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.     

The post-auricular approach for gap arthroplasty - a clinical investigation

Objective of this prospective study was to evaluate and compare posterior auricular approach for surgery of temporomandibular joint ankylosis with preauricular approach. These evaluations were done on the basis of certain parameters like incidences of facial nerve injury, time taken to expose ankylotic mass, haemorrhage and quality of exposure of joint and surrounding structures. This study was conducted among 15 patients of temporomandibular joint ankylosis. A total number of 30 joints were operated. These joints were divided in two groups i.e. Group A - preauricular group, Group B - postauricular group. Fifteen joints were operated in each group. Age of patients was in range of 4-65 years. All the patients were operated under general anesthesia. Preoperative, intraoperative and postoperative evaluations were done according to parameters. Patients were recalled up to 3 months for observations. Results have shown that in postauricular group incidences of facial nerve injury was significantly less, more time was taken to expose the ankylotic mass, incidences of haemorrhage was more and exposure of structures anterior to joint was difficult. Whereas preauricular approach is less time consuming, incidence of facial nerve damage is higher, exposure of structures anterior to joint is good and intraoperative incidences of haemorrhage is less.     

Temporomandibular joint ankylosis: an Indian experience.

Seventy-five condylectomy and coronoidectomy specimens of temporomandibular joint ankylosis in 61 patients were studied. Fourteen patients had bilateral ankylosis, six of whom had fibrous ankylosis on one side. There were two types of ankyloses: intra-articular and juxta-articular. Intra-articular ankylosis was seen only in reankylosis or in postinfective cases. Sixty-six cases were posttraumatic juxta-articular ankylosis. A rudimentary temporomandibular joint with an atrophic condylar articular surface was found in all juxta-articular ankyloses. The size of new bone in the specimens varied from 0.5 to 3 cm. Fusion of the extra-articular bone mass with tympanic plate was also observed. Contracture of temporalis muscle was noted in all the cases, which made excision of the coronoid processes mandatory in all the arthroplasties. Arthroplasty early in childhood did not hamper growth; instead, facial remodeling was enhanced.     

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.     

Inverted, T-shaped silicone implant for the treatment of temporomandibular joint ankylosis

Reconstruction of the ankylosed temporomandibular joint is a challenging task. Speech impairment, difficulties with mastication, poor oral hygiene, facial asymmetry, and mandibular micrognathia results in physical and psychologic disabilities. Various surgical techniques with varying success rates have been reported. Many autogenous and alloplastic materials have been proposed. The authors used an inverted, T-shaped silicone implant for the reconstruction of the temporomandibular joint after the release of the ankylosis in 10 patients without any complications in the postoperative period. The authors assert that the reconstruction of the ankylosed temporomandibular joint with an inverted, T-shaped silicone implant is a reliable and effective alternative. This technique can be used according to the special requirements of each patient and obviating the need for the fixation of the implant and is a safer and better way of using silicone for the treatment of temporomandibular joint ankylosis.     

Post-traumatic severe trismus caused by impairment of the masticatory muscle

Restriction of the mouth opening from a pathologic condition outside the temporomandibular joint is called a pseudo- or extra-articular ankylosis. The authors report two cases of severe post-traumatic pseudoankylosis. One case showed fibrous degeneration of the bilateral masseter muscles without a facial bone fracture, which caused severe trismus, a mouth opening of less than 2 mm, and gradually appeared after blunt injuries to the face. The other was a rare case accompanied with the bone formation in the masseter muscle and was diagnosed as myositis ossificans traumatica, which also presented as severe trismus, with a maximal mouth opening of 5 mm after facial violence. Both were surgically treated with dissection of the affected muscles. In addition, a hemicoronoidotomy was performed in the case of myositis ossificans traumatica. Although a conservative therapy with physical rehabilitation is the basic policy for the management of pseudoankylosis of the temporomandibular joint, a surgical treatment should be considered when the origin of the problems is an osteogenic character or severe extra-articular ankylosis resistant to conservative therapy before completion of true temporomandibular joint ankylosis.     

