Facial nerve function following temporomandibular joint surgery using the preauricular approach.

Sixty-eight patients (83 temporomandibular joints) consecutively operated on who had a variety of temporomandibular joint operations using a preauricular approach were assessed for facial nerve function following surgery. Nine patients (10.84%) showed signs of facial nerve injury in which the temporal and zygomatic branches were involved. The incidence of facial nerve injury was greater in patients who had undergone previous temporomandibular joint surgery (17.64%) than in patients with previously unoperated joints (9%). Normal facial nerve function returned in 9 to 14 weeks except in one patient who showed a mild deficit of the zygomatic branch at 20 weeks. The nature and duration of the surgical procedure did not correlate with facial nerve injury. Scarring of tissues as a result of previous temporomandibular joint surgery may significantly increase the risk of facial nerve injury during subsequent temporomandibular joint surgery.     

Extended modified postauricular incision of the temporomandibular joint

The traditional postauricular approach to the temporomandibular joint has excellent cosmetic results since the entire incision is concealed in the postauricular flexure. Excellent posterior joint exposure, good lateral joint exposure, and fair anterior joint exposure are obtained. The risk of injury to the facial nerve is decreased. An extended modification of the postauricular incision was developed to overcome some of the disadvantages of the postauricular incision while maintaining its advantages. The incision begins inferiorly in a curvilinear manner, over the mastoid tip and progresses superiorly 3 mm posterior to the postauricular flexure. As it ascends superiorly above the level of the external auditory canal, it progresses posteriorly from the flexure. It then progresses superiorly in a curvilinear fashion in the temporal area slightly superior to the customary superior aspect of the preauricular incision. The dissection is carried to and through the temporalis fascia and periosteum, over the root of the zygomatic arch, and anteriorly after crosscut of the external auditory canal to the parotideomasseteric fascia. Dissection anteriorly deep to these fused structures allows a single flap to the skin. With this anterior dissection, the temporal and zygomatic branches of the facial nerve are protected and contained within the skin-fascia flap. The capsule is thus exposed and further dissection into the joint is described. A representative case presentation demonstrates the extended modified postauricular incision.     

An unusual complication of condylectomy: fracture of the temporal bone and intratemporal facial paralysis

The incidence of temporomandibular joint (TMJ) ankylosis appears to be decreasing with the increased socioeconomic status of society. The intraoperative complications were reported to be few, the most dangerous of which are facial nerve injury during the extended preauricular incision and maxillary artery injury during condylectomy. The authors report a case of fracture of the temporal bone tearing the intratemporal portion of the facial nerve, resulting in a total facial nerve paralysis.     

Intraoral endoscopically assisted treatment of temporomandibular joint ankylosis: preliminary report

Temporomandibular joint (TMJ) ankylosis is characterized by the formation of a bony or fibrous mass that replaces the normal articulation. To avoid a possible re-ankylosis it is mandatory to perform a radical, complete resection of the bony/fibrous mass. We treated a patient affected by right temporomandibular joint ankylosis performing the osteotomy of the ankylotic mass through a preauricular and intraoral approach under endoscopic control. Then a temporalis muscle and fascia flap were used as the interpositional material. Through the endoscope it was easy to check the medial aspect of the resection and suture the flap. At 1-year follow-up the patient had significantly increased maximal mouth opening. No evidence of relapse of the joint ankylosis was shown by radiological studies. Intraoral endoscopic assistance may be useful to make the removal of the ankylotic mass safer, and the anchorage of the temporalis muscle and fascia flap more accurate, reducing the risk of re-ankylosis.     

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.     

Temporomandibular joint reconstruction with costochondral graft using modified approach

12 patients presenting with long standing temporomandibular joint (TMJ) ankylosis were treated with a costochondral graft inserted through a modified approach. The age of the patients ranged from 5 to 17 years. A preauricular incision was made for resection of the ankylosed condyle. After release of the ankylosis the contralateral rib was harvested with costal cartilage. An intra-oral incision was made along the external oblique ridge to the mucobuccal fold and was used for resection of the coronoid process and insertion and fixation of the graft. The graft was fixed with a minimum of three titanium screws. The patients were instructed to start physiotherapy 1 week postoperatively and were followed up clinically and radiographically using 3D CT. Postoperative results were encouraging, the graft took well in all patients without postoperative infection or graft rejection. The graft was properly positioned in all cases. There were no visible scars as the preauricular scar is relatively hidden, no possibility of damaging the facial nerve or the marginal mandibular branch and shorter operating time.     

