Soft-tissue, non-osteogenic distraction of the mandible and lower face in bilateral hemifacial microsomia-technical report

The aim of this study is to present a sequential strategy of soft-tissue, non-osteogenic distraction with a novel device, followed by microvascular bony reconstruction for severe cases of mandibular hypoplasia. The case of a 21-year-old woman with Goldenhar syndrome is presented, whose mandible remained severely hypoplastic despite previous attempts at distraction and was not suitable for further osteogenic distraction. Soft tissue deficiency and pin track scarring prevented free fibular transfers. A personalized distractor, anchored to the cranium and the mandibular symphysis, was designed to expand the soft tissues while allowing for physiological temporomandibular joint (TMJ) movement without compression forces. Internal distractors were placed along the osteotomies to prevent condylar luxation. After completion of the soft tissue distraction, the native mandible was resected except for the condyles and reconstructed with two free fibula flaps. This report represents the proof of concept of a sequential approach to severe lower face soft-tissue and bone deficiency, which preserves TMJ function and avoids the transfer of poorly matched skin to the face.

How does changing the vector of transport disc distraction affect the outcomes of surgery in patients of temporomandibular joint ankylosis with obstructive sleep apnea?

PURPOSE

Temporomandibular joint ankylosis (TMJA) in children is associated with retrognathia, reduction in pharyngeal airway volume (PAV), and obstructive sleep apnea (OSA). Distraction-osteogenesis (DO) is the proven method in the management of OSA. There is paucity in literature about the effect of distraction vector on PAV. It can be expected that an oblique vector would improve PAV and relieve OSA. Thus, the study was designed to explore the feasibility, advantages, and disadvantages of this modified technique for managing TMJA and OSA simultaneously.

MATERIALS AND METHOD

The investigators designed a prospective study on patients of TMJA with retrognathia. Ethical approval was obtained (IECPG-547/14.11.2018). In all patients, simultaneous ankylosis release and mandibular distraction were performed. Primary outcome variables were improvement in 3-dimensional (3D) PAV and maximal interincisal opening (MIO). Secondary outcome variables were changed mandibular length, distraction relapse, and re-ankylosis. Paired t-test and multivariate ANOVA were used to assess all the parameters.

RESULT

The study included 13 joints in 8 patients of TMJA with retrognathia (2 unilateral and 6 bilateral ankylosis) with mean age of 14.25 ± 7.37 years. Mean distraction performed was 19 ± 4.0 mm. There was a statistically significant improvement of PAV by 225% (p = 0.002), a reduction in Epworth's scale (p = 0.017), an increase in MIO (p = 0.001), and an increase in mandibular length. Three patients had re-ankylosis at the 25-month follow-up.

CONCLUSION

The results of the present study conclude that modification of distraction vector improves 3D PAV and MIO in TMJA patients, with the added advantage of a reduction in overall treatment time and improved patient compliance.

Does distraction osteogenesis improve the airway volume and quality of life of obstructive sleep apnoea patients secondary to temporomandibular joint ankylosis?

Temporomandibular joint (TMJ) ankylosis leads to mandibular micrognathia that severely collapses the upper airway causing obstructive sleep apnoea (OSA), resulting in deterioration and compromise in the quality of life (QoL) of patients. In this study, we aimed to calculate airway volume changes, apnoea-hypopnoea index (AHI), and improvement in quality of life before and after distraction osteogenesis (DO). Fourteen Patients with OSA secondary to TMJ ankylosis at a mean (SD) age of 17.5 (5.43) years were enrolled in this prospective study. Multivector mandibular distractors were used in all patients following the standard Ilizarov distraction protocol with a mean (SD) anteroposterior distraction of 16.21 (4.37) mm and a consolidation period of 116.92 (14.35) days. The patients were followed up for six months. A polysomnography test (PSG) was done to quantify AHI and a low-dose computed tomographic scan was done to calculate airway volume using Dolphin medical imaging software pre and post-DO. The QoL of the patients was calculated using the OSA-18 questionnaire. Results analysis depicted that the mean (SD) preoperative AHI was 51.44 (37.99)/h which was improved to 9.57 (9.74)/h (p = 0.001) after DO. Airway volume was calculated on Dolphin software before and after DO showed a significant improvement in airway volume by 121.12% (98.30)%. Similarly, the OSA-18 questionnaire showed significant improvement in QoL from severe to normal. This study suggested that DO increases the corpus length of the mandible, leading to an increment in airway volume, which improves the QoL.

Management of temporo-mandibular joint ankylosis using different surgical approaches

Comparison of gap arthroplasty (GAP), interpositional arthroplasty (IAP) and distraction osteogenesis (DO) simultaneous with interpositional arthroplasty (DO+IAP) in management of TMJ ankylosis is of interest to dentists. The study comprised 36 individuals with TMJ ankylosis, 16 of whom were female and 20 of whom were male. Both prior to and following surgery, the maximum inter-incisal opening (MIO) and facial pattern were noted. The postoperative MIO was 33.23 ± 1.23mm, 35.24 ± 1.11mm and 38.24 ± 1.34mm in GAP, IAP and DO+IAP respectively. Data is statistically significant with high MIO observed in DO+ IAP technique and low MIO in GAP technique (p < 0.005). In addition to lengthening the mandible, concurrently processed interpositional arthroplasty alongside DO for TMJ ankylosis corrects gross asymmetry of the face, occlusal mal-alignment, midline change, and creates room for previously un-erupted teeth to emerge.

Treatment of Post-traumatic Facial Deformities

Introduction

Skeletal abnormalities in patients with post-traumatic facial deformities can generally be corrected with current craniomaxillofacial techniques. Delay in operative management secondary to associated life-threatening injuries, failure to appreciate the magnitude of the initial facial injury, inadequate operative treatment and operative complications contribute to their occurrence. Systematic evaluation of the midface, including the position of the globes, orbits, zygomatic (facial) width and occlusion, is of paramount importance. Some contour deficiencies can be camouflaged by relatively simple procedures, whereas some deformities may require osteotomies and repositioning of the displaced segments. Staged procedures need to be planned carefully so that previously diagnosed deformities are not concealed and new deformities are not created. The general goals of reconstruction are (i) to restore normal and anatomic bone alignment, (ii) to re-establish the underlying skeletal support prior to addressing soft tissue abnormalities and (iii) to replace missing tissue with like tissues.

Conclusion

Restoring the normal bony architecture should be the initial consideration unless the quantity or quality of the soft tissue envelope is inadequate to protect the osseous reconstruction. The purpose of this study is to evaluate post-traumatic facial deformities and simulation and organization of all the treatment modalities in a sequential manner.

