Pediatric Temporomandibular Joint Pathology

Pediatric temporomandibular joint (TMJ) disorders represent a broad range of congenital and acquired diagnoses. Dentofacial deformities, including facial asymmetry, retrognathism, and malocclusion, commonly develop. Compared with adult TMJ conditions, pain and articular disc pathology are less common. Accurate diagnosis is paramount in planning and prognostication. Several specific considerations apply in preparation for skeletal correction, including timing in relation to disease progression and growth trajectory, expectation for postcorrection stability, reconstructive technique as it applies to expected durability and need for future revision, management of occlusion, and need for ancillary procedures to optimize correction. This article reviews common conditions and treatment considerations.

3D-CT measurements of facial symmetry in severe CFM patients: A comparative study between mandibular ascending ramus distraction osteogenesis and bone grafting

This study aims to compare the effects of mandibular distraction osteogenesis (MDO) and bone grafting on the facial symmetry of children with Pruzansky-Kaban type IIB and III craniofacial microsomia (CFM). Medical records and three-dimensional computed tomography (3D-CT) data of CFM patients who had primarily undergone MDO and bone grafting were collected. A retrospective analysis of pre-and post-operative 3D imaging data was conducted to compare the improvement rate in facial symmetry between the two groups based on occlusal cant, affected/unaffected ramus height ratio and chin point deviation. The data were tested for normality using the Shapiro-Wilk test. When the data followed a normal distribution, a paired sample t-test was employed for the comparison between preoperative and postoperative data. When the data did not follow a normal distribution, the Wilcoxon signed-rank test for paired samples was used for preoperative and postoperative comparison. The study included 18 children with type IIB and III CFM, 11 in the MDO group and 7 in the bone grafting group. In the MDO group, postoperative Gn-FH and Gn-Cor distances increased significantly, whereas the postoperative Gn-Mid distance decreased significantly. Occlusal cant decreased significantly and ramus height affected/unaffected ratio increased significantly after MDO. In the bone graft group, there was no statistically significant difference in the postoperative ratios of chin deviation, occlusal cant, and ramus height affected/unaffected compared to the preoperative values. Compared to bone grafting, MDO can significantly enhance ramus height ratio, level occlusal plane, and centralize the chin point among patients with CFM. Furthermore, MDO achieves superior enhancements in facial symmetry.

Massive traumatic articular bone loss of the capitulum humeri treated by costal osteochondral autograft reconstruction: A case report

INTRODUCTION

Articular traumatic bone loss is a severe condition with heterogeneous outcomes, often necessitating complex technical solutions and posing challenges in managing both bone and cartilage loss. Thus, some surgeons have used a technique of osteochondral autograft using a rib to fix an articular bone loss to manage both of these tissue losses.

PRESENTATION OF CASE

We present the case of a 25-years-old patient, who had a complex open elbow injury. He presented an association of a terrible triad of the elbow injury with an open traumatic bone loss of the capitulum humeri and unfixable lesion of the lateral collateral ligament complex of the elbow. We initially managed these lesions with an external fixator for 2 months followed by a reconstruction of the capitulum humeri using a costal osteochondral autograft. Unfortunately, the patient was lost to follow-up after the 1 month post-operative consultation but he had some encouraging results.

DISCUSSION

In this case report, we describe our technique using an osteochondral autograft to address complex bone and cartilaginous losses, thereby expanding the treatment options available to trauma surgeons.

CONCLUSION

This case report shows that a reconstruction of the capitellum humeri for a traumatic bone loss with an osteochondral autograft using the eighth rib can be easily performed. More generally, this technique could even help to manage complex traumatic substance loss of both bone and cartilage in other locations.

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.

