Surgical treatment of TMJ ankylosis: our experience (60 cases)

YAP promotes the early development of temporomandibular joint bony ankylosis by regulating mesenchymal stem cell function

To explore the role of YAP, a key effector of the Hippo pathway, in temporomandibular joint (TMJ) ankylosis. The temporal and spatial expression of YAP was detected via immunohistochemistry and multiplex immunohistochemistry on postoperative Days 1, 4, 7, 9, 11, 14 and 28 in a sheep model. Isolated mesenchymal stem cells (MSCs) from samples of the Day 14. The relative mRNA expression of YAP was examined before and after the osteogenic induction of MSCs. A YAP-silenced MSC model was constructed, and the effect of YAP knockdown on MSC function was examined. YAP is expressed in the nucleus of the key sites that determine the ankylosis formation, indicating that YAP is activated in a physiological state. The expression of YAP increased gradually over time. Moreover, the number of cells coexpressing of RUNX2 and YAP-with the osteogenic active zone labelled by RUNX2-tended to increase after Day 9. After the osteogenic induction of MSCs, the expression of YAP increased. After silencing YAP, the osteogenic, proliferative and migratory abilities of the MSCs were inhibited. YAP is involved in the early development of TMJ bony ankylosis. Inhibition of YAP using shRNA might be a promising way to prevent or treat TMJ ankylosis.

Temporal gene expression profiling during early-stage traumatic temporomandibular joint bony ankylosis in a sheep model

BACKGROUND

Investigating the molecular biology underpinning the early-stage of traumatic temporomandibular joint (TMJ) ankylosis is crucial for discovering new ways to prevent the disease. This study aimed to explore the dynamic changes of transcriptome from the intra-articular hematoma or the newly generated ankylosed callus during the onset and early progression of TMJ ankylosis.

METHODS

Based on a well-established sheep model of TMJ bony ankylosis, the genome-wide microarray data were obtained from samples at postoperative Days 1, 4, 7, 9, 11, 14 and 28, with intra-articular hematoma at Day 1 serving as controls. Fold changes in gene expression values were measured, and genes were identified via clustering based on time series analysis and further categorised into three major temporal classes: increased, variable and decreased expression groups. The genes in these three temporal groups were further analysed to reveal pathways and establish their biological significance.

RESULTS

Osteoblastic and angiogenetic genes were found to be significantly expressed in the increased expression group. Genes linked to inflammation and osteoclasts were found in the decreased expression group. The various biological processes and pathways related to each temporal expression group were identified, and the increased expression group comprised genes exclusively involved in the following pathways: Hippo signaling pathway, Wnt signaling pathway and Rap 1 signaling pathway. The decreased expression group comprised genes exclusively involved in immune-related pathways and osteoclast differentiation. The variable expression group consisted of genes associated with DNA replication, DNA repair and DNA recombination. Significant biological pathways and transcription factors expressed at each time point postoperatively were also identified.

CONCLUSIONS

These data, for the first time, presented the temporal gene expression profiling and reveal the important process of molecular biology in the early-stage of traumatic TMJ bony ankylosis. The findings might contributed to identifying potential targets for the treatment of TMJ ankylosis.

Psoriatic arthritis of the temporomandibular joint: A systematic review

OBJECTIVES

Psoriasis is an inflammatory condition brought on by the immune system. This study aimed to perform a systematic review related to psoriatic arthritis (PsA) of the temporomandibular joint (TMJ).

METHODS

The search strategy was developed by a radiologist expert with more than 20 years of experience. The search was performed without time restrictions in five electronic databases: PubMed, Web of Science, Embase, Scopus and Ovid. The search strategy was based on MeSH and Emtree terms. The methodological quality of the studies was rated using the quality assessment tools from the National Heart Lung and Blood Institute (NHLBI).

RESULTS

Twenty-three publications were included, 10 being case reports. One hundred-fifty-one patients with TMJ PsA were reported. Psoriasis evolution ranged from 1.5 years to 24 years. Clinical symptoms of TMJ involvement included: TMJ pain and sounds, limited range of jaw movements, preauricular swelling, malocclusion, headache, tinnitus, neck stiffness and altered dietary function. TMJ was evaluated by magnetic resonance imaging (six studies), computed tomography (eight articles) and by ultrasonography findings (two articles). For TMJ treatment, topical and systemic medication was reported in 11 studies. Five studies included patients needing surgical procedures for TMJ ankylosis.

CONCLUSIONS

A relationship between TMD and psoriasis has been revealed. TMJ PsA has been investigated and debated, although the radiographic findings or clinical symptoms of PsA are not noticeably different from other forms of TMJ arthritis. Conservative therapy can lead to significant improvement of TMJ function.

