The use of costochondral grafts in arthroplasty of the temporomandibular joint

Role of distraction osteogenesis and flip genioplasty to correct sleep apnea and aesthetics in long standing TMJ ankylosis - A case report

INTRODUCTION AND IMPORTANCE

Temporomandibular joint (TMJ) ankylosis triad includes TMJ ankylosis, micrognathia, and obstructive sleep apnea (OSA) which is common in long-standing cases of TMJ ankylosis. Unilateral long-standing cases of TMJ ankylosis also result in a severe discrepancy in the midline of the chin.

CASE PRESENTATION

A young adult female presented with restricted mouth opening and daylight sleepiness. Her AHI was mild and there was excessive facial disfigurement. Right-side TMJ ankylosis was diagnosed with compromised posterior airway space and Ramal height was also short on the affected side. Chin has severely deviated to the affected side.

CLINICAL DISCUSSION

Treatment protocols for TMJ ankylosis are different for different case scenarios. A proper protocol derivation is a must looking into the clinical and radiographical examination of the patient. As mentioned in previous literature, anti-Kaban's protocol has been shown to provide good results. A genioplasty improves the chin midline deviation.

CONCLUSION

A careful assessment and a proper treatment plan should be selected for the management and early relief of the symptoms of the patient. Thorough knowledge and update should be available to the operating surgeon to choose the correct treatment plan for the management of a triad patient.

A Triad of Temporomandibular Joint Ankylosis, Mandibular Retrognathia and Severe Obstructive Sleep Apnoea: Case report

The surgical management of paediatric patients with temporomandibular joint (TMJ) ankylosis, mandibular retrognathia and obstructive sleep apnoea (OSA) is challenging. We report a nine-year-old boy who presented to the Department of Oral Health, Sultan Qaboos University Hospital, Muscat, Oman, in 2016 with complaints of limited mouth opening, loud snoring and excessive daytime sleepiness. He was diagnosed with TMJ ankylosis, mandibular retrognathia and severe OSA. The patient initially underwent mandibular distraction and, subsequently, release of the TMJ ankylosis and rib graft reconstruction. The overall patient outcome was successful, with improvement in OSA-related symptoms, good facial symmetry and adequate mouth opening.

Technical note on the harvesting of rib osteochondral autografts for upper limb bone and joint repair surgery

Rib cartilage grafts are widely used in maxillofacial surgery, but not in orthopedic surgery. The aim of this technical note is to describe the technique used to harvest this graft and to report on donor site complications in the 136 cases we have published on up to now. Harvesting is carried out at the osteochondral junction of the eighth rib. The osteochondral junction is located under the external oblique muscle and a perichondrium layer, which is retracted to allow safe harvesting. The amount of cartilage harvested depends on the size of the area being grafted. Harvesting of a rib osteochondral graft is easy to carry out, provides a considerable amount of hyaline cartilage for the reconstruction of degenerative and traumatic lesions on a joint surface and results in few donor site complications.

Sternoclavicular Joint Graft in Temporomandibular Joint Reconstruction for Ankylosis

Background:

Temporomandibular joint ankylosis is one of the most distressing clinical condition resulting in loss of jaw function and impairment of growth. Ankylosis is a greek word meaning “Stiff Joint”. It is observed that in humans the Sternoclavicular joint and Temporomandibular joint are similar morphologically and histologically as they are the only two synovial joints covered with fibrocartilage. This similarity of the joints have encouraged the surgeons to use SCG as an alternative to costochondral grafts.

Aims:

The purpose of this article was to evaluate the feasibility of using sternoclavicular graft for TMJ reconstruction in TMJ ankylosis patients and to also assess this technique in restoration of mandibular movement, function and growth of the mandible.

Settings and Design:

This retrospective study was conducted in 10 patients with unilateral TMJ ankylosiswho had undergone Interpositional arthroplasty with temporalis fascia and reconstruction of ramus condyle unit with sternoclavicular graft.

Methods and Material:

Ten patients(8 male and 2 female) with unilateral TMJ ankylosis within the growth period were included in the study. Clinical parameters assessed were maximal incisor opening, lateral excursion and protrusive movements.,ramus height,wound infection, donor sitemorbidity, evidence of neurological deficit in both donor and recipient site. Pre and post operative radiographic analysis of graft in relation to glenoid fossa and ramus of mandible was also done and donor site regeneration was also assessed.