Endoscopically assisted reconstruction of the mandibular condyle with a costochondral graft through a modified preauricular approach

We describe our experience with reconstruction of the mandibular condyle with a costrochondral graft (CCG). We retrospectively evaluated 122 patients with diagnoses including osteoarthrosis, ankylosis, tumours, idiopathic condylar resorption, comminuted condylar fracture, and chronic osteomyelitis of the temporomandibular joint (TMJ). We used a modified preauricular approach and an endoscopically assisted technique. The grafts were followed-up by computed tomograms (CTs) and magnetic resonance (MR) examinations. All patients had successful reconstruction of the mandibular condyle with a CCG. No patient had permanent weakness of the facial nerve or any other severe complication. With its wide range of indications, the endoscopically assisted reconstruction of the mandibular condyle with a CCG through a modified preauricular approach can produce good aesthetic and functional results while reducing operating time and tissue damage.     

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.     

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.     

髁突骨折分型及手术治疗50例临床分析

目的 研究出现移位和功能障碍的下颌髁突骨折的分型和疗效.方法 2007年7月至2010年7月,收治有骨折移位和功能障碍的下颌髁状突骨折的患者50例(69侧),依据骨折线的水平分为髁突囊内,髁突颈部和髁突下骨折,采用不同手术方法和固定方法进行治疗.术后3天、1个月、3个月、6个月、1年进行临床随访,从临床和影像学两方面评估术后恢复情况.囊内骨折根据杨驰教授的骨折线分类方法,将骨折分为分为A、B、C、M四型,回顾性分析不同类型手术的特点.结果 50例患者中获得3个月以上随访的48例(66侧),术后平均随访10.45个月,随访期末平均开口度33.89 mm(31.5~43.7 mm),8侧出现暂时性额纹消失,3个月后7侧恢复.术后总体满意度97.92%(47/48),仅1例骨折患者因1年后伴有颞区皮肤麻木和额纹消失不满意,其余无严重并发症出现.结论 对于发生移位和功能障碍的下颌骨髁突骨折分型的不同采取不同的手术方法可达到良好的治疗效果,但对术者的手术技巧和经验要求较高.     

Effect of limited jaw motion on ankylosis of the temporomandibular joint in sheep

The purpose of this study was to investigate the effect of limited movement of the jaw on ankylosis of the temporomandibular joint (TMJ). Eighteen adult sheep were divided into two groups. In Group 1, the temporal and condylar articular surfaces were removed together with the disc on the right. In Group 2, we did the same procedures but in addition the jaw movements were limited by a wire. One sheep was killed just after the operation, four at one month, and four at three months, in each group. The range of jaw movements preoperatively and at the time of death were recorded. The joints were examined radiologically, macroscopically, and histologically. We used a scoring system to assess the radiological changes and histological extent of ankylosis. At one month, the joint spaces were filled with fibrous tissue, but a small joint space existed in all four joints in Group 1. In Group 2, there was full ankylosis in two joints and partial ankylosis in two joints. At three months, similar ankylotic changes were seen in both groups. The histological score for ankylosis at one month showed that those in Group 2 were significantly more ankylosed than in Group 1 (P<0.01). The range of jaw movements was more limited at one month in Group 2, both vertically and to the left, and was significantly decreased in both groups (P<0.01) at three months. Limitation of jaw motion hastens the progress of TMJ ankylosis.     

