Grafts of autogenous coronoid process to reconstruct the mandibular condyle in children with unilateral ankylosis of the temporomandibular joint: long-term effects on mandibular growth

Can growing patients with end-stage TMJ pathology be successfully treated with alloplastic temporomandibular joint reconstruction? - A systematic review

INTRODUCTION

The use of alloplastic total temporomandibular joint reconstruction (TMJR) in growing patients is controversial, mainly due to immature elements of the craniomaxillofacial skeleton. The aim of this systematic review was to evaluate the use of alloplastic TMJR in growing patients, focusing on the patient's clinical presentation, surgical and medical history and efficacy of alloplastic TMJR implantation.

MATERIALS AND METHODS

The literature search strategy was based on the Population, Intervention, Comparator, Outcomes and Study type (PICOS) framework. We searched Pubmed, Google Scholar, Dimension, Web of Science, X-mol, Semantic Scholar and Embase to January 2023, without any restriction on the type of publication reporting alloplastic TMJR in growing patients (age ≤ 18 years for boys and age ≤ 15 years for girls).

RESULTS

A total of 15 studies (case reports: 09, case series: 02, cohort studies: 04) met the inclusion criteria, documenting 73 patients of growing age from 07 countries. Thirty-eight (~ 52%) cases were female. The mean ± SD (range) age and follow-up of patients in all studies was 13.1 ± 3.2 (0-17) years and 34.3 ± 21.5 (7-96) months, respectively. A total of 22 (30%) patients were implanted with bilateral alloplastic TMJR. Over half of the studies (n = 10) were published in the last 3 years. All patients underwent multiple surgeries prior to implantation of alloplastic TMJR. In extreme cases, patients underwent a total of 17 surgeries. Different types of studies reporting inconsistent variables restricted our ability to perform quality assessment measures for evidence building.

CONCLUSIONS

Clinical experience with alloplastic TMJR in growing patients is limited to cases showing poor prognosis with other types of reconstruction. Nevertheless, studies show promising results for the use of alloplastic TMJR in growing patients, highlighting the need for well-controlled prospective studies with long-term follow-up.

Can Alloplastic Total Temporomandibular Joint Reconstruction be Used in the Growing Patient? A Preliminary Report

INTRODUCTION

Although primarily reserved for adult patients, temporomandibular joint (TMJ) total joint reconstructive (TJR) surgery is rarely used in the pediatric population due to its many challenges; it is only performed after all other non-invasive or invasive procedures have been exhausted. Although autogenous grafting has been discussed in the literature, there is very little regarding synthetic or alloplastic materials. In this study, we performed alloplastic TMJ reconstruction on 5 patients with severe ankylosis due to various craniofacial deformities and prior traumatic injuries.

MATERIALS AND METHODS

This is a retrospective case series analysis of skeletally immature patients who received alloplastic TMJ reconstruction for recurrent and advanced ankylosis. Our inclusion criteria were as follows: less than 16 years of age, diagnosis of TMJ ankylosis, skeletally immature patients, and unilateral/bilateral total alloplastic TMJ reconstruction. We used the maximum incisal opening (MIO) changes as 1 component to assess for functional improvement.

RESULTS

Since many of these cases involved gross discrepancies from the normal variants, it was difficult to quantitatively compare the patients with one another. Nevertheless, we used cephalometric analysis to compare pre- and postoperative results on each patient. For this study, we used MIO as our primary assessment: the preoperative average for MIO was 7.4 mm, and the postoperative average 24 mm.

CONCLUSION

It is our experience that the use of alloplastic material will not result in harm to either the growth of the mandible or patient's ability to achieve an improved MIO based on our long- and short-term results. These results demonstrate that for even complex craniofacial deformities and traumatic injuries, our patients experienced a significant improvement in MIO, 1 of the main indicators for TMJ function. We conclude that the alloplastic joint can provide a predictable pathway to restore patient's MIO and obviate the need for repeated surgeries, which can be a more challenging alternative with poorer outcomes.

Mandibular Coronoid Process Hypertrophy: Diagnosis and 20-Year Follow-Up with CBCT, MRI and EMG Evaluations

Coronoid process hypertrophy (CPH) consists of an abnormal volumetric increment of the mandibular coronoid process; as this process grows gradually, the infratemporal space needed for the rotation and translation of the mandible is reduced, which results in a reduction of the range of mouth opening and lateral excursion, limiting mouth opening. The purpose of this case report was to describe a rare case of hypertrophy of coronoid processes with associated temporomandibular ankylosis, monitored for over 20 years. The patient was first visited when he had a facial trauma at the age of 4. Then he was followed through clinical, functional, instrumental, bi-dimensional and three-dimensional radiological evaluations up to the age of 24. Physical therapy was initiated at the age of 10 to improve the condition of the masticatory muscles, while at the age of 14, Transcutaneous Electrical Nerve Stimulations were performed to reduce muscle tension and, a bite plane was delivered to control the parafunctional activity of the jaw in the night and self-control instruction was provided for daytime habits. The adult patient has not accepted surgical intervention; thus, the future objective is to continue monitoring over the years to avoid a detrimental progression of the medical condition through physical and functional therapies while waiting for patient consent to surgery if needed.

Reconstruction of the Mandibular Condyle

The mandibular condyle is an integral structure in the temporomandibular joint (TMJ) serving not only as the hinge point for mandibular opening, but also facilitating mandibular growth and contributing to facial aesthetics. Significant compromise of the TMJ can be debilitating functionally, psychologically, and aesthetically. Reconstruction of the mandibular condyle is rarely straightforward. Multiple considerations must be accounted for when preparing for condylar reconstruction such as ensuring eradication of all chronically diseased or infected bone, proving clear oncologic margins following tumor resection, or achieving stability of the surrounding architecture in the setting of a traumatic injury. Today, there is not one single gold-standard reconstructive method or material; ongoing investigation and innovation continue to improve and transform condylar reconstruction. Herein, we review methods of condylar reconstruction focusing on autologous and alloplastic materials, surgical techniques, and recent technological advances.