Statistical Analysis Used:

The data were analysed using SPSS version 20 (IBM Corporation, SPPSInc; Chicago, IL, USA). Paired T test was used to compare the pre operative and post operativelaterotrusive, protrusive movements and the height of the ramus of the mandible. Repeated measures ANOVA was used to analyse the mouth opening pre operatively ,immediate post operatively and a after 5- year follow up.

Results:

The mean post operative mouth opening achieved was 28.9+_7.57mm with reankylosis in two patients. The mean laterotrusive and protrusive movements were 5.2 +_2.82mm and 2.2 +_.78 mm respectively postoperatively on a five year follow up. There was a 6.2 +_2.57mm increase in ramus height. The sternoclavicular graft had integrated and remodelled satisfactorily in eight patients. There was no change in the body length or midline deviation. Regarding the healing of the donor site there was a complete regeneration of clavicle within one year, however there was a incidence of clavicle fracture in one patient. The shoulder movements were normal in all patients.

Conclusions:

The reconstruction of TMJ with SCG has proved to be successful in this study. With an impressive success rate, the sternoclavicular graft could become a versatile and viable alternative to the surgeons in reconstruction of TMJ as it is relatively simple to carry out with minimal complications and good results.

Transport Distraction Osteogenesis in Reconstruction of Condyle: Use of a 3D Model for Vector Planning

Introduction

The temporomandibular joint (TMJ) is a complex joint, and it allows bilateral synchronous rotatory and translatory movements. TMJ reconstruction has evolved as an important step in the management of conditions affecting the TMJ like ankylosis, traumatic injuries and congenital deformities. Distraction osteogenesis (DO) is a biological process of forming new bone and adjacent soft tissues by gradual and controlled traction applied on osteotomized bone segments.

Case report

Here is a case report of bilateral TMJ ankylosis which was managed effectively by resection of ankylotic mass and reconstruction of TMJ by transport distraction osteogenesis with preoperative vector planning using a 3D printed model.

Conclusion

Distraction osteogenesis can be considered as an effective means of condylar reconstruction for an anatomical and functional TMJ with minimal complications. Use of 3D models can help making such complex TMJ reconstruction procedures simpler.

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.

Fate of Costochondral Graft in Temporomandibular Joint Reconstruction: A Histological Study

OBJECTIVE

To asses the fate of the costochondral graft (CCG) used to stimulate mandibular growth in the management of Temporomandibular joint (TMJ) reconsrtuction in ankylosis-histologically.

MATERIALS AND METHODS

Ten patients who had undergone CCG grafting for TMJ ankylosis between 1994-2009 in the department of Oral & Maxillofacial Surgery, Tamil Nadu Govt Dental College and Hospital, Chennai and had come back with reankylosis, were surgically explored and the graft along with the ankylotic mass was excised and evaluated histologically. There is no documented human study and clinically it is not possible.

RESULTS

Histological evaluation revealed the presence of osseous tissue, fibrous tissue and osteocytes but no evidence of any chondroid tissue.

CONCLUSION

Our study showing the absence of chondroid tissue raises the question on the rationale of CCG in TMJ reconstruction when other interpositional gap arthroplasty can achieve a disease free joint.

Anatomical and computed tomography study of the eighth costochondral junction: topography for costochondral graft harvesting

INTRODUCTION

Costochondral grafts have long been used in maxillofacial reconstruction, but have been little used in trauma and orthopedic cases. This surgical technique requires that a graft be harvested from the thorax in the area of the eighth rib. Pleuropulmonary complications are very rare. Although the harvesting technique is simple, it needs to be demystified.

GOAL OF STUDY

This study was performed to define anatomical relationships in the eighth costochondral junction and identify topographical and anatomical landmarks that will make it easier to harvest this structure.

METHOD

This was a two-part study. First, an anatomical study was carried out on human cadaver thoraxes to define topographical landmarks and study the anatomical surroundings of the eighth costochondral junction. Second, an imaging study was performed using a database of existing patient computed tomography (CT) scans of the chest and abdomen to confirm the topographical landmarks defined in the first part of the study. The spine was used as a reference for both studies. The location of the eighth costochondral junction was defined relative to the spinal processes along with its location on the lower rib cage hemiperimeter in the transverse plane starting at the corresponding spinous process.

RESULTS

The eighth costochondral junction was in line with the spinal process of the twelfth thoracic vertebra in the vast majority of cases and located at two-thirds of the lower rib cage hemiperimeter from the posterior median sulcus, regardless of the patient's chest shape, age and gender. This junction was always located under a single muscle (external oblique) and protected by a thick perichondrium layer, which separates it from the intercostal pedicles, endothoracic fascia and parietal pleura.

