3-D computed tomography measurement of mandibular growth after costochondral grafting in growing children with temporomandibular joint ankylosis and jaw deformity

Long-Term Outcomes and Growth Analysis of Costochondral Grafts for Hemifacial Microsomia: 24-Year Experience of a Single Surgeon

BACKGROUND

Costochondral grafts (CCGs) can be used in mandibular reconstruction of Kaban-Pruzansky IIB/III hemifacial microsomia (HFM). Their growth is variable, occasionally necessitating secondary surgery. This study examined one surgeon's 24-year experience to better quantify long-term outcomes and surgical care required in CCG reconstruction of HFM mandibles.

METHODS

Serial 3-dimensional computed tomography scans, from preoperative to most recent, were analyzed in patients with a minimum of 4 years of clinical follow-up after CCG reconstruction. Graft/ramus height, length, volume, bilateral mandibular body length, and chin deviation were measured. Changes in measurements were analyzed preoperatively, immediately postoperatively, at the most recent imaging before secondary surgery, and at the most recent imaging overall. Growth rates per measure were calculated using scans after CCG but before secondary surgery.

RESULTS

Thirteen patients were analyzed. Median (SD) clinical follow-up was 10.0 (5.1) years. One patient developed temporomandibular joint ankylosis secondary to stacked-graft malposition, which was repaired without further complications. CCG reconstruction led to immediate improvement in graft/ramus height ( P = 0.03), length ( P = 0.002), and volumetric symmetry ( P = 0.02). No difference was found between graft and native ramus height ( P = 0.4) or length measures ( P = 0.5), whereas graft volume and the affected mandibular body grew significantly more slowly. According to the latest imaging, 63% of patients required secondary surgery, including distraction osteogenesis or orthognathic surgery, due to differential graft or hemimandible growth behavior. Based on the most recent clinical follow-up, this proportion increased to 93%.

CONCLUSIONS

CCGs provide significant short-term mandibular and facial symmetry improvement in HFM IIB/III. Long-term analysis reveals frequent undergrowth requiring secondary intervention to promote and maintain symmetry.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Can growing patients with end-stage TMJ pathology be successfully treated with alloplastic temporomandibular joint reconstruction? - A systematic review

INTRODUCTION

The use of alloplastic total temporomandibular joint reconstruction (TMJR) in growing patients is controversial, mainly due to immature elements of the craniomaxillofacial skeleton. The aim of this systematic review was to evaluate the use of alloplastic TMJR in growing patients, focusing on the patient's clinical presentation, surgical and medical history and efficacy of alloplastic TMJR implantation.

MATERIALS AND METHODS

The literature search strategy was based on the Population, Intervention, Comparator, Outcomes and Study type (PICOS) framework. We searched Pubmed, Google Scholar, Dimension, Web of Science, X-mol, Semantic Scholar and Embase to January 2023, without any restriction on the type of publication reporting alloplastic TMJR in growing patients (age ≤ 18 years for boys and age ≤ 15 years for girls).

RESULTS

A total of 15 studies (case reports: 09, case series: 02, cohort studies: 04) met the inclusion criteria, documenting 73 patients of growing age from 07 countries. Thirty-eight (~ 52%) cases were female. The mean ± SD (range) age and follow-up of patients in all studies was 13.1 ± 3.2 (0-17) years and 34.3 ± 21.5 (7-96) months, respectively. A total of 22 (30%) patients were implanted with bilateral alloplastic TMJR. Over half of the studies (n = 10) were published in the last 3 years. All patients underwent multiple surgeries prior to implantation of alloplastic TMJR. In extreme cases, patients underwent a total of 17 surgeries. Different types of studies reporting inconsistent variables restricted our ability to perform quality assessment measures for evidence building.

CONCLUSIONS

Clinical experience with alloplastic TMJR in growing patients is limited to cases showing poor prognosis with other types of reconstruction. Nevertheless, studies show promising results for the use of alloplastic TMJR in growing patients, highlighting the need for well-controlled prospective studies with long-term follow-up.

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.

