Surgical management of temporomandibular joint ankylosis

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.

Dysregulated healing response participates in the pathophysiology of temporomandibular joint ankylosis

This study aimed to characterize samples from patients diagnosed with TMJ ankylosis, using both clinical and histological data. Both clinical and histological analyses of retrieved tissue samples from patients with primary TMJ ankyloses were performed retrospectively (1980-2012). All patients had been subjected to primary arthroplasty. Our study analyzed connective tissue differentiation, ossification patterns, and bone resorption, using histology and immunohistochemistry. Fifteen case records, with a sex ratio of 4:1 (men:woman) and a median age of 8 years, were collected. Six patient samples reported a previous inflammatory event. Histologically, 15 samples exhibited fibrous tissue. Among these, 13 displayed bone at different stages of maturity (fibrous/bony ankylosis). Eleven samples showed aberrant cartilage, characterized by hypertrophic chondrocyte-like cells at the bone/cartilage interface. Four samples revealed inflammatory infiltrate; in one case, this was organized as a lymphoid follicle. Eleven samples showed bone resorption by attached osteoclasts. Interestingly, non-attached osteoclasts were detected, suggesting locally impaired bone remodeling. An association between the presence of mature/lamellar bone and the presence of osteoclasts was observed (p = 0.03). No association was found between previous history of either trauma or infection and the histological type of ankylosis (p = 0.74). There was no association between the histological presence of inflammation or infection and the type of ankylosis (p = 0.63 and p = 0.87, respectively). Retrieved TMJ ankylosis tissues displayed both aberrant ossification and reduced focal bone resorption, suggesting a dysregulated healing response.

Course of the Maxillary Vein and its Positional Relationship With the Mandibular Ramus Require Attention During Mandibuloplasty

PURPOSE

The maxillary vein is associated with major hemorrhage, an intraoperative risk factor during mandibuloplasty. Our objectives in this study were to identify the anatomical course of the maxillary vein relative to the mandible, and to ascertain the relationship of its course with that of the maxillary artery.

METHODS

Thirteen sides of 13 cadavers in the possession of the Department of Anatomy of Tokyo Dental College were used. The maxillofacial region was first dissected, after which the upper part of the mandibular ramus was removed and the maxillary artery, maxillary vein, and pterygoid venous plexus were identified. The length of the maxillary vein and its height from the mandibular plane were then measured, and its anatomical course was recorded.

RESULTS

The maxillary vein ran downward along the inner aspect of the temporal muscle, then from the base of the coronoid process it ran horizontally near the bone surface of the inner aspect of the mandibular ramus. After joining the inferior alveolar vein, it joined the superficial temporal vein to form the retromandibular vein. The mean length of the maxillary vein was 22.2 ± 3.2 mm. At the posterior margin of the mandibular ramus, its mean height above the mandibular plane was 34.2 ± 5.4 mm. From the posterior margin of the mandibular ramus to the lowest point of the mandibular notch, the maxillary vein was located within the areolar connective tissue directly above the periosteum adjoining the inner aspect of the mandibular ramus.

CONCLUSIONS

In the wide area from the center of the maxillary notch to the posterior margin of the mandibular ramus, the maxillary vein runs extremely close to the periosteum on the inner aspect of the mandibular ramus, suggesting that it may pose a risk of hemorrhage in various oral surgical procedures.

Rigid Fiber-Optic Device Intubation in a Child With Temporomandibular Joint Ankylosis

The authors present a case of rigid fiber-optic device intubation in an 8-year-old boy with posttraumatic temporomandibular joint ankylosis. For this intention, a 5 mm diameter Bonfils fiberscope was used. Such practice has never been described before in pediatric patients with temporomandibular joint ankylosis. The procedure was successful and without complications. Therefore, the authors conclude that this method represents a useful alternative in difficult airway management in children with limited mouth opening.

