Interpositional Arthroplasty by Temporalis Fascia Flap and Galea Aponeurotica Combined With Distraction Osteogenesis: a Modified Method in Treatment of Adult Patients With Temporomandibular Joint Ankylosis and Mandibular Dysplasia

Modified Osteotomy for TMJ Ankylosis in Paediatric Patients with Deficient Interpositional Temporalis Muscle Mass and Buccal Fat Pad - A case Series and Literature Review

Ankylosis of the temporomandibular joint (TMJ) is a bony or fibrous fusion of the articular surfaces of the mandibular condyle and the glenoid fossa. Gap arthroplasty, Interpositional arthroplasty, Condyle reconstruction with autogenic or alloplastic grafts and total joint replacement are some common modalities of management. In this article, we discuss a series of three cases of unilateral TMJ ankylosis in paediatric patients, managed by gap arthroplasty using a modified osteotomy cut. The modification was adapted due to inadequate interpositionable temporalis muscle or buccal fat on the affected side and chances of adaptive remodelling of the CCG (Costochondral graft), if placed were rendered negative.

Distraction osteogenesis promotes temporomandibular joint self-remodeling in the treatment of mandibular deviation caused by condylar ankylosis

Craniofacial deformity and malocclusion are primary concerns following temporomandibular joint ankylosis (TMJa) in growing patients, and they pose even greater challenges in adult patients. The treatment objectives always involve restoring proper jawbone structure, achieving stable occlusion, and attaining satisfactory joint mobility. This report presents a 4-year follow-up of an adult patient with TMJa-induced mandibular deviation, who underwent a combined treatment approach involving distraction osteogenesis (DO) and orthodontic-orthognathic surgery. Orthodontic treatment resulted in favorable occlusion and improved facial esthetics. A new condyle with a reconstructed glenoid fossa in a forward position was established after mandibular DO and the damaged TMJ experienced self-remodeling owing to functional improvement. Thus, this case demonstrates the efficacy of DO in promoting adaptive TMJ self-remodeling with long-term stability when treating mandibular deviation caused by condylar ankylosis in adult patients.

Modified minimally invasive surgery in reconstructing the temporomandibular joint disk by transplantation of the temporalis myofascial flap

OBJECTIVE

The transplantation of temporalis myofascial flap (TMF) is an indispensable method to treat severe temporomandibular joint disorders with disk failure. How to select the indication and the ways of transplantation is still a challenging topic for achieving the ideal effect. We reported the new methods and follow-up results of the patients treated with pedicled TMF transplantation.

METHODS

Retrospective case series was performed at Temporomandibular Joint Specialist Clinic, the First Affiliated Hospital of Xinjiang Medical University, from December 2014 to August 2022. 39 patients (50 sides) included anterior disk displacement without reduction and disk perforation who underwent discectomy and immediate reconstruction with pedicled TMF. The initial and postoperative maximum mouth opening (MMO), and pain visual analogue scale (VAS) were compared via paired t-test and Wilcoxon signed-rank sum test, respectively.

RESULTS

The average of follow-up time was 30.07 months. The reconstructed temporomandibular joints basically achieved stable occlusion, good function, and satisfactory effect. The patients displayed a remarkable reduction of VAS score of pain, and improvement of the MMO compared with that before operation (P <  0.001). MR scanning revealed the grafts in joint space showed band-shaped soft tissue density of medium signal and had the clear edges, without interruption and fragment.

CONCLUSION

Reconstruction of the temporomandibular joint disk by transplantation of the TMF applying modified minimally invasive surgery was a feasible method, which could improve the function of joints and prevent adhesion, without obvious complications in donor region.

A systematic review on the outcome of distraction osteogenesis in TMJ ankylosis

Introduction

TMJ ankylosis (TMJa) management by arthroplasty alone fails to address the deformity and the compromised airway. Distraction osteogenesis (DO) can offer a pragmatic solution to TMJa. The aim of the study was to generate evidence towards the role of DO in TMJa, evaluate its efficiency and develop an algorithm for use of DO in TMJa.