Long term complications of costochondral graft reconstruction in temporomandibular joint ankylosis of the young- a systematic review

Costochondral graft has been a popular reconstruction choice in the past for temporomandibular joint ankylosis in young individuals. However, accounts of growth hampering complications have also been observed. Our systematic review aims to compile all existing evidence to determine the occurrence of these unfavourable clinical outcomes as well as factors affecting them to provide a better judgement on further use of these grafts. A systematic review was conducted following PRISMA guidelines where databases like PubMed, Web of science and Google Scholar were searched for the purpose of data extraction. Observational studies performed on patients younger than 18 years of age with a minimum follow-up of one year were selected. Incidence of long term complications like reankylosis, abnormal graft growth, facial asymmetry and others were considered as outcome variables. Eight articles with a total of 95 patients were selected where complications like reankylosis (6.32%), graft overgrowth (13.70%), insufficient graft growth (22.11%), no graft growth (3.20%) and facial asymmetry (20%) were reported. Other complications like mandibular deviation (3.20%), retrognathia (1.05%) and prognathic mandible (3.20%) were also observed. Our review concludes that the occurrence of these complications was noteworthy. Thus use of costochondral graft for reconstruction in temporomandibular ankylosis in young patients holds significant risk in development of growth abnormalities. However, modifications in surgical procedure such as use of appropriate graft cartilage thickness and the presence and type of interpositional material can favourably affect the frequency and type of growth abnormality.

Autogenous Reconstruction of the Temporomandibular Joint

Reconstruction of the temporomandibular joint can optimize many basic functions (airway obstruction, feeding, speech difficulties) and rectify facial deformity. In children, it can restore potential growth. Reconstruction in adults is now mainly performed with alloplastic techniques but autogenous vascularized grafts are often required in patients with large composite facial defects or postradiation treatment. In children, autogenous grafting remains the primary reconstructive choice despite a high further surgery rate and increasing interest in alloplastic techniques. The costochondral graft remains the most widely used technique due to the potential for growth restoration and low donor site morbidity.

Does no-intraoperative correction of chin deviation prevent costochondral graft overgrowth in pediatric temporomandibular joint ankylosis management - an intermediate outcome study

The use of costochondral graft is controversial for pediatric temporomandibular joint reconstruction due to its unpredictable growth. The height of the cartilage is directly responsible for the growth capacity of costochondral graft. Even after keeping the cartilage in costochondral graft to a recommended height, overgrowth has been reported. Traditionally during costochondral graft fixation, chin deviation is corrected intraoperatively. The investigators hypothesized that this intraoperative manipulation of mandible to correct chin deviation and maintaining the chin in new position causes excessive stress and strain in the muscular functional matrix. The authors believe that this may be the reason for excessive growth trigger on the grafted side. This study intends to prove the hypothesis of no-intraoperative correction of chin deviation can prevent overgrowth of the costochondral graft. We implied this technique in pediatric temporomandibular joint ankylosis patients managed with osteoarthrectomy and reconstructed with costochondral graft. Patients with at least a follow-up of 30-months were included in the study. The study sample consisted of 20 patients. All the patients had adequate growth with improvement in facial asymmetry. The results of the present study supports our hypothesis of no-intraoperative correction of chin deviation as a technique to prevent overgrowth of costochondral graft. We recommend this technique to allow catch-up of growth rather than acceleration of growth. This change in technique needs more research, randomized controlled trial for reliability and long-term results.

[Revision of failed resection arthroplasty of the CMC-1 joint using a costochondral graft]

OBJECTIVE

To correct and prevent the proximalisation of the 1st ray by safe stabilisation using an autologous costochondral graft. Reduction of pain and maintaining good pinch and grip strength while preserving the important opposition of the thumb.

INDICATIONS

Painful proximalisation of the 1st ray after failed trapeziectomy with contact between the base of the 1st metacarpal and the trapezoid or scaphoid.

CONTRAINDICATIONS

Painful conditions following trapeziectomy for other causes.

SURGICAL TECHNIQUE

Perioperative antibiotic prophylaxis is required. Extension of the previous incision and exposure of the sensitive radial branches and the radial artery. Longitudinal incision of the capsule and excision of the scar from the trapezium cavity. Dissection of the scar tissue directly around the metacarpal 1 base. After longitudinal resection of the oblique trapezoid surface, insertion of a suture anchor into the scaphoid joint surface close to the trapezoid. Removal of an approximately 2 cm long piece of rib cartilage from the middle costal arch. Insertion of the costochondral graft into the trapezium space and fixation with the suture anchor. Stable capsule closure. Suction drain. Skin suture. Thumb-forearm splint.

