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.     

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.     

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.     

A manipulation technique for treatment of anterior disk displacement without reduction

Anterior disk displacement without reduction, called "closed locking," is a serious stage of the internal derangement of the temporomandibular joint. Many types of conservative and surgical treatments have been applied to this problem. A new manipulation technique to release "closed locking" of the temporomandibular joint and the clinical results on 35 patients are reported in this study. Voluntary maximal mouth opening of the patients were measured as interincisal distance before and after the application of the manipulation technique. The voluntary maximal mouth opening of 14 of 17 patients (82%) who were younger than 30 years was improved to more than 40 mm after the application of the manipulation technique. Contrariwise, the voluntary maximal mouth opening of only 5 of 18 patients (28%) who were older than 30 years was improved to more than 40 mm.     

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.     

Is aggressive gap arthroplasty essential in the management of temporomandibular joint ankylosis?—a prospective clinical study of 15 cases

The purpose of this three-year, prospective, follow-up study was to evaluate whether aggressive gap arthroplasty is essential in the management of ankylosis of the temporomandibular joint (TMJ). Fifteen patients were treated by the creation of a minimal gap of 5–8 mm and insertion of an interpositional gap arthroplasty using the temporalis fascia. Eleven patients had unilateral coronoidectomy and 4 bilateral coronoidectomy based on Kaban's protocol. Preoperative assessment included recording of history, clinical and radiological examinations, personal variables, the aetiology of the ankylosis, the side affected, and any other relevant findings. Patients were assessed postoperatively by a surgeon unaware of the treatment given for a minimum of 3 years, which included measurement of the maximal incisal opening, presence of facial nerve paralysis, recurrence, and any other relevant findings. Of the 15 patients (17 joints), 12 had unilateral and three had bilateral involvement, with trauma being the most common cause. The patients were aged between 7 and 29 years (mean (SD) age 20 (8) years). Preoperative maximal incisal opening was 0–2 mm in 8 cases and 2–9 mm in 9. Postoperatively adequate mouth opening of 30–40 mm was achieved in all cases, with no recurrence or relevant malocclusion during 3-year follow up. However, patients will be followed up for 10 years. Aggressive gap arthroplasty is not essential in the management of ankylosis of the TMJ. Minimal gap interpositional arthroplasty with complete removal of the mediolateral ankylotic mass is a feasible and effective method of preventing recurrence.     

正颌外科治疗颞下颌关节强直伴阻塞性睡眠呼吸暂停综合征

目的 评价正颌外科手术治疗颞下颌关节强直伴阻塞性睡眠呼吸暂停综合征(OSAS)的效果。方法 12例颞下颌关节强直伴OSAS患者(男4例，女8例，年龄10～25岁，平均18．4岁；双侧颞下颌关节强直8例，单侧颞下颌关节强直4例)，采用颞下颌关节成形术、下颌矢状劈开前徙术、颏前徙成形术、舌骨悬吊术以及牵张成骨术移动下颌骨和舌骨。术后随访3～36个月。结果 12例患者张口度由术前的0～2mm增大到术后25～40mm；术后患者颜面形态明显改善；其连续血氧饱和度最低值由术前的42％提高至术后的90％以上，睡眠呼吸障碍解除和睡眠质量获得提高。结论 在颞下颌关节强直伴OSAS患者的治疗中，行颞下颌关节成形术的同时，辅助正颌外科手术，不仅可以增大患者的张口度，而且还能解决患者下颌后缩的畸形，同时解除上气道狭窄，从而缓解或纠正患者的低氧血症。     

Simultaneous costochondral graft and distraction osteogenesis in unilateral TMJ ankylosis associated with mandibular retrognathia and asymmetry

The purpose of this study was to review the long-term effect of simultaneous costochondral graft (CCG) and distraction osteogenesis (DO) in the management of unilateral temporomandibular joint ankylosis associated with severe dentofacial deformities in our clinic. In addition, we sought to analyze the advantages and disadvantages of CCG and DO. Four patients were included in this clinical study during 2005 to 2007. The mean length of ankylosis history was 14.5 years. All patients had significant mandibular retrognathia and asymmetry histories and have been diagnosed with obstructive sleep apnea syndrome by a polysomnogram before surgery. A 1-stage surgery, with gap arthroplasty, CCG, and mandibular DO, was performed. The surgical plan and technique were reviewed. No severe complications were observed after surgery. Distraction was started on day 7 after surgery. The distance of distraction ranged from 20 to 25 mm (mean, 22.5 mm). Mouth opening was increased from 25 to 37 mm (mean, 33.5 mm) during the follow-up period (range of 3.5-5 y). No recurrence of joint ankylosis occurred based on the clinical and radiographic evaluations. All of the patients had significant improvement in obstructive sleep apnea syndrome after surgery. Mandibular asymmetry and retrognathia were well corrected in all of the patietns. In conclusion, a 1-stage surgical treatment with DO and CCG demonstrated its feasibility and effectiveness in management of temporomandibular joint ankylosis combined with severe dentofacial deformity. It is a safe and reliable method of treatment.     