DISCUSSION

This two-part study has identified reliable landmarks for harvesting of an osteochondral graft at the eighth costochondral junction and, by describing its anatomical surroundings, helps take the mystery out of its harvesting. These landmarks were identified in supine cadavers and in free-breathing patients lying in supine for the CT portion. This position must be used when identifying these landmarks in a patient undergoing costochondral autograft harvesting for cartilage reconstruction.

Temporomandibular Joint Surgery: What Does it Mean to India in the 21st Century?

While India boasts the largest collective experience in the surgical management of TMJ ankylosis, times are changing and Indian Surgeons will need to begin thinking about other TMJ disorders that have previously gone under the radar. A growing Indian middle class with greater access to health facilities will demand treatment for TMJ disorders like myofacial pain and dysfunction, internal derangement and osteoarthrosis which Oral & Maxillofacial Surgeons must be prepared to manage. The aim of this paper is to review the role of TMJ surgery and its place in the treatment armamentarium of temporomandibular disorders. Indications, rationale for surgery, risks vs benefits are discussed and complemented with examples of clinical cases treated by the author. As India moves up the economic ladder of success, TMJ disorders that have largely been confined to Western nations will begin to appear in the rising middle classes of India. Indian Oral & Maxillofacial Surgeons must be prepared to recognize and manage disorders which present with more complex symptomatology where the role of TMJ surgery is less clear cut.

Temporomandibular joint surgery: what does it mean to the dental practitioner?

A poor appreciation of the role of surgery in the management of temporomandibular disorders (TMD) may result in some patients being denied access to appropriate care. While surgery is often considered as an option of last resort, there are instances where surgery is the definitive and sometimes the only treatment option. The aim of this paper was to review the role of temporomandibular joint (TMJ) surgery and its place in the treatment armamentarium of temporomandibular disorders. Indications, rationale for surgery, risks vs. benefits are discussed and complemented with examples of clinical cases treated by the author. All dental practitioners should be aware of the benefits of TMJ surgery so that patients do not suffer unnecessarily from ongoing non-surgical treatments that ultimately prove to be ineffective in the management of their condition.

Subankylotic ostectomy for release of TMJ ankylosis using the transmasseteric anterior parotid approach

Twelve patients with temporomandibular joint ankylosis (5 bilateral and 7 unilateral) with preoperative maximal mouth opening ranging from 0 to 11 mm (mean, 2.25 [SD, 3.19] mm) were treated with a subankylotic ostectomy. Inclusion criteria in the study were patients older than 18 years with restricted mouth opening of less than 30 mm and radiographic evidence of temporomandibular joint ankylosis. The mean maximal postoperative mouth opening was 38.92 (SD, 3.11) mm. All patients showed good functional rehabilitation in terms of movement and speech with no radiographic evidence of recurrence and no occurrences of temporary or permanent facial nerve palsy, sialoceles, or salivary fistulae. As this technique does not encroach upon the mass of ankylotic bone but creates a pseudarthrosis beneath it, chances of recurrences are minimized. The entire length and width of the right ramus from the condyle to the angle region can be accessed with this technique.

Management of temporomandibular joint ankylosis associated with mandibular asymmetry in infancy

Temporomandibular joint (TMJ) ankylosis during early childhood always produces alteration of the mandibular growth with facial asymmetry, chin deviation, and malocclusion. The younger the ankylosis happens, the more severe the facial deformity presents. When TMJ ankylosis occurs in infancy, there might be a delay in diagnosis and treatment. In this article, we describe a case of TMJ ankylosis in a 10-month-old boy. The etiology was indistinct. Surgical plan including modified gap arthroplasty, costochondral graft (CCG), temporalis fascial flap, was preformed to this patient. The joint and the mandibular ramus were restored. No severe complication occurred. There was no recurrence of ankylosis and further developing of mandibular asymmetry during 2-year follow-up period.