Outcomes of total joint alloplastic reconstruction in TMJ ankylosis

OBJECTIVE

The purpose of this study was to evaluate subjective and objective outcomes in patients with temporomandibular joint (TMJ) ankylosis treated with TMJ alloplastic reconstruction (TMJR).

STUDY DESIGN

All patients diagnosed with TMJ ankylosis that underwent TMJR at our institution between 2010 and 2019 were retrospectively reviewed. Patients were divided into 2 cohorts: bony and fibrous ankylosis. Subjective variables assessed were facial pain and headaches, TMJ pain, jaw function, diet, and disability. Objective variables assessed were maximum interincisal opening and lateral excursions. The Mann-Whitney test was employed to analyze subjective variables and an unpaired t-test was used to analyze the objective variables. P < .05 was considered statistically significant.

RESULTS

Twenty-eight patients met the inclusion criteria (21 female, 7 male). The mean age at the time of surgery was 42 years, and the mean number of prior TMJ surgeries was 3. A total of 52 TMJRs were performed in the 28 patients, and the mean follow-up time was 46 months. All subjective variables were significantly improved, and the mean maximum interincisal opening increased from 16.9 mm to 37.25 mm.

CONCLUSIONS

The results of the study demonstrate that TMJR is an effective and reliable method for the management of both fibrous and bony TMJ ankylosis.

Absorbance or organization into ankylosis: a microarray analysis of haemarthrosis in a sheep model of temporomandibular joint trauma

Background

Traumatic haemarthrosis was hypothesized to be the etiology of temporomandibular (TMJ) ankylosis. Here, taking haematoma absorbance as a control, we aimed to reveal the molecular mechanisms involved in haematoma organizing into ankylosis using transcriptome microarray profiles.

Material/methods

Disk removal was performed to building haematoma absorbance (HA) in one side of TMJ, while removal of disk and articular fibrous layers was performed to induced TMJ ankylosis through haematoma organization (HO) in the contralateral side in a sheep model. Haematoma tissues harvested at days 1, 4 and 7 postoperatively were examined by histology, and analyzed by Affymetrix OviGene-1_0-ST microarrays. The DAVID were recruited to perform the Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathway analysis for the different expression genes (DEGs). The DEGs were also typed into protein–protein interaction (PPI) networks to get the interaction data. Six significant genes screened from PPI analysis, were confirmed by real-time PCR.

Results

We found 268, 223 and 17 DEGs at least twofold at days 1, 4 and 7, respectively. At day 1, genes promoting collagen ossification (POSTN, BGN, LUM, SPARC), cell proliferation (TGF-β), and osteogenic differentiation of mesenchymal stem cells (BMP-2) were up-regulated in the HO side. At day 4, several genes involved in angiogenesis (KDR, FIT1, TEK) shower higher expression in the HO side. While HA was characterized by a continuous immune and inflammatory reaction.

Conclusions

Our results provide a comprehensive understanding of the role of haematoma in the onset and progress of TMJ ankylosis. The study will contribute to explaining why few injured TMJs ankylose and most do not from the molecular level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-02033-w.

Mutations in the osteoprotegerin-encoding gene are associated with temporomandibular joint ankylosis

OBJECTIVE

This study aimed to investigate genetic variations in the osteoprotegerin-encoding gene (TNFRSF11B) in patients with temporomandibular joint ankylosis (TMJA).

STUDY DESIGN

The sample comprised 17 patients diagnosed with TMJA, of both sexes with ages ranging from 6 to 57 years old. TNFRSF11B mutational analysis was performed using the Sanger sequencing method with DNA extracted from oral cells, and the functional impact prediction of the variants was assessed using bioinformatic analysis.

RESULTS

Sequencing analysis identified 15 (88.23%) patients that presented at least 1 genetic variant in TNFRSF11B. The mutation rs202090603 (p.E33K) was found in 6 individuals, and rs140782326 (p.V281M), rs11573942 (p.L295), and rs1375250340 (p.I389T) were identified in 1 subject each. According to the pathogenicity potential of mutations, 3 variants were considered of low impact (rs2073618, rs202090603, and rs2228568) and 3 as disease causing (rs140782326, rs11573942, and rs1375250340). The variant rs202090603 (p.E33K) was found in the first cysteine domain with differences in the loop positions of p.E33K mutated the 3D structure of osteoprotegerin.

CONCLUSION

Two polymorphisms (rs2073618 and rs2228568) and the mutations rs202090603 (p.E33K), rs140782326 (p.V281M), rs11573942 (p.L295), and rs1375250340 (p.I389T) in the TNFRSF11B gene may be associated with TMJA.

