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

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.

Induction, Treatment, and Prevention of Temporomandibular Joint Ankylosis-A Systematic Review of Comparative Animal Studies

PURPOSE

Several animal models of temporomandibular joint ankylosis (TMJA) have been described for more than the past 2 decades. The aim of this study was 2-fold: 1) to compile and summarize the evidence of animal studies that compare different forms to induce, treat (disease already established), or prevent (after trauma) TMJA; and 2) to address the following focused question: what is the quality of reporting in these studies?

MATERIALS AND METHODS

A systematic review was conducted. Animal studies conducted up to October 2019 comparing at least 2 procedures to induce, treat (disease already established), or prevent (after trauma) TMJA were considered. Compliance with the Animal Research Reporting In Vivo Experiments guidelines was checked for all studies. Studies evaluating treatment of TMJA or preventive measures also were evaluated using the SYstematic Review Center for Laboratory animal Experimentation's risk of bias tool for animal studies.

RESULTS

A total of 24 studies were included. The studies were evaluated for feasibility regarding data synthesis, and a meta-analysis was not suitable because of methodological differences, mainly regarding the animal model chosen and surgical procedures performed to induce TMJA. In 17 articles, authors aimed to investigate different procedures to induce TMJA (fibrous, fibro-osseous, or bony). In 7 articles, different treatment or preventive strategies were compared. The sheep was the most used animal in models of TMJA. Only 25% (6 of 24) of studies reported some step to minimize bias (ie, blinding of investigators, randomization procedures, or allocation concealment). Approximately 54% (13 of 24) of articles clearly commented on study limitations and potential sources of bias. Further animal studies on TMJA should consider improving their reporting standards to increase their validity and improve the reproducibility of animal experiments.

Temporomandibular Joint Ankylosis Release: 17 Years of Experience with 521 Joints

Objective

Various surgical techniques to release temporomandibular joint (TMJ) ankylosis have been described in the literature. The purpose of this paper is to report our Institution's experience regarding the post-surgical outcome of different surgical techniques for the release of ankylosis of the TMJ.

Materials and Methods

The records from our hospital of 386 patients (521 joints) treated for TMJ ankylosis were reviewed. Data analysis included the etiology of TMJ ankylosis, gender distribution, age group, distribution of ankylosis based on location, type, interincisal opening and complications in the perioperative period.

Results

Out of 521 joints, 65.02% were unilateral and 73.89% had bony ankylosis. The mean maximal incisal opening preoperative was 5.4 mm (SD 3.63 mm) and at 1-year follow-up was 36.9 mm (SD 3.3 mm). There was no permanent facial nerve paralysis. However, transient facial nerve paresis was 14.78%. There was an overall recurrence rate of 8.82%.

Conclusion

We conclude that after TMJ ankylosis release with interpositional arthroplasty, reconstruction of the RCU with L ramus osteotomy is the most favorable. This procedure not only causes least complications, but also maintains height of ramus, facilitating surgeries for secondary asymmetry correction.

Surgical management of ankyloses of the temporomandibular joint by a piezoelectric device

INTRODUCTION

Piezosurgery is commonly used in different field of craniomaxillofacial surgery; since its introduction it has become one of the widely adopted technique for performing osteotomies in orthognathic surgery, distraction osteogenesis and dentoalveolar surgery. Little has been written regarding ultrasonic system for temporomandibular joint surgery (TMJ). In this prospective study we describe the use of piezoelectric device for ankylosis of the TMJ.

MATERIALS AND METHODS

We enrolled in this study 19 patients, 10 males and 9 females, mean (SD) age 24.6 (7.6) years, affected by unilateral ankylosis of TMJ who were surgically managed between January 2009 and December 2014 by interpositional arthroplasty with temporomyofascial muscle flap. We adopted in all cases a preauricular approach with temporal extension. The ankylotic block was removed with piezoelectric device in 9 patients and using traditional rotary bur in 10 cases. We investigated and compared the following parameters as surgical outcomes: intraoperative bleeding, duration of operation, incidence of infection, postoperative swelling and hematoma, mouth opening, nerve impairment and rate of recurrence.