Application of the rapid prototyping technique to design a customized temporomandibular joint used to treat temporomandibular ankylosis

Anthropometric variations in humans make it difficult to replace a temporomandibular joint (TMJ), successfully using a standard "one-size-fits-all" prosthesis. The case report presents a unique concept of total TMJ replacement with customized and modified TMJ prosthesis, which is cost-effective and provides the best fit for the patient. The process involved in designing and modifications over the existing prosthesis are also described. A 12-year- old female who presented for treatment of left unilateral TMJ ankylosis underwent the surgery for total TMJ replacement. A three-dimensional computed tomography (CT) scan suggested features of bony ankylosis of left TMJ. CT images were converted to a sterolithographic model using CAD software and a rapid prototyping machine. A process of rapid manufacturing was then used to manufacture the customized prosthesis. Postoperative recovery was uneventful, with an improvement in mouth opening of 3.5 cm and painless jaw movements. Three years postsurgery, the patient is pain-free, has a mouth opening of about 4.0 cm and enjoys a normal diet. The postoperative radiographs concur with the excellent clinical results. The use of CAD/CAM technique to design the custom-made prosthesis, using orthopaedically proven structural materials, significantly improves the predictability and success rates of TMJ replacement surgery.

Overgrowth of a costochondral graft in reconstruction of the temporomandibular joint

We report the case of a 3-year-old girl with temporomandibular ankylosis, which was treated with a costochondral graft and required two further resections because the grafted tissue had overgrown.

Mandibular condyle reconstruction with inlay application of autogenous costochondral graft after condylectomy: Cerrahpaşa's technique

PURPOSE

Mandibular condyle reconstruction with free costochondral grafting is the most common method because of some advantages, such as its biological and anatomic similarities to the condyle, and growth potential in juveniles. Application techniques of the costochondral graft were reported in numerous articles with several advantages and disadvantages up to now. The purpose of this article is to present a new modification in application of the costochondral graft to the ramus of the mandible. This technique is pretty simple, but very effective.

MATERIALS AND METHODS

The new technique described here consisted of a costochondral graft application for temporomandibular joint reconstruction, which was inserted into the medullary cavity of the mandibular ramus in 4 patients. This modification provided the graft placement as anatomical as the original condyle and further stabilized the graft in its position and inhibited its displacement without any fixation. This technique is pretty simple because an additional incision to the preauricular, facial nerve dissection, wide exposition and stabilization efforts are not required.

RESULTS

Clinical and radiological evaluations on 14-month mean follow-up of 4 cases showed very satisfactory functional results with normal anatomic adaptation and configuration. In all cases, function of mandible was considered to be good with at least maximal interincisal opening of 30 mm. Good anatomical position of the graft and good bony healing were seen on the radiographs. Additionally, there was no need for postoperative intermaxillary fixation.

CONCLUSION

With this technique, temporomandibular joint reconstruction by the costochondral graft can be performed as far as possible to the original condyle position.

Costochondral autograft as a salvage procedure after failed trapeziectomy in trapeziometacarpal osteoarthritis

PURPOSE

Osteoarthritis at the base of the thumb is a common problem, especially in women. Among the many surgical procedures aimed at restoring the function of the trapeziometacarpal joint, total trapeziectomy has been shown to provide good long-term results in most patients. But in some patients continued pain may lead the surgeon to consider a revision procedure. We report the use of costochondral autograft as an interposition material in revision of trapeziectomy in trapeziometacarpal osteoarthritis and to study its usefulness.

METHODS

The study design was retrospective. All of the patients had a costochondral autograft as a revision procedure after a failed trapeziectomy with ligament reconstruction. Patients were clinically assessed before and after surgery. The follow-up period was 24 months. Results were assessed as follows: good, complete relief of pain; fair, persistent mild pain and stiffness; poor, no relief of pain or any improvement with revision surgery.

RESULTS

Four patients were included; there were 2 good results, 2 fair results, and no poor result. Pain relief was obtained in all patients. Thumb opposition showed a slight improvement in 1 patient and no change in the other 3 patients. Pinch strength showed no change. One case of iatrogenic injury of the sensory branch of the radial nerve was noted.

CONCLUSIONS

Costochondral autograft as a revision procedure after failed trapeziectomy is a reliable procedure. These preliminary outcomes showed that the result did not compare favorably with soft-tissue interposition. Nevertheless, in case of an iterative procedure, the lack of available soft-tissue material to interpose may lead the surgeon to consider a costochondral autograft. This procedure should be considered a salvage procedure.