Computer-assisted surgery with custom prostheses and human amniotic membrane in a patient with bilateral class IV TMJ reankylosis: a case report

A gold-standard technique has yet to be found for the treatment of temporomandibular joint ankylosis (TMJa), particularly in patients with recurring ankylosis. A 58-year-old male patient, with a history of multiple TMJ surgeries and severe limitation of mouth opening (maximum interincisal distance [MID] was 10 mm). Computerised tomography (CT) imaging highlighted a bilateral type IV ankylosis. The surgical guides were manufactured using a 3D printing method after obtaining a proper design of the osteotomy lines. The positioning of the fossa and condyle components of the custom TMJ prosthesis was digitally performed. Osteotomies were carried out using surgical guides and TMJ prostheses were placed as per the virtual planning. A human amniotic mambrana is inserted between the two prosthetic components to avoid ranchylosis. The post-operative CT showed the correct positioning of the condylar prosthesis. MID after 10 days was 37 mm. Total joint reconstruction surgery using 3D virtual surgical planning may be an effective surgical option for achieving a precise surgical outcome and making use of a single-stage approach in cases of TMJa and the use of the amniotic membrane, thanks to its healing properties and reduction of pain perception, seems to improve the quality of the immediate post-operative period.

Temporomandibular Joint Ankylosis among Patients at Saint Paul's Hospital Millennium Medical College, Ethiopia: A 9-Year Retrospective Study

Background

Temporomandibular joint ankylosis (TMJA) is a gradually developing pathological condition manifested by a limited mouth opening. It can result in an extremely disabling deformity that may affect mastication, swallowing, speech, oral hygiene, and facial cosmetic appearance. The present study aimed to determine the pattern of TMJA at St. Paul's Hospital millennium medical college (SPHMMC), Addis Ababa, Ethiopia.

Methods

A retrospective descriptive study design was conducted at SPHMMC. All medical records of patients with the diagnosis of TMJA that visited the Maxillofacial Surgery unit from September 2010 through August 2019 were reviewed. Sociodemographic and clinical data including age, sex, place of residency, duration of TMJA cases, etiology, clinical presentations, imaging results, type of surgical operation, and complications after surgery were collected and analyzed using IBM SPSS software version 20 for Windows (Armonk, NY, USA: IBM Corp) computer program.

Results

A total of 130 patients' medical records were reviewed. Out of this, 95 were included in the study. Forty-two (44.2%) of the TMJA cases were males, while the remaining 53 (55.8%) were females with a male to female ratio of 0.79 : 1. 20-29-year-old patients were the most affected, 36 (37.9%), followed by the 30 to 39 years age group, 33 (34.7%). Trauma (77.9%) was identified as the most common cause of TMJA. Notably, bilateral ankylosis (72.6%) was more common than unilateral (27.3%), and micrognathia was the most common (23.0%) deformity observed. The majority 52 (54.7%) of TMJA patients were treated with gap arthroplasty.

Conclusions

TMJA was predominant among females than their male counterparts. Of note, 20-29-year-old patients were the most affected group. The majority of TMJA cases were treated by gap arthroplasty with almost no postoperative complications. Early detection and intervention to release the ankylosed joint is needed to improve patients' quality of life.

Efficacy of temporomandibular joint arthroplasty and insertion of a Matthews device as treatment for ankylosis of the joint: a case series

Temporomandibular joint (TMJ) ankylosis is a condition in which bony or fibrous adhesion of the anatomical joint components results in loss of function. This is particularly distressing and debilitating for patients who struggle to maintain good oral hygiene, which results in additional pain, oral disease, and ultimately, a poor aesthetic profile. A retrospective chart review was carried out to document the cases of three patients who attended a single centre for the management of ankylosis of the TMJ. Consent for chart review and use of photographs was gained from each one. Charts were obtained, records reviewed, and each of the cases written up for presentation in a case series. All three underwent arthroplasty of the TMJ and insertion of Matthews devices (two patients unilateral, one bilateral). All were followed up postoperatively. They experienced significant improvements in vertical mouth opening which have been maintained to the present. The Matthews device allows movement and physiotherapy postoperatively whilst maintaining the surgically created space. This prevents impingement on the tissues placed between the glenoid fossa and mandible, and appears to prevent relapse and further ankylosis. To our knowledge, few studies to date have documented the use of the Matthews device following interpositional arthroplasty of the TMJ.

Differential regulation of blood vessel formation between traumatic temporomandibular joint fibrous ankylosis and bony ankylosis in a sheep model

OBJECTIVES

Clinical and experimental studies show that the etiology of traumatic temporomandibular joint (TMJ) fibrous ankylosis and bony ankylosis are associated with the severity of trauma. However, how the injury severity affects the tissue differentiation is not clear. We tested the hypothesis that angiogenesis affects the outcomes of TMJ trauma, and that enhanced neovascularization after severe TMJ trauma would promote the development of bony ankylosis.

METHODS

Bilateral condylar sagittal fracture and discectomy were performed for each sheep, with the glenoid fossa receiving either severe trauma to induce bony ankylosis or minor trauma to induce fibrous ankylosis. At days 7, 14, 28, and 56 after surgery, total RNA was extracted from the ankylosed callus. Temporal gene expressions of several molecules functionally important for blood vessel formation were studied by real-time PCR.