Tapia syndrome following TMJ gap arthroplasty: A case report and review of literature

Tapia syndrome is an extremely rare condition involving simultaneous paralysis of cranial nerves X (recurrent laryngeal branch) and XII. It is mostly believed to occur as a neuropraxic complication of intraoperative airway management. We present a unique case of a 17-year-old female with dysphonia, dysphagia, and deviation of tongue to the right side following temporomandibular joint gap arthroplasty for release of left TMJ ankylosis. A clinical diagnosis of Tapia's syndrome was made on exclusion of surgical or intracranial etiology and conservative management was performed. The aim of this study is to discuss the possible etiology, symptoms, and treatment of this disease along with a review of seven cases of Tapia syndrome associated with maxillofacial surgeries.

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

INTRODUCTION AND IMPORTANCE

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

CASE PRESENTATION

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

CLINICAL DISCUSSION

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

CONCLUSION

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

A Clinical Re-Evaluation of an Unexplored Technique for Post Gap Arthroplasty Retrognathic Mandible

Aims

The current manuscript explores the viability of reverse sagittal split osteotomy technique for correction of ankylotic cases with post gap arthroplasty mandibular retrognathia to achieve socially acceptable esthetic results.

Method

Reverse sagittal split osteotomy which was introduced by Collins et al in 1983 was performed with certain modifications on two cases to correct mandibular hypoplasia in post gap arthroplasty cases. The paper also highlights intraoral as well as extraoral approach for performing the osteotomy along with better management of bad split under direct vision.

Result

It was observed that the reverse sagittal split technique for advancement of mandible in cases of tmj ankylosis-induced dentofacial deformity provided better proximal control, reduced chances of bad split, greater range of advancement (11-14 mm) with esthetically acceptable results. The osteotomy cuts on lateral surface of mandible make the procedure effectively easier and quicker with better control over proximal segment and management under direct vision.

Conclusion

When Distraction Osteogenesis and conventional orthognathic is not a choice in management of dentofacial deformity of post-release ankylosis cases due to the poor proximal control and concern over bad split, reverse sagittal split can be an appropriate choice to manage these deformities without any donor site morbidity.

Bilateral Biplanar Distraction Osteogenesis in Facial Deformity Secondary to Temporomandibular Ankylosis

Background

The purpose of this single-centre prospective clinical study was to evaluate the correction of severe facial deformity and Obstructive sleep apnoea hypopnoea syndrome (OSAHS) in 22 patients aged from 9 to 42 years (mean 20.09) of bilateral Temporomandibular joint ankylosis.

Materials and Methodology

Patients underwent multisegment distraction using external bilateral bidirectional distractors. Facial deformity was evaluated clinically in terms of mouth opening and neck chin angle and cephalometrically in terms of corpus length (gonion-pogonion), ramal height (articulare-gonion), chin deficiency (N perpendicular to Pog and SNB). OSAHS was evaluated through Epworth sleepiness scale, Berlin's questionnaire, pharyngeal airway space, apnoeic hypoapnoeic index, oxygen desaturation index, average arterial oxygen saturation and minimal fall in O2 saturation. Patients were followed up for a period of 13-74 months (mean 28.68).

Results

Statistically highly significant results were obtained in all parameters. Complications encountered were pin infection (13.63%), loosening of pins (4.5%), wound dehiscence (9.09%), tooth fracture (4.5%) and parotid fistula (9.09%). Intermediate segment necrosis and vector loss were not observed.

Conclusion

This study is a large case series using two corticotomy cuts for external bilateral bidirectional distracters with concomitant neo callous moulding in patients both pre- and post-ankylosis release. It is extremely efficient in correcting mandibular corpal and ramal deficiency as well as improving OSAHS.

Puricelli biconvex arthroplasty as an alternative for temporomandibular joint reconstruction: description of the technique and long-term case report

Background

There are several indications for partial or total replacement of the temporomandibular joint (TMJ), including neoplasms and severe bone resorptions. In this regard, several techniques have been suggested to increase the functionality and longevity of these prosthetic devices. This case report describes the treatment of a TMJ ankylosis patient with the Puricelli biconvex arthroplasty (ABiP) technique, with a long-term follow-up.

Case presentation

In 1978, a 33-year-old male polytraumatised patient developed painful symptoms in the right preauricular region, associated with restricted movement of the ipsilateral TMJ. Due to subcondylar fracture, an elastic maxillomandibular immobilisation (EMMI) was applied. Subsequently, the patient was referred for treatment when limitations of the interincisal opening (10 mm) and the presence of spontaneous pain that increased on palpation were confirmed. Imaging exams confirmed the fracture, with anteromedial displacement and bony ankylosis of the joint. Exeresis of the compromised tissues and their replacement through ABiP was indicated. The method uses conservative access (i.e., preauricular incision), partial resection of the ankylosed mass, and tissue replacement using two poly(methyl methacrylate) components, with minimal and stable contact between the convex surfaces. At the end of the procedure, joint stability and dental occlusion were tested. The patient showed significant improvement at the postoperative 6-month follow-up, with no pain and increased mouth opening range (30 mm). At the 43-year follow-up, no joint noises, pain or movement restrictions were reported (mouth opening of 36 mm). Imaging exams did not indicate tissue degeneration and showed the integrity of prosthetic components.

Conclusions

The present case report indicates that ABiP enables joint movements of the TMJ, allowing the remission of signs and symptoms over more than 40 years of follow-up. These data suggest that this technique is a simple and effective alternative when there is an indication for TMJ reconstruction in adult patients with ankylosis.

Pediatric temporomandibular joint (TMJ) arthritis, an elusive complication of acute mastoiditis

INTRODUCTION

Septic arthritis of the Temporomandibular joint (TMJ) is a rare complication of acute middle ear infection. Presentation is elusive and could be easily missed. Often diagnosis is made only with consequential development of TMJ ankylosis. This study intends to characterize patients and course of disease and suggest a diagnostic and therapeutic strategy.

METHODS

Retrospective review of all children diagnosed with TMJ arthritis and/or TMJ ankylosis secondary to acute middle ear infection, treated in a tertiary pediatric medical center between the years 2005 and 2021.

RESULT

Seven patients were identified with otogenic TMJ arthritis. Median age at presentation was 1.14 years (IQ range 1.1-1.5). All seven were diagnosed with acute mastoiditis. CT scans demonstrated TMJ related collections in 5/7 and intracranial complications in 3/7. Treatment included cortical mastoidectomy for 5/7. One patient had a concomitant surgical washout of the TMJ. Two patients had drainage only of subperiosteal collections. Six of the seven patients went on to develop TMJ ankylosis that presented within a median of 2.8 years (IQ range 2.6-3.9) after the episode of acute mastoiditis. All six patients presented with trismus and facial growth anomalies, and all but one required surgery to release the ankylosis.

