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.     

创伤性颞下颌关节强直

颞下颌关节（TMJ）强直是一种严重影响下颌运动的疾病,创伤是其常见的病因,但创伤如何引起TMJ强直的发生,目前尚未完全阐明,本文就创伤性颞下颌关节强直危险因素、发病机制假说进行综述。     

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颞下颌关节强直是口腔颌面部一类严重的疾病,其临床分型主要依据颞下颌关节骨性融合情况及其周围附属结构受累情况而定。临床针对颞下颌关节强直的治疗主要以手术为主,术后加以功能训练。外科手术治疗颞下颌关节强直的主要途径可以概括为以下三方面：解除关节强直的解剖因素;恢复或重建关节基本结构;对继发畸形的治疗。目前针对以上三方面的多种治疗手段各有利弊,本文将对近年来常用的手术治疗方法予以分类介绍。     

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.     

Quality of life assessment in temporomandibular joint ankylosis patients after interpositional arthroplasty: a prospective study

Temporomandibular joint (TMJ) ankylosis significantly impacts both physical and psychosocial patient wellbeing. A complete evaluation of treatment outcomes necessitates knowing the extent to which a patient’s quality of life (QoL) is impacted. This study was performed to evaluate the impact of TMJ ankylosis on QoL in 25 TMJ ankylosis patients treated by interpositional arthroplasty. The patients completed OHIP-14 and UWQoL questionnaires once before and then at 3 months after the surgery. There was a significant improvement in mean cumulative scores for both questionnaires. With the exception of functional limitation, all OHIP domains showed significant improvement. Preoperatively, the worst scores were found in the psychological distress domain, followed by the social handicap, physical pain and physical disability domains. More than half of the subjects (56%) reported having suicidal thoughts. Amongst the individual UWQoL domains, appearance, chewing, anxiety (P < 0.01), recreation and mood (P < 0.05) showed improved scores. Appearance and chewing were the top ranked priority domains before and after surgery. No significant change was found in speech, taste, sleep, or breathing. Psychosocial factors were found to play a much bigger role than previously thought. The physical, psychological, and social factors were intricately related and dynamically interacted with each other. Surgical treatment produced a definitive QoL improvement in the patients.     

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颞下颌关节强直（temporomandibular joint ankylosis．TMJA）是口腔颌面部常见的疾病,可导致患者开口受限、咀嚼困难等,严重影响患者的身心健康。临床上,TMJA多由创伤引起。因此,创伤性TMJA的发生机制以及如何在临床上预防其发生一直是众所关注的热点和难点。     

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外伤性颞下颌关节强直的手术方法主要有裂隙式关节成形术、插入式关节成形术及关节重建术。如何选择正确的手术方法和理想的插入材料,是手术成功的关键。术后有效的早期开口训练也是改善开口度的重要手段。本文就这些方面的新进展做一综述。     

Clinical investigation of early post-traumatic temporomandibular joint ankylosis and the role of repositioning discs in treatment

This study investigated the development of temporomandibular joint (TMJ) ankylosis after condylar fracture and the functional results of surgery that included repositioning of the articular discs. In a total of 18 patients, there were 13 cases of fibrous ankylosis (type I) and 11 of partial bony ankylosis (type II). CT scans for both groups and MRI scans for type I patients were analysed. Intraoperative inspection of the damaged disc, the sites of adhesion or bony fusion, and remaining intra-articular movement was recorded. After release arthroplasty and repositioning of discs, follow-up was for 1 to 3.5 years (mean 2.2 years). Post-traumatic TMJ ankylosis was highly associated with sagittal and comminuted condylar fractures. Type I ankylosis usually formed in the 4th to 5th month post-trauma with mean interincisal opening distance of 18.3+/-5.5mm. Progression from type I to II ankylosis occurred 1 year post-trauma and caused a reduction of 5mm in the range of mouth opening. The disc was displaced for each of the involved joints, and intra-articular adhesions or ossification initiated at the site where there was no intervening disc present. After surgical repositioning of the disc, stable joint function and mouth opening from 30 to 45 mm were obtained in all patients but one (recurrence due to dislocation). Sagittal and comminuted condylar fractures predispose the TMJ to ankylosis, and the displacement of the articular disc plays a critical role. Early surgical intervention to reposition the disc was successful for early trauma-induced TMJ ankylosis.     

