Modifications of the inverted T-shaped silicone implant for treatment of temporomandibular joint ankylosis.

PURPOSE: Inverted T-shaped silicone implants have been used for reconstruction of ankylosed temporomandibular joints for 10 years. As the implant is custom made during the operation, dimensional adjustments according to individual need are routine. MATERIAL AND METHOD: A new modification to increase the stability of the inverted T-shaped silicone implant is presented. The modification consists of a middle process on the long arm of the T-shaped silicone implant, the first of which was inserted into the medullary cavity of the mandibular ramus. This modification further stabilizes the implant position and helps prevent its displacement. The modification was used on difficult cases such as bilateral ankylosis, osteotomies below the condylar notch or incompliant patients. This modification was used in six patients. RESULTS: No dislocation, nor extrusion of the implant or re-ankylosis of TMJ was observed.     

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。     

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.     

Postoperative evaluation of surgically treated cases with temporary silicone implant in temporomandibular joint

We have carried out temporary silicone implants after diskectomies or arthroplasties in temporomandibular joint surgeries to avoid postoperative adhesion and to maintain articular space. We evaluated 19 joints in 15 patients who had received dacron-reinforced silicone implant after silicone sheet removal through follow-up for at least 6 months. The cases included temporomandibular joint disorder (10 joints in 9 patients), psoriatic arthritis (2 joints in 1 patient), ankylosis (4 joints in 3 patients) and synovial chondromatosis (2 joints in 2 patients). On the basis of the criteria of temporomandibular dysfunction for the results, they were classified as bad (4 patients). It is thought that factors other than the implant are related to the bad results in the postoperative evaluation. In this study, lymphadenopathy induced by exfoliated silicone debris could not be confirmed. The temporary silicone implant in the temporomandibular joint was thought to be useful.     

One stage management of ankylosis of the temporomandibular joint with a custom-made total joint replacement system

Alloplastic joint prostheses have been used in the treatment of severe diseases of the temporomandibular joint (TMJ) for many years. Treatment of ankylosis of the TMJ has been difficult, with many surgical approaches being used that traditionally involved multistage procedures, long treatment times, and increasing expense. We report a single stage technique for replacement of an ankylosed joint using a custom-made prosthesis, and discuss the technical aspects of the procedure, including our use of a custom-made acrylic glenoid fossa template.     

Fibrous ankylosis after distraction osteogenesis of a costochondral neomandible in a patient with grade III hemifacial microsomia.

Distraction osteogenesis has recently become a mainstay for treatment of craniofacial syndromes with mandibular hypoplasia. This article presents the difficult case of a patient with a previous costochondral rib graft who underwent mandibular distraction and developed a fibrous pseudoarthrosis at the distraction site. This was attributed in part to an associated temporomandibular joint ankylosis. Resorption of the pseudoarthrosis occurred once the distractor was removed. It appears that distraction osteogenesis of a mandible with an ankylosed temporomandibular joint can result in healing with a fibrous union, presumably because of movement at the distraction site when masticating. This can result in a pseudo "temporomandibular joint" at the distraction site. A temporomandibular joint arthroplasty was performed, followed by repeat distraction. We conclude that if there is an ankylosed temporomandibular joint or a stiff temporomandibular joint that may ankylose during the course of the distraction process, then a temporomandibular joint arthroplasty should be performed before or at the time the distractor is placed.     

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.     

Addition of a Temporal Silastic and Metal Implant to a Metallic Condyle

The patient described in this case report had a history of temporomandibular joint problems, and she had been fitted with Kent-Vitex condylar implants. However, sclerosis and ankylosis had occurred and the patient was suffering temporomandibular joint, ear, and face pain and limited opening.

The authors added a metal and Silastic implant to each joint after removing excess tissue and bone from the condyles. This surgery relieved the patient's symptoms and increased her mouth opening. The authors recommend this type of implant to help protect the fossa from the impact of metallic condyles.     