Preservation of condyle and disc in the surgical treatment of type III temporomandibular joint ankylosis: a long-term follow-up clinical study of 111 joints

The purpose of this study was to establish the role of retaining the condyle and disc in the treatment of type III ankylosis, by clinical and computed tomography (CT) evaluation. A total of 90 patients with type III ankylosis met the inclusion criteria; 42 patients had left temporomandibular joint (TMJ) ankylosis, 27 patients had right TMJ ankylosis, and 21 had bilateral TMJ ankylosis, thus a total 111 joints were treated. Considerable improvements in mandibular movement and maximum mouth opening were noted in all patients. At the end of a minimum follow-up of 2 years, the mean inter-incisal mouth opening was 30.7 mm. Postoperative occlusion was normal in all patients, and open bite did not occur in any case because the ramus height was maintained through preservation of the pseudo-joint. Only three patients had recurrence of ankylosis, which was due to a lack of postoperative physiotherapy. The advantages of condyle and disc preservation in type III ankylosis are: (1) surgery is relatively safe; (2) the disc helps to prevent recurrence of ankylosis; (3) the existing ramus height is maintained; (4) the growth site is preserved; and (5) there is no need to reconstruct the joint with autogenous or alloplastic material. It is recommended that the disc and condyle are preserved in type III TMJ ankylosis.     

保留颞下颌关节盘治疗外伤性颞下颌关节强直

目的：应用保留颞下颌关节盘的手术方法治疗外伤性颞下颌关节强直,达到恢复颞下颌关节结构、改善面部外形和防止术后复发的目的。方法：对36例外伤所致Ⅱ型和Ⅲ型颞下颌关节强直病例进行手术,男16例,女20例,年龄5～54岁,病程1～16a,最大开口度0～1.5cm。新的手术方法是凿开关节窝与髁突之间的骨性融合,凿除前内侧移位的髁突骨折碎片,将残余的关节盘向外牵拉、复位,与外侧关节囊缝合,同时将髁突与关节窝磨改光滑。结果：36例病例中,21例术后随访1～7a,保留关节盘手术的病例均无复发,术后平均开口度为3.37cm。1例11岁患儿术后面部畸形得到改善。结论：保留颞下颌关节盘正常结构在防止外伤性颞下颌关节强直手术后复发以及生长发育期患者面部畸形中具有重要作用。     

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。     

Preservation of disc for treatment of traumatic temporomandibular joint ankylosis.

PURPOSE: A new operating method was used to treat traumatic temporomandibular joint (TMJ) ankylosis, to restore the structure of the TMJ, to improve the secondary maxillofacial deformity, and prevent recurrence of TMJ ankylosis. PATIENTS AND METHODS: Thirty-six patients (20 females, 16 males; aged 5 to 54 years old) with TMJ ankylosis type II or III of 1 to 16 years' duration, with a maximal mouth opening from 0 to 15 mm preoperatively participated. The new method was to separate bony fusion between condyle and glenoid fossa, remove the condylar fragment that displaced medially or anteroinferiorly, mobilize the remains of the disc over the condylar stump and suture it with articular capsule, and shave the surface of the condylar stump and glenoid fossa smooth. RESULTS: Follow-up was performed from 1 to 7 years postoperatively in 21 cases. No recurrences occurred in patients whose TMJ disc was retained during operation. Patients had an average maximal mouth opening of 33.7 mm postoperatively. An 11-year-old patient showed an improved facial symmetry after surgery. CONCLUSION: By restoring the normal structure of the TMJ and preservation of the disc, recurrence of traumatic TMJ ankylosis and facial deformity in younger patients can be prevented.     

Discectomy as an effective treatment for painful temporomandibular joint internal derangement: a 5-year clinical and radiographic follow-up.

PURPOSE: The purpose of this prospective study was to compare the preoperative and 5-year postoperative status of patients after unilateral discectomy for painful internal derangement of the temporomandibular joint. PATIENTS AND METHODS: The study was based on 64 patients. Fifty-six had disc displacement without reduction and 8 had disc displacement with reduction. The patients were examined clinically and radiographically before and 5 years after the operation according to a standardized protocol. RESULTS: Eighty-five percent of the patients (n = 52) had good results, 6% had acceptable results, and 9% had a poor outcome. Three patients (5%) were reoperated and 5 other patients (8%) needed a contralateral operation during the 5-year follow-up. The median increase in maximum mouth opening was 11 mm (range, -8 to +35 mm) and 83% of the patients had more than 40 mm maximal mouth opening postoperatively. Seventy-five percent of the patients had crepitation at 5-year follow-up compared with 27% before the operation. Postoperatively, the majority of the joints showed radiographic evidence of osteophytes, flattening, and sclerosis. The radiographic alterations did not correlate with the patients' symptoms. CONCLUSIONS: The results of this long-term follow-up after unilateral discectomy support the use of this operation in patients with painful internal derangement who show no improvement after prior nonsurgical treatment. The postoperative radiographic alterations should be interpreted as adaptive changes rather than progressive degenerative joint disease.     