小儿颞颌关节强直手术的麻醉处理

目的 探讨小儿颞下颌关节强直手术的麻醉方法及并发症的防治。方法 31例病人全部经鼻腔盲探插管。结果 麻醉插管成功30例,气管切开1例,全麻诱导与插管期间发生低氧6例,鼻出血2例,导管插入后出现呛咳5例。结论 充分的鼻腔准备和完善的咽喉表面麻醉是经鼻腔插管成功的关健。患者年龄越小麻醉的风险越大,并发症越多。     

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 use of virtual planning and navigation in the treatment of temporomandibular joint ankylosis

Temporomandibular joint ankylosis is not common in our community but can occur as a result of severe facial trauma or significant connective tissue disorders such as rheumatoid arthritis, osteoarthritis and psoriatic arthritis, and unfortunately as a result of iatrogenic causes. Ankylosis surgery is aimed at gap arthroplasty and mobilization of the joints. However, the removal of the bony ankylosis and the production of a gap between the ramus of the mandible and the base of the skull is often difficult because of the size of the ankylosis and the anatomy on the inner aspect of the mandible. As a result of this, the author has found that surgical navigation has been useful with the removal of the ankylosis, both on the medial side of the mandible and the cranial base. Once the ankylosis has been freed and the mandible mobilized, the gap arthroplasty needs to be maintained or the release of the ankylosis will fail and the joints will re‐ankylose. It is important to maintain the space produced by the arthroplasty but this is difficult when autogenous materials such as temporalis muscle, dermis fat and other like materials are used. The gap ultimately closes under the influence of the masseter and medial pterygoid muscles and the ankylosis may return. This case report presents three representative patients in whom ankylosis has been released and the gap reconstructed with a total alloplastic joint replacement. All patients have had their ankylosis removed with the aid of a navigation system and all patients have been reconstructed with bilateral Biomet prosthesis. One patient has had their implant selected using virtual planning and the production of templates to help with placement of the stock implant.     

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目的观察采用下颌升支垂直截骨上推术治疗真性颞颌关节强直的疗效。方法对2004年12月至2008年5月山西医科大学第一临床医院口腔颌面外科收治的19例真性颞颌关节强直患者采用下颌升支垂直截骨上推术治疗,并按期随诊,监测指标,观察其疗效。结果所有患者张口度均接近或达到正常,无关节疼痛及弹响症状,随访期内无一例复发。结论根据国内外文献及术后观察,下颌升支垂直截骨上推术是治疗真性颞颌关节强直的一种可选择的、有效的方法。     

Lemierre syndrome leading to ankylosis of the temporomandibular joint

Lemierre syndrome, also known as Lemierre's disease is a rare condition that was first described by Andre Lemierre in 1936. We present a case of a 3-year-old boy who presented with ankylosis of the right temporomandibular joint (TMJ) secondary to a mastoid infection as part of Lemierre syndrome. His ankylosis resulted in restricted mouth opening, which had a considerable impact on his speech and ability to eat. Surgical treatment comprising right coronoidectomy, gap arthroplasty of the TMJ, and interpositional fat grafting, enabled him to move his jaw and function has returned. This case report highlights the consequences of Lemierre syndrome and the need for clinicians to be aware of its features and the impact it may have on patients.     

Condyle-preserved arthroplasty versus costochondral grafting in paediatric temporomandibular joint ankylosis: a retrospective investigation

We aimed to evaluate results of condyle-preserved arthroplasty and costochondral grafting in growing children with temporomandibular joint ankylosis through medium-term follow-up and three-dimensional metric analysis. We assessed 11 patients (14 sides) with type II ankylosis (group A) and 11 patients (13 sides) with type III/IV (group B) from January 2012 to December 2015. Group A patients received condyle-preserved arthroplasty and group B patients received costochondral grafting. Postoperative computed tomography was used to measure condylar height, condylar width, mandibular ramus height and mandibular body length. Changes in maximum mouth opening were evaluated >1 year postoperatively.Postoperative follow-up showed similar average maximum mouth opening and one case of recurrence in each group. Computed tomography measurements showed that condylar width and mandibular ramus height increased in both groups A and B (P < 0.05). Moreover, in group A, condylar angulation of medially displaced malformation decreased by 13.2° (P < 0.05), and mandibular body length increased by 5.7 mm (P < 0.05). Thus, both condyle-preserved arthroplasty and costochondral grafting were effective surgical methods for treatment of temporomandibular joint ankylosis. Moreover, compared with group B, group A patients manifested more remarkable mandibular growth, at least in the anteroposterior direction of the mandibular body.     