Role of Custom-Made Prosthesis for Temporomandibular Joint Replacement in Unilateral Ankylosis - An Evaluative Study

Introduction

Ankylosis is a physically and psychologically distressing condition to a patient. The aim of this study was to evaluate the efficiency of custom-made temporomandibular joint (TMJ) prosthesis (fossa-condyle component) in patients with unilateral ankylosis in restoring the form and functions of the TMJ.

Materials and Methods

This retrospective study was conducted in ten patients with unilateral TMJ ankylosis who had undergone TMJ reconstruction with custom-made TMJ prosthesis. Clinical parameters assessed were maximal mouth opening, lateral movements, improvement of the pain levels, and dietary efficiency of the patient. The data were analyzed using SPSS version 20 (IBM Corporation, SPSS Inc.; Chicago, IL, USA).

Results

The mean preoperative mouth opening was 5.70 ± 3.62 mm. After gap arthroplasty, it was 32.50 ± 3.31 mm. The postoperative mouth opening after the reconstruction of TMJ using alloplastic joint prosthesis was 34.90 ± 2.69 mm, and after a mean follow-up period of 4 years, the mean postoperative mouth opening was 34.60 ± 2.50 mm. The mean preoperative movement toward the right and left side was 0.9 ± 1.2 mm and 1.3 ± 1.25 mm, respectively. The mean right and left lateral movements of the TMJ after reconstruction were 3.5 ± 0.97 mm and 3.70 ± 1.06 mm, respectively. There was decrease in deviation of the unaffected jaw during mouth opening and closure. Functional occlusion was maintained postoperatively. There was no appreciable change in the visual analog pain scales. The dietary efficiency improved from a scale of 10 (liquids) to a scale of 0 (no restriction to diet) in eight patients and 1 in two patients. The dietary score improved significantly after alloplastic reconstruction (P = 0.000). No evidence of facial nerve paralysis or foreign body reactions was noted in the patients during the follow-up period. Radiographic assessment revealed good positioning and adaptation of the fossa component and the condylar ramal component both postoperatively and after a mean 4-year follow-up period. There was no evidence of screw loosening or prosthesis breakage during the follow-up period.

Discussion and Conclusion

The custom-made TMJ-total joint replacement (TJR) devices provide stable, improved long-term results, thereby increasing the quality of life of the patient. The custom-made alloplastic TMJ-TJR prosthesis proves to be the optimal surgical procedure to reconstruct the TMJ in comparison to the autogenous grafts (to avoid complications) in severe degenerated and ankylosed joints. However, long-term clinical and radiological studies on a larger sample size are imperative to establish the versatility of this procedure.

Association between maximum mouth opening and area of bony fusion in simulated temporomandibular joint bony ankylosis

The aim of this study was to investigate the quantitative association between active/passive maximum mouth opening (AMMO/PMMO) and the severity of simulated temporomandibular joint (TMJ) bony ankylosis. Twenty-eight male sheep were divided randomly and equally into surgical and control groups. Surgical group animals underwent bilateral TMJ osteotomy during which left lateral pterygoid muscle function was blocked. Control animals did not undergo surgery. Body weight, AMMO/PMMO, and TMJ morphological features were evaluated preoperatively and at 12 and 24 weeks post-surgery. In the surgical group, only the right TMJ complexes with maintained lateral pterygoid muscle function developed TMJ bony ankylosis. The AMMO/PMMO and end-feel distance in the surgical group were significantly lower than those in the control group (P < 0.001, both) at 12 and 24 weeks post-surgery. Moreover, AMMO (r = -0.940 and -0.952, P < 0.001, both) and PMMO (r = -0.944 and -0.953, P < 0.001, both) were negatively correlated with the area (mm²) of bony fusion post-surgery. These findings may be useful for the clinical treatment of early mandibular condyle fracture, with the use of occlusal pads/open-mouth plates to relax the lateral pterygoid muscle and block its function. When bony ankylosis developed in the TMJ, the greater the area of bony fusion, the more limited were AMMO/PMMO.

Mandibular ascending branch and condyle reconstruction in adolescence by a costochondral rib graft with an observation period over 8 years

Introduction: The need to resect and reconstruct the condylar process of the mandible in a teenager is rare. Reconstruction strategy must be accurately assessed in terms of donor side morbidity, postoperative risks (ankylosis) and the possibility of sufficient development in a growing patient. Observation: A 14-year-old boy presented with the radiographic finding of a large cystic lesion of the right condylar process. There were no clinical symptoms as pain, a limitation of mouth opening or malocclusion. Pathohistological examination confirmed a solitary bony cyst. The resected ascending jaw and condylar process was reconstructed by a costochondral rib graft. Commentaries: Over 8 years the development of the reconstructed ascending jaw and condyle was observed. There was an undisturbed growth. The cartilaginous part of the costochondral graft remodeled to a sufficient condylar process without ankylosis, resorption or overgrowth. Conclusion: The reconstruction of the growing mandible and condylar process in an adolescent is a challenge. Observation over 8 years showed a sufficient reconstruction. Intraoperative the chondral portion of the graft has to be handled carefully to avoid a separating from the bony part. The growth potential of the costochondral rib transplant allows a functional reconstruction without substantial donor side morbidity in adolescent patients.