Analysis of the effect on costochondral graft for TMJ ankylosis with jaw deformities in pediatrics

OBJECTIVES

To evaluate the effects of costochondral grafting (CCG) used for temporomandibular joint ankylosis (TMJA) in growing patients.

MATERIALS AND METHODS

Pediatric patients with TMJA treated by CCG from 2010.5 to 2021.7 were included in the study. CT scans were performed before and after operations with at least 1 year follow-up. The height of the mandibular ramus, menton deviation or retraction, osteotomy gap, etc. were measured by ProPlan CMF1.4 software. CCG growth, resorption, and relapse were evaluated and analyzed with influencing factors such as age, ostectomy gap, etc. by generalized estimating equation.

RESULTS

There were 24 patients (29 joints) with an average age of 6.30 ± 3.13 years in the study. After operation, the mandibular ramus was elongated by 5.97 ± 3.53 mm. Mandibular deviation or retrusion was corrected by 4.82 ± 2.84 mm and 3.76 ± 2.97 mm respectively. After a mean follow-up of 38.91 ± 29.20 months, 58.62% CCG grew (4.18 ± 7.70 mm), 20.69% absorbed (2.23 ± 1.16 mm), and 20.69% re-ankylosed. The re-ankylosis was negatively correlated with the osteotomy gap (OR:0.348,0.172-0.702 95%CI, critical value = 6.10 mm). CCG resorption was positively correlated with the distance of CCG ramus elongation (OR:3.353,1.173-9.586 95%CI, critical value = 7.40 mm).

CONCLUSIONS

An adequate osteotomy gap and CCG ramus elongation distance are the key factors for successful treatment of TMJA with jaw deformities in growing patients.

CLINICAL RELEVANCE

TMJA affects mouth opening and jaw development in pediatric patients. The most common autogenous bone graft for pediatric patients is CCG due to its growth potential, convenient access and easy contouring. Also, it can simultaneously reconstruct the TMJ and improve jaw deformity by lengthening the mandibular ramus. But the growth of CCG is unpredictable. In this study, we explored several factors that may affect the absorption and re-ankylosis of CCG, expecting to provide several suggestions to improve future CCG treatment.

Long term complications of costochondral graft reconstruction in temporomandibular joint ankylosis of the young- a systematic review

Costochondral graft has been a popular reconstruction choice in the past for temporomandibular joint ankylosis in young individuals. However, accounts of growth hampering complications have also been observed. Our systematic review aims to compile all existing evidence to determine the occurrence of these unfavourable clinical outcomes as well as factors affecting them to provide a better judgement on further use of these grafts. A systematic review was conducted following PRISMA guidelines where databases like PubMed, Web of science and Google Scholar were searched for the purpose of data extraction. Observational studies performed on patients younger than 18 years of age with a minimum follow-up of one year were selected. Incidence of long term complications like reankylosis, abnormal graft growth, facial asymmetry and others were considered as outcome variables. Eight articles with a total of 95 patients were selected where complications like reankylosis (6.32%), graft overgrowth (13.70%), insufficient graft growth (22.11%), no graft growth (3.20%) and facial asymmetry (20%) were reported. Other complications like mandibular deviation (3.20%), retrognathia (1.05%) and prognathic mandible (3.20%) were also observed. Our review concludes that the occurrence of these complications was noteworthy. Thus use of costochondral graft for reconstruction in temporomandibular ankylosis in young patients holds significant risk in development of growth abnormalities. However, modifications in surgical procedure such as use of appropriate graft cartilage thickness and the presence and type of interpositional material can favourably affect the frequency and type of growth abnormality.