Intraoral distraction osteogenesis for the correction of facial deformities following temporomandibular joint ankylosis: a modified technique

The aim of this study was to evaluate the feasibility of transoral bimaxillary distraction osteogenesis before releasing temporomandibular joint (TMJ) ankylosis using intraoral mandibular distractors. Nine patients (5 males, 4 females) aged 14-35 (mean 19) years were included. A bilateral Le Fort I osteotomy was performed together with a mandibular osteotomy on the affected side(s). An intraoral distractor(s) was inserted in the lower jaw, followed by an intermaxillary fixation (IMF) to maintain preoperative dental occlusion. The distractor was activated, after a latency period of 5-7 days, 2 times daily by 0.5 mm. There followed a consolidation period of 6-8 weeks. TMJ ankylosis was then released via a peri-auricular incision, a gap arthroplasty was performed, and mandibular movement was established after removal of the IMF and distractor. Optimal results were achieved clinically and radiologically with minimal relapse and complications. Apart from minor complaints, the distraction process was smooth and tolerable in all cases. Total mandibular elongation ranged from 17 to 25 mm (20.7 mm). Occlusal canting decreased to 0 degrees in 7 patients and to 1 degree in 2 patients (mean 0.2 degrees). After a mean follow-up period of 17 months, a mean postoperative mouth opening of 34.7 mm was achieved (0.6 mm preoperatively) and no re-ankylosis was detected. Intraoral distraction of a deformed mandible and maxilla before releasing TMJ ankylosis is a feasible and perhaps advantageous technique.

The role of surgery in the management of disorders of the temporomandibular joint: a critical review of the literature. Part 2

The literature is unequivocal in its support for surgery in the management of certain disorders of the Temporomandibular joint (TMJ). Unfortunately, the literature on TMJ surgery is based more on observation than science since randomised clinical trials comparing surgical treatment of the TMJ with medical treatment and no treatment (i.e., placebo) do not exist. Because the application of scientific principles in clinical studies which involve surgical intervention are ethically unfeasible, the true benefit of surgical intervention for Temporomandibular Disorders (TMD) may never be conclusively established. Waiting for properly designed, placebo controlled, random clinical trials will only impede the progress of surgical experience and frustrate the decision making for both clinicians and patients. Therefore, the current recommendations for surgery must rely on the best available evidence. The aim of this, the second of two papers, is to scrutinize the role of TMJ surgery in light of the controversies that have appeared in the literature in recent years.

Treatment of TMJ ankylosis in Jordanian children - a comparison of two surgical techniques

INTRODUCTION

The aim of this study was to report Jordanian experience in surgical treatment of TMJ ankylosis in 22 children.

PATIENTS AND METHODS

This retrospective clinical study included children who were diagnosed with TMJ ankylosis and were treated in a dental teaching centre between 1993 and 2001. Patients underwent the release of 24 temporomandibular joint ankyloses and two different surgical techniques were used: either reconstruction of the condyle using costochondral grafts, or using the temporalis muscle as an interpositional material. Patients were followed up for 1-8 years.

RESULTS

Twenty-two children (13 males and 9 females) were included in the study. Costochondral grafts were used as a reconstruction material in 16 TMJs (67%), whilst temporalis muscle was used as an interpositional material in 8 joints (33%). The mean preoperative maximum interincisor distance was 6.6 mm+/-1.3, which was increased to a mean of 30.3 mm+/-2.5 postoperatively. Two female patients (9%) suffered recurrence of the ankylosis within 6-12 months postoperatively. In one of these, a costochondral graft was used and temporalis muscle interposition in the other.

CONCLUSION

Costochondral graft as a reconstruction material and temporalis muscle as an interpositional material showed comparable success rates when treating TMJ ankylosis in 22 children.

A retrospective study of the costochondral graft in TMJ reconstruction

A retrospective review of 76 costochondral grafts (57 patients) was undertaken to determine outcome with respect to the extent of previous surgery (none, disc surgery or soft tissue graft, alloplastic disc, alloplastic joint, previous graft) and to initial and preoperative diagnosis. The minimum follow up period was 2 years and for each patient both subjective (pain and dietary interference scores) and objective (interincisal distance) data was recorded. Collectively there was improvement in pain (mean 6.7 to 3.5) and diet (mean 2.2 to 3.0) scores with a moderate increase in interincisal distance (mean 21 to 24mm). In patients with no previous surgery, arthritic disease or congenital deformity the costochondral graft performed well but in patients with previous alloplastic discs and/or total joints the results were less predictable. A preoperative diagnosis of ankylosis was associated with a high complication and further surgery rate suggesting caution in this group of patients.

The role of simultaneous gap arthroplasty and distraction osteogenesis in the management of temporo-mandibular joint ankylosis with mandibular deformity in children

INTRODUCTION

Temporo-mandibular joint ankylosis is a common cause of acquired deformity in children.

PURPOSE

Surgical correction of the ankylosis only leaves the patient with an uncorrected mandibular deformity. This study was to evaluate the use of distraction osteogenesis for simultaneous correction of the mandibular deformity.