RESULTS

Histological examination revealed a prolonged hematoma phase and a lack of cartilage formation in fibrous ankylosis. mRNA expression levels of HIF-1α, VEGF, VEGFR2, SDF1, Ang1, Tie2, vWF, CYR61, FGF2, TIMP1, MMP2, and MMP9 were distinctly lower in fibrous ankylosis compared with bony ankylosis at several time points.

CONCLUSIONS

Our study indicates that inhibition of angiogenesis after TMJ trauma might be a promising strategy for preventing bony ankylosis in the future.

Diamond-like carbon films over reconstructive TMJ prosthetic materials: Effects in the cytotoxicity, chemical and mechanical properties

Increasingly more young patients have been submitted to reconstruction of the Temporomandibular Joint (TMJ), so, the prostheses must to present more functional longevity.

Objective

To evaluate the effect of diamond-like carbon film (DLC) over titanium alloy (Ti6Al4V) and polyethylene (UHWPE) samples, their mechanical and chemical properties and cellular cytotoxicity.

Methods

Titanium and UHWPE specimens, with 2.5 cm in diameter and 2 mm thickness were coated through plasma enhanced chemical vapor deposition (PECVD) with DLC or DLC doped with silver (DLC-Ag). Scanning electron microscopy (SEM) morphological analysis, Energy-dispersive spectroscopy (EDS) chemical analysis, scratching test, mechanical fatigue test, surface roughness analysis, and cellular cytotoxicity were performed. Data were statistically analyzed using one-way ANOVA (p < 0.05) or two-way ANOVA and multiple comparison Tukey test.

Results

In the SEM analysis, morphological differences were observed on substrates after DLC deposition. The film chemically modified the substrate surfaces, according to the EDS analysis. The initial critical load failure occurred at 6.1 N for DLC and 9.7 N for the DLC-Ag film. The DLC film deposition over the polyethylene promoted a decrease in the polymer's damaged area after mechanical fatigue cycling. The cytotoxicity analysis demonstrated less biocompatibility in experimental groups, when compared to control, however, increased biocompatibility was observed, at 10 days, in all groups.

Conclusion

The diamond-like carbon coating enhanced the chemical and mechanical properties from substrates, however modified biological interaction course of the titanium alloy (Ti6Al4V) and polyethylene (UHWPE) samples. Parameters for film deposition remain to be improved in order to obtain best biocompatibility.

A New Method To Reposition the Displaced Articular Disc For a Patient With Comminuted Condylar Fracture

BACKGROUND

Repositioning the displaced articular disc is the key procedure that prevents ankylosis of the temporomandibular mandibular joint (TMJ) in the treatment of patients with comminuted condylar fractures. The conventional procedure performed clinically is to use two anchors and sutures to reposition the displaced articular disc. Therefore, this paper introduces a new and economical method to reposition the articular disc without metallic implantation materials.

CLINICAL PRESENTATION

A 60-year-old male patient who had fainted suddenly 3 days before came to our hospital to complain of pain of the bilateral TMJ areas and limited mouth opening. Clinical examination revealed severe restriction of mouth opening and the disappearance of bilateral condylar movements. Preoperational 3-dimensional computed tomography (3-DCT) indicated bilateral intracapsular comminuted fractures of the mandibular condyles. The patient was operated in a bilateral preauricular approach for repositioning of the bilateral articular discs and removal of the fracture fragments. Instead of repositioning the displaced disc with anchors, we designed a method to use sutures to stabilize the TMJ disc and to assess the disc's position using a magnetic resonance imaging (MRI) scan when following up. There were no severe complications during the operation. Results of an MRI scan 1 month after operation showed that post-operation articular discs kept their normal position, the mouth opening and the lateral and protrusive movements of the mandible recovered when followed up for 3 months.

CONCLUSION

The method of using sutures to reposition and stabilize the articular disc for a patient with comminuted fractures is effective. There is great significance not only for patients with comminuted condylar fractures but for treatment of TMJ dysfunction especially for patients with high psychological pressure who persist in requiring the removal of metallic anchors although there are no clinical symptoms.

