The role of muscle grafts in temporomandibular joint ankylosis: short-term experimental study in sheep

The temporalis muscle flap can be used as an inter-positional graft placed into a gap arthroplasty site in temporomandibular joint (TMJ) ankylosis. The purpose of this study was to investigate the role of the muscle graft in sheep. Five pure-bred adult Merino sheep were used and ankylosis was induced in all right TMJs. At 3 months, the ankylosis was released by gap arthroplasty and reconstructed with a masseter muscle graft, because the temporalis muscle is short and poorly vasculized in sheep. The sheep were killed at 3 months after muscle grafting. The maximal mouth opening was recorded before and after operation and at death. The joints were examined radiologically and histologically. In 4 sheep mouth opening remained at the pre-operative level. A clear radiolucent space remained between the smooth temporal and ramus stumps. Histologically, the muscle graft remained vital but with some fibrous tissue formation between the bone ends. One sheep developed an infection at the operative site following the muscle graft; this partly resolved with antibiotics, but the TMJ developed a fibrous reankylosis that was demonstrated clinically, radiologically and histologically. These results indicate that an uncomplicated temporalis muscle graft reconstruction with gap arthroplasty is a successful and stable procedure in human TMJ ankylosis.     

The effect of autogenous costochondral grafts on temporomandibular joint fibrous and bony ankylosis: A preliminary experimental study.

PURPOSE: The purpose of this study was to test the functional and histologic fate of costochondral grafts (CG) in temporomandibular joint (TMJ) reconstruction for unilateral ankylosis in the sheep. MATERIALS AND METHODS: Five pure-bred adult Merino sheep were used. Ankylosis was induced by articular damage, disc removal, and placement of a bone graft. At 3 months, a gap arthroplasty was performed with a CG from the thirteenth rib. The sheep were sacrificed 3 months after CG reconstruction. The range of jaw movements were recorded at first operation, at lysis of ankylosis, and at sacrifice. The joints were examined radiologically, macroscopically, and histologically. RESULTS: All sheep showed a decrease in masticatory function, as shown by weight loss and decreased jaw opening, during the ankylosis period. On release, they regained weight and increased the range of jaw movement. Histologically, the joint space was filled with fibrous tissue. However, the partial spaces around the CG head were covered by fibrous tissue and/or fibrous cartilage. CONCLUSIONS: This study shows that, when CGs are used with a gap arthroplasty in a fibrous and bony ankylosed TMJ, masticatory function is restored.     

Autogenous auricular cartilage graft in temporomandibular joint ankylosis—an evaluation

Purpose

Recurrence is a major problem after release of temporomandibular joint (TMJ) ankylosis. The purpose of this study was to evaluate the use of autogenous auricular cartilage graft as an interposition material after arthroplasty for TMJ ankylosis.

Materials and methods

Ten patients (M?=?4; F?=?6) with TMJ ankylosis were treated with autogenous auricular cartilage graft interposition arthroplasty. Minimal follow-up was 2 years. The possible reasons for ankylosis and pre- and postoperative mouth opening at final follow-up were recorded.

Results

There was a single case of bilateral ankylosis, and a total of 11 joints were operated. The cause of ankylosis could be traced to trauma (n?=?7) and ear infection (n?=?3). The ages at operation ranged from 6 to 23 years. Postoperative mouth opening was satisfactory in all patients except one in whom relapse occurred. No donor site deformity was observed in any of the patients.

Conclusion

Autogenous auricular cartilage graft is a good interposition material for successful treatment of TMJ ankylosis.     

Sliding reconstruction of the condyle using posterior border of mandibular ramus in patients with temporomandibular joint ankylosis

The traditional approach for ankylosis is gap arthroplasty or interpositional arthroplasty followed by reconstruction of the condyle using, for example, costochondral grafts. As these are non-pedicled grafts, there is eventual resorption with subsequent decrease in height of the ramus, facial asymmetry and deviated mouth opening. The authors have applied the method of total and partial sliding vertical osteotomy on the posterior border of the mandibular ramus for reconstruction of the mandible condyle as a pedicled graft for the correction of temporomandibular joint (TMJ) ankylosis. From 2004 to 2008, 18 patients who were diagnosed with TMJ ankylosis underwent operations for resection of the ankylosed condyle. Two methods were performed depending on the level of osteotomy on the posterior part of the mandibular ramus. All patients were followed-up for an average of 36 months (range 24-48 months). All patients showed apparent improved joint function with no cases of re-ankylosis. The results showed that sliding vertical osteotomy on the posterior border of the mandibular ramus seems to be an alternative and promising method for condylar reconstruction in patients with TMJ bony ankylosis.     