Facial growth after treatment of unilateral temporomandibular joint ankylosis in childhood without growth centre transplantation. A serial cephalomorphometric study

Our aim was to study the influence of early surgical treatment of temporomandibular joint ankylosis on further facial growth and development. At the Department of Maxillo-Facial Surgery, Zurich, 11 children with a unilateral TMJ-ankylosis met the criteria of a maximal preoperative interincisal mouth opening of 15 mm, of a minimal long-term postoperative interincisal mouth opening of 30 mm, and of excellent documentation. 30 anatomical landmarks were defined on the copies of the follow-up cephalograms using the structure-superimposition technique. The points were perforated and digitized. Analysis and graphic-plotting were followed by computer. The hypothesis that mandibular growth continues once the ankylosis was successfully treated (without transplantation of a growth centre) and mandibular function definitely restored, was confirmed. The treatment does normalize the growth rate, but it seems that abnormal growth patterns cannot be influenced by it. As a consequence, the surgical release of the ankylosis should be performed as early as possible.     

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.     

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.     

Transport distraction osteogenesis as a method of reconstruction of the temporomandibular joint following gap arthroplasty for post-traumatic ankylosis in children: a clinical and radiological prospective assessment of outcome

This clinical and radiographic study investigated the use of transport distraction osteogenesis in unilateral temporomandibular joint (TMJ) ankylosis patients. Six patients aged between 4 and 8 years were selected for the study; the mean preoperative maximal inter-incisal opening (MIO) was 3.5 mm without lateral and protrusive mandibular movements. The ankylotic mass along with the posterior border of the ascending ramus was exposed via ‘lazy-S’ incision. A gap arthroplasty was performed, followed by a ‘reverse L’ osteotomy on the posterior border of the ramus. In-house manufactured extraoral distraction devices were used for this prospective study. Follow-up clinical and radiographic evaluation was carried out for 13–27 months after completion of the activation period. After a mean follow-up of 19 months, the mean MIO was 29.1 mm and the lateral and protrusive movements changed from none to slight. Cone beam computed tomography images of all patients showed remodelled neocondyle created by transport distraction osteogenesis with no statistically significant differences observed for average cancellous bone density, trabecular number, and trabecular spacing between the neocondyle of the operated side (test) and the condyle of the non-operated side (control). Neocondyle formation by transport distraction osteogenesis using the in-house distraction device is a promising treatment option for TMJ reconstruction in ankylosis patients.     

Management of temporomandibular joint ankylosis type III: lateral arthroplasty as a treatment of choice

Many surgical techniques for the management of temporomandibular joint (TMJ) ankylosis have been described in the literature. The purpose of this study was to report our experience using a lateral arthroplasty technique in the management of type III ankylosis. The records of 15 patients treated for TMJ ankylosis at our institution between 2007 and 2011 were reviewed. Pre- and postoperative information collected included age, gender, aetiology, ankylosis type/classification, existing facial asymmetry, maximum pre- and postoperative mouth opening, complications, and recurrence of ankylosis. The mean maximum inter-incisal opening in the preoperative period was 12.9 mm and in the postoperative period was 36.2 mm. No major complication was observed in any patient. No recurrence was noted in any patient. Our working hypothesis was that for patients with ankylosis type III, the medially displaced condyle and disc can fulfil their role in mandibular function and growth after extirpation of the ankylozed mass. Although they are located in an awkward medial position, they should function exactly as they would after a properly treated, displaced condylar fracture.     

Development of temporomandibular joint ankylosis in rats: a preliminary experimental study

The objective of this study was to evaluate a model for the development of temporomandibular joint ankylosis in rats using disc removal and articular damage. In 30 adult male Wistar rats, articular damage was induced and disc removal performed in the right joint to induce ankylosis. The rats were divided into groups according to the time of killing (7, 15, 30, 60 and 90 days). Maximal mouth opening, mandibular deviation, initial and final weights, and duration of surgery were recorded and evaluated. After death, the joints were submitted to histological study in order to score the ankylosis. The mean duration of surgery was 14.23 min. Mean difference between initial and final maximal mouth opening was 3.38 mm, being greatest at the 15-day evaluation and lowest at 90 days, and was statistically significant at 15 days (p=0.043), 30 days (p=0.027) and 60 days (p=0.027). No mandibular deviation was observed at any of the evaluation times. Histological scores increased with time of evaluation from 7 to 30 days, when they started to fall. This study model permitted the development of fibrous ankylosis in the majority of the animals, and no bony bridge was observed between the mandibular condyle and the temporal bone.     

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.