Interpositional arthroplasty for ankylosis of the temporomandibular joint

The relevant literature relating to the etiology and treatment of intra-articular ankylosis of the temporomandibular joint is reviewed, and three cases of ankylosis (one unilateral and two bilateral) are reported. Two of these occurred subsequent to trauma, while the other was a manifestation of severe ankylosing spondylitis. They were successfully treated by interpositional arthroplasty with silicone rubber tubing.     

Interpositional arthroplasty of post-traumatic temporomandibular joint ankylosis: A modified method

The purpose of this study was to evaluate a modified method of interpositional arthroplasty for post-traumatic temporomandibular joint ankylosis.All patients were treated with a modified interpositional arthroplasty that included: navigation-assisted accurate bone dissection with minimal removal of only 5 mm of the ankylosed bony mass, novel application of bone wax and porcine acellular dermal matrix to prevent re-ankylosis, and a unique 3D-printed splint for occlusal stabilization and gap maintaining. The pre- and post-operative physical and radiological examinations of patients were recorded during routine follow-up visits. Postoperative follow-up visits lasted at least 12 months.Twelve patients, seven males and five females, ranging from 21 years to 59 years, were enrolled in this retrospective case series. All of the twelve patients with eighteen bony ankylosed temporomandibular joints were treated by our new method. The post-operative follow-up periods ranged from 1 year to 4 years. During the follow-up visits within at least 1 year, no one manifested re-ankylosis. The mean maximum incisor opening changed from 7.4 ± 5.3 mm (p < 0.001, before surgery) to 37.6 ± 3.9 mm (p < 0.001, last follow-up visit). No sign of post-operative infection or foreign body rejection was observed during the follow-up visits. The post-operative occlusal relationship was sound and stable.It is suggested that the modified method of interpositional arthroplasty provides favorable clinical and radiographic outcomes after a short-term follow up.     

自体冠突移植在颞下颌关节强直关节重建术中的应用

目的：探讨自体冠突移植在颞下颌关节强直关节重建术中的应用及效果。方法：对2008年9月—2010年9月期间收治的9例颞下颌关节强直患者应用自体冠突移植关节重建术式治疗,间隙插补物采用自体关节盘或口腔生物膜,比较术前、术后开口度、咬合情况和锥形束CT检查结果。结果：术后随访12～24个月,术后最大开口度得到明显改善,咬合关系无改变,在随访期内, 所有患者无复发。锥形束CT显示,移植冠突与下颌支骨性愈合,移植的冠突顶端变圆钝,向髁突形态转变。结论：自体冠突移植关节重建术是治疗颞下颌关节强直的有效术式。     

Auricular cartilage graft interposition after temporomandibular joint ankylosis surgery in children.

PURPOSE: After surgery for temporomandibular joint (TMJ) ankylosis, relapse is frequently due to fibrosis and ossification occurring in the space of the joint. The object of this study was to evaluate the use of autogenous auricular cartilage graft as an interposition material after arthroplasty of the TMJ ankylosis. PATIENTS AND METHODS: Seven patients with TMJ ankylosis were treated with autologous auricular cartilage graft interposition arthroplasty. With 4 to 6 years of follow-up, the function of the TMJ was evaluated. RESULTS: In 7 patients with TMJ ankylosis treated with autologous auricular cartilage graft interposition arthroplasty, the function of the TMJ recovered well. At 6-year follow-up, no relapse had occurred and no deformities resulted in the ear from which the cartilage had been harvested. CONCLUSION: Autologous auricular cartilage interposition arthroplasty is an ideal method for the prevention of relapse of TMJ ankylosis.     

