Is aggressive gap arthroplasty essential in the management of temporomandibular joint ankylosis?-a prospective clinical study of 15 cases

Reankylosis of temporomandibular joint 5 years after interpositional arthroplasty using gold foil: management and follow up (a case report)

INTRODUCTION

Temporomandibular Joint (TMJ) reankylosis is one of TMJ arthroplasty complications that can interfere masticatory function and aesthetics. This case report aimed to describe a TMJ reankylosis in growing age patient that occurred 5 years after interpositional arthroplasty using gold foil. Interpositional arthroplasty using temporalis fascia and costochondral graft followed by unilateral coronoidectomy could be a treatment option.

CASE PRESENTATION

A 17-year-old female came with inability to open her mouth 5 years after first interpositional arthroplasty using gold foil due to traumatic TMJ ankylosis. Patient was diagnosed type IV left TMJ reankylosis with left coronoid process hyperplasia. Patient was treated with interpositional arthroplasty using temporalis fascia as an interposition material for articular disc substitution, costochondral graft for ramus condyle unit (RCU) reconstruction and followed by unilateral coronoidectomy. Postoperative mouth opening was ±26 mm. One year evaluation showed stable mouth opening and no recurrency occured.

DISCUSSION

Age at growing period, insufficient gap width, surgical technique and the effects of previous surgery may generate TMJ reankylosis. Temporalis fascia widely used for interposision material and act as a lubricant that makes movement frictionless. Costochondral graft can be used for RCU reconstruction to prevent decreasing mandibular ramus height and openbite.

CONCLUSION

Growing age increases the risk of TMJ reankylosis. Interpositional arthroplasty, which used temporalis fascia and a costochondral graft, has resulted in a sufficient mouth opening and an improvement in masticatory function. Recurrence was not found in the 1-year postoperative evaluation.

Management of paediatric ankylosis

Temporomandibular joint ankylosis (TMJa) is one of the most crippling craniomaxillofacial pathological conditions characterized by replacement of normal architecture of temporomandibular joint (TMJ) with fibrous or bony tissue. The incidence of TMJa is most common in the paediatric population [first and second decades of life] and is commonly associated with maxillofacial trauma. Comprehensive management entails a thorough evaluation of the associated anatomy of the ankylotic mass and other pertinent details like the presence or absence of obstructive sleep apnoea. Categorizing patients based on these variables helps in selecting an appropriate surgical intervention. Various resective and reconstructive surgical techniques are discussed; along with their merits and demerits. Long-term physiotherapy, long-term clinical follow-up and appropriate family counselling are the essential pillars for success. In this review, the authors present an algorithmic approach to evaluation and management of paediatric TMJa. Appropriate recommendations are made based on evidence to select optimum surgical intervention.

Can malocclusion provide clinicians with information for differential diagnosis of temporomandibular joint diseases?: A review

The aim of this literature review was to summarize the clinical characteristics and symptoms of temporomandibular joint diseases, and to discuss the associations between temporomandibular joint diseases and categorization of malocclusion. Electronic literature searches were performed using the PubMed database. The authors established a differential diagnostic method for temporomandibular joint diseases related to malocclusion. A literature search using PubMed yielded 213 texts, of which based on exclusion criteria, 28 were included in this study. Malocclusions were categorized into 5 types. The authors suggested a diagnostic tree of temporomandibular joint diseases based on the types of malocclusion and 4 variables in clinical characteristics and symptoms. Clinicians treating malocclusions must attempt to clarify the cause of the occlusal condition. If caused by temporomandibular joint disease, it is important to make a proper differential diagnosis at first, and not to overlook the causative disease. Further clinical knowledge of associations between temporomandibular joint diseases and malocclusions should be accumulated, and the diagnostic tree should be improved based on new information.