RESULTS

We noticed a substantial reduction in bleeding with the piezoelectric bone cutter when compared to traditional mechanical surgery (103 ml versus 117 ml; p < 0.05); however, we did not report any severe bleeding from the pterygoid plexus or maxillary artery. Operating time was longer in the piezo group (101 min versus 88 min; p < 0.05). There was a lower incidence of postoperative hematoma and swelling following piezoosteotomy. However, regarding postoperative nerve impairment and infection we did not observe any differences between the two groups. At one year follow-up mean (SD) mouth opening was 34 (4.3) mm. We did not report recurrence of the disease.

CONCLUSION

Piezoelectric bone removal for the release of ankylosis of the TMJ is associated with minimal bleeding and few postoperative complications. We believe that piezosurgery allows surgeons to achieve better results compared to a traditional surgery. It is a possible alternative due to the clinical benefits demonstrated.

Post-Ankylotic Temporomandibular Joint Reconstruction Using Autogenous/Alloplastic Materials: Our Protocol and Treatment Outcomes in 22 Patients

The purpose of this study was to evaluate the various options of autogenous and alloplastic reconstruction modalities available for posttraumatic temporomandibular joint (TMJ) ankylosis. In a retrospective study of 22 patients, various autogenous/alloplastic materials were used based on type and severity of ankylosis and age of patient. Final outcome of reconstruction was critically evaluated in terms of maximal mouth opening, occlusion, and facial symmetry. Fourteen patients (63.63%) developed TMJ ankylosis due to road traffic accidents and eight patients (36.36%) had a history of fall. The mean age was 15.61 years. The mean preoperative maximum interincisal mouth opening (MIMO) for the entire series was 3.39 mm ± 2.16 and postoperative MIMO was 43.69 mm ± 2.63. Costochondral grafts were used in seven children, whereas titanium reconstruction plate with condylar head was used in five adults and interpositional arthroplasties using temporalis muscle, temporalis fascia, and relocation of the articular disc were used in the rest of the ten patients. We conclude that all these age-specific treatment modalities yield clinically comparable results in terms of postoperative mouth opening and facial symmetry with no evidence of reankylosis in a follow-up ranging from 24 to 96 months.

Choosing sheep (Ovis aries) as animal model for temporomandibular joint research: Morphological, histological and biomechanical characterization of the joint disc

Preclinical trials are essential to the development of scientific technologies. Remarkable molecular and cellular research has been done using small animal models. However, significant differences exist regarding the articular behavior between these models and humans. Thus, large animal models may be more appropriate to perform trials involving the temporomandibular joint (TMJ). The aim of this work was to make a morphological (anatomic dissection and white light 3D scanning system), histological (TMJ in bloc was removed for histologic analysis) and biomechanical characterization (tension and compression tests) of sheep TMJ comparing the obtained results with human data. Results showed that sheep processus condylaris and fossa mandibularis are anatomically similar to the same human structures. TMJ disc has an elliptical perimeter, thinner in the center than in periphery. Peripheral area acts as a ring structure supporting the central zone. The disc cells display both fibroblast and chondrocyte-like morphology. Marginal area is formed by loose connective tissue, with some chondrocyte-like cells and collagen fibers in diverse orientations. Discs obtained a tensile modulus of 3.97±0.73MPa and 9.39±1.67MPa, for anteroposterior and mediolateral assessment. The TMJ discs presented a compressive modulus (E) of 446.41±5.16MPa and their maximum stress value (σmax) was 18.87±1.33MPa. Obtained results suggest that these animals should be considered as a prime model for TMJ research and procedural training. Further investigations in the field of oromaxillofacial surgery involving TMJ should consider sheep as a good animal model due to its resemblance of the same joint in humans.

Use of the suture anchor in interpositional arthroplasty of temporomandibular joint ankylosis

BACKGROUND

The purpose of this article is to demonstrate the use of a mini suture anchor to attach the temporal myofascial flap to the head of the mandibular condyle in interpositional arthroplasty for the treatment of temporomandibular joint (TMJ) ankylosis.

CASE REPORT

A 29-year-old patient, with unilateral posttraumatic temporomandibular joint osseous ankylosis and pre-operative maximal interincisal distance of 9 mm, was treated by the interpositional gap arthroplasty using the temporal myofascial flap. After rotation, the flap and the TMJ capsule were attached to the lateral pole of the condyle by a non-absorbable mini suture anchor. The surgery was uneventful. On the first post-operative day, the range of motion was considerably improved, with a maximal interincisal distance of 26 mm, a mandibular protrusion of 1 mm and a lateral mandibular excursion of 4 mm to the left and 7 mm to the right. On the 20th post-operative day, the maximal interincisal distance was 30 mm, protrusion 4 mm, the lateral excursion to the right 7 mm and to the left 5 mm. On the third post-operative month, the maximal interincisal distance reached 40 mm.