CONCLUSION

Otogenic TMJ arthritis develops mostly in young children with acute mastoiditis and intratemproal and/or intracranial suppuration. Imaging is helpful in making the diagnosis, with TMJ related collections on CT being the most common finding. TMJ ankylosis can develop within a few years and present with trismus and abnormal facial growth. Cortical mastoidectomy does not seem to prevent ankylosis. It remains unclear whether focused treatment to the TMJ or physiotherapy could be beneficial in that.

Infiltrating lipomatosis, an etiology for TMJ ankylosis?

Infiltrating lipomatosis is a rare benign condition causing diffuse fatty infiltration into the surrounding soft tissue and in rare cases causes hyperplasia of the adjacent bone. We report a case with clinical and radiological evidence of a 34-year-old female patient who reported a swelling in the left middle third of the face with exophytic temporomandibular joint (TMJ) ankylosis of the left side resulting in restricted mouth opening and facial asymmetry since 21 years. The number of cases reported in the literature is rare. Surgery is the treatment of choice.

Autogenous grafts for reconstruction arthroplasty in temporomandibular joint ankylosis: A systematic review and meta-analysis

Autogenous methods for reconstruction arthroplasty (RA) for the surgical management of the temporomandibular joint (TMJ) have been extensively reported. The present review was aimed to systematically review and pool data on clinical outcomes of autogenous grafts for RA in subjects with TMJ ankylosis. Major electronic databases and prominent subject-specific journals were searched up to December 2020. Randomised controlled trials (RCT), cohort studies, and retrospective studies reporting outcomes of autogenous grafts for RA in TMJ ankylosis were included. A total of 35 studies with 700 subjects was included. The most commonly employed grafts were costochondral grafts (CCG) and coronoid process grafts. Postoperative change in maximum incisor opening (MIO) was comparable amongst all grafts and was in the clinically acceptable range (27.21-31.38 mm). The recurrence rate was comparable for all grafts and was ≈ 8% except for coronoid grafts, where the recurrence rate was 2.98%. Growth assessment for CCG revealed that 55.89%, 30.89%, and 13.24% of subjects depicted optimal growth, overgrowth, and undergrowth, respectively. Within the limitations of the present review, the recurrence rate for all grafts was comparable except for coronoid graft, which depicted least recurrence rate and resultant postoperative change in MIO was in the clinically acceptable range.

Vascularized Second Metatarsal Joint Transfer with Concomitant Orthognathic Surgery for Reconstruction of the Temporomandibular Joint: Our Pilot Experience

Background

Temporomandibular joint ankylosis-associated deformity and dysfunction is a challenge to reconstruct. Alloplastic temporomandibular joints, both stock and custom-made, are used to replace the ankylotic mass with a functional joint. Still, the cost of these alloplastic joints is so expensive that it cannot be affordable to most of our population.

Purpose

A primary objective of achieving at least 35 mm of mouth opening was planned. Secondarily we planned to achieve a functional occlusion with acceptable facial balance and symmetry.

Method

Autologous TMJ reconstruction using vascularized second metatarsal joint transfer with concomitant orthognathic surgery. The surgery aims to achieve a significant functional rehabilitation with correction of maxillomandibular deformity in a single-stage surgery.

Results

As a result of this, we present our initial experience to rehabilitate the patient with temporomandibular joint ankylosis both functionally and aesthetically by performing simultaneously joint replacement using the patient's own vascularized second metatarsal joint and concomitantly performing the orthognathic surgery. By this, we could holistically treat the patient with minimal cost and make them socially acceptable.

Conclusion

We do not propose a 2nd metatarsal vascularized flap as a substitute for a custom-made total TMJ prosthesis. Still, we suggest a viable option in a selected set of patients where TMJ prosthesis cannot be afforded or has failed with a history of multiple surgeries in the same region.

Transport distraction osteogenesis compared with autogenous grafts for ramus-condyle unit reconstruction in temporomandibular joint ankylosis: A systematic review and meta-analysis

This systematic review was planned to assess the clinical outcomes of transport distraction osteogenesis (TDO) compared with autogenous grafts for reconstruction of the ramus condyle unit (RCU). We searched Medline, Embase, Cochrane Library, Clinicaltrial.gov, and the references of included trials. The primary outcome was maximal incisal opening (MIO). Of the 148 studies retrieved, five were included (TDO = 49, autogenous grafts =123). The mean difference in MIO between TDO and autogenous graft RCU reconstruction, based on the random-effects model was 1.28 mm (95% CI 0.167 to 2.403) in favour of TDO. Re-ankyosis was observed in four cases in the costochondral graft group and none in the TDO group. Reconstruction of the RCU using TDO is comparable to autogenous grafts after the release of TMJ ankylosis, though the evidence is weak considering the small number of trials, high risk of bias, and absence of long-term results.

Modified Gap Arthroplasty for Temporomandibular Joint Ankylosis Following Radiotherapy for Rhabdomyosarcoma: Report of an Unusual Case and Brief Literature Review

Radiotherapy at the temporomandibular joint (TMJ) area often results in trismus, however, post radiation ankylosis is extremely rare and has not been previously reported in literature. Radiation is known to impact the vasculature of bony structures leading to bone necrosis with certain risk factors including surgical intervention, even teeth extraction, that could lead to osteoradionecrosis. Accordingly, gap arthroplasty for such case seemed rather challenging. In this report, we introduce for the first time, a rare case of temporomandibular joint ankylosis post radiotherapy for management of rhabdomyosarcoma in a 12 years-old boy. A modified gap arthroplasty technique combined simultaneously with pterygo-masseteric muscle flap was applied to lower the risk of osteoradionecrosis due surgical trauma at irradiated area. Computed tomographic scan on the head indicated that the TMJ architecture was completely replaced by bone, with fusion of the condyle, sigmoid notch, and coronoid process to the zygomatic arch and glenoid fossa. The patient’s problem was totally solved with no osteoradionecrosis or relapse of ankylosis observed at follow up visits. Herein, the modified gap arthroplasty combined with pterygo-masseteric muscle flap could be recommended to be applied on other cases of ankylosis especially after receiving radiotherapy.

Autogenous Fat as an Ideal Interpositional Material in Temporomandibular Joint Surgery

Interpositional gap arthroplasty has established itself as the the standard surgical treatment of Temporomandibular joint (TMJ) ankylosis. The autogenous tissue has replaced the alloplastic and other xenografts materials owing to its bioavailability, easy uptake, and no additional cost. Commonly used autogenous tissue has been temporalis muscle and fascia, fascia lata, skin graft, auricular and costal cartilage, the masseter and/or medial pterygoid muscle. With the turn of the century, TMJ surgeons started using autogenous fat from the lower abdomen and today it has taken over as the most favored autogenous filler material in TMJ ankylosis surgery or total joint replacement (TMJ-TJR). The use of buccal fat pad (BFP) has increased in the last decade due to its local availability and pedicled nature. This paper will discuss various autogenous tissues used in interposition and bring forth the journey of the autogenous fat as the preferred interpositional material now and rest the case in its favor.