Acquired Facial, Maxillofacial, and Oral Asymmetries—A Review Highlighting Diagnosis and Management

Facial asymmetry refers to the absence of, or the deviation from the regular mirror image of facial structures, relative to a referenced midline axis. It can be attributed to a wide spectrum of deformities, including congenital, developmental, or acquired conditions, which can originate either prenatally or postnatally. Though highly prevalent, asymmetry commonly goes undiagnosed due to its subtle or relative nature. Among the spectrum of conditions, acquired cases are triggered postnatally, in previously normal individuals, thus subjecting them to sudden, eventful psychological and psychosocial disharmony. When detected early, timely management may help intervene progressive growth of these conditions. This, therefore, emphasizes the need for a thorough diagnostic workup including medical/dental history, clinical examinations, study models, photographic and radiographic records for a case-by-case basis to prevent severe functional and aesthetic complications. Recently, advanced diagnostic procedures, such as stereophotogrammetry, 3D stereolithographic models, skeletal scintigraphy (radionucleotide scans), 3D computed tomographic scans, cone-beam computed tomography, and magnetic resonance imaging, have provided innovative diagnostic instruments for numerous craniofacial defects. This descriptive review aims at focusing on the factors leading to frequently encountered conditions of acquired facial asymmetry and highlights their clinical evaluation, conservative and surgical interventions by a multi-disciplinary team of clinicians.

Classification and surgical management of temporomandibular joint ankylosis: a review

The paper reviews various classifications and surgical techniques for the treatment of temporomandibular joint ankylosis. PubMed, EBSCO, Web of Science, and Google Scholar were searched using a combination of keywords. Articles related to classification, resection-reconstruction of the temporomandibular joint, and management of airway obstruction were considered and categorized based on the objectives. Seventy-nine articles were selected, which included randomized clinical trials, non-randomized controlled cohort studies, and case series. Though several classifications exist, most classifications are centered on the radiographic extent of the ankylotic mass and do not include the clinical and functional parameters. Hence there is a need for a comprehensive staging system that takes into consideration the age of the patient, severity of the disease, clinical, functional, and radiographic findings. Staging the disease will help the clinician to adopt a holistic approach in treating these patients. Interpositional arthroplasty (IA) results in better maximal incisal opening compared with gap arthroplasty, with no significant difference in recurrent rates. Distraction osteogenesis (DO) is emerging as a popular technique for the restoration of symmetry and function as well as for relieving airway obstruction. IA, with a costochondral graft, is recommended in growing patients and may be combined with or preceded by DO in cases of severe airway obstruction. Alloplastic total joint replacement combined with fat grafts and simultaneous osteotomy procedures are gaining popularity. A custom-made total joint prosthesis using CAD/CAM can efficiently overcome the shortcomings of stock prostheses.

Ankylosis of the Temporomandibular Joint in Pediatric Patients

INTRODUCTION

While surgical interventions for temporomandibular joint (TMJ) ankylosis are well-documented, there is lack of consensus regarding the ideal approach in pediatric patients. Surgical interventions include gap arthroplasty, interpositional arthroplasty, or total joint reconstruction.

METHODS

A systematic review of PubMed (Jan 1, 1990-Jan 1, 2017) and Scopus (Jan 1, 1990-Jan 1, 2017) was performed and included studies in English with at least one patient under the age of 18 diagnosed with TMJ ankylosis who underwent surgical correction. Primary outcomes of interest included surgical modality, preoperative maximum interincisal opening (MIO) (MIOpreop), postoperative MIO (MIOpostop), ΔMIO (ΔMIO = MIOpostop - MIOpreop), and complications.

RESULTS

Twenty-four case series/reports with 176 patients and 227 joints were included. By independent sample t tests MIOpostop (mm) was greater for gap arthroplasty (30.18) compared to reconstruction (27.47) (t = 4.9, P = 0.043), interpositional arthroplasty (32.87) compared to reconstruction (t = 3.25, P = 0.002), but not for gap compared to interpositional (t = -1.9, P = 0.054). ΔMIO (mm) was greater for gap arthroplasty (28.67) compared to reconstruction (22.24) (t = 4.2, P = 0.001), interpositional arthroplasty (28.33) compared to reconstruction (t = 3.27, P = 0.002), but not for interpositional compared to gap (t = 0.29, P = 0.33). Weighted-average follow-up time was 28.37 months (N = 164). 4 of 176 (2.27%) patients reported development of re-ankylosis. There was no significant difference in occurrence of re-ankylosis between interventions.

CONCLUSIONS

Given the technical ease of gap arthroplasty and nonsignificant differences in ΔMIO, MIOpostop, or occurrence of re-ankylosis between gap and interpositional arthroplasty, gap arthroplasty should be considered for primary ankylosis repair in pediatric patients, with emphasis on postoperative physiotherapy to prevent recurrent-ankylosis.