改良耳颞切口在颞下颌关节手术中的应用

目的:评价改良耳颞切口在颞下颌关节手术中的效果。方法:回顾分析1998年7月～2002年11月间收治的72例颞下颌关节病患者,男性35例,女性38例,年龄4～72岁,平均年龄36.1岁。所有患者均采用改良耳颞切口及进路术式,于耳颞部行美容切口设计,先翻开耳前皮瓣,暴露颞浅血管分支,然后沿耳颞神经血管束前缘进入,向前下翻开颞深筋膜瓣,倒“L”形切开关节囊后暴露髁突。结果:72例患者中获得随访38例(49侧),随访期4～45个月,平均17.7个月。仅1侧右颞区皮肤麻木,3侧额纹消失,总体对手术切口满意度为97.4%(37/38),不满意1例为髁突骨折患者,术后8个月术区瘢痕仍很明显,伴有颞区皮肤麻木和额纹消失。结论:改良耳颞切口及进路是目前治疗颞下颌关节疾病的理想术式之一。     

Potential role of disc repositioning in preventing postsurgical recurrence of traumatogenic temporomandibular joint ankylosis: a retrospective review of 17 consecutive cases

The potential role of disc repositioning in preventing postsurgical recurrence of traumatogenic temporomandibular joint (TMJ) ankylosis was investigated. Seventeen cases of traumatogenic TMJ ankylosis underwent disc repositioning during arthroplasty. During surgery, the dislocated disc was carefully dissected outside the ankylotic TMJ and repositioned over the top of the condylar stump, and then sutured to the soft tissue of the zygomatic root. In the 22 ankylotic TMJs of the 17 patients, dislocated discs were found in front of the ankylotic TMJ, behind the ankylotic TMJ or between the ramus and fossa. At the last follow-up (longer than 1 year) examination, interincisal opening distances ranged from 24 to 43 mm (mean 32.86 mm). No recurrence and TMJ symptoms were found during the period of follow-up. Disc repositioning in the treatment of traumatogenic TMJ ankylosis proves to be a feasible and effective method of preventing recurrence of this condition.     

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.     

口内下颌骨升支垂直截骨倒置治疗颞下颌关节强直

目的：应用口内下颌骨升支垂直截骨倒置及耳前切口去除骨球关节窝成形术治疗颞下颌关节真性强直,评价其重建颞下颌关节的效果。方法：对5例颞下颌关节骨性强直患者切除病变区骨质,形成关节窝,采用口内下领骨升支垂直截骨倒置升支后部构造新的”髁突”,重建颞下颌关节。手术后常规随访,评价其疗效。结果：全部病例术后随访3～24个月,开口度3．1～4．1cm,平均开口度3．6cm,效果满意。结论：应用口内下颌骨升支垂直截骨倒置及耳前切口去除骨球关节窝成形术治疗颞下颌关节真性强直具有多方面优势,减少了并发症的发生,是治疗颞下颌关节真性强直的有效手术治疗方法。     

创伤性颞下颌关节强直的分类和治疗-84例临床资料分析

目的:探讨创伤性颞下颌关节强直以冠状CT为基础的分类和治疗方法。方法:选择2001—2009年上海交通大学口腔颌面外科关节组收治的创伤所致颞下颌关节强直84例(124侧)患者作为研究对象,所有患者术前、术后均进行CT扫描,关节区冠状重建,据此提出创伤性关节强直的4型分类,即A1～A4型。根据分类进行相应的治疗。A1型,纤维组织松解或髁突切除+肋骨移植+颞肌筋膜瓣修复;A2和A3型,切除外侧融合骨球,保留内侧髁突和关节盘+颞肌瓣或咬肌瓣外侧间隙填塞(外侧成形术),如果内侧髁突残余较小不能负重,骨球切除后用肋骨移植+颞肌瓣或咬肌瓣修复;A4型,切除全部骨球,肋骨移植关节置换+颞肌瓣或咬肌瓣修复。对治疗结果进行CT和临床随访评价。结果:84例124侧创伤性关节强直中,A1型14侧,占11.3%;A2型43侧,占34.7%;A3型46侧,占37.1%;A4型21侧,占16.9%。其中部分A1型,全部A2和A3型有内侧移位的髁突残余,占75%(93/124)。根据分类采用的治疗方式包括外侧成形术82侧,占66.1%;肋骨移植重建33侧,占26.6%;其他9侧,占7.3%。48例68侧关节强直术后随访10个月～4a,占57%。其中,48侧行外侧成形术的关节中有7侧复发,占14.6%;17侧行肋骨移植的关节中有4侧复发,占23.5%。结论:基于冠状CT的关节强直新分类对于临床治疗有重要指导意义。外侧成形术+颞肌瓣修复是治疗A2和部分A3型关节强直(内侧有足够承重的髁突和关节盘残余)的理想方法,肋骨移植+颞肌瓣修复治疗完全骨性强直效果良好。     