Guidelines for Single-Stage Correction of TMJ Ankylosis, Facial Asymmetry and OSA in Adults

Introduction

Treatment for TMJ Ankylosis aims at restoring joint function, improving the patient's aesthetic appearance and quality of life and preventing re-ankylosis. Mouth opening is achieved by gap arthroplasty with various options of interpositional materials. Ramus-condyle unit (RCU) reconstruction maintains the height of the ramus and prevents secondary occlusal problems. Advancement genioplasty corrects chin deformities as well as increases the posterior airway space (N-PAS) by the forward pull exerted on geniohyoid and genioglossus.

Materials and Methods

This prospective single-centre study on 43 joints in 25 adult patients with TMJ Ankylosis aimed at providing a single-staged management plan of ankylosis release, RCU reconstruction and extended advancement centering genioplasty. Interpositional arthroplasty was done using temporalis myofascial flap, abdominal dermis fat or buccal fat pad. RCU reconstruction was done either by vertical ramus osteotomy or L osteotomy.

Observations and Results

Follow-up ranged from 12 to 20 months (mean 14.4). Average mouth opening at maximum follow-up was 34.36 mm with re-ankylosis in no case. Cephalometric parameters showed increase in point P to Pog, decrease in N perpendicular to Pog, angle N-A-Pog, Cg-ANS to Cg-Menton, neck-chin angle and labiomental angle. N-PAS increased, and average 50% improvement in AHI was seen in all patients with OSA. Most common complications involved transient paraesthesia of temporal and zygomatic branches of facial nerve.

Conclusion

Based on the findings of the above study, we propose treatment guidelines for treatment of TMJ ankylosis in adult patients with AHI < 20.

Pseudoankylosis Between Lateral Pterygoid Plates and Mandible: Report of One Case

Temporomandibular joint (TMJ) ankylosis is the abnormal fusion of TMJ anatomic components that impedes free jaw movements. This restriction in motion ranges from minimal to a complete inability to open the jaw. This condition can be categorized as true ankylosis, which is attributed to pathologic conditions of the TMJ, or false ankylosis (pseudoankylosis), which describes restrictions of movement resulting from extracapsular abnormalities outside the TMJ. The literature shows that trauma is the leading cause of TMJ disorders and appears to be the most common cause of pseudoankylosis. Pseudoankylosis caused by pterygomandibular bony impingement has rarely been reported in the literature. This case report adds a new case of pseudoankylosis to the existing scanty literature, which was characterized by bilateral mechanical impingement between abnormally elongated lateral pterygoid plates and the coronoid processes of the mandible.

Trismus in Face Transplantation Following Ballistic Trauma

BACKGROUND

Trismus can be a challenging consequence of ballistic trauma to the face, and has rarely been described in the setting of face transplantation. Almost half of all current face transplant recipients in the world received transplantation to restore form and function after a ballistic injury. Here we report our experience and challenges with long standing trismus after face transplantation.

METHODS

We reviewed the medical records of our face transplant recipients whose indication was ballistic injury. We focused our review on trismus and assessed the pre-, peri- and postoperative planning, surgery and functional outcomes.

RESULTS

Two patients received partial face transplantation, including the midface for ballistic trauma. Both patients suffered from impaired mouth opening, speech intelligibility, and oral competence. Severe scarring of the temporomandibular joint (TMJ) required intraoperative release in both patients, and additional total condylectomy on the left side 6 months posttransplant for 1 patient. Posttransplant, both patients achieved an improvement in mouth opening; however, there was persistent trismus. One year after transplantation, range of motion of the jaw had improved for both patients. Independent oral food intake was possible 1 year after surgery, although spillage of liquids and mixed consistency solids persisted. Speech intelligibility testing showed impairments in the immediate postoperative period, with improvement to over 85% for both patients at 1 year posttransplant.

CONCLUSIONS

Ballistic trauma to the face and subsequent reconstructive measures can cause significant scarring and covert injuries to structures such as the TMJ, resulting in long standing trismus. Meticulous individual planning prior to interventions such as face transplantation must take these into account. We encourage intraoperative evaluation of these structures as well as peri- and postoperative treatment when necessary. Due to the nature of the primary injury, functional outcomes after face transplantation in these patients may differ substantially from those of other indications.