Matrix-associated chondrocyte transplantation for reconstruction of articulating surfaces in the temporomandibular joint: a pilot study covering medium- and long-term outcomes of 6 patients

Objective

Matrix-associated chondrocyte transplantation is routinely used in joints of the extremities but not in the temporomandibular joint (TMJ).

Study Design

We report the first case series in 7 patients of a tissue engineering approach to regenerate severely degraded articulating surfaces in the TMJ by simultaneously completely resurfacing both the mandibular condyle and the articular eminence/glenoid fossa with a commercially available collagen sponge seeded with autologous cells stabilized within a fibrin matrix. To facilitate healing, we temporarily employed a silicone membrane to protect the engineered tissues. The indications for surgery were posttraumatic fibro-osseous ankylosis, ankylosing osteoarthritis, or late-stage osteoarthritis.

Results

Six of the patients were recalled for follow-up after 3 years 6 months to 12 years 1 month. The maximum incisal opening was 18.2 ± 9.2 mm (range, 9-33 mm) before and 31.2 ± 13.6 mm (range, 12-47 mm) at the latest follow-up. Histologic specimens taken at 4 months showed beginning differentiation of fibrocytes into chondrocytes, whereas at 3 and 11 years, mature hyaline cartilage—not typical for the TMJ—was present.

Conclusions

We conclude that the reconstruction of TMJ surfaces by matrix-associated chondrocyte transplantation may become a routine method for cartilage regeneration in the TMJ in the future.

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.

Prophylactic embolisation of the internal maxillary artery in patients with ankylosis of the temporomandibular joint

The aim of the present study was to assess the efficacy of using prophylactic embolisation of the internal maxillary artery to minimise the risk of bleeding during gap arthroplasty. We studied a prospective series of 14 patients with ankylosis of the temporomandibular joint (TMJ) between January 2011 and February 2016, who were under the care of one surgeon. They were all treated by embolisation of the internal maxillary artery 24hours before gap arthroplasty. The main outcome variable was estimated blood loss, and others included the need to extend the gap arthroplasty, and the risk of reankylosis. We studied nine women and five men, mean (SD) age 51 (18) years, seven with unilateral and seven with bilateral ankylosis. Their mean (SD) estimated blood loss was 136 (77) ml, which we considered to be minimal. Patients were followed-up at six-monthly intervals, during which time there was no reankylosis or limitation of mouth opening. No patient lost more than 250ml blood in total. Prophylactic embolisation of the internal maxillary artery seems to be beneficial and safe in the management of selected cases of ankylosis of the TMJ.

Surgical management of ankyloses of the temporomandibular joint by a piezoelectric device

INTRODUCTION

Piezosurgery is commonly used in different field of craniomaxillofacial surgery; since its introduction it has become one of the widely adopted technique for performing osteotomies in orthognathic surgery, distraction osteogenesis and dentoalveolar surgery. Little has been written regarding ultrasonic system for temporomandibular joint surgery (TMJ). In this prospective study we describe the use of piezoelectric device for ankylosis of the TMJ.

MATERIALS AND METHODS

We enrolled in this study 19 patients, 10 males and 9 females, mean (SD) age 24.6 (7.6) years, affected by unilateral ankylosis of TMJ who were surgically managed between January 2009 and December 2014 by interpositional arthroplasty with temporomyofascial muscle flap. We adopted in all cases a preauricular approach with temporal extension. The ankylotic block was removed with piezoelectric device in 9 patients and using traditional rotary bur in 10 cases. We investigated and compared the following parameters as surgical outcomes: intraoperative bleeding, duration of operation, incidence of infection, postoperative swelling and hematoma, mouth opening, nerve impairment and rate of recurrence.

RESULTS

We noticed a substantial reduction in bleeding with the piezoelectric bone cutter when compared to traditional mechanical surgery (103 ml versus 117 ml; p < 0.05); however, we did not report any severe bleeding from the pterygoid plexus or maxillary artery. Operating time was longer in the piezo group (101 min versus 88 min; p < 0.05). There was a lower incidence of postoperative hematoma and swelling following piezoosteotomy. However, regarding postoperative nerve impairment and infection we did not observe any differences between the two groups. At one year follow-up mean (SD) mouth opening was 34 (4.3) mm. We did not report recurrence of the disease.