颞肌筋膜瓣联合冠突移植治疗颞下颌关节强直

目的:应用带蒂颞肌筋膜瓣联合冠突移植治疗颞下颌关节真性强直,评价其重建颞下颌关节的效果。方法:对6例颞下颌关节真性强直患者切除病变区骨质,形成骨间隙,采用带蒂颞肌筋膜瓣转移充填骨间隙和冠突切取植入构造新的“髁突”,重建颞下颌关节。手术后常规随访,评价其疗效。结果:全部病例术后随访4～28个月,开口度3.1～3.8cm,平均开口度3.5cm,效果满意。结论:带蒂颞肌筋膜瓣联合冠突移植治疗颞下颌关节真性强直具有多方面优势,是防止颞下颌关节术后复发的有效手术治疗方法。     

Report of ankylosis of the temporomandibular joint: treatment with a temporalis muscle flap and augmentation genioplasty

A case of true bilateral ankylosis of the temporomandibular joint (TMJ) is presented. A 19-year-old male patient had a life-threatening ear infection at the age of ten resulting in a progressive restriction of his mouth opening. He presented with almost complete lack of mobility of the mandible. Surgical treatment was a resection of the ankylotic mass, interpositional temporalis composite muscle flaps, and early mobilization and aggressive physiotherapy. The functional results of the interpositional arthroplasty were excellent. After a two-year follow up, an augmentation genioplasty was performed in order to improve facial aesthetics.     

Total reconstruction of the temporomandibular joint. Up to 8 years of follow-up of patients treated with Biomet® total joint prostheses

12 patients underwent temporomandibular joint (TMJ) reconstruction with Biomet total joint prostheses. Indications for TMJ reconstruction included ankylosis, rheumatoid arthritis, degenerative joint disease and condylar resorption. Five patients had unilateral procedures, seven had bilateral. The follow-up ranged between 2 and 8 years. Amongst the ankylotic patients the mean jaw-opening capacity increased from 3.8 mm preoperatively to 30.2 mm 1 year after surgery, and in most of those patients the opening capacity remained stable over the years. The other patients maintained a mean opening capacity of more than 35 mm. Joint related pain and interference with eating were eliminated after TMJ reconstruction. There were no permanent facial nerve disturbance, no postoperative infections and no device related complications. The outcome supports prosthetic TMJ reconstruction as a useful treatment modality in patients with advanced TMJ disease.     

罕见右侧颞下颌关节骨性强直伴同侧颌面部广泛异位骨化1例及文献复习

目的:回顾分析颞下颌关节骨性强直伴颌面部异位骨化的发病原因、临床表现及诊治方法。方法:回顾性分析2017-04就诊于遵义医科大学附属口腔医院的1例右侧颞下颌关节骨性强直伴颌面部广泛异位骨化的病例资料,并结合文献复习分析其发病原因,总结其特征临床表现、诊断及治疗原则。结果:根据临床表现及影像学检查结果,该患者被确诊为右颞下颌关节骨性强直伴颌面部异位骨化,无明确外伤史。采用“右关节成形术+牵张成骨+异位骨化部分切除术”治疗,术后张口度恢复正常,面型稍有改善。出院时主动张口约2.0 cm,被动张口可达3.0 cm。嘱患者使用开口器积极张口训练并同期进行下颌骨牵张成骨,但患者配合度较差。患者于术后4个月再次出现进行性张口受限,颌面部异位骨化增多;于术后5个月取出牵张器,同时行关节强直松解术,术中可被动张口2.5 cm;但术后再次出现进行性张口受限,颌面部异位骨化继续增多,患者放弃治疗。结论:颞下颌关节骨性强直伴颌面部广泛异位骨化在临床上较为罕见,可能的病因有外伤、遗传等。依据影像学检查可明确诊断,治疗以手术为主。如何在行关节成形的同时治疗颌面部的广泛异位骨化是临床上的难题。