三维手术模拟辅助自体喙突移植再造髁突关节成形术

目的研究计算机三维手术模拟系统在利用自体喙突移植再造双侧颞下颌关节强直患者髁突关节成形术中的应用及其临床效果。方法对2007~2009年我院收治的8位双侧颞下颌关节骨性强直患者,利用Surgicase CMF软件行术前设计和三维手术模拟并行相关测量。在相关数据的指导下行双侧强直块切除术、自体喙突游离移植再造髁突。术后行临床检查,放射检查等对骨瓣愈合情况和颞下颌关节功能进行评价。结果术后患者获得良好的开口度与咬合关系。曲面体层X线片示,所有患者的移植喙突位于关节窝内,愈合良好;喙突有一定吸收,但未引起咬合的明显改变。随访期间未有复发患者,无其它明显并发症。结论在自体喙突移植再造双侧颞下颌关节强直患者髁突成形术中应用计算机辅助三维手术模拟系统可以使得手术更加精确和方便,提高了患者的满意度。     

Retrospective comparison of autogenous cosotochondral graft and coronoid process graft in the management of unilateral ankylosis of the temporomandibular joint in adults

We retrospectively compared the clinical outcomes of autogenous coronoid process grafts (n = 32) and costochondral grafts (n = 28) in condylar reconstruction for the treatment of unilateral ankylosis of the temporomandibular joint (TMJ) in adults. Preoperative and postoperative assessments included diet scores, cone-beam computed tomography (CT), maximal interincisal opening, lateral excursion, and mandibular deviation on opening the mouth. There were no significant differences between the 2 groups in the measurements before and after the operation with respect to incisal opening, lateral excursion, mandibular deviation, diet scores, or recurrence rate, but in both the postoperative incisal opening, lateral excursion, and diet scores had improved significantly compared with preoperatively. After costochondral graft 3 patients developed intraoperative plural tears, and 6 had temporary pain at the donor site. The frontal branch of the facial nerve was temporarily affected in 5 patients after costochondral graft and 3 after coronoid process grafts, all of which recovered in 3–6 months. There was no recurrence after coronoid process grafting, and one after costochondral grafting. The clinical outcomes in both groups were satisfactory and comparable. Autogenous coronoid process grafting may therefore be a good alternative for condylar reconstruction in patients with ankylosis of the TMJ.     

自体肋软骨和自体喙突移植在成人单侧颞颌关节强直治疗中的临床效果比较

目的：比较成人单侧颞颌关节强直髁突重建中自体喙突移植和肋软骨移植的临床效果。方法：选取32例自体喙突移植和28例自体肋软骨移植重建髁突的颞下颌关节强直病例,对其术前和术后的饮食分数、最大张口度、侧向运动、开口型偏斜、CT扫描影像学等方面进行评价。结果：两组患者的关节强直治疗均取得满意效果。在饮食分数、张口度、侧向运动、开口型偏斜和复发率等术前及术后的测量值中,两组间差异无统计学意义（P>0．05）,但两组病例中术后张口度、侧向运动及饮食分数均较术前有显著改善。肋软骨移植术中有3例患者出现了胸膜撕裂,6例患者出现了移植骨供区的暂时性疼痛。肋软骨移植及喙突移植术后分别有5例和3例患者的面神经颞支受到了损伤,3－6月内康复。喙突移植组中无关节强直复发,肋软骨移植组中有1例复发。结论：在颞下颌关节强直矫治中,自体喙突移植是一种较好的髁突重建骨移植材料。     

Computer-assisted condylar reconstruction in bilateral ankylosis of the temporomandibular joint using autogenous coronoid process

During the past 10 years, more than 20 patients a year have been treated at our centre for bilateral ankylosis of the temporomandibular joint (TMJ). Here we describe the use of computer-assisted three-dimensional surgical planning and its clinical effects in condylar reconstruction for such patients using autogenous coronoid process. Sixteen patients with bilateral bony ankylosis of the TMJ from March 2006 to March 2009 were randomly divided into 2 groups and treated by bilateral osteoarthrectomy and condylar reconstruction by free grafting of autogenous coronoid process with and without three-dimensional simulation using Surgicase CMF™ (Materialise, Belgium) software. Clinical examination, radiographs, photographs, and details of the operation and its outcome were used postoperatively to evaluate the clinical effects of the technique. Satisfactory mouth opening was achieved in all cases. There were fewer postoperative malocclusions among patients who had three-dimensional simulation. The combination of computer-assisted three-dimensional surgical planning and simulation and free grafting of autogenous coronoid process is a sound and predictable method for the reconstruction of condyles in patients with bilateral ankylosis of the TMJ as it makes the operation easier and more accurate.     