POSTOPERATIVE MANAGEMENT

Postoperative immobilisation of the carpometacarpal (CMC)-1 joint for 4 weeks in medium abduction position. In case of uneventful wound healing also with a well-fitting orthosis. Afterwards independent movement exercises and exercises in warm water. Hand therapy only in case of difficult mobilisation at the earliest 2 months after surgery.

RESULTS

From 2015-2018, 18 patients underwent surgery using this technique. The follow-up was at least 2 years after surgery. Of the 15 patients available for follow-up, 93% were classified as good and improved according to the Conolly-Rath score.

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.

Temporomandibular joint reconstruction with costochondral graft: case series study

Various techniques have been used to reconstruct the temporomandibular joints, including autogenous transplants and alloplastic implants. Among autogenous grafts, costochondral grafts have mainly been used. A costochondral graft has many advantages over other autogenous grafts and alloplastic implants. Harvest is easy and has minimal impact on patients. The graft can bear functional load well and biocompatibility is excellent. A costochondral graft obviates foreign body reactions and further surgery for revision of alloplastic replacements if the graft takes well. Although long-term prognosis remains unclear, it appears that for autogenous condylar reconstruction, costochondral grafts can be used with few complications and acceptable results. This article describes cases and discusses surgical techniques and considerations related to costochondral grafts.

Strategies to reduce re-ankylosis in temporomandibular joint ankylosis patients

The purpose of the study was to define a protocol for the prevention of re-ankylosis after surgical management of temporomandibular joint ankylosis (TMJA). The investigators designed a retrospective study on all TMJA patients treated with different treatment modalities from 2013 to 2019. The investigators observed that complete removal of the ankylotic mass particularly on the medial side; use of a piezoelectric scalpel for a clean and smooth osteotomy with copious irrigation to remove bone chips and slurry; less trauma to the local tissue; osteotomy design parallel and inferior osteotomy at the narrowest part, which mostly corresponds to the condylar neck; performance of a coronoidectomy (if mouth opening is <30mm), fat interposition; no intraoperative correction of any pre-existing chin deviation when treated with costochondral graft; patient motivation; and aggressive physiotherapy, and use of a vacuum drain are all important to prevent re-ankylosis, irrespective of the treatment modality. A total of 114 patients (n=152 joints), [bilateral (n=38), unilateral (n=76)] were evaluated retrospectively. Interpositional arthroplasty with fat was performed in n=43, CCG was used for reconstruction in n=30 and total joint replacement (TJR) was done in n=41 patients. Re-ankylosis was seen in n=3 (2.6%) patients (2 in CCG and 1 patient in interpositional arthroplasty). The follow-up ranged from 12-80 months. The results conclude that following the suggested best practice protocol is effective in reducing re-ankylosis.

Can costochondral grafts fulfil ramus-condyle unit reconstruction goals in children with temporomandibular joint ankylosis?

The purpose of this study was to analyse whether costochondral grafts (CCG) fulfil temporomandibular joint (TMJ) reconstructive goals in children with TMJ ankylosis. A total of 23 patients (12 male, 11 female, aged 3-16 years) with unilateral or bilateral TMJ ankylosis operated on between January 2014 to April 2018 were included in the study. Maximal incisal opening (MIO), frequency of reankylosis, and growth of CCG, were evaluated at one month and six months for one year, and after that once yearly. Mouth opening changes with time were assessed by the Friedman test and growth was compared at follow up and analysed using the paired t test. Mean (range) follow up was 18 (12-48) months. Study results revealed follow up MIO at 12 months was highly significant (p=0.001). Out of 27 CCG studied, only one graft had undergone re-ankylosis. Based on the predetermined criteria using condylion to gnathion (Co-Gn) measurement in the posteroanterior cephalogram, CCG were categorised into optimum, sub-optimum, and overgrowth. However, long-standing TMJ ankylosis cases still displayed mandibular asymmetry at the end of the study, even with "optimal growth" radiographically. Overall comparison between the immediate postoperative and last follow up Co-Gn measurements in either unilateral or bilateral cases was not significant. CCG with functional matrix maintained the growth of the mandible and MIO in TMJ ankylosis. It can be concluded that CCG partially fulfils reconstructive goals; however, patients need to be followed up till the end of puberty for a substantive conclusion.