Management of Young Patients with Temporomandibular Joint Ankylosis-a Surgical and Anesthetic Challenge

Temporomandibular joint ankylosis is a unique disease where fracture of the mandibular condyle or any other cause leading to ankylosis of the joint can lead to multiple problems if not detected and treated early. If affected in early years of life, it may cause facial dysmorphism, restricted mouth opening, and difficulty in eating, speech, and sleep. Early surgery and physiotherapy can restore the joint function to a great extent. Anesthetizing a pediatric patient with this disorder is a definite challenge which needs expertise in difficult airway management.

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.

Osteoclast Deficiency Contributes to Temporomandibular Joint Ankylosed Bone Mass Formation

Ankylosed bone mass in temporomandibular joint ankylosis (TMJA) is an important factor affecting mouth-opening limitation. However, the mechanism underlying the occurrence of ankylosed bone mass remains unknown. Research has shown that osteoblasts and osteoclasts maintain balance in bone remodeling. Thus, we hypothesized that aberrant osteoclastogenesis and osteogenesis may be involved in the occurrence of ankylosed bone mass in TMJA. In this study, we characterized the osteogenesis of bone marrow stem cells and the osteoclastogenesis of myelomonocyte in clinical specimens of TMJA and normal controls. Results showed that, compared with control bone marrow stem cells, TMJA bone marrow stem cells had lower proliferative and osteogenic capacities. The number of osteoclasts in the ankylosed bone mass group dramatically decreased, and myelomonocyte osteoclastogenic potential was impaired. The RANKL/OPG ratio of the ankylosed bone mass group was lower than that of the control group. Thus, our study suggests that osteoclast deficiency may be an important factor affecting bone mass ankylosis.

Fiberscope Assisted Videolaryngoscope Intubation in the Surgical Treatment of TMJ Ankylosis

Temporomandibular ankylosis is characterized by the formation of a bony mass which replaces normal temporomandibular joint (TMJ) articulation. Anaesthetic management in these patients requires expertise and dependable intubation technique that allows successful intubation due to anticipated difficulty in accessing the airway. A novel technique of endotracheal intubation is used for the successful airway management during the surgical treatment in patients with TMJ ankylosis with the assistance of fiberscope and GlideScope(®) videolaryngoscope. GlideScope(®) videolaryngoscope is a recently introduced system for tracheal intubation that has a dedicated video camera encased into a laryngoscope blade and provides better panoramic view than the conventional laryngoscopes. This technique avoids complications such as trauma to soft tissue structures surrounding the glottis during the passage of the tube over the fiberscope. It gives a clear view of the tube and its cuff position during intubation. It also abbreviates the time required for intubation which is a crucial determinant in this subset of patients owing to the difficult airway associated with paediatric age group.

Two-stage total prosthetic reconstruction of temporomandibular joint in severe and recurrent ankylosis

Temporomandibular joint ankylosis is a devastating condition for the patient associated with both functional disability and aesthetic deformities. Various techniques have been described in the literature to overcome this problem; however, there is still a high risk of reankylosis in patients undergoing multiple temporomandibular joint operations, severe heterotopic ossification, and fibrosis of the soft tissues. This study includes 5 patients with severe and recurrent ankylosis. Two-stage reconstruction with excision of the bony mass and placement of a distraction device in the first stage, followed by gradual distraction of soft tissues, and placement of a total joint prosthesis in the second stage were performed in all patients. The 2-step approach helps to overcome the fibrosis and adhesions in the soft tissues and allows placing an implant with a higher ramus component. This approach seems to be a useful and effective technique for the management of such patients with high risk of reankylosis.

Retrospective study of absorbable gelatin sponge soaked in triamicinolone acetonide as interpositioning material in temporomandibular joint ankylosis in 350 patients

AIM

To evaluate the feasibility and usefulness of absorbable gelatin sponge soaked in triamcinolone acetonide as an interposition material in the treatment of temporomandibular joint (TMJ) ankylosis.