Reconstruction of the mandibular condyle due to degenerative disease

Degenerative joint disease (DJD), also known as osteoarthritis is the most common form of arthritis and can affect the temporomandibular joint (TMJ). TMJ DJD is characterized by degradation of the articular cartilage and synovial tissues resulting in characteristic morphologic changes in the underlying bone. DJD can occur at any age, but it is more common in older age groups. TMJ DJD may be unilateral or bilateral. The American Academy of Orofacial Pain categorizes TMJ DJD into primary and secondary types. Primary DJD is seen in the absence of any local or systemic factors and secondary DJD is associated with a prior traumatic event or disease process. Frequently, these patients present with pain and limited residual mandibular function resulting in significantly diminished quality of life. Classic radiographic features on orthopantogram and CT imaging include loss of joint space, osteophytes (bird-beak appearance of the condyle), subchondral cysts, erosions, flattening of the condylar head, bony resorption and/or heterotopic bone (Figure 1). Conservative and medical management is successful in the majority of patients until the active degenerative phase burns out, but some will progress to end stage joint disease and require reconstruction of the TMJ. Reconstruction of the mandibular condyle should be considered to restore mandibular function and form to patients who have lost it secondary to degenerative joint disease affecting the glenoid fossa/mandibular condyle unit.

Do simultaneous mandibular advancement and temporomandibular joint prosthesis impact the upper airway in TMJ ankylosis patients?

Background

Ankylosis of the temporomandibular joint (TMJ) is a pathological disorder which results in patients’ limited or even complete failure of mouth opening. When TMJ ankylosis occurs during the growing age, moderate to severe micrognathia might be the proposed scenario of such cases, accompanied by obstructive sleep apnea and hypopnea syndrome (OSAHS). TMJ reconstruction using total TMJ prostheses with mandibular advancement (MA) can simultaneously improve the function and aesthetic profile of such patients. The purpose of this study was to determine whether the upper airway can be improved after TMJ reconstruction with total TMJ prostheses combined with or without MA in TMJ ankylosis patients.

Methods

Fourteen patients with pre-(T1) and post-(T2) operative CT scans were included. Patients were divided into two groups according to the operation with or without MA (MA/WoMA). The changes of the upper airway and jaw bones were comparatively analyzed within and between the two groups.

Results

In MA Group, the volume of the total upper airway (Vt) and palatopharynx (V1), together with the surface area (SA) of the total upper airway (SAt) and palatopharynx (SA1) increased significantly after the operation by 41.4%, 43.2%, 36.3% and 36.6%, respectively. In WoMA Group, V1, SAt and SA1 increased significantly by 21.0%, 19.0% and 23.1% following surgery. The changes of Point B (P<0.01), Y-axis angle (P<0.01), SNB (P<0.01), and ANB (P<0.01) were significantly greater in MA Group than in WoMA Group. Comparing both groups, the maxilla, and mandible were more backward in MA Group than in WoMA group before the operation, but there was no significant difference of the final position of the maxilla and mandible after the operation between both groups.

Conclusions

Release of TMJ ankylosis and condylar reconstruction using total joint prostheses simultaneously with MA could significantly improve the total volume and other various parameters of the upper airway, while, only the dimension of the palatopharynx increased in cases without MA.

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.

Mandibular ascending branch and condyle reconstruction in adolescence by a costochondral rib graft with an observation period over 8 years

Introduction: The need to resect and reconstruct the condylar process of the mandible in a teenager is rare. Reconstruction strategy must be accurately assessed in terms of donor side morbidity, postoperative risks (ankylosis) and the possibility of sufficient development in a growing patient. Observation: A 14-year-old boy presented with the radiographic finding of a large cystic lesion of the right condylar process. There were no clinical symptoms as pain, a limitation of mouth opening or malocclusion. Pathohistological examination confirmed a solitary bony cyst. The resected ascending jaw and condylar process was reconstructed by a costochondral rib graft. Commentaries: Over 8 years the development of the reconstructed ascending jaw and condyle was observed. There was an undisturbed growth. The cartilaginous part of the costochondral graft remodeled to a sufficient condylar process without ankylosis, resorption or overgrowth. Conclusion: The reconstruction of the growing mandible and condylar process in an adolescent is a challenge. Observation over 8 years showed a sufficient reconstruction. Intraoperative the chondral portion of the graft has to be handled carefully to avoid a separating from the bony part. The growth potential of the costochondral rib transplant allows a functional reconstruction without substantial donor side morbidity in adolescent patients.