Autologous costochondral graft harvest in children

INTRODUCTION

Autologous costochondral grafting is a commonly employed technique in pediatric otolaryngology for reconstructing a cartilaginous or bony structure, such as the trachea, larynx, nose or mandible by harvesting rib cartilage or bone from the same patient. Complications include infection, pneumothorax, hematoma, scarring, and pleural leak, and the literature regarding these complication rates in pediatric patients undergoing this procedure is sparse. The objective of this study was to determine the donor site complication rate associated with rib graft harvest procedures performed by pediatric otolaryngologists in infants and children and to compare this to established complication rates reported in adults.

METHODS

A retrospective cohort study was performed, examing the charts of 33 patients who underwent airway, mandible, nose, or external ear reconstruction by means of autologous rib grafting between 2010 and 2018 at an urban tertiary medical center in Boston, Massachusetts. All patients were under the age of 18 years old and had undergone rib harvest and subsequent airway, mandible, nose, or external ear reconstruction by two pediatric otolaryngologists.

RESULTS

Of these, 20 were female and 13 were male, with a mean age of 2.5 years at date of surgery. No patients were excluded. A total of 41 costochondral graft harvests from a total of 36 incision sites were included. Pooled donor site complication incidences were 1 intraoperative pleural leak (2.8%) and 1 incision site infection (2.8%). Drains were not utilized postoperatively; there were no incidences of postoperative hematoma or seroma. No outside specialty consults were necessary to manage these. There were 2 instances of hypertrophic scarring, both developing in patients who underwent skin excisions for skin graft harvest or scar excision from the same incision used for graft harvest (5.6%).

CONCLUSIONS AND RELEVANCE

Autologous rib grafting amounts to a simple, extrapleural chest wall procedure, which may be safely performed in children by pediatric otolaryngologists with acceptably low complication rates.

Remodeling of Neocondyle

Temporomandibular joint (TMJ) ankylosis in children is one of the most complex and challenging problems managed by oral and maxillofacial surgeons. TMJ ankylosis in growing children often leads to facial deformity, difficulty in chewing and swallowing, severe malocclusion, poor oral hygiene, multiple decayed teeth, and impairment of speech. A good functional and esthetic outcome can be achieved after reconstruction with the autogenous grafts. Here, we present a case of a 9-year-old patient treated with condylectomy and ipsilateral coronoidectomy, followed by reconstruction with costochondral graft with 5 years of follow-up. During this period, the reconstructed graft remodeled into a neocondyle and also regrowth of the coronoid process. The mouth opening and facial symmetry were acceptable.

Combined correction of the nasal tip and upper lip in bilateral cleft lip patients: A novel approach

Secondary nasal deformity in bilateral cleft lip is one of the great surgical challenges. The problems are an under projected tip, an infra-tip lobule merging with the pro-labium and a short columella. Upper lip vermillion border deformity is a further significant problem. We demonstrate our novel approach to management by classifying patients into 3 groups depending on the status of important features such as the anatomy of the prolabial skin island, length of columella and upper lip width and fullness. We demonstrate that cleft patients with nasal deformity and poor upper lip aesthetics can be managed with a single operation.

Sternoclavicular Graft Versus Costochondral Graft In Reconstruction of Ankylosed Temporomandibular Joint

Introduction

The temporo-mandibular joint (TMJ) is a complex anatomical structure that is concerned with mastication, deglutition, and speech. Ankylosis of the TMJ occurs when the condyle gets fused to glenoid fossa by bony or fibrous tissue. It is an incapacitating problem, commonly occurring in children and is usually associated with trauma or infection.

Materials and Methods

A total of ten patients with written informed consent having TMJ ankylosis (unilateral/bilateral) fulfilling the inclusion criteria were selected for the study and were operated under general anaesthesia with arthrectomy followed by reconstruction of ramal condylar unit with SCG (Group I) or CCG (Group II). Pre-operative and post-operative evaluation assessments were done at regular intervals for maximum mouth opening, range of mandibular movements, and height of ramus.

Results

Statistical analysis shows that the increase in maximum mouth opening was found 1.1% higher in Group II (75.9%) as compared to Group I (74.9%). The increase in lateral excursion at affected side was found 1.3% higher in Group I (84.6%) as compared to Group II (83.3%). The increase in lateral excursion at non-affected side was found 10.3% higher in Group I (76.9%) as compared to Group II (66.7%). The increase in protrusive movement was found 17.5% higher in Group II (88.9%) as compared to Group I (71.4%). Six months post-operative height of ramus was found 10.5% higher in Group II as compared to Group I.