MATERIALS AND METHODS

This retrospective study was conducted in 350 patients of TMJ ankylosis who visited our outpatient department between 2000 and 2010, and were treated by the same surgeon. Patients were randomly divided into two groups, where in group 1, absorbable gelatin sponge soaked with triamcinolone acetonide was interposed in the surgical gap created after arthroplasty and in group 2, temporalis fascia was interposed. Preoperative assessment included history and physical examination, along with cause of ankylosis, Postoperative observation were undertaken for maximum mouth opening (MMO), facial nerve paralysis and recurrence.

RESULTS

At one year follow-up, in group 1 MMO ranged from 35 to 45 mm with no case of re-ankylosis while in the other group 25-43 mm, with re-ankylosis in 20 patients (13.69%).

CONCLUSION

The findings of this study showed successful management of TMJ ankylosis using absorbable gelatin sponge soaked in triamcinolone acetonide in cases which did not require condylar reconstruction.

New protocol to prevent TMJ reankylosis and potentially life threatening complications in triad patients

The management of patients with the triad of temporomandibular joint (TMJ) ankylosis, micrognathia and obstructive sleep apnea syndrome is challenging for the oral and maxillofacial surgeon because it involves achieving the desired oral opening, correction of micrognathia, and correction of the obstructed airway. Seven of the authors' triad patients, in whom only the release of ankylosis was performed, developed bradycardia and respiratory distress during postoperative jaw physiotherapy, leading to their non-compliance for active jaw physiotherapy and subsequent reankylosis. This paper suggests a new surgical protocol for the management of patients with the triad, to achieve correction of the obstructed airway, relief of the respiratory distress symptoms, correction of micrognathia and restricted mouth opening. It also provides a logical reason for the occurrence of bradycardia following ankylosis release and its potential role in TMJ reankylosis. It emphasizes that the occurrence of bradycardia in triad patients during jaw exercises is dictated by the severity of their apnea-hypopnea index and the degree of narrowing of their posterior airway space. The recognition and prevention of this by the new protocol is discussed in 7 patients.

Two-stage treatment protocol for management of temporomandibular joint ankylosis with secondary deformities in adults: our institution's experience

PURPOSE

Treatment of adult patients with temporomandibular joint (TMJ) ankylosis and secondary deformities is a challenging problem. Although various techniques, including arthroplasties, orthognathic surgery, autogenous bone graft, and distraction osteogenesis, have been described for the management of patients with this condition, an appropriate treatment protocol has not been established. The purpose of this report is to describe a 2-stage treatment protocol, comprising TMJ reconstruction as the initial surgery, followed by orthodontic treatment, and correction of secondary deformities as the second surgery, for the management of TMJ ankylosis with secondary deformities in adults.

PATIENTS AND METHODS

From January 2003 to December 2009, 24 adult patients (30 joints) with TMJ ankylosis and secondary deformities underwent TMJ reconstruction as the initial surgery, followed by orthodontic treatment and correction of secondary deformities as the second surgery. Clinical outcome was assessed based on oral function, radiography, and medical photography.

RESULTS

Patients were followed up for a minimum of 12 months to a maximum of 32 months (mean, 18.6 months). No relapse of TMJ ankylosis occurred in any patient during the follow-up period. Oral function and skeletal deformities were significantly improved in all patients. Satisfactory occlusion was achieved with the help of orthodontic treatment. Most of the patients were satisfied with the final outcome.

CONCLUSIONS

The 2-stage treatment protocol described not only restores oral function but also improves the patient's esthetic appearance. We believe that it is a good approach for management of TMJ ankylosis with secondary deformities in adult patients.

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.

Correction of rabbit model with mandibular ramus shortening by distraction osteogenesis at condylar neck

PURPOSE

The rabbit model has been established to mimic the effect of temporomandibular joint (TMJ) arthroplasty of ankylosis, and distraction at the level of the condylar neck is used to elongate the ascending ramus. The histomorphologic changes of TMJ and distraction gap were investigated.