Development of temporomandibular joint ankylosis in rats using stem cells and bone graft

64 male Wistar rats were used: 24 for the removal of stem cells, 4 as a control group, and 36 for the experiment, in which either stem cells or bone graft was used. The rats were divided into groups according to the type of procedure and time span (15, 30 or 60 days). The joints were submitted to histological study in order to score the ankylosis. The mean differences between initial and final maximal mouth opening (MMO) were gradually increased from 15 to 60 days, for all times of evaluation for both groups, being statistically significant at 15 days (p = 0.045) in the bone-graft group. When both groups were compared, the mean differences between initial and final MMO were statistically significant at 15 days (p = 0.018) and 30 days (p = 0.029). In relation to the histological scores, in the bone-graft group almost all animals had intra-articular fibrosis at all times of evaluation (n = 17). In the stem-cell group, there was new bone at 15 days (n = 4), 30 days (n = 3) and 60 days (n = 4). The study model permitted the development of fibrous ankylosis in the majority of animals for both groups and no bony bridge was observed.     

Navigation-guided gap arthroplasty in the treatment of temporomandibular joint ankylosis

Gap arthroplasty, used in the treatment of temporomandibular joint (TMJ) ankylosis, is challenging, requiring resecting of massive abnormal bone formation at the skull base with complex and distorted anatomy. This study evaluated the application of image-guided navigation to gap arthroplasty. Four gap arthroplasties were performed on patients with unilateral TMJ ankylosis under computer-assisted navigation guidance. After preoperative planning and 3-dimensional simulation, the normal anatomic structures of the TMJ were created by superimposing and comparing the unaffected and affected sides. The amount and range of ankylotic bone to be resected was determined and displayed. Registration achieved an accurate match between the intra-operative anatomy and the CT virtual images. Anatomic structures and the position of surgical instruments were shown real time on the screen. In all cases the accuracy of the system measured by the computer did not exceed 1 mm. No complications occurred and the mean minimal thickness of the skull base between middle cranial fossa and reconstructed glenoid fossa was 1.97 mm. Using image-guided navigation resulted in safe surgical excision of the bony ankylosis from the skull base. Navigation-guided resection of the ankylotic bone in the TMJ gap arthroplasty was a valuable and safe technique in this potentially complicated procedure.     

The autogenous dermal graft in temporomandibular joint disc surgery

Repair or replacement of the disc in 58 patients (64 joints) with temporomandibular joint internal derangement was done using an autogenous dermal graft. Long-term follow-up of 3 to 8 years revealed successful elimination of symptoms and restoration of mandibular function in 51 patients (87.9%). The autogenous dermal graft, rather than alloplastic materials, may be the procedure of choice when repair or replacement of the temporomandibular joint disc is indicated.     

Effect of auricular cartilage graft in the surgical treatment of temporomandibular joint ankylosis: An animal study using sheep.

PURPOSE: The purpose of this study was to test the functional and histologic fate of an auricular cartilage graft used in reconstruction of an ankylosed sheep temporomandibular joint (TMJ). MATERIALS AND METHODS: Five sheep were used in this study. TMJ ankylosis was induced in the right joints and the left joints were used as controls. The ankylosed TMJ was released by gap arthroplasty with an interposed auricular cartilage graft at 3 months. The sheep were sacrificed at 3 months after the arthroplasty. The maximal mouth opening was measured pre- and postoperatively. The joints were evaluated radiologically and histologically. RESULTS: Maximal mouth opening was maintained after placement of an auricular graft into the gap arthroplasty. Radiographically the surfaces of the temporal bone and ramus stumps were irregular, but radiolucent gaps were formed between them. Histologically, the auricular cartilage graft was alive and well attached to the mandibular ramus stump. In all operated joints, there was joint space between the grafted cartilage and temporal bone, with the space filled with fibrous connective tissue, which was oriented parallel to the temporal surface. CONCLUSION: Auricular cartilage graft with gap arthroplasty is useful in preventing reankylosis after TMJ gap arthroplasty for ankylosis.     