DISCUSSION

The mini suture anchor demonstrated to be a good tool for the fixation of the temporalis myofascial flap to the condyle, also allowing with the same suture to attach the capsular tissue to the lateral surface of the condyle. The bone-anchored suture permits the restoration of a more physiologic TMJ anatomy. The treatment of TMJ ankylosis should be comprehensive; physiotherapy plays an important role in the rehabilitation period to restore the normal function.

Management of temporomandibular ankylosis--compromise or individualization--a literature review

Temporomandibular joint ankylosis is defined as bony or fibrous adhesion of the anatomic joint components accompanied by a limitation in opening the mouth, causing difficulties with mastication, speaking and oral hygiene as well as inadvertently influencing mandibular growth. Surgical treatment procedures include arthroplasty of the joint cavity with or without a reconstruction and a coronoidectomy, an autogenous costochondral rib graft, distraction osteogenesis and intensive mouth-opening exercise, corrective orthognathic surgery or alloplastic joint prostheses. The authors of this study would like to provide the reader with an evidence-based review of the literature in order to determine the most efficient way to manage TMJ ankylosis and re-ankylosis. The authors have concluded that in order to achieve a satisfactory and durable effective treatment, an individualized approach is necessary in each case.

Surgical Induction of Temporomandibular Joint Ankylosis: An Animal Model

PURPOSE

The aim of this study was to develop an animal model of temporomandibular joint (TMJ) bony ankylosis for future evaluation of surgical reconstructive methods.

MATERIALS AND METHODS

An animal model was selected on the basis of 2 sequential experiments. Four goats and 4 minipigs were used in the first experiment, in which 1 goat and 1 minipig served as control animals. Condylectomy with disc preservation was performed on 1 side of 3 animals in each group. On the contralateral TMJ, condylectomy with discectomy was performed, and the arthroplasty gap was filled with the autogenous bone chips. In the second experiment, TMJ ankylosis was induced bilaterally in 3 additional animals of the species that achieved better ankylosis results in the first experiment. All animals were killed postoperatively at 3 months, and the TMJ complexes were examined by plain radiography, computed tomography, and histological evaluation.

RESULTS

In the first experiment, only fibrous ankylosis was observed in the bone-grafted side of 2 goats and 3 minipigs, whereas fibro-osseous ankylosis was achieved in the remaining goat. The extent of ankylosis was found to be more severe in the goats than the minipigs. Hence, goats were selected for bilateral surgery in the second experiment, which achieved consistent bony ankylosis of the TMJ in all animals.

CONCLUSIONS

Goats provide a better TMJ bony ankylosis model than minipigs. Consistent bony ankylosis can be induced by bilateral condylectomy, disectomy, and bone grafting of the arthroplasty gap.

Effect of Auricular Cartilage Graft in the Surgical Treatment of Temporomandibular Joint Ankylosis: An Animal Study Using Sheep

PURPOSE

The purpose of this study was to test the functional and histologic fate of an auricular cartilage graft used in reconstruction of an ankylosed sheep temporomandibular joint (TMJ).

MATERIALS AND METHODS

Five sheep were used in this study. TMJ ankylosis was induced in the right joints and the left joints were used as controls. The ankylosed TMJ was released by gap arthroplasty with an interposed auricular cartilage graft at 3 months. The sheep were sacrificed at 3 months after the arthroplasty. The maximal mouth opening was measured pre- and postoperatively. The joints were evaluated radiologically and histologically.

RESULTS

Maximal mouth opening was maintained after placement of an auricular graft into the gap arthroplasty. Radiographically the surfaces of the temporal bone and ramus stumps were irregular, but radiolucent gaps were formed between them. Histologically, the auricular cartilage graft was alive and well attached to the mandibular ramus stump. In all operated joints, there was joint space between the grafted cartilage and temporal bone, with the space filled with fibrous connective tissue, which was oriented parallel to the temporal surface.