Considerations for Temporomandibular Joint Procurement in Vascularized Composite Allotransplantation

Methods for harvest of the temporomandibular joint (TMJ) for transplantation may involve several anatomic levels. The authors aim to assess the feasibility and identify challenges with 2 such methods, resuspending the donor condyles from the recipient glenoid fossae and en bloc harvest of the joint and surrounding temporal bone with plate-fixation to the recipient skull base. Two mock face transplantations were carried out using 4 fresh cadavers. Computed tomography imaging was obtained before and after the procedures to assess the technical success of each method. Both techniques were technically successful, allowing for full passive jaw range of motion following graft transfer and appropriate condyle positioning as assessed by computed tomography. En bloc TMJ harvest allowed for transfer of the entire joint without violating its capsule or altering its biomechanics. The authors found this technique better able to avoid issues with size mismatch between the donor mandible and recipient skull base width. When no such mismatch exists, graft harvest at the level of the mandibular condyle is technically easier and less time consuming. Although both methods of TMJ harvest are technically feasible with acceptable immediate postoperative jaw position and range of motion, the en bloc technique allows for more natural jaw function with less risk of postoperative joint immobility by preserving the joint capsule and its ligamentous support.

Role of extra oral monofocal distractor device in the correction of the facial asymmetry, sleep apnoea, and quality of life associated with TMJ ankylosis

OBJECTIVES

The purpose of this study is to evaluate the role of primary osteo-distraction prior to ankylosis release in patients, diagnosed with sleep apnoea, facial asymmetry, and reduced quality of life secondary to temporomandibular joint (TMJ) ankylosis.

METHODS

Ten patients in the age group of 13-40 years with TMJ ankylosis underwent primary osteo-distraction for mandibular advancement. They were evaluated pre- and post-operatively using radiographs, various questionnaires, and subjective evaluation of facial asymmetry, sleep apnoea, and quality of life (QOL).

RESULTS

All the ten patients showed significant improvement in their sleep apnoea symptoms with a mean of 6.20 ± 1.39 (P < 0.05). The mean advancement of the mandible in all the ten patients (both bilateral and unilateral ankylosis) was 15.8 mm (P < 0.05). The quality of life showed marked improvement from very poor to very satisfactory (P < 0.001).

CONCLUSION

Primary mandibular distraction is an effective method of correction of facial asymmetry, sleep apnoea, and quality of life in patients with TMJ ankylosis.

Co-culture of bone marrow stromal cells and chondrocytes in vivo for the repair of the goat condylar cartilage defects

This study explored the feasibility of inducing the differentiation of BMSCs into chondrocytes through co-culture with chondrocytes in hydrogel constructs (Pluronic F-127 gel) in vivo for the repair of goat mandibular condylar cartilage defects. Chondrocytes and BMSCs were isolated from goat auricular cartilage and bone marrow, respectively, and were mixed at a ratio of 3:7. BMSCs were labelled with green fluorescence protein (GFP) using a retrovirus vector for tracing. Mixed cells were re-suspended in 30% Pluronic F-127 at a concentration of 5×10⁷ cells/ml to form a gel-cell complex. The gel-cell complex was implanted into the temporomandibular joint condylar articular cartilage defects. The whole temporomandibular joint and adjacent tissues were harvested at 4, 8, and 12 weeks after surgery, and gross observation, histology and collagen II expression were evaluated. In the co-culture group, cartilage-like tissues were formed, and abundant type II collagen could be detected by immunohistochemistry in the condylar cartilage defects. Confocal microscopy revealed that implanted GFP-labelled BMSCs were embedded in cartilage-like tissues. The co-culture system described herein provides a chondrogenic microenvironment to induce the chondrogenic differentiation of BMSCs in vivo without any additional cellular factors.

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.

Matthews device arthroplasty presents superior long-term mouth opening than interpositional arthroplasty in the management of temporomandibular joint ankylosis

BACKGROUND

The aim of this study is to describe the surgical outcomes of a single-institution experience in the surgical management of temporomandibular joint ankylosis, comparing interpositional arthroplasty with autogenous tissue and Matthews device arthroplasty.

METHODS

A retrospective analysis of temporomandibular joint ankylosis patients (n = 15), who underwent interpositional arthroplasty or Matthews device arthroplasty, was conducted. The surgical outcomes (preoperative, recent [4-6 weeks], intermediate [1 year], and late [3 years] postoperative maximal incisal opening, hospital stay, and complication, relapse, and reoperation rates) were compared.

RESULTS

Significant (all p < 0.05) differences were recorded in temporomandibular joint ankylosis patients treated with interpositional arthroplasty with autogenous tissue (53.3%) versus Matthews device arthroplasty (46.7%) according to intermediate (25 ± 7 vs. 34 ± 5 mm) and late (19 ± 8 vs. 33 ± 5 mm) postoperative maximal incisal opening, intermediate (31% vs. 7%) and late (47% vs. 12%) postoperative relapse, and reoperation rate (38% vs. 0%). There was similarity (all p > 0.05) in preoperative (4.8 ± 2.9 vs. 4.9 ± 2.9 mm) and recent (35 ± 4 vs. 37 ± 4 mm) postoperative maximal incisal opening, hospital stay (3.5 ± 0.8 vs. 3.6 ± 0.8 days), and surgery-related complications (13% vs. 14%).