The interpositional dermis-fat graft in the management of temporomandibular joint ankylosis

The aim of this retrospective clinical study is to present the clinical experience of using dermis-fat interpositional grafts in the surgical management of temporomandibular joint (TMJ) ankylosis in adult patients. Eleven adult patients who presented with ankylosis of the TMJ were identified and included in the study. All patients underwent a TMJ gap arthroplasty which involved the removal of a segment of bone and fibrous tissue between the glenoid fossa and neck of the mandibular condyle. The resultant gap was filled with an autogenous dermis-fat graft procured from the patient's groin. All patients were followed up for a minimum of 2 years. Five of the 11 patients were found to have osseous ankylosis while 6 patients had fibro-osseous ankylosis. Two patients had bilateral TMJ ankylosis that were also treated with costochondral grafts which were overlaid with dermis-fat graft. The average interincisal opening was 15.6 mm on presentation which improved to an average of 35.7 mm following surgery. Patients were followed up from 2 to 6 years post-operatively (mean 41.5 months) with only 1 re-ankylosis identified out of the 13 joints treated. This study found that the use of the autogenous dermis-fat interpositional graft is an effective procedure for the prevention of re-ankylosis up to 6 years following the surgical release of TMJ ankylosis.     

Treatment guidelines for temporomandibular joint ankylosis with secondary dentofacial deformities in adults

Temporomandibular joint (TMJ) ankylosis with secondary dentofacial deformities in adult patients is a severely disfiguring condition and surgical treatment of this disease remains a great clinical challenge. Treatment goals are to restore the joint function, to improve facial appearances and to correct malocclusion, as well as to re-establishing harmony among them. Currently, various surgical techniques, such as arthroplasty with or without interpositional material, orthognathic surgery, distraction osteogenesis, autologous bone or bone replacement materials graft and plastic surgery, have been described in the literature. In most cases these techniques should be used in combination to achieve satisfactory outcomes. The biggest difficulty for most clinicians is to determine the proper sequence of these procedures because no uniform treatment protocol has been established. Based on the published literature and our own clinical experiences, we have prepared this review article to provide some guidelines for the surgical management of TMJ ankylosis with dentofacial deformities in adults, which will be modified and updated periodically to provide the best treatment options to benefit our patients.     

异体肋软骨移植治疗颞下颌关节强直的临床研究

目的:评价应用异体肋软骨移植治疗真性颞下颌关节(TMJ)强直的效果。方法:选择6例颞下颌关节强直患者,经耳前进路,凿除关节区增生、融合的骨质,保持凿开间隙1.0cm。形成的假关节间隙内植入雕刻成型的、经液氮保存的同种异体肋软骨。结果:所有患者术后均未见排异反应发生,随访3年均无关节强直复发,开口度3.0～4.5cm,开口型无明显偏斜,面部外形无明显畸形。结论:同种异体肋软骨移植可以用于TMJ真性强直的治疗,其术后重建的颞下颌关节的功能和患侧面部形态令人满意,但其远期效果有待进一步研究。     

Overgrowth of a costochondral graft in a case of temporomandibular joint ankylosis

Ankylosis of the temporomandibular joint (TMJ) involves fusion of the mandibular condyle to the base of the skull. When it occurs in a child, it can have devastating effects on the future growth and development of the jaws and teeth. Furthermore, in many cases, it has a profoundly negative influence on the psychosocial development of the patient because of the obvious facial deformity. Reconstruction of the mandibular condyle with costochondral grafts(CCGs) in children may result in overgrowth at the reconstructed side of the mandible. The growth pattern of the CCG is extremely unpredictable, and mandibular overgrowth on the grafted site can actually be more troublesome than the lack of growth. We report the case of a 3-year-old boy with temporomandibular ankylosis, which was treated with a CCG. The mandibular condyles and coronoid were resected unilaterally and immediately reconstructed with autogenous CCGs. He required one further resection because the grafted tissue had overgrown 5 years later.