CONCLUSION

Piezoelectric bone removal for the release of ankylosis of the TMJ is associated with minimal bleeding and few postoperative complications. We believe that piezosurgery allows surgeons to achieve better results compared to a traditional surgery. It is a possible alternative due to the clinical benefits demonstrated.

A comparative study of different surgical methods in the treatment of traumatic temporomandibular joint ankylosis

Two different surgical methods for the treatment of unilateral traumatic temporomandibular joint (TMJ) ankylosis with a medially displaced residual condyle are described. Eighteen patients with unilateral traumatic TMJ ankylosis and a medially displaced residual condyle, treated between 2008 and 2013, were included in this study. Group A patients (n=10) were treated with an autogenous coronoid process graft (ACPG) for reconstruction of the mandibular condyle, while group B patients (n=8) were treated by lateral arthroplasty (LAP); a temporalis myofascial flap (TMF) was used as interpositional material in both groups. The long-term results of the two treatments were compared through postoperative computed tomography and clinical follow-up examinations. The two groups were compared in terms of the recurrence rate, facial pattern change, and improvement in maximum inter-incisal opening (MIO) using SPSS 18.0 software. All patients were followed up for 12-24 months. Two patients in group A (20%) had reankylosis; no reankylosis was observed in group B patients. Compared with the ACPG, LAP improved the facial pattern and MIO significantly (P<0.05). LAP is a feasible and effective surgical method for the treatment of unilateral traumatic TMJ ankylosis when the displaced residual condyle is bigger than one third of the condylar head.

Conservative gap arthroplasty in temporomandibular ankylosis not involving the sigmoid notch: a selected age group study

In this prospective, cohort, clinical follow-up study we aimed to investigate the role of conservative gap arthroplasty without interpositional material in managing ankylosis of the temporomandibular joint (TMJ). Thirteen patients (15 joints) with ankylosis who fulfilled the other inclusion criteria were enrolled. The ankylotic mass was excised to create a gap of 7-9mm. No interpositional material was used. Ipsilateral or bilateral masseter reflection, pterygomasseteric sling, and temporalis tendon release plus coronoidectomy were considered if maximum mouth opening failed to reach 35mm. A physiotherapy protocol was started on the first day. Patients' ages ranged from 13-38 (mean (SD) 18 (7) years). Trauma was the main cause. Duration of ankylosis at presentation ranged from 1-17 years (mean (SD) 5 (4) years). Eleven patients had unilateral, and two bilateral, ankylosis that did not involve the sigmoid notch. The mean (SD) maximum incisal opening (mm) was 38 (4) two years' postoperatively. The facial nerve was affected temporarily in two patients. Mean (SD) duration of follow-up was 4 (2) years without recurrence. Within our selection criteria, conservative gap arthroplasty of 7-9mm without interpositional material and with vigorous postoperative physiotherapy has a role in treating ankylosis of the TMJ and preventing its recurrence for more than four years.

Ultrasonography for the volumetric analysis of the buccal fat pad as an interposition material for the management of ankylosis of the temporomandibular joint in adolescent patients

The aim of this study was to analyse preoperatively with ultrasound the minimum volume of buccal fat that would be required for interposition of a pad after gap arthroplasty, and to emphasise the value of such a pad in the management of ankylosis of the temporomandibular joint (TMJ) during a short term follow up. Nineteen patients with ankylosis of the TMJ (22 joints) were selected, whose mean (SD) mouth opening was 4.9 (3.7) mm. In 10 joints in which the mean (SD) volume of the buccal fat pad was 0.7 (0.2) ml, the harvested buccal fat was inadequate for interposition, so they were treated with other materials. The remaining 12 joints had a mean (SD) volume of 1.1 (0.3) ml, which gave enough fat for interposition after gap arthroplasty. Investigation with ultrasound at 15 days and 6 months postoperatively showed that the fat pad was viable and the volume had shrunk by 28%. The 6-month postoperative computed tomographic (CT) scan showed little or no heterotopic calcification. We conclude that a buccal fat pad with a preoperative mean (SD) volume of 1.1 (0.3) ml is easy to harvest as interposition material. At a mean follow up of the 12 joints after 31 (range 24-36) months there was progressive improvement in mouth opening with a mean (SD) of 32.5 (5.0) mm, which established that a pedicled buccal fat pad is a stable, efficient, viable soft tissue barrier in the management of ankylosis of the TMJ.

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

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