Conclusion

The present study concludes the superiority of costochondral graft over sternoclavicular graft in terms of growth and function. Continued deliberation between the two grafts with larger sample size and a longer follow-up with multicentric consensus will be required to draw definitive indications of the two grafts.

Costochondral Graft Versus Total Alloplastic Joint for Temporomandibular Joint Reconstruction

Presently, there are 2 options for the replacement of the temporomandibular joint for end-stage pathology: autogenous bone grafting or alloplastic joint replacement. This article presents evidence-based advantages and disadvantages for each of these management options to assist both surgeons and their patients in making that choice.

Primary aesthetic correction of nasal anomaly with costal graft in treating orbital hypertelorism

Orbital hypertelorism is a common congenital craniofacial anomaly in Asians. As Tessier pointed out, the correction of hypertelorism is effectively the correction of the nasal deformity, which is characterized by a broad, flat nose accompanying an increased interorbital distance and a lack of nasal projection.

OBJECTIVES

To measure the changes in the orbital and nasal parameters after Tessier box osteotomy and primary aesthetic rhinoplasty, performed concurrently with otogenous costochondral graft.

METHODS

From 2009 to 2013, 49 hypertelorism patients were treated in our craniofacial unit. Correction involved a classic Tessier box osteotomy combined with aesthetic augmentation and reconstruction of the nasal dorsum using a costochondral graft. All patients underwent photographic and tomographic documentation both before and 12 months after surgery. Patients underwent morphometric analysis to document the change in interorbital distance, IOD, hypertelorism index, and aesthetic nasal parameters, including the nasal dorsum and alar width, the nasal dorsal height, and the index of nasal apex protrusion versus nasal length.

RESULTS

All patients were satisfied with the outcome of the combined orbital and nasal repair. Morphometric analysis indicated that the IOD, hypertelorism index, and aesthetic nasal parameters all improved following surgery. The resorption rate of the costochondral graft was 16-19%, and graft warpage was nearly absent. Although complications included infection, cerebrospinal fluid leak, and hyposomia, no severe or life-threatening complications occurred.

CONCLUSION

Tessier box osteotomy with primary aesthetic rhinoplasty using costochondral grafts has shown to be efficacious in the treatment of patients with hypertelorism.

Management of facial asymmetry due to overgrowing costochondral graft: A case report

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Costochondral grafts are the gold standard in TMJ replacement in growing patients.

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On occasion, growth in these grafts can sometimes be unpredictable, resulting in facial asymmetry.

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Careful surgical planning is required to ensure that correction of facial asymmetry does not affect the long term function of the temporomandibular joint.

Costochondral grafts are used to replace the mandibular condyle in cases of TMJ ankylosis, and are generally viewed as a gold standard for autogenous reconstruction of the mandibular condyle (Güven, 2000; Posnick and Goldstein, 1993 [1,2]). We report a case where overgrowth of costochondral grafts is seen, resulting in asymmetric mandibular growth and dentofacial asymmetry (Posnick and Goldstein, 1993 [2]).

A 17 year old male patient presented with an existing costochondral graft performed due to TMJ ankylosis during childhood. He fell from a height at the age of 4, and was lost to follow up through non-attendance until the age of 9, when he presented with a progressive reduction in maximal incisal opening (MIO).

At this stage his maximal incisal opening was noted to be 11 mm, and the CT showed a grossly deformed ankylosed left TMJ. This post traumatic ankyloses was managed with gap arthroplasty and costochondral graft reconstruction. This immediately improved his MIO to 22 mm and at 1 year follow up was noted to be 30 mm.

At age 12 he was noted to have a clinically obvious overgrowth of the left ramus of the mandible, and deviation of the chin point to the right. MIO remained at 38 mm.

He declined orthognathic surgery and represented 2 years later requesting treatment without orthodontic intervention for his facial asymmetry. He subsequently underwent a Le Fort 1 impaction osteotomy, right BSSO and left condylar ostectomy, coronoidectomy and left lower border mandibulectomy. Regrowth of the CCG occurred during the 6 months of follow up.