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.     

A clinical study on ankylosis of the temporomandibular joint.

INTRODUCTION: Restoration of normal function and jaw movement in patients with temporomandibular joint (TMJ) ankylosis is difficult. Various techniques have been defined for the treatment of the condition. PATIENTS: This study is based on the pre-, intra- and post-operative evaluation of 78 TMJ operations in 59 patients who were treated for TMJ ankylosis between 1985 and 2002. METHODS: The patients in this study were evaluated with regard to age, gender, aetiology of ankylosis, ankylosis type/classification, existing facial asymmetry, maximal pre- and post-operative mouth opening, the arthroplasty methods (gap and interpositional arthroplasty) including complications and recurrence of ankylosis. RESULTS: Falls represented the most widespread aetiological factor (85%), and women constituted the group with the highest incidence of ankylosis (61%). Forty cases were unilateral (68%) and 19 bilateral (32%); 82% (64 joints) were of the bony type. Gap arthroplasty was applied in 34 of the 59 cases (58%) and interpositional arthroplasty in the remaining 25 (42%). Pre- and post-operative mean mouth opening were 3.5+/-1.7 and 30.7+/-3.0mm, respectively. Re-ankylosis was noted in 5%. CONCLUSION: In addition to radical and sufficient resection of the ankylosed bone, early post-operative exercises, appropriate physiotherapy and close follow-up of the patient play an important role in the prevention of post-operative adhesions and re-ankylosis.     

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。     

The effect of gap arthroplasty on temporomandibular joint ankylosis: an experimental study.

The aim of this study was to demonstrate the functional and anatomical changes after gap arthroplasty release of unilateral temporomandibular joint (TMJ) ankylosis. Five adult sheep weighing an average of 57 kg were used. All right joints were operated. Ankylosis was induced in the right TMJ by articular damage, disk removal and placement of a bone graft plus immobilization wire. At 3 months the gap arthroplasty were performed. All TMJs were examined functionally, radiologically, macroscopically and histologically. Functionally, the range of jaw movements decreased following induction of ankylosis (P<0.0001), increased immediately on release but was reduced again at 3 months after release (the vertical movement, no statistically significant difference; the right movement, P<0.001; the left movement, P<0.0001). Histologically, all operated joints showed fibrous adhesions across the gap, and further, the articular surface was irregular with osteophytes and with bony islands in the gap. This appearance is more consistent with a fibrous reankylosis than a functioning pseudo joint. This study shows that the gap arthroplasty for TMJ ankylosis did not restore the TMJ functionally and histologically to the preexisting state.     

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。     

Management of recurrent ankylosis in arthrogryposis: new solutions to a rare problem

Arthrogryposis is a rare condition that comprises contracture of the joints, muscular weakness, and fibrosis. Restricted mouth opening caused by coronoid hyperplasia has been reported but to our knowledge, ankylosis of the temporomandibular joint (TMJ) has not. Standard management of ankylosis includes creation of a gap arthroplasty and possible reconstruction with autogenous or alloplastic materials. We describe management of a patient with arthrogryposis who developed ankylosis for a second time after satisfactory gap arthroplasty and total replacement of the TMJ with a custom-made prosthesis. The original prosthesis was removed, the ankylosis resected, and the prosthesis replaced. This has given an excellent outcome at 12 months.     

创伤性颞下颌关节强直的病程特点与分类治疗

目的调查创伤性颞下颌关节强直（TMJA）的髁突骨折类型及病程特点；探讨各分类治疗方法及疗效。方法31例42侧创伤性TMJA，按Sawhney分类分成4型。Ⅰ型和Ⅱ型强直分别行关节松解和融合骨切除术＋关节盘复位术；Ⅲ型和Ⅳ型强直分别行全关节切除和全关节扩大切除术＋颞肌筋膜瓣衬垫术、选择性下颌支后缘垂直骨牵引及颏成形术。术后复查9～54个月（平均30个月），评价治疗效果。回顾调查引起强直的髁突骨折类型和强直发生的过程。手术与CT及MRI对照观察早期骨化部位、关节盘移位和关节残余运动方式。结果创伤性TMJA均继发于髁突矢状和粉碎性骨折，且关节盘发生移位者。I型（纤维性）强直通常出现在伤后4～5个月，平均张口度18．3mm。术中探及的关节盘全部发生移位，早期强直骨化发生在无关节盘区域。随诊期内，2例（6．45％）复发，其他患者张口度均稳定维持在30mm以上。结论髁突矢状和粉碎性骨折是最容易导致关节强直的骨折类型。关节盘移位是强直形成的重要因素。早期手术可以复位关节盘，避免后期强直时必须切除全关节。     

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.     