CONCLUSION

Both surgical procedures evaluated were successful in initial management of temporomandibular joint ankylosis, but the Matthews device arthroplasty avoided postoperative relapse.

Management of extra-capsular temporo-mandibular joint ankylosis: does conservative approach to treatment have a role?

BACKGROUND

The conventional management of fibrous extracapsular temporo-mandibular joint (TMJ) ankylosis, a debilitating disease, is associated with surgical complications and financial burden on the patients.

OBJECTIVE

To assess the outcome of conservative approach to the management of fibrous extracapsular TMJ ankylosis.

PATIENTS AND METHODS

This is a prospective study of patients who presented at the Dental and Maxillofacial Surgery Clinic of the University of Calabar Teaching Hospital, Nigeria, during the period from January 1999 to December 2012 with a history of inability to open the mouth diagnosed as fibrous extracapsular TMJ ankylosis.

RESULTS

Twenty-one subjects were treated and their ages ranged from 11 to 22 years with mean at 15.0 years. There were 13 (61.9 %) males and 8 (38.1 %) females with male: female ratio of 1.6:1. The aetiological factor that predisposed to formation of extracapsular TMJ ankylosis was facial trauma. There was no facial asymmetry and the side distribution of the affliction showed that 1 (4.8 %) was bilateral while 20 (95.2 %) were unilateral. Eight cases (38.1 %) were incomplete ankylosis while the rest (n = 13, 61.9 %) were complete. The shorter the duration of fibrous ankylosis and the greater the initial inter-incisal distance before treatment, the better the treatment outcome.

CONCLUSION

The outcome of treatment suggests that the conservative approach to management of this condition was beneficial to these patients because they presented early. However, randomized controlled clinical trials are needed to validate this treatment option.

Gap Arthroplasty versus Interpositional Arthroplasty for Temporomandibular Joint Ankylosis: A Meta-Analysis

Gap arthroplasty (GA) and interpositional arthroplasty (IA) are widely used for the treatment of temporomandibular joint ankylosis (TMJA). However, controversy remains as to whether IA is superior to GA. PubMed, EMBASE, the Cochrane Library, the Web of science and the China National Knowledge Infrastructure were searched for literature regarding these procedures (published from 1946 to July 28, 2014). A study was included in this analysis if it was: (1) a randomized controlled trial or non-randomized observational cohort study; (2) comparing the clinical outcomes between GA and IA with respect to the maximal incisal opening (MIO) and reankylosis; (3) with a follow-up period of at least 12 months. The methodological quality of the included studies was evaluated according to the Newcastle-Ottawa Scale Eight non-randomized observational cohort studies with 272 patients were included. All the statistical analyses were performed using the RevMan 5.3 and Stat 12. The pooled analysis showed no significant difference in the incidence of reankylosis between the IA group (13/120) and the GA group (29/163) (RR= 0.67, 95% CI=0.38 to 1.16; Z=1.43, p=0.15). The IA group showed a significantly larger MIO than the GA group (MD=1.96, 95% CI=0.21 to 3.72, Z=2.19, p=0.03, I²=0%). In conclusion, patients with TMJA could benefit more from IA than GA, with a larger MIO and a similar incidence of reankylosis. IA shows to be an adequate option in the treatment of TMJA based on the results of maximal incisal opening.

Correlation between the disc status in MRI and the different types of traumatic temporomandibular joint ankylosis

OBJECTIVES

We aimed to investigate the correlation between the disc status in MRI and the different types of traumatic temporomandibular joint (TMJ) ankylosis.

METHODS

51 consecutive patients (69 joints), diagnosed with traumatic TMJ ankylosis with a residual condyle (Types A2 and A3), were included in this study. All patients had pre-operative MRI, which was reviewed to determine the disc shape, length and position. The results were compared using the Mann-Whitney test.

RESULTS

There were 37 joints of Type A2 ankylosis and 32 joints of Type A3. All joints of Type A2 and 27 joints of Type A3 (84.4%) definitely had a discernible disc, while 5 joints of Type A3 had no discernible discs. Among the discernible discs, the lateral disc of Type A2 and the whole disc of Type A3 had severe deformity, while the medial disc of Type A2 had mild deformity. The mean (standard deviation) disc length was 10.88 (1.19) mm in Type A2, but 7.50 (0.82) mm in Type A3. There was a significant difference between Types A2 and A3 (p < 0.05). As for the disc position, the intermediate position was found in all joints.

CONCLUSIONS

There is a correlation between the disc status and the different types of traumatic TMJ ankylosis. Therefore, MRI examination is needed to help treatment planning and predict post-operative TMJ function.

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.

Imaging and histologic features of traumatic temporomandibular joint ankylosis

OBJECTIVE

We aimed to study the pathology underlying traumatic temporomandibular joint ankylosis (TMJA).