CONCLUSION

Auricular cartilage graft with gap arthroplasty is useful in preventing reankylosis after TMJ gap arthroplasty for ankylosis.

Mandibular Condylectomy and Meniscectomy for the Treatment of Septic Temporomandibular Joint Arthritis in a Horse

OBJECTIVE

To report use of mandibular condylectomy for treatment of advanced degenerative joint disease of the temporomandibular joint (TMJ) caused by sepsis.

DESIGN

Clinical case report.

ANIMALS

Two-year-old Noriker filly.

METHODS

Computed tomography (CT) was used to confirm advanced degenerative joint disease of the left TMJ and for follow-up after mandibular condylectomy and removal of necrotic meniscus.

RESULTS

Painful swelling (3 weeks duration) with drainage located just caudal to the left lateral canthus of the eye was associated with atrophy of the left masseter muscle, masticatory problems, and inappetence. There was incisor malocclusion with a 1.4 cm resting lateral mandibular deviation to the right and inability to open the mouth more than a few centimeters. Left mandibular condylectomy combined with meniscectomy and thorough debridement of the septic left TMJ resulted in resolution of clinical signs and complete return of function. Streptococcus zooepidemicus, intermediately resistant to penicillin and subsequently to enrofloxacin, was isolated from the wound. Regeneration of a mandibular "pseudocondyle" was evident on CT at 4 months. At 4 months and 1 year the filly had maximal mouth opening >10 cm and no malocclusion.

CONCLUSION

Mandibular condylectomy can be used to facilitate management of septic TMJ arthritis. There was no radiologic or clinical evidence of TMJ ankylosis >1 year after meniscal removal.

CLINICAL RELEVANCE

Mandibular condylectomy, including meniscectomy, is an acceptable treatment option for advanced TMJ septic arthritis and allowed return of normal masticatory function.

The role of muscle grafts in temporomandibular joint ankylosis: short-term experimental study in sheep

The temporalis muscle flap can be used as an inter-positional graft placed into a gap arthroplasty site in temporomandibular joint (TMJ) ankylosis. The purpose of this study was to investigate the role of the muscle graft in sheep. Five pure-bred adult Merino sheep were used and ankylosis was induced in all right TMJs. At 3 months, the ankylosis was released by gap arthroplasty and reconstructed with a masseter muscle graft, because the temporalis muscle is short and poorly vasculized in sheep. The sheep were killed at 3 months after muscle grafting. The maximal mouth opening was recorded before and after operation and at death. The joints were examined radiologically and histologically. In 4 sheep mouth opening remained at the pre-operative level. A clear radiolucent space remained between the smooth temporal and ramus stumps. Histologically, the muscle graft remained vital but with some fibrous tissue formation between the bone ends. One sheep developed an infection at the operative site following the muscle graft; this partly resolved with antibiotics, but the TMJ developed a fibrous reankylosis that was demonstrated clinically, radiologically and histologically. These results indicate that an uncomplicated temporalis muscle graft reconstruction with gap arthroplasty is a successful and stable procedure in human TMJ ankylosis.

Preservation of disc for treatment of traumatic temporomandibular joint ankylosis

PURPOSE

A new operating method was used to treat traumatic temporomandibular joint (TMJ) ankylosis, to restore the structure of the TMJ, to improve the secondary maxillofacial deformity, and prevent recurrence of TMJ ankylosis.

PATIENTS AND METHODS

Thirty-six patients (20 females, 16 males; aged 5 to 54 years old) with TMJ ankylosis type II or III of 1 to 16 years' duration, with a maximal mouth opening from 0 to 15 mm preoperatively participated. The new method was to separate bony fusion between condyle and glenoid fossa, remove the condylar fragment that displaced medially or anteroinferiorly, mobilize the remains of the disc over the condylar stump and suture it with articular capsule, and shave the surface of the condylar stump and glenoid fossa smooth.

RESULTS

Follow-up was performed from 1 to 7 years postoperatively in 21 cases. No recurrences occurred in patients whose TMJ disc was retained during operation. Patients had an average maximal mouth opening of 33.7 mm postoperatively. An 11-year-old patient showed an improved facial symmetry after surgery.

CONCLUSION

By restoring the normal structure of the TMJ and preservation of the disc, recurrence of traumatic TMJ ankylosis and facial deformity in younger patients can be prevented.

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.