Arthroplasty Followed by Distraction Osteogenesis Versus Distraction Osteogenesis Followed by Arthroplasty in the Management of TMJ Ankylosis: A Comparative Study

Aim

To compare treatment outcome of arthroplasty followed by distraction osteogenesis (AFD) and distraction osteogenesis followed by arthroplasty (DFA) in the management of mandibular deficiencies in temporomandibular joint (TMJ) ankylosis.

Materials and methods

A total of 20 patients with TMJ Ankylosis were included in the study. Patients were randomly divided into two groups. Group 1 consisted of patients for whom arthroplasty was done prior to distraction osteogenesis (AFD) for the correction of deficient mandible. Group 2 included patients where distraction osteogenesis was performed prior to arthroplasty (DFA). The treatment outcome was assessed based on maximum interincisal distance, overjet, corpus length, ramus height, upper airway, lower airway, duration of the procedure and the complications for the treatment at the end of 3, 6 and 12 months.

Results

After the treatment was ended, the patients of both groups had increase in mouth opening and appearance was improved remarkably. There was general increase in all the parameters in both the groups. But at the end of 12 months, airway and the ramus height were more stable and the control of the proximal segment was superior in DFA group. Open bite was noticed in 2 cases of AFD group which was treated by elastics. There required additional surgery for the removal of distractors in the AFD Group. Establishing the airway during the surgery was easier in AFD group.

Conclusion

The study concludes that distraction followed by arthroplasty was a better procedure for the management of TMJ ankylosis owing to its stable results and less number of surgeries.

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.

Analysis of maximum bite force and chewing efficiency in unilateral temporomandibular joint ankylosis cases treated with buccal fat pad interpositional arthroplasty

There is limited knowledge about masticatory function after the release of temporomandibular joint (TMJ) ankylosis. In this study, masticatory function was evaluated by measuring maximum voluntary bite force (MVBF) and chewing efficiency in 30 unilateral TMJ ankylosis patients who were treated with buccal fat pad (BFP) interpositional arthroplasty. Eighteen subjects over 12 years of age were included in study Group A and 12 subjects below 12 years of age in study Group B. Patients in the study groups had completed a minimum follow up of one year after surgery. Control groups C (over 12 years of age, n = 18) and D (under 12 years of age, n = 12) consisted of age, sex, and weight-matched normal subjects. The mean MVBF was measured between occluding molar teeth with a strain gauge transducer. Chewing efficiency was measured with two different coloured chewing gum strips. These were chewed for 5, 10, 20, 30, and 50 strokes. Compared with normal subjects, the study groups (A and B) could generate 64.7% (p = 0.004*) and 89.8% (p = 0.121) of MVBF, respectively. Overall chewing efficiency was 88.7% in Group A and 92.9% in Group B (p = 0.014* and p = 0.138, respectively) when compared with normal subjects. The study has shown that BFP interpositional arthroplasty effectively restores masticatory function.

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.

Management of a rare case of extra hepatic portal vein obstruction with temporomandibular joint ankylosis and review of literature

Extrahepatic portal venous obstruction (EHPVO) and temporomandibular joint (TMJ) ankylosisis are significant problems in Asian countries. Both EHPVO and bilateral TMJ ankylosis may have rare association due to protein C and S deficiency which may cause hypercoagulability as well as reduced fibrinolytic activity. Ankylosis arising in early childhood is associated with facial asymmetry, feeding difficulty and speech development alterations. It is also associated with great challenges of endoscopic management in extra hepatic portal vein obstruction (EHPVO) with variceal bleed as well as air way management during surgical management and post-operative recovery. Recently a case series had shown association of TMJ ankylosis with EHPVO due to protein C deficiency which might be an etiological factor for both EHPVO as well as TMJ ankylosis. This case report documents a case of 14 year young girl who had TMJ ankylosis due to ear infection and EHPVO with esophageal varices had multiple episodes of upper GI bleed with mild deficiency of protein C and S, successfully managed with proximal splenorenal shunt to prevent further episodes of upper GI bleed, as endoscopic management is not feasible due to TMJ ankylosis.

Variants and Modifications of the Retroauricular Approach Using in Temporomandibular Joint Surgery: A Systematic Review

Introduction: The retroauricular approach (RA) has been developed in order to expose the temporomandibular joint in a way that minimizes the risk of injury to the facial nerve and masks the postoperative scar. One of its characteristics is an excellent posterolateral view of the mandibular head, which allows for the preservation of the lateral temporomandibular joint ligaments in the course of open intracapsular surgery. Aim: The aim of this study is to systematically review the currently used variants and modifications of RA. Materials and Methods: The construction of the following study is based on PICOS and PRISMA protocols. A systematic literature search was performed based on the PubMed and BASE search engines; furthermore the authors performed a more detailed search in the Google Scholar article database as well as a loop search within the references of papers included in the systematic review. Results: Searching medical articles databases, Google Scholar, and references yielded a total of 85 records. First the titles and abstracts were blindly screened which was followed by a full-text eligibility check resulting in eventually including and qualifying 7 articles for detailed analysis. Discussion: All known variants and modifications of RA are characterized by high safety for the facial nerve and an aesthetically hidden scar. There were no reports of auricle necrosis in the collected material. Conclusions: In this systematic review, 2 variants and 2 modifications of RA that allow for open temporomandibular joint surgery have been identified; all of them together cover a large spectrum of indications for joint surgery, including reposition and osteosynthesis of mandibular head fractures, eminoplasty, or eminectomy and treatment of some forms of ankylosis.

Ankylosis management with autogenous grafts: A systematic review

A systematic review was performed to assess the clinical outcomes of the reconstructive methods using autogenous grafts for the management of temporomandibular joint (TMJ) ankylosis A comprehensive electronic and manual search of the literature without date or language restriction was performed in January 2021 to identify randomized controlled trials, prospective, and retrospective studies with the aim of comparing the various surgical modalities for TMJ ankylosis. Twenty-six publications were included: prospective (n ​= ​17), retrospective (n ​= ​7), randomised control trial (n ​= ​1) and ambispective study (n ​= ​1). Costochondral graft was the most common graft used followed by Coronoid process graft. Meta-analysis was not possible as most of studies were non-controlled in nature. Based on the available data, there was a strong evidence that autogenous grafts especially Costochondral grafts and coronoid grafts have remained one of the most favoured methods of reconstruction. Prospective and randomized control studies are recommended for the best stratification for the use of autogenous grafts for the management of TMJ ankylosis.

Template guided extra oral vertical ramus osteotomy for facial deformity correction - a technical note

OBJECTIVE

To assess the efficacy of template as a guide in performing extra-oral vertical ramus osteotomy.