STUDY DESIGN

Specimens from 10 patients with traumatic TMJA were categorized using the Sawhney classification and were decalcified and stained with hematoxylin-eosin, alcian blue/periodic acid-Schiff, alizarin red, and Masson stains. Immunostaining with anti-CD34 antibody was performed. Computed tomography and pathologic findings were compared.

RESULTS

Ankylosed areas consisted of fibrocartilaginous tissues. Bone formation occurred by osteophyte extension from the osteochondral surface toward the mass center. Endochondral ossification and osteophyte proliferation, alone or simultaneously, participated in bony ankylosis. Sequestra in the cartilaginous ankylosis preferentially formed bony bridges. Newly formed capillaries participated in ossification from the bony surface of the bone-cartilage junction; bone formed around the capillaries. Osteoclasts were present at the capillary tips.

CONCLUSIONS

Types II and III were cartilaginous-bony ankylosis, with similar components. Bony traumatic TMJA was formed by osteophyte proliferation and endochondral ossification.

Bilateral temporomandibular joint ankylosis as sequel of bilateral fracture of the mandibular condyle and symphysis

BACKGROUND

Temporomandibular joint (TMJ) ankylosis is an extremely disabling affliction that causes problems in mastication, digestion, speech, appearance, and hygiene. The disease also has an impact on the psychological development of the patients.

CASE REPORT

A 49-year-old male patient came to our unit with complaint of restriction in his alimentation and of mouth opening. In the anamnesis, the patient reported that this limitation began 11 years ago, soon after a serious car accident that caused trauma on the face. In the clinical examination, the patient's mouth opening was 1 mm, and there was satisfactory occlusion. He was diagnosed with bilateral temporomandibular joint (TMJ) ankylosis after an imaging examination.

DISCUSSION

In order to confirm the post-traumatic etiology of the anquilose, we got the medical records from the hospital where the patient received the first treatment. The records, at that time, reported facial trauma with bilateral condylar fracture and comminuted symphyseal fracture which was reduced and fixed followed by maxillomandibular fixation that remained for 45 days. After collecting all the information needed for diagnosis, surgical treatment was proposed through arthroplasty. The patient was placed on immediate post-operative jaw physiotherapy, and 12 months after surgery, his mouth opening improved to 35 mm. Thus, in our case, ankylosis may have been developed as a sequel of the mandibular fractures.

DESIGN, MANUFACTURE AND CLINICAL EVALUATION OF A NEW TMJ EXERCISER

Temporomandibular joint (TMJ) ankylosis or hypomobility is a major clinical problem that affects many patients suffering from facial trauma, infection, TMJ dysfunction, inflammatory diseases and tumors. Postoperative physiotherapy is recognized as essential for the prevention or treatment of TMJ hypomobility or ankylosis. Traditional methods using stacked tongue depressors and the reported TMJ opening exercisers all have disadvantages and cannot achieve clinical requires. This study employed CAD/CAM techniques to develop a new TMJ exerciser that would be user-friendly and performed clinical trails to test the efficacy of the device. A power screw was used to overcome the small force control difficulty, allowing gradually increased TMJ opening performance. The front end of the device was designed as U-shape platform that could be inserted into the patient's mouth to allow easy TMJ exercise performance. A streamlined handle also designed to be held by the patients to decrease the mouth loading. This device is convenient for long-term physiotherapy. The clinical trail results indicated that the improvements of the incisor opening range could increase from 108% to 258% within one mouth after postoperative physiotherapy. The developed TMJ exerciser is effective, convenient, easy to use, light weight and has long-term durability for postoperative physiotherapy.

Modified gap arthroplasty and Myrhaug's incision as a treatment option in management of temporomandibular joint ankylosis: a study of 10 cases

PURPOSE OF THE STUDY

The purpose of this study was to evaluate effectiveness of modified gap arthroplasty procedure and modified Myrhaug's preauricular incision for treating bony temporomandibular joint (TMJ) ankylosis.

MATERIALS AND METHODS

A total of 10 cases were included in the study with Sawhney's type III and IV TMJ ankylosis. Study consisted of 6 males and 4 females. Three cases were treated for bilateral ankylosis and 7 were treated for unilateral ankylosis. All the patients were treated with modified gap arthroplasty and modified Myrhaug's incision was used. In this modification, osteotomy cuts were modified in such a way that coronoid process was also removed simultaneously along with the osteotomized ankylosed mass in one piece.

RESULTS

All the patients were followed up for 5 years and none of them presented with recurrence. Two patients had transient paresis to zygomatic and temporal branch of facial nerve and none had permanent damage to the nerve. Seven patients had mouth opening more than 25 mm (p) when followed for 5 years. Anterior open bite was seen in 4 patients and deviation of the jaw on ipsilateral side was noted in 2 patients.

