Temporomandibular joint ankylosis: is hypercoagulable state of blood a predisposing factor?

Did temporomandibular gap arthroplasty with temporalis interpositional flap improve function and pain in patients with end-stage joint disease? A 5-year retrospective follow-up

The primary aim of this study was to investigate whether patients with end-stage temporomandibular joint (TMJ) disease treated with gap arthroplasty with temporalis interpositional flap (GAT) had improved maximal interincisal opening (MIO) and TMJ pain in a long-term perspective. All patients with severe osteoarthritis, or fibrous or bony ankyloses, and subjected to GAT between 2008 and 2015 were included. The criteria of treatment success were TMJ pain VAS score ≤4 and MIO ≥30 mm. Reoperation was considered as a failure. Forty-four patients (mean age 47 years) were included in this retrospective descriptive case series and followed up for up to 7 years (mean 4.5). Comorbidities were frequent (n = 34) and most commonly rheumatic disease (n = 17). The indications for surgery were ankylosis (n = 32) or severe osteoarthritis (n = 12). Of the 44 included patients, 84% (n = 37) had a history of earlier TMJ surgery. The preoperative mean values for TMJ pain and MIO (VAS 7 and 23 mm, respectively) changed significantly (p < 0.001) to postoperative means of VAS 3 and 34 mm, respecitvely. The success rate was 59% (n = 26). When compared with a previous 2-year follow-up, the success rate was found to have decreased over time (p = 0.0097). The rate of successful treatment outcome in terms of MIO alone was 82% (n = 36). The most common reason for treatment failure was residual pain. In conclusion, the success-rate after GAT did not show long-term stability and continued to drop over time in this patient cohort. TMJ pain seems to be the main reason for failure.

Facial Deformity in an Operated Case of Bilateral Temporomandibular Joint Ankylosis

Temporomandibular joint (TMJ) ankylosis results in malocclusion, poor feeding, difficulty in maintaining oral hygiene, and facial esthetic deformity. The basic surgical objectives in the treatment of TMJ ankylosis are to establish joint movement, prevent relapse, and achieve normal growth and development. Here, we present an operated case ofsurgical correction of mandibular hypoplasia; however, the patient came back after three years due to unsatisfactory results and underwent bilateral coronoidectomy and gap arthroplasty. Bones were osteotomized at the LeFort I level and the maxillary segment was down-fractured and mobilized to bring into occlusion with the mandible. In the present case, the lower pharyngeal airway changed from 5 mm pre-treatment to 10 mm post-treatment, and the facial angle was changed from 73 to 84 post-treatment. Assessment of the pharyngeal airway is done with a high suspicion of obstructive sleep apnea and facial deformity is mandatory in the management of TMJ ankylosis.

Managing Temporomandibular Joint Ankylosis Concurrent With Extrahepatic Portal Vein Obstruction: A Report of a Rare Case and Literature Review Investigating the Hypercoagulability Link

This report describes the understudied co-occurrence of temporomandibular joint ankylosis (TMJA) and extrahepatic portal vein obstruction (EHPVO), exploring a shared pathway involving hypercoagulability. TMJA is an acquired pathology where joint surfaces fuse, causing restricted mouth opening and facial asymmetry. Globally, TMJA is prevalent among 1.5 to 5 patients/million, with a higher incidence in developing countries. While trauma and infections often cause TMJA, the pathogenesis remains unclear in many cases. Recent literature notes a link between TMJA and EHPVO, a noncirrhotic vascular disorder causing portal hypertension and upper gastrointestinal bleeding in children. Prothrombotic disorders such as protein C and S deficiency may contribute to EHPVO, mirroring TMJA's association with hypercoagulability. This report focuses on an 11-year-old female diagnosed with TMJA, accompanied by a history of ear infection and concurrent EHPVO. We further presented clinical observations, surgical interventions, and outcomes alongside a literature review to understand the probable connection between EHPVO and TMJA.

Management of a rare case of extra hepatic portal vein obstruction with temporomandibular joint ankylosis and review of literature

Extrahepatic portal venous obstruction (EHPVO) and temporomandibular joint (TMJ) ankylosisis are significant problems in Asian countries. Both EHPVO and bilateral TMJ ankylosis may have rare association due to protein C and S deficiency which may cause hypercoagulability as well as reduced fibrinolytic activity. Ankylosis arising in early childhood is associated with facial asymmetry, feeding difficulty and speech development alterations. It is also associated with great challenges of endoscopic management in extra hepatic portal vein obstruction (EHPVO) with variceal bleed as well as air way management during surgical management and post-operative recovery. Recently a case series had shown association of TMJ ankylosis with EHPVO due to protein C deficiency which might be an etiological factor for both EHPVO as well as TMJ ankylosis. This case report documents a case of 14 year young girl who had TMJ ankylosis due to ear infection and EHPVO with esophageal varices had multiple episodes of upper GI bleed with mild deficiency of protein C and S, successfully managed with proximal splenorenal shunt to prevent further episodes of upper GI bleed, as endoscopic management is not feasible due to TMJ ankylosis.