MATERIAL

This study was done on six children with temporo-mandibular joint ankylosis and mandibular deformity. Uniaxial double pin distractors with Schanz pins were used in this study.

METHODS

The patients underwent simultaneous gap arthroplasty and mandibular osteotomy (retromolar) with distractor insertion. Distraction was started on the fifth post-operative day. The patients were put on dynamic temporo-mandibular joint exercises on the first post-operative day.

RESULTS

All patients had a satisfactory mouth opening on follow-up. Satisfactory cosmetic correction of the mandibular deformity was also achieved in all these patients. Some degree of malocclusion resulted from treatment due to which the patients were placed on orthodontic treatment.

CONCLUSIONS

Distraction osteogenesis can be used simultaneously with gap arthroplasty in patients with temporo-mandibular ankylosis, for the correction of the mandibular deformity.

Regeneration of the mandibular head from grafted periosteum

Grafted periosteum has a rich potential to induce heterotopic bone formation. In the current study the authors investigate whether autogenous periosteal grafts can regenerate the mandibular head in a rabbit model. They removed the mandibular head of Japanese white rabbits and grafted tibial periosteum to the cut surface of the mandible. Grafted periosteum was observed histologically and radiographically at day 7, 14, 21, and 45 after surgery. At day 7 after grafting, grafted tissue showed remarkable cell proliferation. By 14 days these cells had differentiated into chondrocytes to form cartilage, and endochondral ossification took place after 21 days. At 45 days after surgery, soft X-ray findings showed a newly formed mandibular head, which was similar histologically to that of a normal mandibular head. The cut mandible without periosteal graft showed no regeneration. These findings indicate that grafted periosteum can regenerate the mandibular head without special procedures such as bone fixation in a rabbit model, and suggest that this technique may be useful clinically.

Growth of the mandible after replacement of the mandibular condyle: an experimental investigation in Macaca mulatta

PURPOSE

The study goal was to investigate growth of the mandible after temporomandibular joint reconstruction in juvenile monkeys.

MATERIALS AND METHODS

Sixteen juvenile monkeys (Macaca mulatta) were used as experiment subjects. Animals were equally divided into 4 experimental groups based on the method of temporomandibular joint reconstruction after bilateral condylar excision via extraoral vertical ramus osteotomies. Group Condyle animals had their condylar segments immediately replaced to serve as surgical controls. Group Bone animals were reconstructed with a bony strut. Group sternoclavicular joint (SCJ) animals were reconstructed with the sternal end of their clavicles. Group costochondral junction (CCJ) animals were reconstructed with costochondral junction of ribs. Standardized lateral cephalometric radiographs with the aid of tantalum bone markers were used to evaluate mandibular growth. Twenty animals were used as controls and were allowed to grow undisturbed for an 18-month period (Group Control).

RESULTS

All animals showed good mandibular function and a Class I molar relationship after an 18-month follow-up period. Statistical and graphic comparisons showed no significant difference in mandibular growth among any of the groups.

CONCLUSIONS

The results of this investigation suggest that, within the limits of this model, the choice of autograft for condyle replacement may be irrelevant.

Reconstruction of the temporomandibular joint autogenous compared with alloplastic

The aims of and indications for temporomandibular joint (TMJ) reconstruction are well-established but the method of reconstruction is controversial. We describe a retrospective, two-centre audit of 49 patients treated with costochondral grafting and 50 patients treated with alloplastic joints. The characteristics of the patients were similar in both centres and the minimum follow-up period was 2 years. For each patient a number of variables were recorded including both subjective scores (pain and interference with eating) and objective data (interincisal distance). Patients in both groups showed an improvement in symptoms but more patients required reoperation in the autogenous group.

Effect of partial immobilization on reconstruction of ankylosis of the temporomandibular joint with an autogenous costochondral graft:an experimental study in sheep

The purpose of this study was to show the effect of partial immobilization of a costochondral graft reconstruction of an ankylosed temporomandibular joint (TMJ) in five adult sheep. Ankylosis was induced in all right TMJs. At three months, a graft was inserted and partially immobilized. Three months after the second operation, four sheep were killed by an overdose with pentothal. One sheep was killed at one month because of infection. Functionally, the body weight, which decreases with ankylosis, did not recover after insertion of the graft and the range of jaw movements got worse. Histologically, the grafts were well attached to the mandibular rami in three of four joints. In one joint, the graft showed signs of resorption and a foreign body reaction. We conclude that, if the reconstructed joint is partially immobilized, then there will be a degree of reankylosis. There was also a high failure rate.