再论“乙”状切骨术治疗颞颌关节强直

作者在５０年代发表了“乙”状切骨及筋膜帽治疗颞颌关节强直”一文￣［１］，其后按此原则用游离植骨术及再植术原位重建颞颌关节，以治疗不同的颞颌关节病损。逐步形成了重建颞颌关节的新概念，已推广应用于临床￣［２］，８０年代曾对有关重建骨关节结构的各种方法作了讨论￣［３］。本文进一步讨论以下４个方面的内容：１．重建此种关节结构有关理论根据。２．彻底松解粘连，移植脂肪，减少对下颌及关节运动的外周阻力。３．恢复颌肌功能，加强对颌骨的动力。４．术后用板治疗，以促进双侧骨关节的正常改建，以及颌肌平衡的重建。以上４方面环绕以“动”为总目的，松解及预防粘连重建关节，恢重功能，防止强直复发。     

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.     

Two-stage total prosthetic reconstruction of temporomandibular joint in severe and recurrent ankylosis

ABSTRACT: Temporomandibular joint ankylosis is a devastating condition for the patient associated with both functional disability and aesthetic deformities. Various techniques have been described in the literature to overcome this problem; however, there is still a high risk of reankylosis in patients undergoing multiple temporomandibular joint operations, severe heterotopic ossification, and fibrosis of the soft tissues.This study includes 5 patients with severe and recurrent ankylosis. Two-stage reconstruction with excision of the bony mass and placement of a distraction device in the first stage, followed by gradual distraction of soft tissues, and placement of a total joint prosthesis in the second stage were performed in all patients. The 2-step approach helps to overcome the fibrosis and adhesions in the soft tissues and allows placing an implant with a higher ramus component. This approach seems to be a useful and effective technique for the management of such patients with high risk of reankylosis.     

Temporomandibular joint morphology following post-traumatic ankylosis in 26 patients

This study evaluated the joint morphology on coronal computed tomography of ankylosed temporomandibular joints in 26 patients. All patients developed ankylosis following blunt trauma. Post-ankylosis joint morphology was assessed to determine if the precursor condylar fracture could be identified and this was compared to the condylar fracture prevalence to determine if any condylar fractures have an increased risk factor for ankylosis. Mean age at presentation was 20.9+/-14.41 years (range 6-58) and mean age at injury was 13.84+/-13.81 years (range 3-53). Thirty-seven joints were ankylosed in 26 patients (11 bilateral, 15 unilateral) with 27 joints in 19 patients showing vestiges of a medially dislocated condylar fracture (72.9% of joints). The prevalence of MDCF at our unit over a period of 6 months was 16.8% (16 of 95 condylar fractures). This suggests that a medially dislocated condylar fracture is more likely to ankylose than other condylar fractures. A hypothesis is proposed to explain this increased risk.     

肋骨肋软骨移植在颞颌关节强直关节重建术中的应用

近十年来我们采用自体肋骨肋软骨游离移植对２１例颞颌关节真性强直患者进行颞颌关节重建术，术后经过１～１０年的随访，功能和外形收到了令人满意的效果，Ｘ线检查示１７例植入的肋骨依然可见或已被下颌骨替代，有４例植入的肋骨吸收消失。     

人工关节头应用于颞下颌关节骨性强直治疗的临床探讨

目的：回顾性研究分析人工关节头在颞下颌关节骨性强直治疗中进行关节重建的方法和临床治疗效果。方法：对2007年8月～2012年3月间收治的6例（10侧）颞下颌关节骨性强直患者进行人工关节头关节重建。对治疗方法和效果进行综合分析。结果：6例均采用人工关节头置换恢复颞下颌关节,术后患者张口度恢复理想。结论：人工关节头置换用于治疗颞下颌关节骨性强直具有可行性,并能达到良好的治疗效果。     

Navigation-guided resection of temporomandibular joint ankylosis promotes safety in skull base surgery.

