Interposition arthroplasty in temporomandibular joint ankylosis

Treatment of Temporomandibular Joint Reankylosis by Submandibular Anchorage Technique with Temporalis Myofascial Flap

Management of temporomandibular joint (TMJ) ankylosis is challenging for the oral and maxillofacial surgeon because it involves the mouth opening, dentofacial deformity, diet problem, and quality of life. Although surgical techniques to treat TMJ ankylosis have improved, reankylosis is a persistent problem. The temporalis myofascial flap provides good material for interpositional arthroplasty, because of its good vascular supply, anatomic proximity, and adequate thickness. This case report examines the efficacy of submandibular anchorage to prevent reankylosis by inhibiting flap dislocation.

Temporomandibular joint ankylosis fixation technique with ultra thin silicon sheet

BACKGROUND

Temporomandibular joint ankylosis is a highly distressing condition in which the joint space is obliterated by scar tissue and the patient has an inability to open the mouth. Different autogenous and alloplastic interposition materials have been used after the resection of the ankylotic bone to achieve desirable and long lasting results. The recurrence of disease is most distressing for both patients and surgeon. We have been using ultra thin silicon sheet as our preferred material for providing proper fixation and cover to the joint. We have been encouraged by good patient compliance, no implant extrusion and favourable outcome.

MATERIALS AND METHODS

The clinical study included 80 patients with temporomandibular joint ankylosis, treated between April 2001 and March 2009. In all patients, temporomandibular joint ankylosis had resulted following trauma. Diagnosis was based on clinical assessment supplemented by radiographic examination consisting of a panoramic radiograph, axial and coronal computer tomography. The technique of using ultra thin silicon sheet covering whole of the joint space fixed with non-absorbable nylon 3-0 suture both medially to medial pterygoid muscle and laterally to periosteum of zygomatic arch was employed in all patients.

RESULTS

A total of 80 patients were in this study (59 males and 21 females). The aetiology of temporomandibular joint ankylosis was post-traumatic in all cases. The patients' age ranged from 5 to 45 years. The disease was unilateral in 61 cases and bilateral in 19 cases. Twelve patients, who had previous surgery done in the form of gap arthroplasty in 6 cases, costochondral graft in 4 cases and temporalis muscle in 2 cases, presented with recurrence on the same side. The pre-op inter-incisal mouth opening ranged from 4 to 12 mm. The intraoperative inter-incisal mouth opening ranged from 28 to 46 mm. An additional procedure was done in 13 patients, including placement of costochondral graft with coronoidectomy in 4 of these cases. There was no immediate complication and no incidence of facial nerve injury. There was no extrusion of the implant in immediate and follow-up period.

CONCLUSIONS

The use of alloplastic implants with less volume and proper fixation covering all the raw bone joint space prevents reunion of bone; fixation of the sheet prevents its movement and thus extrusion.

The versatility of temporalis myofascial flap in maxillo-facial reconstruction: a clinical study

OBJECTIVES

This clinical study was conducted in the department of Oral & Maxillofacial Surgery, at our institute, to study the versatility of temporalis myofascial flap in maxillofacial reconstruction.

METHODS

The study group comprised of 20 patients, both male and female patients between the age group of 6 years and 60 years underwent surgery under general anesthesia and temporalis myofascial flap was used for reconstruction of various types of maxillofacial defects including maxillectomy defects arising as a result of ablative surgery for tumors and treatment of aggressive cysts, as an interposing material in TMJ ankylosis surgery and facial reanimation in cases of long standing facial nerve paralysis. Following surgery the cases were evaluated for clinical parameters weekly for first post-operative month followed by monthly review for a minimum period of one and maximum of three years from January 2003 to June 2006.

RESULTS

Temporalis myofascial flap fared well in 16 out of 20 cases (80%), in remaining four cases (20%) three reported back with reankylosis, and in one case of facial reanimation flap breakdown occurred due to infection leading to failure of the procedure.

CONCLUSION

The temporalis myofascial flap is a versatile option for reconstruction of moderate to large sized maxillofacial defects, the muscle can provide abundant viable and vascular tissue, with minimal to no functional morbidity or esthetic deformity at the donor site.

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

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