Pathogenesis of traumatic temporomandibular joint ankylosis: a narrative review

OBJECTIVE

To comprehensively review the literature and summarize the results from human and animal studies related to the possible causes and pathogenesis of traumatic temporomandibular joint ankylosis (TMJA).

MATERIALS AND METHODS

The Google Scholar, Embase, and Web of Science databases were used to search for articles related to traumatic TMJA from 2011 to 2020. All articles were screened according to the inclusion and exclusion criteria, collected, and analyzed.

RESULTS

Nineteen relevant articles were collected. These articles were classified into three groups: predisposing and etiological factors, cellular studies, and molecular studies.

CONCLUSION

The pathological mechanisms are similar between TMJA and nonunion hypertrophy. Aberrant structural and etiological factors as well as disordered cellular and molecular mechanisms might contribute to TMJA formation. Although preclinical and clinical data have provided new evidence on the pathogenesis of traumatic TMJA, the molecular mechanisms and biological events require further exploration.

Use of a Macintosh blade in extrahepatic portal vein obstruction with difficult intubation: two case reports

Background

We report the management of two patents from the Indian subcontinent with extrahepatic portal vein obstruction presenting with anticipated difficult airway. A Macintosh blade was used to secure the airway after using various instruments designed for difficult airway. To the best of our knowledge, no case has previously been reported in which a Macintosh blade was used successfully in patients with extrahepatic portal vein obstruction with a difficult airway.

Case presentation

Two women (case 1 and case 2) of South Asian ethnicity with extrahepatic portal vein obstruction presented for an elective splenorenal shunt. They both had micrognathia and restricted mouth openings. They had similar airway profiles with mouth openings of just 2 cm, Mallampati class IV, a thyromental distance <4 cm, a hyomental distance <2.5 cm, and a sternomental distance of 10 cm. Awake intubation was attempted in both patients after standard airway preparation in the form of preoperative 4 % lignocaine nebulization and 2 % viscous lignocaine gargle along with an on-table supralaryngeal nerve block using 2 % lignocaine and transtracheal infiltration with 4 % lignocaine.

The patient in case 1 tolerated the procedure well whereas the patient in case 2 had to be given propofol 60 mg. Endotracheal intubation with a 6.5 mm polyvinyl chloride endotracheal tube was attempted using a Truview EVO2, an Airtraq, and a Miller blade no. 3 but was unsuccessful. Finally, a trial intubation was performed successfully with a Macintosh blade with a stubby handle assisted by a Frova Intubating Introducer in case 1 and a gum elastic bougie in case 2.

Conclusions

Although many instruments have been introduced to manage difficult airways, our experience in these cases suggests that the Macintosh blade can be used first when attempting endotracheal intubation before using other instruments. Patients from the Indian subcontinent with extrahepatic portal vein obstruction are often found to have associated temporomandibular joint ankyloses (hence difficult airways). We hypothesize that a difficult intubation should be anticipated in these patients. Such an association has not been made before.

Severe bony ankylosis of the temporomandibular joint on one side and contralateral adhesion: A case report

Bony fusion between the mandibular condyle and skull base involves temporomandibular joint (TMJ) bony ankylosis. This condition might originate from trauma, infection, or systemic disease. TMJ adhesion can develop after synovial damage. Both TMJ ankylosis and adhesion lead to functional impairment and pain. Here, we present a case of a 50-year-old female who had bony ankylosis of the right TMJ and adhesion of the left TMJ. She had otitis media in the right ear. A large mass in the right TMJ was observed on computed tomograph. Magnetic resonance image showed a large fused bone mass with normal bone marrow in the right TMJ and flattening of the condyle with a thin disk in the left TMJ. Gap arthroplasty with temporal fascia was performed on the right TMJ, and discectomy, high condylectomy, and coronoidectomy were performed on the left TMJ. During a 2-year follow-up after surgery, the patient had no recurrence.

Current concepts in the pathogenesis of traumatic temporomandibular joint ankylosis

Traumatic temporomandibular joint (TMJ) ankylosis can be classified into fibrous, fibro-osseous and bony ankylosis. It is still a huge challenge for oral and maxillofacial surgeons due to the technical difficulty and high incidence of recurrence. The poor outcome of disease may be partially attributed to the limited understanding of its pathogenesis. The purpose of this article was to comprehensively review the literature and summarise results from both human and animal studies related to the genesis of TMJ ankylosis.