PURPOSE: Computer-assisted surgery (CAS) has not been a routine part of craniomaxillofacial surgery to date. This report investigates the use of CAS to promote the safe removal of ankylosed temporomandibular joint bone in the skull base. PATIENTS AND METHODS: Out of a total pool of experience with 102 navigation-guided CAS procedures between January 1998 and December 2000, we report on 2 cases of navigation-aided resection of severe ankylosis of the mandibular condyle with a predetermined safety margin of the resection toward the middle cranial fossa, and identification of the foramen ovale. RESULT: The use of CAS with navigation resulted in the promotion of safe surgical excision of the ankylosed skull base tissue. CONCLUSIONS: We regard navigation-aided resection of an ankylosis fo the mandibular condyle as a valuable additional technique in this potentially complicated procedure.     

A retrospective study of temporomandibular joint ankylosis secondary to surgical treatment of mandibular condylar fractures

We investigated the incidence of ankylosis of the temporomandibular joint (TMJ) after open operations for fractures of the mandibular condyle, and analysed possible risk factors in a total of 385 patients with 492 condylar fractures who had been operated on in our department from 2001 to 2010. Sixteen patients developed postoperative ankylosis of the TMJ with 26 joints (5%) affected during a follow-up of 6 months–10 years. Of the 492 condylar fractures, the most common ones that were associated with postoperative ankylosis were those of the condylar head (20/248), followed by the condylar neck (6/193). Subcondylar fractures did not cause postoperative ankylosis (0/51). Among the 16 patients with postoperative ankylosis, 13 had associated anterior mandibular fractures. Long-screw (bicortical screw) fixation of fractures of the condylar head seemed to be associated with a lower incidence of postoperative ankylosis than fixation by miniplate and wire or removal of the fractured fragment. The articular discs were damaged in all ankylosed joints, and the remaining fractured fragment was found in 10 ankylosed joints after fractures of the condylar head. The results suggest that fractures of the condylar head are more prone to lead to postoperative ankylosis of the TMJ, and that the possible risk factors seem to include the technique used for fixation and damage to the disc, together with an anterior mandibular fracture with the fractured fragment remaining.     

Intraoral mandibular distraction osteogenesis in facial asymmetry patients with unilateral temporomandibular joint bony ankylosis

Gap arthroplasty and costochondral rib bone graft are commonly performed by oral and maxillofacial surgeons to reconstruct the temporomandibular joint with ankylosis. However, unpredictable and unsatisfactory results such as re-ankylosis, growth disturbance, and facial asymmetry often occur. Even if the costochondral graft is successful, donor-site morbidity is inevitable. More recently, surgeons have become interested in distraction osteogenesis as a means of temporomandibular joint reconstruction. This case series presents the results of intraoral mandibular distraction osteogenesis and gap arthroplasty in two patients with facial asymmetry and unilateral temporomandibular joint bony ankylosis. Both patients had experienced failed gap arthroplasty and costochondral graft for the reconstruction of the temporomandibular joint. Distraction osteogenesis with gap arthroplasty proved successful in these two patients with follow-up of longer than 2 years.     

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。     

Facial nerve paralysis: a complication of distraction osteogenesis of the mandibular ramus in the treatment of temporomandibular joint ankylosis

Distraction osteogenesis is a useful technique in temporomandibular joint reconstruction after gap arthroplasty for ankylosis. We report a case of unilateral facial nerve paralysis during the distraction phase of treatment in a patient with temporomandibular joint ankylosis who was treated with gap arthroplasty and distraction osteogenesis. The clinical course is described and discussed.     

计算机辅助外科技术在颞下颌关节疾病治疗中的应用

计算机辅助外科技术已经在口腔颌面外科诸领域（如创伤重建、正颌外科、头颈部肿瘤的切除与重建等）得到广泛应用。其在颞下颌关节疾病治疗中的应用近年来也有很大的发展,例如在颞下颌关节强直骨球的截除、髁突骨折的固定及髁突良恶性肿瘤的切除等方面。本文就此部分内容做一综述。