MATERIALS AND METHODS

The unilateral condyles and articular discs were extirpated, and the experimental mandibular rami were shortened by 5 mm. An embedded distracter was used to restore the height of the mandibular ramus by unilateral condylar neck distraction (0.8 mm daily for 7 days). A total of 12 adult white rabbits were used, 8 in the experimental group and 4 in the control group. Of the 8 rabbits in the experimental group, 4 each were killed at 4 and 8 weeks after completion of distraction. The TMJ and distracted calluses were harvested and processed for radiographic and histologic examination.

RESULTS

An open bite was seen in all rabbits postoperatively that had diminished at the end of distraction. The newly formed condyles radiologically showed remodeling, flattening, and sclerosis. The bony transport disc had gradually remodeled to a new condyle that was similar to the original condyle in appearance and structure. The surface of the transport disc was covered with a fibrous tissue. Moreover, the bony regeneration was perfect in the distraction gap.

CONCLUSION

These results suggest that distraction osteogenesis at the condylar neck using the traditional preauricular approach of TMJ surgery, without the additional incision, can be performed concurrently with arthroplasty of TMJ ankylosis at the same region.

A Retrospective Study of Temporalis Muscle and Fascia Flap in Treatment of TMJ Ankylosis

BACKGROUND

This study sought to determine the efficacy of interpositional arthroplasty with temporalis muscle and fascia flap in the treatment of unilateral temporomandibular joint (TMJ) ankylosis in adults.

METHODS

This retrospective study of nine cases evaluated the postoperative results of interpositional arthroplasty on temporalis muscle and fascia flap in adults. The operative protocol for unilateral TMJ ankylosis entailed (1) resection of ankylotic mass, (2) intraoral ipsilateral coronoidectomy, (3) contralateral coronoidectomy when necessary, (4) interpositional tissue transfer to the TMJ with temporalis muscle, fascia flap, and (5) early mobilization, aggressive physiotherapy.

RESULTS

The study evaluated nine patients with follow-up checks from 13 to 31 months (mean 18.3 months). Patients had a preoperative maximal interincisal opening of 9-19 mm (mean 11.7 mm). During the last follow-up observation after surgery, the patients had a maximal interincisal opening of 35-40 mm (mean 38.3 mm).The results of this protocol were encouraging, the functional results of interpositional arthroplasty on temporalis muscle and fascia flap were also satisfactory.

CONCLUSION

The findings of this study support the use of temporalis muscle and fascia flap in adult patients with unilateral TMJ ankylosis. Early postoperative initial exercise, physiotherapy and strict follow-up play an important role in preventing postoperative recurrences.

An experimental study on reconstruction of the condyle of the temporomandibular joint using free autogenous costal perichondrial grafts in rabbits

OBJECTIVE

The purpose of this study was to develop a new method to regenerate articular cartilage of the temporomandibular joint (TMJ) by transplantation of free autogenous costal perichondrium (PC).

STUDY DESIGN

In the study, 50 adult rabbits received the operation. For the surgery in the test group, the rabbits were randomly matched in pairs within the group and underwent the surgery of cross transplantation of costal PC after trimming the articular surface of the condyle. Operations were carried out in the same way in the experimental group except for PC transplantation. Instead, the suture was stitched in stratified order in the control group. Examination methods included observation of sections under the microscope, observation of specimens under the electron microscope, proliferating cell nuclear antigen (PCNA) staining, and biochemical analysis of glucuronic acid (GA) content and collagen content. The results of different groups were compared with ANOVA.

RESULTS

The transplanted homologous PC escaped observable immune repulsion so that it could survive to form new joint cartilage with approximately normal tissue structure and biochemical constitution. The reproduction process was similar to the normal one, but was prolonged a little. At the later stage, the degeneration and calcification in the basal layer increased. However, because of its limited scope, no apparent effect on cartilage growth and function was observed.

CONCLUSIONS

Homologous xenografting of free costal PC will not result in an apparent immunorejection of the host. Instead, the grafts can maintain their existence by obtaining nutrition from surrounding tissues and regenerate cartilage tissue.