Gap arthroplasty of temporomandibular joint ankylosis by transoral access: a case series

This article describes a technique of gap arthroplasty in temporomandibular joint (TMJ) ankylosis performed by transoral access. The treatment of TMJ ankylosis by creating an adequate gap is of paramount importance in preventing any future recurrence and this can be achieved only when good access is gained to this complex anatomical joint. Five patients with TMJ ankylosis (eight TMJ) were treated by gap arthroplasty using an intraoral approach. The average mouth opening before surgery was 8.6 mm and the average mouth opening achieved postsurgery was 37.9 mm. The average follow-up time was 13 months and none of the patients had any recurrence or significant complications during or after surgery. Our technique relies on the use of a stable landmark to trace the superior-most extent of the ankylotic mass thereby facilitating the removal of the entire mass including the medial extent. We found that even though transoral access is technically challenging and took an average time of 84 min, it has many advantages over conventional extraoral approaches in terms of facial scars and facial nerve injury. The authors also emphasize the importance of good postoperative physiotherapy and presurgical patient counselling to prevent future recurrences.     

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 <30 mm), 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.     

Outcome of eminectomy combined with discectomy and silastic interpositional graft for temporomandibular joint dysfunction: a retrospective study of 20 years

Internal derangement of the temporomandibular joint (TMJ) is usually treated conservatively, but about 5% require surgical treatment. We designed a retrospective study to assess the long-term outcomes of eminectomy combined with discectomy and silastic interpositional graft in 44 patients who had chronic TMJ dysfunction that had not responded to traditional conservative treatment and arthrocentesis. The maximum mouth opening, pain score, Wilkes stage, and clinical dysfunction index were measured before, and two years after, operation. All the patients showed significant improvement in mouth opening and reduced pain scores (p < 0.0001 in each case). There were no long-term operative complications, and postoperative magnetic resonance scans showed that the silastic interpositional graft was in a stable position with no evidence of degenerative changes on the surfaces of the joint and no lymphadenopathy.     

自体喙突移植重建髁突对儿童颞下颌关节强直患者下颌骨生长的远期影响

目的 儿童期下颌骨髁突受损通常导致错颌畸形和面部生长不协调。本研究目的是评价自体喙突移植重建下颌骨髁突对儿童颞下颌关节强直患者面部生长发育的远期影响。方法 追踪评估2008年1月1日至2016年12月31日期间收治于四川大学华西口腔医院正颌及关节外科的10名单侧颞下颌关节强直的儿童患者,其中包括3名男性和7名女性,于5~12岁期间接受了关节间隙成形术、同侧喙突移植髁突重建术和带蒂颞筋膜瓣置入术。术后追踪3~8年,平均4.9年。术后拍摄曲面断层X线片,测定患侧下颌体长度和下颌支高度的生长量并与健侧相比较。结果 所有患者术后恢复良好,追踪结束时10名患者的最大开口度为32~41 mm,平均35.6 mm。自体喙突移植重建髁突解除强直后下颌支高度和下颌体长度均继续生长,但是依然存在生长不足的现象。与初始数据（术后）相比,患侧下颌支高度（随访结束）增加了25.3%（P<0.05）,患侧下颌体长度增加了26.1%（P<0.05）。对比患侧与健侧的下颌骨生长率,患侧下颌支高度增长量与健侧相比少47.1%（P<0.05）,患侧下颌体长度的增长量与健侧相比少27.2% （P<0.05）。结论 自体喙突移植重建下颌骨髁突治疗儿童颞下颌关节强直后,患侧下颌骨可继续生长,但依然会存在生长不足的现象。在颞下颌关节强直治疗完成后,相比于健侧,患侧的生长率是减小的。     

髁突囊内骨折与创伤性颞下颌关节强直的研究进展

颢下颌关节强直(TMJA)是口腔颌面外科的一种常见疾病,严重影响患者的面部形态和功能,创伤是其主要发病因素.目前,有关创伤性TMJA的确切发病因素和形成机制尚不完全清楚.研究表明,髁突囊内骨折与之关系密切,特别是当骨折明显移位合并关节面严重损伤、关节盘移位以及下颌骨宽度增加和活动度减小等因素时,更加好发.下面就近年来对髁突囊内骨折与创伤性1MJA的流行病学、囊内骨折的生物力学研究和分类、动物试验和临床研究作一综述.