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 modalities of TMJ ankylosis: experience in Delta Nile,Egypt

The study reports the authors’ experience in managing TMJ ankylosis in Delta Nile, Egypt (1995–2006) and compares the surgical modalities used. 101 patients (109 joints) were reviewed in this retrospective study. Pre- and postoperative assessment included history, radiological and physical examination, and mouth opening. Age, sex, aetiology, joint(s) affected, surgical modality, complications and follow up periods were evaluated. Various types (fibrous, fibro-osseous and bony) of TMJ ankylosis were diagnosed; trauma was the commonest aetiology. The patients’ age range was 2–41 years, 62% were female, and the follow up period ranged from 14 to 96 months. Average mouth opening was significantly increased from 5.3 mm pre-operatively to 32.9 mm 12 months postoperatively (P = 0.0001). Marked improvement in mouth opening was documented when the ramus-joint complex was reconstructed using distraction osteogenesis (34.7 mm), costochondral graft (34.4 mm) and Surgibone (34.6 mm). Gap arthroplasty showed least satisfactory mouth opening compared with other techniques (P = 0.001). Minor and major complications were encountered in 33% of cases, including 5% 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 successful for managing TMJ ankylosis.     

Lateral Thigh Fascia Lata as Interpositional Graft for Temporomandibular Joint Ankylosis

Successful management of temporomandibular joint (TMJ) ankylosis depends on adequate gap arthroplasty and interpositional graft; the objective is to produce a functioning pseudoarthrosis that prevents reankylosis and provides adequate mobility. Several interpositional grafts have been used for the treatment of temporomandibular joint ankylosis such as indigenous pterygomasseteric sling, temporalis muscle/fascia, auricular cartilage, fat and dermis-fat. Lateral thigh fascia lata (LTFL) graft is commonly used in neurosurgical practice and in other surgical specialities. We present a case of lateral thigh fascia lata used as interpositional graft for the treatment of a unilateral fibrous temporomandibular joint ankylosis.     

自体耳廓软骨瓣置换或重建颞下颌关节盘——临床疗效评价

目的　为了对己严重病变的关节盘进行置换及对关节强直进行重建关节盘 ,本文报道耳廓软骨移植的手术方法和临床疗效 ,并结合文献报道中的有关资料进行讨论。方法　对 4侧结构紊乱、4侧骨关节病、2侧滑膜软骨瘤病及 3侧关节强直 ,共 13侧颞下颌关节 ,用自体耳廓软骨瓣置换或重建关节盘 ,其中 ,6例合并应用关节刨削术 ,2侧用颞深筋膜瓣重建关节外侧囊 ,1侧耳廓软骨瓣复合颞深筋膜修复关节盘以获得足够的厚度。结果　随访期 1～ 13月 ,所有软骨瓣无感染 ,均成活 ,临床疗效满意 ,供区无或轻微变形。结论　在形态和厚度方面 ,人类的耳廓软骨瓣与关节盘较相似 ,是一种置换或重建关节盘的较好材料     

Piezoelectric osteoarthrectomy for management of ankylosis of the temporomandibular joint

We describe the use of a piezoelectric osteotome for removal of bone in patients with ankylosis of the temporomandibular joint (TMJ) and its advantages over conventional techniques. We studied 35 patients with ankylosis of 62 TMJ (27 bilateral and 8 unilateral, 2 recurrent) who were treated by gap arthroplasty between 1 January 2011 and 31 December 2012. We used a preauricular, with extended temporal, incision in all cases. The ankylosis was released with a piezoelectric scalpel. There were 23 men and 12 women, mean (SD) age 16 (9) years. We noticed a substantial reduction in bleeding with the piezoelectric bone cutter compared with the dental drill, though the operating time was longer. We noticed no bleeding from the maxillary artery or pterygoid plexus. Mean (SD) bleeding/side was 43 (5) ml, and mean (SD) operating time was 77 (8) minutes for a single joint. At 6 months’ follow-up mean (SD) passive mouth opening was 35 (3) mm. Piezoelectric bone removal for the release of ankylosis of the TMJ is associated with minimal bleeding, few postoperative complications, and satisfactory mouth opening at 6 months’ follow up.     