牵引成骨术治疗儿童单侧颞下颌关节强直伴OSAHS 4例报道

目的:评价牵引成骨术治疗儿童单侧颞下颌关节强直伴阻塞性睡眠呼吸暂停低通气综合征(OSAHS)的治疗效果。方法:4例儿童单侧颞下颌关节强直伴发OSAHS患者,男女各2例,年龄5～13岁(中位年龄6.5岁)。均采用颞下颌关节成形术以恢复开口功能,下颌体牵引成骨术治疗OSAHS;其中3例行同期手术,1例行分期手术;单侧和双侧下颌体牵引各2例。固定期约3个月时行呼吸监护仪监测(PSG)复查和牵引器拆除术。结果:4例患儿OSAHS症状均消失,平均AHI由术前的42.7降到4.9,平均最低血氧饱和度由术前的74.3%上升到89.8%;平均开口度由6.5mm增加至25.5mm;面部畸形得到满意矫正。经过平均38.1个月(13～58个月)的随访,无1例复发。结论:下颌骨牵引成骨术联合颞下颌关节成形术能够有效地治疗儿童单侧颞下颌关节强直及其伴发的OSAHS、面部不对称畸形,并且可以同期手术。     

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目的总结超声骨刀在真性颞下颌关节强直手术中的临床应用经验,评价其临床效果。方法 2007—2010年在深圳市人民医院口腔医学中心对11例真性颞下颌关节强直病例,应用超声骨刀进行截骨,形成间隙,完成裂隙关节成形术9例以及间置物关节成形术2例。观察超声骨刀的临床使用特点和临床效果。结果 11例真性颞下颌关节强直患者均顺利完成关节成形术,无损伤关节内侧面动脉而引起大出血和颅底损伤,伤口均一期愈合。结论应用超声骨刀实施真性颞下颌关节强直手术,手术安全,精确度高,损伤小。     

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颞下颌关节强直是口腔颌面部一类严重的疾病,造成患者张口受限,语言、咀嚼功能障碍,口腔卫生状况下降,面部不对称以及小颌畸形等。本文简要介绍了颞下颌关节强直的病因、病理以及临床治疗的基础与临床研究。     

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。     

Temporomandibular Joint Ankylosis: A Case Report

This report is based on a case of temporomandibular joint ankylosis discovered in a cadaver during routine student dissection in the Department of Anatomy at Tokyo Dental College. Extensive osseous ankylosis in the left temporomandibular joint was evident in this case which exhibited a distinctive bird-like facial deformity caused by a mandibular growth disorder. This resulted in the underdevelopment of the mental area in particular. Furthermore, abnormally enlarged antegonal notching was present along the inferior border of the mandible anterior to the angle. Both these manifestations indicated the likelihood that the ankylosis had contributed to the abnormalities and had commenced at an early stage of skeletal development.     

Temporomandibular joint ankylosis: a case report

This report is based on a case of temporomandibular joint ankylosis discovered in a cadaver during routine student dissection in the Department of Anatomy at Tokyo Dental College. Extensive osseous ankylosis in the left temporomandibular joint was evident in this case which exhibited a distinctive bird-like facial deformity caused by a mandibular growth disorder. This resulted in the underdevelopment of the mental area in particular. Furthermore, abnormally enlarged antegonal notching was present along the inferior border of the mandible anterior to the angle. Both these manifestations indicated the likelihood that the ankylosis had contributed to the abnormalities and had commenced at an early stage of skeletal development.     

Do we need three-dimensional computed tomography in maxillofacial surgery?

In a retrospective clinical study (2000-2003), 121 patients' radiographs and computed tomography scans were reviewed to establish the clinical value of three-dimensional computed tomography. Eighty patients had computed tomography scans; 48 had three-dimensional computed tomography scans for diagnosing facial fractures, 3 for diagnosing temporomandibular joint ankylosis, 1 for tumor with bone destruction, and 1 for a mandibular cyst. It is concluded that axial, coronal, and three-dimensional computed tomography is of crucial importance and should be mandatory for all suspected comminuted and displaced midface fractures instead of plain radiographs. Three-dimensional computed tomography is also recommended for comminuted mandibular fractures and temporomandibular joint ankylosis. Three-dimensional computed tomography is not recommended for the diagnosis of minimally displaced fractures.     