METHODS

A 21-year-old male patient, reported with complaints of facial asymmetry and restricted mouth opening due to ankylosis involving the right TMJ. Interpositional arthroplasty along with extra oral vertical ramus osteotomy and coronoidectomy was planned to correct the ankylosis of TMJ and facial asymmetry. An acrylic template was used as a guide for performing the osteotomy. Intra operative accuracy of the osteotomy and post-operative neurosensory functioning of inferior alveolar nerve was assessed subjectively and objectively by static two-point discrimination test.

RESULTS

In a follow up period of six months, no subjective and objective sings of neuro sensory impairment were reported.

CONCLUSION

Using a template as guide in making vertical ramus osteotomy, avoids intra operative damage to the inferior alveolar nerve.

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.

Viability and Volumetric Analysis of Free Autogenous Dermis Fat Graft as Interpositional Material in TMJ Ankylosis: A Long-Term MRI Study

Aims and Objectives

Dermis fat graft has shown good clinical results as an interpositional material in temporomandibular joint (TMJ) ankylosis and prevents heterogeneous calcification following gap arthroplasty. However, survival of the graft and volume retention is still debatable. The main purpose of our study was to assess the viability of the graft, tissues changes associated with the graft and volume retention using magnetic resonance imaging (MRI).

Materials and Methods

Fifteen patients with TMJ ankylosis underwent gap arthroplasty followed by placement of abdominal dermis fat graft and were randomly divided into two groups. Group 1 was subjected to MRI analysis of the graft at 3-6 months and Group 2 was analyzed at 1-2 years post-operatively. The graft was evaluated using T1- and T2-weighed images along with fat suppression (FS) sequences in all the three planes and the volume was also calculated.

Results

Both Group 1 (7 patients and 11 joints) and Group 2 (8 patients and 13 joints) showed the presence of viable fat on T1 and T2 images, confirmed by FS images. Minor tissue changes were observed at the center of the graft in 5 patients of Group 1 and 3 patients of Group 2. Average volume of the graft was 4.154 cm³ at 3-6 months and 4.269 cm³ at 1-2 years, respectively, and when compared to the original volume of the graft (4.583 cm³ in Group 1 and 4.712 cm³ in Group 2), the difference was statistically insignificant (p > 0.005).

Conclusion

MRI shows long-term survival of autogenous dermis fat graft without significant volumetric reduction. This along with positive clinical results make dermis fat an excellent choice as an interpositional material for TMJ ankylosis.

Application of Navigation Surgery in Temporomandibular Joint Ankylosis Case and Review of Literature

The aim of this article is to develop a navigation-guided oral and maxillofacial surgery including surgical planning, simulation and navigation in temporomandibular joint ankylosis case practiced in tertiary care hospital. After getting the computed tomographic angiography of head and neck, the special software of Brain lab^® is used to mark the arteries and veins of the patient, which was in close approximation to the mandibular condyle. Brain lab^® navigation system was used during the surgery to ascertain the middle meningeal artery location, and osteotomy cut was given. Navigation technology use in the neurosurgery is not new. But its use in the subcontinent in the field of maxillofacial surgery is quite rare. First time, it has been used scientifically in temporomandibular joint ankylosis case. Navigation technology use in the maxillofacial surgery requires a holistic imaginative/creative approach to make the surgeries more predictive and safe.

Unusually rare occurrence and recurrence of temporomandibular joint ankylosis and oral submucous fibrosis simultaneously in a patient: A surgeon's dilemma

We here present a rare case of simultaneous occurrence and recurrence of TMJ ankylosis and submucous fibrosis in the same patient. Patient presented with limited mouth opening at both occasions. However, the diagnosis of submucous fibrosis was overlooked at the first presentation. The patient reported with recurrence of both the conditions after a period of 15 years. We presume that noncompliance of jaw exercises aggravated both the conditions as one led to the other. Since fibrosis sets in earlier than bony fusion, we theorized that the patient had acquired OSMF before TMJ ankyloses recurrence. The case was managed with release of fibrous bands intraorally followed by release of TMJ ankylosis and interposition with dermis fat graft. Physiotherapy is extremely essential when either pathology is treated in patients, especially when both are present in a single patient.

Gap Arthroplasty or Interpositional Arthroplasty for the Management of TMJ Ankylosis? A Prospective Randomized Comparative Multicenter Clinical Trial

Aim

The main aim of this study is to compare the gap arthroplasty with interpositional gap arthroplasty for the management of TMJ ankylosis.

Methodology

A prospective randomized multicenter clinical trial had been performed, on 60 patients diagnosed with TMJ ankylosis from August 2005 to June 2015. Patients were equally divided into two groups: Group I patients were treated with gap arthroplasty, while patients in Group II were treated with interpositional arthroplasty.

Results

The mean age in Group I was 27.9 years and in Group II was 25.6 years. Trauma was the common etiological factor in both the groups. The mean postoperative mouth opening after 1 month, 6 months and 24 months was found to better in Group II. Open bite after 24 months was present in six patients in Group I and in one case in Group II. Permanent facial nerve palsy was present in one patient in both the groups. Frey's syndrome was present in one patient from Group I and none from Group II. Reoccurrence occurred in eight cases from Group I (26.6%) and none from Group II.

Conclusion

This study concluded that interpositional arthroplasty is better than gap arthroplasty in terms of mouth opening and reankylosis.

True bony TMJ ankylosis in children: Case report

INTRODUCTION

The clinical importance of ankylosis in children is concerning with its massive effect and disturbance on the mandibular future growth causing gross deformity apart from the limited mouth opening. Trauma is the most common cause of bony and fibrous ankylosis. History, physical examination and radiographical examination of each patient with ankylosis of TMJ is mandatory in arriving to a final diagnosis, severity, involvement of adjacent structures and ultimately to plan the treatment.

CASE PRESENTATION

Ten years old girl presented with her family seeking solution for a severely limited mouth opening. From the history, the child has suffered from height fall at the age of 4 years. She had complained from swelling and pain near the ear, treated by analgesics, gradually subsided and neglected. This limitation affects on feeding and had an impact on the child's health, seeking for management for the condition became mandatory. Clinical examination, radiographical examination is prepared in beside that ethical approval with full discussion with the parents done. Blind nasal intubation done.

DISCUSSION

Patients with true bilateral ankylosis are considered as the aggressive type. It's not just because of ankylosis. Surgeons should keep in their minds that well experienced anesthetist is important; also extension of the ankylosed bone with amount of cutting is important and re ankylosis as a complication must be avoided.

CONCLUSION

The surgeons agree with the statement that success in the preventing reankylosis after TMJ gap arthroplasty. Its primarily refers to the early postoperative physiotherapy, maintained on a long term.

The Nuances of Temporomandibular Joint Ankylosis Surgery: Tips and Tricks

Introduction

A plethora of surgical options have been described in the literature for the management of temporomandibular joint (TMJ) ankylosis, but one cannot subscribe to a modality that is infallible in regard to recurrence. The incidence of recurrence is attributed to poor surgical technique and poor patient compliance. This article proposes incorporation of subtle modifications into the surgical techniques that could prove to be helpful in the management and prevention of reankylosis.