Ramus Condyle Unit Reconstruction Using Vertical Ramus Osteotomy in Temporomandibular Joint Ankylosis

Introduction

Treatment of bony Temporomandibular Joint (TMJ) Ankylosis includes release of the ankylosis and creation of a gap with or without insertion of interposing material and complete reconstruction of the joint using e.g. costochondral, autogenous coronoid/ankylosed mass, sternoclavicular, clavicular bone grafts etc. As these are non-pedicled grafts, there is eventual resorption with subsequent decrease in height of the ramus, facial asymmetry, deviated mouth opening and reankylosis. The authors have applied the method of vertical ramus osteotomy (VRO) on the posterior border of the mandibular ramus for reconstruction of the ramus condyle unit (RCU) as a pedicled graft along with Myofascial Temporalis Interposition for the correction of TMJ Ankylosis.

Materials and methods

Ten patients of TMJ Ankylosis were included in this study. All ten patients were treated using VRO for the RCU reconstruction with posterior border of mandibular ramus after Gap Arthroplasty. Temporalis myofascial flap was used as an interpositional material in all patients. Patients were followed from 20 to 30 months (mean 24 months).

Results

As a result of successful procedure the post-operative maximal mouth opening of 32–45 mm (mean 37 mm) was achieved. No patient experienced pain and infection at surgical site. None of the patients had graft rejection and reankylosis at follow-up.

Conclusion

The results showed that VRO on the posterior border of the mandibular ramus seems to be an alternative and promising method for RCU reconstruction in patients with TMJ Ankylosis.     

Intraoral approach for arthroplasty for correction of TMJ ankylosis

This study evaluates the authors’ technique using the intraoral approach for the management of temporomandibular joint (TMJ) ankylosis. The technique was used on 16 TMJs in 14 patients with a mean age of 28.5 years; their average postoperative mouth-opening was 33.7 mm. All the patients had Sawhney's type IV TMJ ankylosis except a child with type I. One patient had recurrent ankylosis and was managed using the same intraoral approach again. Average follow-up was 56 months. The protocol consists of interpositional arthroplasty via an intraoral approach and aggressive mouth-opening exercises. An intraoral incision is made over the buccal shelf and the soft tissue of the mandibular ramus reflected. Osteotomy is carried out at the coronoid process and adequate osteotomy is accomplished at the level of the condylar neck. Adequate gap osteotomy at the ankylosed condyle is performed and followed by placement of the interpositional material, such as rib cartilage, masseter, buccal fat pad and costochondral graft. The wound is then closed meticulously. The advantages of this intraoral approach are excellent cosmetic appearance with no facial scar, lower risk of injury to the facial nerve or auriculotemporal nerve and no salivary fistula formation.     

Is dermis fat arthroplasty better than plain gap arthroplasty? A prospective randomised controlled trial

The aim of the study was to compare interpositional arthroplasty using a dermis fat graft with gap arthroplasty in the management of ankylosis of the temporomandibular joint (TMJ). We organised a prospective randomised study of 22 patients who presented with ankylosis of the TMJ. They were randomised to be treated with either plain gap arthroplasty or dermis fat arthroplasty, and the predictor variable was the method of treatment. The primary outcome variables were mouth opening and pain on jaw exercises. Pain and interincisal opening were measured on day 5, day 14, at the end of one month, and at six months, one year, two years, and three years. There was a significant difference between the two groups on two occasions: postoperative day 5 (p = 0.013) and at one year (p = 0.018). The mean (SD) scores for mouth-opening were higher in the dermis fat group at all times (41.20 (4.69) mm compared with 39.50 (2.46) mm in gap arthroplasty at two years, and 41.40 (3.60) mm compared with 38.9 (2.02) mm at three years). The visual analogue pain scores were also lower in the dermis fat graft group. The groups showed similar results at the end of three years follow up, with no significant difference in mouth opening. We conclude therefore that the two techniques have similar outcomes in the management of ankylosis of the TMJ.