The use of acrylic marbles for interposition arthroplasty in the treatment of temporomandibular joint ankylosis: follow-up of 47 cases

This is a retrospective analysis of 47 patients (21 males, 26 females) with osseous or fibro-osseous temporomandibular joint ankylosis. who were referred to our clinic between 1981 and 1998. In all cases, an acrylic marble was used as the interpositional material to prevent recurrence after aggressive resection of the ankylotic mass. The mean mouth opening was 15.65 mm preoperatively and 32.48 mm postoperatively. Complications during the follow-up period, which ranged from 1 to 17 years, included reankylosis in three cases and extrusion and displacement of the acrylic marbles in two cases. The method produced good results and we believe that it is a simple alternative to other interposition arthroplasty procedures. Moreover, it has the advantages of reducing operating time and not requiring any personal skill.

Temporomandibular joint reconstruction in children using costochondral grafts

PURPOSE

The aim of this study was to evaluate the postoperative growth of the mandible after reconstruction of the condylar process using costochondral grafts in children.

PATIENTS AND METHODS

Temporomandibular joint (TMJ) ankylosis was surgically treated and the joint reconstructed with a costochondral graft (CCG) in two boys and eight girls with a mean age of 7.4 years. Two children had bilateral ankylosis. Postoperative changes and craniofacial growth were monitored by lateral and posteroanterior (PA) cephalograms annually from 2 to 6 years (mean of 4 years).

RESULTS

Postoperatively, in the eight children with unilateral TMJ reconstruction, the mandible (Co-Gn) grew an average of 14.7 mm in length on the affected side and 15.1 mm on the nonaffected side; ramus length (Co-Go) increased an average of 7.1 mm on the affected side and 7.3 mm on the nonaffected side. However, in five of the children the chin progressively deviated toward the nonaffected side after TMJ reconstruction. The CCGs tended to have a more vertically directed condylar growth pattern and a more laterally positioned condyle. In the two cases with bilateral TMJ reconstruction, the CCGs grew until there was a mandibular prognathism that required orthognathic surgery to set back the mandible.

CONCLUSIONS

Using CCGs to reconstruct TMJ ankylosis in children provides a functional condyle with growth potential. However, there is a possibility of excessive growth of the graft, resulting in deviation of the chin and mandibular prognathism years later.

Costochondral grafts to replace mandibular condyles in juvenile chronic arthritis patients: long-term effects on facial growth

Long-term facial growth and clinical outcome after replacement of arthritic mandibular condyles by costochondral grafts and postoperative orthodontic guidance of the occlusion were studied until completion of facial growth in patients (n = 12) with juvenile chronic arthritis (JCA) affecting their temporo-mandibular joints (TMJs). The patients were between 10.1 and 16.7 years of age at surgery. Clinical records and radiographs for cephalometric measurements were taken preoperatively, 6-8 weeks after surgery and after completion of facial growth. A considerable potential for growth of the costochondral graft/mandible unit was demonstrated in all patients. The results also indicated a considerable risk of asymmetrical mandibular overgrowth (n = 8), which could not be correctly assessed until after skeletal maturation was complete. Without any active orthodontic treatment, compensatory growth of the alveolar processes closed the lateral open bites, which were created during surgery. The functional results of the reconstructed temporo-mandibular joints were good and the morbidity rate was low. Costochondral grafting is a versatile treatment when the TMJs are severely affected by JCA, but requires supervision of patients until skeletal maturation, to monitor possible mandibular overgrowth. Advantages of this method were re-established mandibular growth, good mandibular function, a low morbidity rate and early aesthetic improvement.

Cranial bone graft to reconstruct the mandibular condyle in Macaca mulatta

PURPOSE

The purpose of this study was to evaluate the efficacy of cranial bone grafts to reconstruct the mandibular condyle in a nonhuman primate model.

MATERIALS AND METHODS

The right mandibular condyle was resected in eight female, adult, nongrowing monkeys (Macaca mulatta) and the mandible was reconstructed with autogenous, full-thickness cranial bone harvested from the frontal area of the skull and stabilized with rigid fixation. Joint function, facial symmetry, and occlusion were evaluated preoperatively and over the course of 1 year postoperatively. The height of the bone graft was measured intraoperatively and at 1 year postoperatively.