Materials and Methods

Twenty-one patients with TMJ ankylosis with an age range of 10-29 years (mean age 19 years) were operated, of whom six (28.5%) were bilateral and 15 unilateral (71.5%), and 14 (66.6%) had a history of previous surgery for ankylosis. The preoperative and intraoperative mean inter-incisal opening (MIO) was 4.4 mm and 43.2 mm, respectively. All patients fared well at the late postoperative evaluation at 24 months with a mean MIO of 36.9 mm.

Conclusion

The subtle modifications address various aspects such as the adequacy of the preauricular approach, the use of a wide flame-shaped bur, the obliquity of the arthroplastic osteotomy, burnishing the residual ramal stump devoid of irrigation, temporalis muscle release and coronoidectomy, aggressive intermittent intraoperative jaw physiotherapy, mandatory use of a vacuum drain and rigorous postoperative jaw physiotherapy.

Surgical treatment of type III temporomandibular joint ankylosis with a lateral arthroplasty while retaining the medially displaced condyle

INTRODUCTION

We discuss our findings on the retention of the medially displaced residual condyle during the treatment of type III temporomandibular joint ankylosis, as well as the postoperative results observed during follow-up.

MATERIALS AND METHODS

Thirty-two patients with type III temporomandibular joint ankylosis that met the inclusion criteria of the study were included as subjects. The morphological integrity of the medially displaced residual condyle was verified in all of the participating patients through the use of cone beam computed tomography. The duration of the ankylosis ranged from 2 to 12 years. The maximum length that patients were able to open their mouths ranged from 6 mm to 14 mm. The surgical treatments used in this report included the separation of bony fusions between the condyle and the glenoid fossa, resection of the ankylosed sites, preservation of the displaced condyles in their medial position and suturing the remains of the disc to its typical position or taking the temporalis myofascial flap instead. The long-term results were evaluated by computed tomography and clinical follow-up examinations.

RESULTS

Three-year postoperative follow-up examinations were performed for all of the patients included in this study. No recurrences were observed in the patients who adhered to the postoperative therapeutic advice. Patients had an average maximal mouth opening distance of 34.50 ± 5.75 mm as recorded during the final follow-up examination.

CONCLUSIONS

The released medially residual condyle can still function normally in temporomandibular joint movement and without reankylosis after a bone fusion resection. The displaced condyle should thus be preserved instead of being removed during the treatment of type III temporomandibular joint ankylosis.

Extensive temporomandibular joint ankylosis involving medial pterygoid plates and the maxillary tuberosity- a case report

Background

Temporomandibular joint ankylosis is a distressing condition which leads to significant functional debility and facial blemish. It can be surgically managed with gap or interposition arthroplasty, with an objective to restore joint function and prevent re-ankylosis. Sometimes TMJ ankylosis can present with atypical presentations like skull base ankylosis. The main aim of this surgery is to successfully treat such conditions efficiently without any possible complications. However, surgical procedures for such atypical presentations in this disease are rarely reported.

Case summary

Here we report a 27 year old male with Left TMJ ankylosis involving the skull base. The patient presented with reduced mouth opening with a previous history of trauma. For treatment we performed a surgery by doing osteoarthrectomy with interpositional arthroplasty of left TMJ using piezosurgery. To our knowledge this is the only TMJ ankylosis case with involvement of bones of the skull base treated with piezosurgery. Intraoperatively we achieved a mouth opening of 30 mm, and postoperatively after 15 days mouth opening up to 30 mm was achived with physiotherapy.

Conclusion

Some times TMJ ankylosis can present with atypical presentations in which bones of the skull base are involved. These are very rare and could be termed as 'skull base ankylosis'. Such cases can be surgically challenging and some surgical treatment modalities like Computer Assisted Surgery (CAS), 3D Navigation and Piezo-electric surgery could be beneficial in avoiding complications and facilitating efficient treatment.

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.

Pre-arthroplastic mandibular distraction osteogenesis for the correction of OSA in TMJ ankylosis: a prospective observational study of 25 cases

INTRODUCTION

In severe TMJ ankylosis cases, the lack of growth of the mandible creates an anatomically narrow airway with a reduced pharyngeal airway space [PAS] which predisposes these patients towards obstructive apnoea [OSA]. There is evidence in the literature that such patients experience severe discomfort during physiotherapy if such airway abnormalities are not corrected prior to ankylosis release. This eventually leads to non-compliance towards physiotherapy and increases the risk of re-ankylosis.

OBJECTIVE

In our study, pre-arthroplastic mandibular distraction osteogenesis [DO] was used to increase the PAS and resolve the underlying OSA prior to releasing the ankylosis.

MATERIALS AND METHODS

Twenty-five cases of TMJ ankylosis with micrognathia and OSA were included in this prospective observational sleep study. They were further divided into a paediatric group [14 subjects] and an adult group [11 subjects]. All cases presented with a history of onset of ankylosis during childhood [before the completion of craniofacial growth] as result of which there was a lack of forward growth of the mandible. Subjects included in our study underwent initial DO of the mandible followed by a second procedure for distractor removal and ankylosis release. Questionnaires, lateral cephalograms and sleep studies were taken pre-operatively (T0), immediate post-distraction to the desired length (T1) and 12 months post the distractor removal and ankylosis release (T2). The parameters studied were PAS width, apnoea hypopnea index [AHI], O₂ saturation, mouth opening and mandibular advancement.

RESULTS

The paediatric group variables were as follows: mean PAS width which increased from 3.5 mm [T0] to 9 mm [T2], mean AHI which decreased from 48.04 [T0] to 3.60 [T2], mouth opening which increased from 4.5 mm [T0] to 34 mm [T2] and mean O₂ saturation which increased from 89.86% [T1] to 96.88% [T2]. The adult group variables were as follows: mean PAS width which increased from 5 mm [T0] to 11 mm [T2], mean AHI which decreased from 31.45 [T0] to 1.43 [T2], mouth opening which increased from 5 mm [T0] to 34 mm [T2] and mean O₂ saturation which increased from 92.01% [T0] to 96.84% [T2]. Statistical analysis revealed that DO of the mandible significantly improved OSA by increasing the PAS which was evident by the lower AHI score. Mouth opening was also significantly improved post ankylosis release and maintained at the T2 interval. Ten subjects followed up beyond the T2 interval [mean 28 months post ankylosis release] and their data also revealed positive compliance towards physiotherapy, adequate mouth opening and maintenance of normal AHI.

CONCLUSION

Pre-arthroplastic mandibular DO has proved to be a successful modality for treatment of OSA in TMJ ankylosis patients with stable results at 12 months. By resolving the narrow airway and OSA, compliance towards physiotherapy was improved thus reducing the risk of re-ankylosis in the long term.