Two-stage treatment of TMJ ankylosis by early surgical approach and distraction osteogenesis

Temporomandibular joint (TMJ) ankylosis is characterized by the formation of bone or fibrous adhesion of the anatomic joint components, which replaces the normal articulation and limitation of mouth opening. Early surgical intervention is considered as a treatment procedure to release the joint ankylosis and to maintain the function of the joint. Longstanding temporomandibular joint ankylosis which starts during the active growth period in early childhood resulting in facial asymmetry. Thus, the importance of the evaluation for the facial asymmetries and unfavorable remodeling of the mandible has to be considered during the initial treatment planning. Further operations, either osteotomies or distraction osteogenesis, are required for the treatment of maxillofacial deformities. The present study reports a case of unilateral TMJ ankylosis treated by interpositional arthroplasty prior to distraction osteogenesis for the treatment of mandibular secondary deformity. Various treatment procedures and timing protocols are reviewed and discussed.     

Treatment of temporomandibular joint ankylosis and facial asymmetry with bidirectional transport distraction osteogenesis technique

Transport distraction technique is a good treatment modality for unilateral temporomandibular joint ankylosis. However, with a unidirectional distraction, it is not possible to correct facial asymmetry that results from mandibular hypoplasia associated with early-onset unilateral temporomandibular joint ankylosis. For this purpose, gap arthroplasty and simultaneous bidirectional transport distraction was used to correct these deformities. Although vertical distraction corrects vertical deficiency of the ramus and creates a neocondyle, the simultaneous anteroposterior distraction of the transport segment corrects facial asymmetry resulting from horizontal shortness of mandible. Three patients, whose mean mouth opening was 8.6 mm, were successfully treated with this technique. Mean advancements in vertical and anteroposterior direction were 14.7 and 7.7 mm, respectively. Mean maximal mouth opening was 29.7 mm postoperatively. The average follow-up period was 13 months (range, 12-15 mo). During this period, reankylosis was not observed, and the interincisal distance did not decrease. Gap arthroplasty and bidirectional transport distraction of the mandibular ramus is a good and effective therapeutic option in treatment.     

Rehabilitating children with temporomandibular joint ankylosis.

Although the probability of ankylosis following injury of the temporomandibular joint is small, patients, especially children with temporomandibular joint ankylosis, are greatly handicapped. Of the 42 cases of ankylosis seen in our clinic, six occurred in the adult, and 36 in children under 14 years of age. Treatment in all cases was surgical, and the results were beneficial, although the greatest difficulty in the treatment had been the early recurrence of ankylosis. Based on our experience, osteoarthrotomy for temporomandibular joint ankylosis in children has been advocated.     

Subankylotic ostectomy for release of TMJ ankylosis using the transmasseteric anterior parotid approach

Twelve patients with temporomandibular joint ankylosis (5 bilateral and 7 unilateral) with preoperative maximal mouth opening ranging from 0 to 11 mm (mean, 2.25 [SD, 3.19] mm) were treated with a subankylotic ostectomy. Inclusion criteria in the study were patients older than 18 years with restricted mouth opening of less than 30 mm and radiographic evidence of temporomandibular joint ankylosis. The mean maximal postoperative mouth opening was 38.92 (SD, 3.11) mm. All patients showed good functional rehabilitation in terms of movement and speech with no radiographic evidence of recurrence and no occurrences of temporary or permanent facial nerve palsy, sialoceles, or salivary fistulae. As this technique does not encroach upon the mass of ankylotic bone but creates a pseudarthrosis beneath it, chances of recurrences are minimized. The entire length and width of the right ramus from the condyle to the angle region can be accessed with this technique.     

A woman with ankylosis of the temporomandibular joint

A 56-year-old woman was referred to an oral and maxillofacial surgeon because of facial stiffness and restricted mouth opening, 13 years after receiving multiple mandible fractures in a car accident. After clinical investigation and computer tomography, ankylosis of the right temporomandibular joint was diagnosed. The patient was treated by means of gap-arthroplasty, in which a myofascial flap of the temporalis muscle was used as an interposition transplant. After a period of physiotherapy, an acceptable recovery of the mouth opening was achieved. Traumatic injury is by far the most prevalent etiology of temporomandibular joint ankylosis, followed by an infection of the temporomandibular joint. Treatment consists basically of a gap-arthroplasty, with or without interposing a transplant between the ramus mandibulae and the joint socket or resection of the ankylotic tissues followed by reconstruction of the mandibular caput with an autologue transplant or an alloplastic material.     

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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。     

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.