Protocol for the management of ankylosis of the temporomandibular joint

Ankylosis of the temporomandibular joint (TMJ) is a severely deforming, disabling condition as a result of craniomandibular fusion caused mainly by condylar fractures with displacement of the meniscus. Ankylosis may be fibrous, fibro-osseous, or bony, and unilateral or bilateral. The severity of the deformity is based on the onset, duration, and type of ankylosis. Various surgical techniques have been described for treatment, but no single treatment is recommended because of inconsistent results and the high rate of failure. While our total experience extends to 300 cases, we have developed a protocol using the most recent 193 patients to address our earlier high failure rate. The onset was during childhood in 168 patients, and 25 were adults. We describe the protocol that we developed for these two groups. Our management included gap arthroplasty, costochondral grafting, temporalis flaps, ramus osteotomies, and transport distraction.     

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.     

A sheep model for temporomandibular joint ankylosis.

PURPOSE: The purpose of this study was to develop an animal model for temporomandibular joint (TMJ) ankylosis. MATERIALS AND METHODS: Five sheep had removal of the temporal and condylar articular surface plus discectomy in the right TMJ; the left side was used as a control. One sheep was killed just after operation and four at 3 months. The joints were examined histologically, and a scoring system was developed to evaluate the extent of the ankylosis. The range of jaw movement was compared between preoperatively and 3 months. RESULTS: Two sheep lost 4% of their body weight by 3 months. The range of jaw movement, particularly to the left, decreased at 3 months (P < .001). The joint spaces were filled with fibrous tissue and cartilage-like tissue. Development of new bone from the damaged temporal and condylar surfaces was seen, but full bony fusion did not occur. The average histologic score of a zone was 4.9 on the degree-of-ankylosis scale and 1.7 on the degree-of-calcification scale. There were statistically significant differences between the operated and control TMJs for both changes (P < .0001). CONCLUSION: Fibrous ankylosis occurs rapidly after removal of the TMJ articular surfaces and the disc. This model can be further developed to isolate relative factors in the development of ankylosis and in evaluation of different treatment methods.     

髁突置换治疗创伤性颞下颌关节强直五例

目的 总结用人工髁突置换治疗创伤性颞下颌关节强直(temporomandibular joint ankylosis,TMJA)的临床效果.方法 2006年8月至2008年4月北京大学口腔医学院·口腔医院口腔颌面外科共5例创伤性TMJA患者接受人工髁突置换手术,患者均为男性.术前行CT检查后,用快速成形技术制作三维头模,在头模上模拟切除关节骨球、关节成形、选择适宜的人工髁突,术中依术前设计安放并固定人工髁突.术后1周和复查时评价手术效果.结果 5例共植入6侧人工髁突(1例为双侧).3例复查时间为术后8～30个月,另外2例失访.复查时张口度平均为30 mm,2例咬合关系良好,1例前牙区有约1 mm的开骀.结论 人工髁突置换可以作为创伤性TMJA手术治疗的方法之一,其临床效果还需进一步验证.     

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.     

创伤性颞下颌关节强直临床分析

目的 分析引发创伤性颞下颌关节(temporomandibular joint,TMJ)强直的高风险髁突骨折类型,初步探讨TMJ强直发生的可能性机制.方法 对18例创伤性TMJ强直进行临床、影像学检查及评估.取纤维性强直外侧变性的关节囊、关节间的致密纤维组织及骨性强直关节外侧骨块和内侧骨块,HE染色,光镜观察.结果 ...     

A jaw exerciser for fibrous ankylosis of the temporomandibular joint

A bstract — Indications for the use of an individually designed jaw exerciser together with the method of fabrication and patient instructions and reports of two cases of post-traumatic progressive fibrous ankylosis of the temporomandibular joints are described.     

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。     

Videofluoroscopic analysis of temporomandibular joint ankylosis

The causes of temporomandibular joint (TMJ) ankylosis, or hypomobility, are many, and it is important to understand the underlying etiology before treatment. Classically, TMJ ankylosis has been diagnosed by clinical evaluation and static imaging techniques such as plain radiographs, computed tomography, and magnetic resonance imaging. Static imaging demonstrates the size and location of the bones and soft tissues of the TMJ at a given moment; however, it fails to show the dynamic relationship of structures as the condylar head goes through its range of motion. The purpose of this study is to evaluate the use of videofluoroscopy as a dynamic means of assessing TMJ ankylosis. To do so, videofluoroscopy must be able to distinguish between bony fusion, fibrosis of the surrounding soft tissues, degeneration of the joint space, and mechanical causes of joint limitation. Six patients--2 healthy controls and 4 patients with known TMJ ankylosis--were submitted to standardized videofluoroscopic evaluation and thorough physical examination that included measurement of mandibular excursion. Videofluoroscopic data were compared with physical data. Condylar displacement was recorded in all patients, and values ranged from 0% to 100%. Videofluoroscopy allowed for the measurement of the TMJ joint space and for a detailed observation of bony and soft tissue components as they ranged in motion. In all cases, the exact cause limiting mandibular excursion was noted. Videofluoroscopy has become our preferred method of imaging the TMJ because it provides a detailed and dynamic evaluation at a reasonable cost.     

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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。     

Surgical correction of temporomandibular joint ankylosis

The correction of temporomandibular joint ankylosis is frequently followed by re-ankylosis, occlusal disturbance and alteration of functional masticatory movements. A multitude of surgical procedures have been devised in an attempt to overcome the complication of re-ankylosis in particular, and to create a functioning pseudoarthrosis where distance between resected bone surfaces and/or interpositional autogenous, homologous or alloplastic material is relied upon to prevent re-ankylosis and facilitate functional joint activity. Success in preventing re-ankylosis is said also to depend on long-term patient compliance in undertaking frequent and usually painful mandibular movement exercises. Achieving a functioning joint often precludes the maintenance of the occlusion and depends on resection of large amounts of bone and the use of alloplastic implants. A surgical technique is presented whereby a minimal gap arthroplasty in the region of the obliterated temporomandibular joint is completed. This minimizes deviation of the mandible to the operated side with the formation of an anterior open bite. Separation of the resected bone surfaces is accomplished using a composite free auricular skin and cartilage graft in order to prevent re-ankylosis as efficaciously as possible, while allowing for the promotion of immediate postoperative mandibular function, continued growth and the construction of a joint similar in broad terms to the pre-existing joint. A two-stage correction of temporomandibular joint ankylosis and concomitant secondary maxillofacial deformity is recommended. The results in 13 patients (17 joints) with a follow-up range of 1.5 to 5.5 years show that in all but one instance (of fibrous re-ankylosis following postoperative joint infection), satisfactory postoperative mandibular function and mouth opening was achieved.