This case illustrates the problems that can occur after condylar trauma. It also highlights issues with costochondral grafts which can continue to grow.

Coronoid process and residual ankylotic mass as an autograft in the management of ankylosis of the temporomandibular joint in young adolescent patients: a retrospective clinical investigation

The aim of this non-randomised investigation was to assess the feasibility of using autogenous grafts (such as coronoid process and the resected ankylotic mass) in reconstruction of the condyle after gap arthroplasty for ankylosis of the temporomandibular joint (TMJ). Sixteen patients (23 joints) operated on between 2007 and 2009 were studied and postoperative measurements of maximum interincisal opening, bite force, range of movement, and infection were recorded. After a mean (SD) follow up of 55 (2.25) months mouth opening improved from 3 (3.84) mm to 33 (1.66) mm in patients treated with coronoid graft, while in patients treated with an ankylotic mass after a mean (SD) follow up of 58 (1.58) months it increased from 4 (2.64) mm to 26 (8.04) mm. Bite force six months postoperatively ranged from 18.25kg/cm(2) - 27.5kg/cm(2) after reconstruction with the coronoid process and 18.5kg/cm(2) - 23.25kg/cm(2) after reconstruction with the ankylotic mass. One patient developed reankylosis postoperatively and another developed infection, in both of which the ankylotic mass had been used. Both were managed successfully. Both the ankylotic mass and the coronoid process gave satisfactory results and seem to be options for reconstruction. However, the coronoid process graft was better than residual ankylotic mass in terms of masticatory efficiency, bite force, and range of movement.

Computer-aided resection and reconstruction in a case of aneurysmal bone cyst of the mandibular condylar head

A case is presented of a 16-year-old girl with an aneurysmal bone cyst (ABC) of the mandibular condyle of the temporomandibular joint (TMJ). This lesion rarely involves the mandibular condyle, and involvement of condylar head is even rarer. To our knowledge, only 12 cases have been reported in the literature so far. This is the first case of ABC of the mandibular condyle with 3D planning of costochondral graft reconstruction described in the literature.

Costochondral Graft as Interpositional material for TMJ Ankylosis in Children: A Clinical Study

ABSTRACT

TMJ ankylosis is one of the most disruptive anomaly that affects the masticatory system. The inability to move the mandible has significant functional ramification, such as the inability to eat a normal diet. Additionally, speech is affected, making it difficult for some individuals to communicate and express themselves to others. As there are several biologic and anatomic similarities to the mandibular condyles, autogenous costochondral grafts have been considered to be the most acceptable tissue for temporomandibular joint reconstruction. In addition donor site complications are infrequent and regeneration of the rib usually occurs within a year post operatively in children.

AIM

The aim of this study was to evaluate the function of costochondral grafts to replace the mandibular condyles and to assess the position, growth, overgrowth, function, success, failure and resorption of costochondral grafts.

MATERIALS AND METHODS

Ten TMJ ankylosis patients were operated in the Department of Oral and Maxillofacial Surgery at Institute of Dental Sciences, Bareilly. Out of the 10 cases 6 were male patients and 4 female patients in age group of ≤14 years; of which 8 patients were of unilateral TMJ ankylosis and 2 were of bilateral TMJ ankylosis. All ten patients underwent interpositional gap arthroplasty with reconstruction of the condyle by costochondral graft.

RESULTS

All patients with costochondral grafts had improved mandibular symmetry and growth with adequate mouth opening.

CONCLUSION

This study indicates that using costochondral grafts to reconstruct TMJ ankylosis in children provides a good result.

Tenosynovial, diffuse type giant cell tumor of the temporomandibular joint, diagnosis and management of a rare tumor

The purpose of this paper was to describe a rare unusual case of primary mandibular condylar tenosynovial giant cell tumor of diffuse type with predominantly intraosseous growth and its management by resection and functional reconstruction with a vascularized costochondral graft. Clinical presentation was swelling in the right condylar area and limited mouth opening with radiological evidence of central bone destruction and magnetic resonance imaging showed central hemosiderin deposition. Fine needle aspiration did not lead to a diagnosis and an open biopsy had to be performed. Management consisted of tumor resection and reconstruction with a free vascularized costochondral graft. Tenosynovial diffuse type giant cell tumor of the temporomandibular joint is very rare. Complete resection leads to a low recurrence rate and reconstruction with a costochondral free vascularized flap leads to an excellent functional outcome.