Versatility of uniplanar prearthoplastic distraction osteogenesis in the correction of post-ankylosis facial deformities-a report of five different cases

PURPOSE

Unilateral or bilateral ankylosis can lead to severe micrognathia and facial deformity that requires multiple, often, staged surgical corrections. To date, there is no ideal treatment modality that satisfactorily corrects the complex anatomy, restores the ramal height, and corrects the micrognathia and microgenia. Distraction osteogenesis has been acclaimed as a successful modality for the treatment of such deformities. It is a cost-effective approach with low morbidity and less relapse thus providing better functional and esthetic outcomes. It allows the surgeon to correct the deformity in various planes by using various devices by changing osteotomy designs and vectors, with simultaneous hard tissue and soft tissue reconstruction.

PATIENTS AND METHODS

Here, we present a series of five cases where different types of distraction osteogenesis were combined with various other procedures to correct post-ankylotic facial asymmetry. In one case, simultaneous maxillo-mandibular distraction [Molina's technique] was used.

RESULTS

All patients showed significant improvement in function and esthetics. Outcome assessment was made using clinical photographs and radiographs.

CONCLUSION

Pre-arthroplastic distraction osteogenesis is a versatile cost effective approach that can be customized for every patient based on their needs.

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.

The autogenous graft versus transport distraction osteogenesis for reconstruction of the ramus-condyle unit: a prospective comparative study

This study aimed to compare the joint function and morphology achieved following condylar reconstruction using sternoclavicular grafts (SCG) versus transport distraction osteogenesis (TDO) in temporomandibular joint (TMJ) ankylosis patients. Twenty-two patients with TMJ ankylosis underwent TMJ reconstruction with SCG or TDO (n=11 each). Radiographic and clinical evaluations were performed at 1 week and at 1, 3, and 6 months post-surgery. Clinical criteria examined included the duration of surgery, mean postoperative mouth opening, excursive jaw movements, and pain scores. The radiographic evaluation 6 months postoperatively (computed tomography) included subjective assessment of joint morphology and measurements of the mean condylar height, width achieved, and amount of condylar resorption. The χ² test and Student t-test were used to compare qualitative and quantitative variables, respectively. Similar mean mouth opening (SCG=31.8mm, TDO=32.1mm at 6 months), excursive movements, and pain scores were observed in the two groups throughout follow-up. Mean condylar resorption was significantly greater in the TDO group (TDO=7.0mm, SCG=2.7mm; P=0.005). The duration of reconstruction surgery was greater in the SCG group (P=0.035). A greater incidence of complications was observed with TDO. In conclusion, based on the protocols used in this study, SCGs are superior to TDO in terms of condylar morphology, stability, and surgical safety.

The sequential management of recurrent temporomandibular joint ankylosis in a growing child: a case report

Background

Temporomandibular joint (TMJ) ankylosis in children often leads to facial deformity, functional deficit, and negative influence of the psychosocial development, which worsens with growth. The treatment of TMJ ankylosis in the pediatric patient is much more challenging than in adults because of a high incidence of recurrence and unfavorable growth of the mandible.

Case report

This is a case report describing sequential management of the left TMJ ankylosis resulted from trauma in early childhood. The multiple surgeries including a costochondral graft and gap arthroplasty using interpositional silicone block were performed, but re-ankylosis of the TMJ occurred after surgery. Alloplastic TMJ prosthesis was conducted to prevent another ankylosis, and signs or symptoms of re-ankylosis were not found. Additional reconstruction surgery was performed to compensate mandibular growth after confirming growth completion. During the first 3 years of long-term follow-up, satisfactory functional and esthetic results were observed.

Conclusions

This is to review the sequential management for the recurrent TMJ ankylosis in a growing child. Even though proper healing was expected after reconstruction of the left TMJ with costal cartilage graft, additional surgical interventions, including interpositional arthroplasty, were performed due to re-ankylosis of the affected site. In this case, alloplastic prosthesis could be an option to prevent TMJ re-ankylosis for growing pediatric patients with TMJ ankylosis in the beginning.

Interventional Radiology and Bleeding Disorders: What the Oral and Maxillofacial Surgeon Needs to Know

Endovascular techniques are essential for controlling acute head and neck bleeding that cannot be controlled by local or systemic measures. Detailed knowledge of the head and neck vascular anatomy, advances in catheterization techniques, and the availability of new embolic materials have improved the safety, efficacy, and predictability of these procedures. To improve patient safety, the oral and maxillofacial surgeon must be familiar with these techniques.

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.

Silicone vs temporalis fascia interposition in TMJ ankylosis: A comparison

OBJECTIVE

Temporomandibular joint ankylosis (TMJa) is a distressing condition, but can be surgically managed by gap or interpositional arthroplasty, with an aim to restore joint function and prevent re-ankylosis. The aim of this paper is to compare two interposition materials used in management of TMJ ankylosis.

METHODS

15 patients with TMJa were randomly allocated to two groups: group A (n = 6), interposition material used was medical-grade silicon elastomer, and group B (n = 9) where the interposition material used was temporalis fascia. Patients were followed up at regular intervals of 1 and 2 weeks, 1 month, 3 months, and 6 months and were assessed on following parameters: pain by VAS Scale, maximal mouth opening (MMO), implant rejection, and recurrence.

RESULTS

The results showed a loss of 4.6% and 7.9% in maximal interincisal mouth opening at 3rd and 6th months in Group A while Group B had a mean loss of 9% and 10% at 3rd and 6th months respectively without any significant difference. None of our cases showed recurrence or implant rejection.

CONCLUSION

We conclude that silicone is comparable to temporalis fascia in terms of stability, surgical ease, and adaptability. It not only restores the function of mandible and ensures good maximum interincisal opening but also maintains the vertical ramal height. Also, it requires less operating time and is easy to handle but is not economical. It might be an effective way to restore function and prevent re-ankylosis.

Incremental increase in percentage mouth opening after coronoidectomy in temporomandibular joint ankylosis

The aim of this study was to evaluate the incremental improvement in mouth opening following coronoidectomy. Twenty-three patients with unilateral temporomandibular joint (TMJ) ankylosis (Sawhney types I-III) were assessed preoperatively; physical and radiological examinations were done (panoramic radiography and computed tomography). Data including demographic and clinical parameters were recorded. Patients with bilateral ankylosis, recurrent cases, and those with Sawhney type IV TMJ ankylosis were not included. The improvement in mouth opening was measured after ostectomy, after ipsilateral coronoidectomy, and after contralateral coronoidectomy. The improvements in mouth opening at each stage were analysed using the Student's t-test and Pearson's correlation coefficient. There was a marked improvement in maximal incisal opening (MIO) from 5.7 ± 4.2mm to 23.7 ± 5.9 mm after removal of the ankylotic bony mass. MIO was significantly increased after ipsilateral coronoidectomy (31.6 ± 7.4mm), and after contralateral coronoidectomy, a mean MIO of 39.4 ± 11.2mm was achieved. At more than 1 year of follow-up, all patients showed improved mouth opening. In conclusion, coronoidectomy plays an important role in improving mouth opening in the treatment of TMJ ankylosis.