RESULTS

Seven monkeys survived for 1 year. The animals' weights were stable postoperatively. There were no statistically significant changes in maximal incisal opening or lateral excursion, as well as no statistically significant changes in facial symmetry or occlusion. On average, the total decrease in height of the graft was 0.7 +/- 0.9 mm (P = .07).

CONCLUSION

After reconstruction of the mandibular condyle in Macaca mulatta, full-thickness cranial bone grafts provided a functional joint that resisted resorption. Cranial bone may therefore provide a suitable alternative to other autologous or alloplastic graft materials for reconstruction of the human mandibular condyle in nongrowing patients.

Clinical and computed tomographic findings in costochondral grafts replacing the mandibular condyle

PURPOSE

The aim of this study was to evaluate by computed tomography (CT) and clinically the structure and function of costochondral grafts (CCG) used to replace the mandibular condyles.

MATERIAL AND METHODS

CT and clinical examination were performed in 11 patients with CCGs (9 female, 2 male; mean age at surgery, 25 years; range, 9 to 44 years) approximately 4.5 years after surgery (range, 5 months to 10.5 years). One mandibular condyle was replaced in six patients and two in five patients.

RESULTS

Facial asymmetry was observed in two cases and palpation tenderness of the TMJs or clicking and crepitation were found in 10 of 16 operated TMJs. In three cases coronal CT scans showed the graft to be situated laterally in the mandibular fossa, and lateral overgrowth of the graft was seen in three cases. In two cases, coronal CT slices showed that a new fossa had developed. In most cases translatory movement of the graft was minimal. The graft was either partially or almost completely mineralized, especially in cases with longer follow-up.

CONCLUSIONS

Most of the patients in this study seemed to have benefitted from replacement of the deformed mandibular condyle with a CCG as estimated by improved range of mandibular movements and decreased symptoms. There were some problems related to unpredictable growth and location of the graft, as well as restricted movement of the replaced condyle. In the future, care should be taken to ensure proper postoperative functional therapy and to examine the role of cartilage thickness on future growth in young patients.

Overgrowth of a costochondral graft in an adult male

This paper is the first report of overgrowth of a costochondral graft in an adult male. The case supports the notion that this graft partly exhibits features of a primary growth center with inherent potential for growth.

The compressible silicone rubber prosthesis in temporomandibular joint disease

An alternative technique for temporomandibular joint arthroplasty is described, in which the mandibular condyle is replaced by a soft compressible silicone rubber prosthesis. A modified Nicolle-Calnan metacarpo-phalangeal joint prosthesis was used to reconstruct 31 joints in 24 patients. Results suggest that in those patients where there has been no loss of the prosthesis, function continues to be markedly improved when compared with the pre-operative condition. Painful symptoms were relieved in cases of specific joint pathology but the technique was of little value in the management of dysfunctional pain when radiographic evidence of joint pathology was absent. A specifically designed TMJ prosthesis of this type may be a useful addition to the surgeon's armamentarium.

Early surgical-orthodontic treatment of mandibular hypoplasia in juvenile chronic arthritis

This study is an intermediate evaluation of early surgical-orthodontic treatment in 7 patients with uni- or bilateral hypoplastic mandibular growth due to juvenile chronic arthritis. Resection of the condylar heads and reconstruction with costochondral grafts was undertaken between 10 and 14 years of age and followed by orthodontic treatment. At the latest follow-up, 2-4.5 years postoperatively, all patients showed mandibular growth. Some even showed a tendency towards progenia. The scheduling of the surgery in relation to completion of growth seemed to be of importance in relation to the magnitude of mandibular growth. At the latest check-up, only one patient had attained skeletal maturation and a more long-term follow-up is needed before this method can be finally evaluated.

Growth of costochondral fragments transplanted from mature to young isogeneic rats

Experiments were carried out to determine whether growth of costochondral grafts is associated with age-related humoral factors. Rib fragments containing either short (without germinative zone) or long (with proliferative and germinative zones) cartilaginous ends were excised from adult rats, and the sections transplanted across the interparietal suture in 10-day-old isogeneic rats. The animals with short cartilage transplants were killed 15 or 25 days later; those with long cartilage transplants 25 days postoperatively. Measurements on dry skulls with short transplants showed neurocranial width to be greater in the experimental rats than in the unoperated controls at 25 days, whereas 10 days later the difference was no longer significant. By the latter time, however, the neurocranium was significantly wider in the long cartilage group than in the other groups. It is suggested that the declining growth potential of the costal cartilages from the adult rats was reactivated when transplanted to younger animals, i.e., the growth of costochondral transplants is related to humoral factors.