The studies were graded on a two-level scale: 0-1. In the case of 1, sample size (SS) and effect size (ES) were calculated.

RESULTS

In the entire study sample, SS was used in 58% of studies, while ES was used in 15% of studies.

CONCLUSIONS

Quality should improve as research increases. One factor that influences quality is the level of statistics. SS and ES calculations provide a basis for understanding the results obtained by the authors. Access to formulas, online calculators and software facilitates these analyses. High-quality trials provide a solid foundation for medical progress, fostering the development of personalized therapies that provide more precise and effective treatment and increase patients' chances of recovery. Improving the quality of TMD research, and medical research in general, helps to increase public confidence in medical advances and raises the standard of patient care.

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.

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.

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.

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.

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.

Multidetector computed tomography in preoperative planning for temporomandibular joint ankylosis: A pictorial review and proposed structured reporting format

Ankylosis of the temporomandibular joint (TMJ) is a disabling disease resulting from fibrous or bony fusion of the mandibular condyle and the glenoid fossa. Early diagnosis and surgical treatment are essential to prevent facial deformity and other complications. Conventional radiography has limitations in demonstrating the true extent of ankylosis. It is important for surgeons to be aware of the size and degree of bony ankylosis in order to perform complete resection of the ankylotic mass. In addition, a detailed evaluation of the relationship with adjacent vital structures such as the internal maxillary artery, inferior alveolar nerve canal, external auditory canal, and skull base are crucial to avoid iatrogenic injury. Multidetector computed tomography (MDCT) is the current imaging modality of choice for preoperative assessments. Herein, the authors propose a structured CT reporting template for TMJ ankylosis to strengthen the value of the preoperative imaging report and to reduce the rates of intraoperative complications and recurrence.

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.

Reconstruction of bilateral ramus-condyle unit defect using custom titanium prosthesis with preservation of both condyles

BACKGROUND

Novel technologies for management and reconstruction of complex bony defects regarding both function and facial appearance are interestingly used in maxillofacial surgery. In the current study, we demonstrated reconstruction of a bilateral ramus-condyle unit (RCU) defect while preserving both condyles by a novel designed titanium prosthesis using virtual surgical planning (VSP), computer-aided design and manufacturing (CAD/CAM), and Selective Laser Melting (SLM) technologies.

MATERIALS AND METHODS

A 3D customized titanium prosthesis was designed for a 49 -year-old patient with bilateral mandibular aggressive central giant cell granuloma (CGCG) according to mandibular normal anatomy and structure while preserving bilateral intact condyles. Finite element study was performed to investigate the effects of new design strength and the stress shielding phenomenon. The design of macro-pores inside the body of prosthesis allowed it to act as a scaffold for bone tissue engineering under load bearing conditions.

RESULTS

Analysis of the strength and stress shielding phenomenon demonstrated favorable outcomes regarding the novel design. For instance, there was no stress shielding in any of the preserved condyles with regard to the size and distribution of stresses. Also, the stress distribution around the pores showed that these pores had no effect on the strength of the prosthesis. Thirty month follow-ups after reconstruction of bilateral RCU defect showed normal jaw function with a favorable facial appearance and mandibular contour.

CONCLUSION

We design a novel patient-specific prosthesis with desirable biomechanical features for reconstruction of bilateral RCU defect after resection of the benign tumor with preservation of bilateral intact condyles.

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.

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.

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.

Evaluation of fit feasibility of stock total joint replacement in temporomandibular joint ankylosis patients

Long standing adult temporomandibular joint ankylosis (TMJA) results in smaller ramal height, and warped and undulated ramus. Despite the efforts made to standardise the sizes available in stock joint (Zimmer Biomet®), the system causes fit challenges in TMJA patients. The aim of the study was to evaluate the virtual feasibility of stock prostheses in TMJA patients. The data included amount of bone contouring for fossa placement, available ramal length, length discrepancy if placed straight, angulation of mandibular component required to adapt to the bone, and mediolateral fit discrepancy. CT data of 50 TMJA patients (71 joints; unilateral, n=29; bilateral, n=21; male, n=33; female, n=17) with mean age of 24.26±8.88 years were included. 53 joints required more than 3mm lateral bone reduction for fossa placement. The ramal length were categorised into ranges 35-40mm (n=15), 41-45mm (n=14), 46-50mm (n=28) and >50mm (n=14). Correlation between the age of occurrence of ankylosis and ramal length using the Pearson correlation coefficient revealed a positive correlation (r=0.38, p=0.001). Length discrepancy, angulation of mandibular component, and mediolateral fit discrepancy decreases as the ramal length increases. Only 14 joints had appropriate fit of stock prostheses while the remaining 57 joints warranted compromised placement. Even the smallest available stock mandibular component (45mm) had a compromised fit in terms of length and adaptability on the lateral aspect of ramus. The study concludes that a short ramus is mostly limiting factor in using stock prosthesis in TMJA patients. There is a need for still smaller size stock prostheses.

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.