Late reconstruction of condylar neck and head fractures

Condyle fractures are a common injury, but only a few of these injuries require immediate or late reconstruction. The complications that most frequently necessitate condylar reconstruction include proximal segment degeneration, malunion, and ankylosis. Costochondral grafts and total joint prostheses, both stock and custom, remain the most common methods of reconstruction. Reconstruction plates with condylar extensions should only be used temporarily as an unacceptable number cause serious complications. Distraction osteogenesis may have an occasional role in reconstructing the posttraumatic condyle.

Alloplastic or autogenous reconstruction of the TMJ

Reconstruction of the irreparably damaged temporomandibular joint (TMJ) is dependent on the cause of damage and the patient's age. In childhood the current preference is for autogenous reconstruction which can potentially "grow" with the child. This is either with soft tissue interposition (temporalis fascial interposition), local osteotomy, distraction osteogenesis, non-vascularised tissue (costochondral, sternoclavicular) or vascularised tissue (second metatarsal). Current debate centres around the possibility of alloplastic reconstruction particularly where autogenous tissue has failed. The resultant failure of growth - if this occurs, can be dealt with in late adolescence with either osteotomy, distraction osteogenesis or replacement of the condylar component of the prosthesis. In the adult the choice is currently in favour of alloplastic reconstruction as this gives a more stable long term result and facilitates early mobilisation. Initial cost is clearly an issue, but when weighted against the reduced length of stay and reduced morbidity, often the costs are equivalent in the short term and come to benefit alloplasts in the medium term. Their long term outcomes beyond 15 years are however not clear.

A long-term evaluation of 150 costochondral nasal grafts

INTRODUCTION

This paper reviewed the outcome of cantilevered costochondral grafts used for dorsal nasal augmentation in the management of patients treated at the Australian Craniofacial Unit (ACFU), Adelaide over a 29-year period.

MATERIALS AND METHODS

All patients undergoing dorsal nasal augmentation with costochondral grafts as part of their craniofacial management between 1981 and 2009 were identified using the ACFU database, and their medical notes were reviewed.

RESULTS

107 patients (50 M, 57 F), with a mean age of 12.3 years (range: 2-62 years) and requiring a total of 150 costochondral grafts, were identified from the departmental database. Mean follow-up after nasal augmentation was 5.6 years (1 month-31.5 years). 46% of the patients were diagnosed with Binder syndrome/Chondrodysplasia punctata; other diagnoses included Tessier midline clefts, cleft lip and palate and frontonasal dysplasia. A dorsal midline incision (49%) was the commonest method of access, with 84% of patients having mini-screw fixation for graft stabilisation. Complications included screw palpability, infection, skin necrosis and graft fracture. The commonest reasons for a replacement graft were graft atrophy and fracture, infection and persistent deformity.

CONCLUSION

Cantilevered nasal costochondral grafting is an excellent technique for improving nasal contour and function in a wide variety of clinical situations.

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.

Plexiform ameloblastoma

The ameloblastoma is a benign but aggressive neoplasm of odontogenic origin. However, no enamel or hard tissue is formed by the tumor cells. Ameloblastomas are infamous for their invasive growth and their tendency to recur. Robinson (1937) as a benign tumor that is ‘usually unicentric, nonfunctional, intermittent in growth, anatomically benign and clinically persistent.’ They may occur at any age, even though nearly half of the tumors do occur between the ages of 20 and 40 years. This is the most common neoplasm affecting the jaws, yet only accounts for 1% of all tumors of the maxilla and mandible and 11% of all odontogenic tumors.

This report presents a case of ameloblastoma involving entire ramus and part of body of mandible with resorption of the mesial and distal root apices of second molar and distal root of mandibular first molar. The lesion extending till the base of mandible surrounding the crown of the unerupted third molar resembling the dentigerous cyst. This was surgically resected followed by harvesting the contralateral sixth costochondral rib graft.

How to cite this article: Celur S, Babu KS. Plexiform Ameloblastoma. Int J Clin Pediatr Dent 2012;5(1):78-83.