Material and methods

The research question was formulated using the PICOS statement for reporting guidelines in systematic reviews, where the efficiency of DO was evaluated in terms of mouth opening, correction of facial deformity and asymmetry, airway correction, and its long term effects.

Results

1130 articles reported DO as a treatment modality for TMJ ankylosis, of which 32 prospective studies, 16 retrospective and 2 RCTs were included in the study. DO was used for mandibular distraction in 45 studies and for simultaneous maxillamandibular distraction in only five studies. An algorithm for use of DO in TMJa was developed.

Conclusion

Although DO has proven its application in TMJ ankylosis cases, its best use is for correction of obstructive sleep apnoea. Relapse causing loss of posterior ramal height is a concern after transport DO. Prearthroplastic DO appears to best correct mandibular deformity. A maxillomandibular deformity requires simultaneous maxillomandibular distraction. However, a metanalysis is still awaited for effectiveness of DO in TMJ ankylosis.

Controversies in the management of temporomandibular joint ankylosis using distraction osteogenesis - A systematic review

Background:

The three commonly employed sequences of distraction osteogenesis (DO) in the management of temporomandibular joint (TMJ) ankylosis with dentofacial deformities include post-arthroplastic distraction osteogenesis (PAD), simultaneous arthroplastic distraction osteogenesis (SAD), and pre-arthroplastic distraction osteogenesis (PrAD).

Objective:

The aim of this systematic review is to compare the effectiveness of various sequences of DO in the management of TMJ ankylosis with micrognathia/and obstructive sleep apnea syndrome (OSAS).

Data Sources:

A comprehensive online and manual search of English language literature with no date restrictions was done on March 2020.

Eligibility Criteria:

Inclusion criteria were case series and prospective and retrospective studies involving adult/paediatric human subjects with unilateral/bilateral TMJ ankylosis and micrognathia/OSAS treated with DO.

Study Appraisal and Synthesis Methods:

Of 73 studies identified, only 10 were included in the qualitative synthesis. The outcomes assessed were as follows: maximum mouth opening (MMO), posterior airway space (PAS), polysomnography variables, reankylosis, mandibular length, and chin and mandible position.

Results:

All the included studies showed high risk of bias. MMO and mandibular length increased, chin and mandibular position improved by the end of treatment in all the three sequences, and polysomnography variables and PAS significantly improved in PrAD compared to PAD and improved in SAD compared to baseline. Reankylosis was significantly less in PrAD.

Conclusion:

More well-designed studies comparing the three sequences of DO should be carried out to arrive at a consensus.

Staged therapeutic approach for rehabilitation of severe asymmetric Class II dentofacial deformity secondary to long standing unilateral temporomandibular joint ankylosis

Despite being one of the most pervasive debilitating skeletal problems in the craniofacial region, surgical-orthodontic management of long-standing asymmetric Class II dentofacial deformities is often a unique challenge posed to the clinicians. This case report describes the encouraging results of systematically sequenced and staged therapeutic approach adopted for successful rehabilitation of an adult patient with asymmetric Class II dentofacial deformity with mandibular micrognathia secondary to unilateral TMJ ankylosis. Concurrent gap arthroplasty and bilateral distraction of mandibular body were performed during the first operation for functional restoration of mandibular movements and correction of mandibular micrognathia and associated asymmetry. After 13 months of post-distraction orthodontic treatment, Le Fort I osteotomy for inferior repositioning and sagittal advancement of maxilla was performed during the second operation, in conjunction with adjunctive alloplastic reconstruction of inferior border of mandible for optimization of facial aesthetics. Postsurgical orthodontic detailing facilitated achievement of stable, balanced interdigitation. The total active treatment period was 29 months. After treatment, both the skeletal disharmony and the functional stability were significantly improved with establishment of functional occlusion. The morphological and functionally acceptable results were reasonably well-maintained during three-year follow-up. The merits of mandibular osteodistraction vs. conventional mandibular orthognathic surgery and the potential advantages of staged surgical approach are discussed.