CONCLUSION

Modified gap arthroplasty gave successful results in the follow-up period and eliminated the need of separate coronoidectomy. Use of modified Myrhaug's preauricular approach, provided excellent visibility particularly of the elongated coronoid process, minimized bleeding, prevented damage to the vital anatomical structures surrounding the joint and gave acceptable cosmetic results.

CLINICAL SIGNIFICANCE

The modified incision has been found to be reducing intra- and postoperative morbidity as well as provides excellent accessibility. The modified osteotomy technique eliminated the need for separate coronoidectomy thus significantly reducing the operating time.

Comparison of clinical efficacy of temporalis myofascial flap and dermal graft as interpositional material in treatment of temporomandibular joint ankylosis

Temporomandibular joint (TMJ) ankylosis is a very distressing structural condition. Interpositional arthroplasty has become the acceptable standard for the primary surgical management of TMJ ankylosis. Up to now, diverse interpositional materials have been proposed in this regard, with especial advantages and limitations. The temporalis muscle and facial flap, as well as the dermal graft, are among the most popular ones. This study aimed to compare the short-term clinical consequences between these 2 interpositional materials in patients with operated TMJ ankylosis.

MATERIALS AND METHODS

Twenty patients with TMJ ankylosis were randomized in 2 age- and sex-matched 10-patient groups and received either a temporalis muscle and facial flap or a dermal graft as the interpositional material. The maximal incisal opening (MIO) and the amount of lateral excursion (LE) were measured before and 3 months after surgery, and the mandibular deviation (MD) at the mouth opening 3 months after operation was compared between the 2 groups.

RESULTS

Twenty patients were enrolled in the study. The presurgical MIO and LE were not significantly different between the 2 groups. Three months after the operation, evaluation of the patients did not reveal a significant difference considering the amount of the MIO, LE, or MD. The mentioned parameters were significantly improved 3 months after the operation in both groups.

CONCLUSIONS

The interpositional arthroplasty in TMJ ankylosis patients using either a temporalis muscle and facial flap or a dermal graft would yield a comparable and almost satisfactory clinical outcome.

Interposition arthroplasty in post-traumatic temporomandibular joint ankylosis: A retrospective study

Temporomandibular joint ankylosis which is most frequently caused by trauma, presents with restriction in mouth opening in early stages and if children are the victim and not treated early, it presents with growth retardation of the involved mandibular side. Various methods are available for surgical correction. We have reviewed our experience with the efficacy of different interpositional materials in post-traumatic cases in our set up with special reference to temporal fascia over last three years. Twenty seven patients with history of trauma, mostly fall from height, have been studied. They were evaluated clinically and by computed tomography (CT) scan, orthopantogram and x- ray lateral oblique view. The most common age group was 10-15 years with mean 12.5 years and male to female ratio 1:2. Preoperative mouth opening (inter incisor distance) was 1-2 mm in 17 cases and 2-4 mm in 10 cases. We have used temporalis fascia in nine, costochondral graft in seven, silastic sheets in five and T-plates in six cases. Post-operatively, adequate mouth opening of 30-50 mm was observed in six months follow-up and more than 50 mm at one year follow up in 21 cases out of which nine cases have interpositional material as temporalis fascia alone. The postoperative period was uneventful in all cases and none required re-operation for recurrences. We conclude that interpositional arthroplasty, especially with pedicled temporal fascia, is the best method to prevent recurrences and establish good mouth opening and full range of jaw movements.

Surgical management of temporomandibular joint ankylosis

Ankylosis of the temporomandibular joint (TMJ) is one of the causes of persistent and progressive limitation of mouth opening. It usually requires to be corrected surgically; an intervention not without complications. This study was conducted in a central surgical hospital in Iraq (Baghdad) in the era hallmarked by shortage of nearly all facilities needed to accomplish solutions for a surgical task. The surgical procedure is displayed along with modifications, complications, and follow-up protocol. Fifteen patients (21 joints) have been treated surgically for TMJ ankylosis of different severities. All patients were treated at the Department of Oral and Maxillofacial Surgery, Specialized Surgical Hospital-Baghdad Medical City, Iraq. The study was carried out in the period between 1998 and 2002 (inclusive). Patients' ages ranged between 4 and 52 years. In addition to the clinical diagnoses, further evaluation of the ankylosis area was assisted by the use of orthopantomography and spiral computerized scanning (axial, coronal sections, and three-dimensional views). Maximal incisal opening was registered before and after surgery for further follow-up evaluation. Al-Kayat and Bramely approach is advocated to expose the joint area. All 21 joints were operated through blind nasoendotracheal intubation general anesthesia. Computed tomography scans, wide exposures, aggressive resections, proper interposition materials, strict postoperative physiotherapy, and good family and patient compliance all may decrease the possibility of relapse and offer better results. Early management of TMJ ankylosis is important if more damage in orofacial structures and consolidation of bony union are to be avoided.