Single stage treatment of ankylosis of the temporomandibular joint using patient-specific total joint replacement and virtual surgical planning

Ankylosis of the temporomandibular joint (TMJ) is a debilitating condition that can result in pain, trismus, and a poor quality of life. It can be caused by injury, infection, and rheumatoid disease. Current management includes gap arthroplasty, interpositional arthroplasty, and reconstruction. Traditionally, joints are reconstructed using stock implants, or the procedure is done in two stages with an additional computed tomography (CT) scan between the resective and reconstructive procedures and use of stereolithographic models to aid the design of the definitive prostheses. We describe a technique for the resection of ankylosis and reconstruction of the joint in a single operation using virtually designed custom-made implants. Five patients with ankylosis of the TMJ had a single stage operation with reconstruction between 2010 and 2012. All had preoperative high-resolution CT with contrast angiography. During an international web-based teleconference between the surgeon and the engineer a virtual resection of the ankylosis was done using the reconstructed CT images. The bespoke cutting guides and implants were designed virtually at the same time and were then manufactured precisely using computer-aided design and manufacture (CAD-CAM) over 6 weeks. After release of the ankylosis and reconstruction, the patients underwent an exercise regimen to improve mouth opening. Follow-up was for a minimum of 6 months. Four patients had one operation, and one patient had two. Median/Mean maximum incisal opening increased from 0.6mm before operation to 25 mm afterwards (range 23-27), and there was minimal surgical morbidity. This new method effectively treats ankylosis of the TMJ in a single stage procedure. Fewer operations and hospital stays, and the maintenance of overall clinical outcome are obvious advantages.

Treatment of long standing bilateral temporomandibular joint ankylosis with condylar prosthesis

INTRODUCTION

TMJ ankylosis is a condition which results in partial to complete inability to open the mouth due to fusion of head of condyle and glenoid fossa.

CASE REPORT

A 28 year old man reported to our department with a complaint of inability to open mouth since 13 years. On basis of clinical examination, radiographs and CT scans, he was diagnosed with complete bilateral bony TMJ ankylosis. The treatment plan included bilateral condylectomy with coronoidectomy through a combination of endaural and rhytidectomy incision and interpositional grafting with temporalis myofascial flap. Reconstruction of the TMJ was done with specially designed stainless steel partial condylar prosthesis. Extended genioplasty was done to advance the chin. Post-operative early physiotherapy was initiated with a custom made oral physiotherapy device. Complete oral rehabilitation was done with fixed partial dentures, and patient is on regular follow up.

RESULTS

Patient had mouth opening of 29 mm and also had a satisfactory esthetic appearence.

One-year prospective outcome analysis and complications following total replacement of the temporomandibular joint with the TMJ Concepts system

Total replacement of the temporomandibular joint (TMJ) is increasingly accepted as the gold standard for reconstruction of irreparably damaged or ankylosed joints. The TMJ Concepts system (TMJ Concepts, Ventura, USA) has the longest follow-up of the 2 systems used in the UK. A total of 74 patients had placement of TMJ Concepts prostheses. The primary diagnoses were degenerative disease, multiple previous operations, injury, rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and ankylosis. Of these, 12 were revisions of previous replacements (3 after multiple operations). Over the year there was a significant mean (SD) reduction in pain score (10 cm visual analogue scale) from 72 (2.5) to 8 (1.7) (p<0.0001), and mean (SD) improvements in mouth opening from 22.4 mm (9.4) to 33.7 mm (6.2) (p<0.0001), and dietary consistency (10 cm analogue liquid 0 to solid 100) from 38 (23) to 93 (16) (p<0.0001). No patient had worse symptoms postoperatively. Joints in 2 patients failed because of biofilm infections. Two patients required blood transfusion and one required ligation of the external carotid artery. Five had perioperative dislocation, which responded to elastic intermaxillary fixation for one week. A total of 31 patients had partial, and 2 had total weakness of the facial nerve. All resolved fully except weakness of the temporal branch in one patient, which required brow lift. Total TMJ replacement gives good early improvements in function and pain with few complications. Of the 74 patients, 71 were very pleased to have had the procedure. One was dissatisfied despite complete pain relief and improvement in mouth opening from 3 to 30 mm, and 2 were ambivalent (one had infection, revision, and permanent weakness of the temporal branch of the facial nerve).

Autogenous Reconstructive Modalities of TMJ Ankylosis-A Retrospective Analysis of 45 Cases

The study reports the authors' experience in managing temporomandibular joint (TMJ) ankylosis in Chennai, India (1995-2006) and compares the surgical modalities used. Forty-five patients (67 joints) were reviewed in this retrospective study. Pre- and post-operative assessment included history, radiological, physical examination, and range of mouth opening. Age, gender, aetiology, joint(s) affected, surgical modality, complications and follow-up periods were evaluated. Various types (fibrous, fibroosseous and bony) of TMJ ankylosis were diagnosed. Trauma was the commonest aetiology. The patients' age range was 2-50 years, 51.1 % were males and the follow-up period ranged from 14 to 96 months. Average mouth opening was significantly increased to 32 mm 12 months post-operatively. Mouth opening was compared following different interpositional materials like temporalis interpositioning (33 mm), costochondral graft (30.6 mm) and autograft (30 mm). Minor and major complications were encountered in 37.4 % of cases, including 6.7 % recurrence rate. Early release of TMJ ankylosis; reconstruction of the ramus height with distraction osteogenesis or bone grafting combined with interpositional arthroplasty, followed by vigorous physiotherapy is a successful strategy for the management of TMJ ankylosis.

Overgrowth of costochondral graft in temporomandibular joint ankylosis: An unusual case

Costochondral graft (CCG) replacement of the mandibular condyle was first described by Gilles in 1920. Since then CCGs have gained increasing popularity in reconstruction of the TMJ and condyle in children. The influence of CCGs on mandibular growth and function is not known in detail. Adaptation of the graft has been observed to be better in children, but CCGs have also been shown to grow in adult patients. One of the major disadvantages of the CCGs is its growth pattern, which is extremely unpredictable and may manifest as excessive growth or no growth at all. A mandibular overgrowth on the grafted site can actually be more troublesome than lack of growth. Furthermore, maxillary growth is proportionality influenced by vertical mandibular growth of the graft. This is a report of such a case in which a bizarre overgrowth of the graft was seen following a reconstruction of TMJ by CCG and the devastating outcomes of the treatment. He required one further resection because the grafted tissue had overgrown five years later.