Ankylosis Patients Research Articles

Assessment of the role of coronoid in restrictive jaw disorders and physiologic mandibular movements

Introduction: Restricted mouth opening has major health implications, such as malnutrition, difficulty in speech, and poor oral hygiene resulting in a functional shortage of the masticatory system. Reduced mouth opening can occur due to trismus, as in the oral submucous fibrosis (OSMF) condition. Excision of fibrous bands in OSMF leads to reestablishment of the mouth opening. Other than trismus, temporomandibular joint (TMJ) ankylosis is another common condition that causes fibrosis or bony ankylosis between articular surfaces. Coronoidectomy is a useful procedure that various authors nowadays apply. It is the most popular surgical procedure used as a conventional method of treatment, which includes the detachment of temporalis muscle. Materials and Methods: A group of 15 patients with OSMF and TMJ ankylosis with written informed consent were selected for the study and were operated on under general anesthesia. Preoperative and postoperative assessment was done for bite force management, measuring and comparing mandibular movements, and the electromyography (EMG) study. Results: Statistical analysis shows the increase in maximum mouth opening and lateral excursions in OSMF and TMJ ankylosis patients on the seventh, 15th, 90th days, and six months postoperatively treated either without coronoidectomy and with coronoidectomy; however, there was no significant difference was found in mean EMG and bite force readings in both groups. Conclusion: The present study concludes that the coronoidectomy not only increases the mouth opening, but masticatory efficacy is also improved with an increase in mandibular movements postoperatively in patients with OSMF and TMJ ankylosis.

Elucidation of Factors Influencing Spinal Ankylosis in Patients with Axial Spondyloarthritis.

Spondyloarthritis encompasses conditions such as ankylosing spondylitis (AS) and psoriatic arthritis (PsA). Advanced axial spondyloarthritis causes significant spinal fusion, affecting daily activities. Recent therapeutic agents have enhanced the control of inflammation, yet they do not consistently stop the axial progression. This study aimed to identify factors influencing the progression of axial lesions over a two-year period in Japanese patients with axial spondyloarthritis. This retrospective and cross-sectional study included 47 axial spondyloarthritis patients. Spinal lesions were assessed using the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). Patients were categorized into progressive and non-progressive groups based on changes in their mSASSS scores. Various clinical parameters were analyzed for correlation with ankylosis progression. The study found no significant correlation between ankylosis progression and traditional factors, including the level of inflammation or the use of biologics. However, modified Health Assessment Questionnaire (mHAQ) scores were associated with disease progression. The baseline mSASSS was another significant factor, underscoring the importance of early detection and management. This study showed that patient-reported outcomes and baseline mSASSS scores are crucial for assessing axial spondyloarthritis progression. This underscores the need for a comprehensive treatment strategy that addresses both clinical indicators and patient-reported outcomes.

Comparison of Surgical Techniques for Correction of Mandibular Asymmetry in TMJ Ankylosis Patients.

Temporomandibular joint (TMJ) ankylosis frequently results in mandibular asymmetry, which impairs an affected person's ability to function and look good. Because of the intricacy of TMJ ankylosis and the variety of surgical procedures available, correcting mandibular asymmetry surgically can be difficult. Patients with mandibular asymmetry and TMJ ankylosis who had surgery at a tertiary care facility between certain periods were the subject of a retrospective investigation. Medical records were used to gather information on patient demographics, pre-operative imaging, surgical methods, and post-operative results. Surgical methods included condylectomy with or without reconstruction, joint reconstruction with or without orthognathic surgery, and unilateral or bilateral mandibular distraction osteogenesis (MDO). Occlusion, patient-reported results, and facial symmetry made up the evaluation criteria. The study had a total of 50 patients, with different surgical method distributions. Comparing unilateral and bilateral MDO to condylectomy and joint reconstruction, notable gains in face symmetry and occlusion were seen. The largest complication rate was seen with condylectomy, mostly from recurrence and device-related issues, albeit the rates of other procedures varied as well. In conclusion, customized treatment planning is necessary for the correction of mandibular asymmetry in individuals with TMJ ankylosis. Although mandibular distraction osteogenesis produces better results for occlusion and facial symmetry, it is crucial to carefully weigh the risks involved. While still feasible treatments, condylectomy and joint reconstruction require strict monitoring for any consequences. In order to enhance patient care in this difficult patient group, future research should concentrate on improving treatment procedures and long-term results.

Variations in the Position of Mandibular Foramen in Temporomandibular Ankylosis Patients.

To evaluate the variation in the position of the mandibular foramen and mandibular canal in patients with and without temporomandibular joint ankylosis. 100 temporomandibular joints were evaluated of which 50 joints were ankylosed joints (Group A) and the rest 50 were normal joints (Group B) without ankylosis. These groups were further divided into those with growing potential (less than 18years) and those without growing potential (above 18years). The position of the mandibular foramen was measured from its center to the glenoid fossa, sigmoid notch, coronoid notch, gonion and posterior border on CBCT scans. The position of the mandibular canal was measured from the outer aspect of the canal to the lower border of the mandible, buccal and lingual cortical plates and the alveolus in the region of the 1st, 2nd and 3rd molars. The mean distance of the foramen from the base of the skull in Group A was 19.01mm while the same for Group B was 31.26mm. The mandibular foramen was found to be closer to the occlusal plane (5.43mm) in Group A as compared to the mean distance of 6.21mm reported in Group B. There was no significant difference in the position of the foramen from the posterior border, gonion and sigmoid notch between the groups. The mental foramen wasseen more commonly posterior to the 2nd premolar and closer to the first molar region in Group A while in Group B it was seen anterior or near the 2nd premolar. In Group A, the mean distance of the canal to the buccal cortical plate in the 1st and 2nd molar regions was 3.65mm and 5.76mm, respectively, while in Group B it was 6.09mm and 6.59mm. The canal was further away from the lower border in ankylosis cases (8.79mm) than the control group (7.41mm). On comparing the unaffected side in unilateral cases with the normal mandible, the canal and the foramen location were similar to that of a normal mandible with the values in the lower range that is usually seen in normal mandibles. Ankylosis of the mandible is a debilitating condition especially when it develops in an individual prior completion of growth as it can affect the mandibular anatomy. Understanding the variations that accompany a deranged mandible can assist the surgeon in planning of surgical procedures in a manner that limits the possible complications resulting from surgery.

A novel solution for the patient with knee ankylosing spondylitis: a case report

Link of Video Abstract: https://youtu.be/wskQdvBx0c0 Background: Knee ankylosis is a joint condition that causes functional limitation that becomes more severe when accompanied by pain. Arthroplasty is a complex and intricate reconstruction procedure that is more challenging when there is a structural limitation that requires a technique modification. In this report, we presented a rare case of a young patient with knee ankylosis and flexion contracture treated with arthroplasty. Case Presentation: A 20-year-old young woman came to the hospital with stiffness in her left knee, inability to sit well and crouch, and difficulty getting up from sitting. Based on the physical examination and X-ray of the left knee, the patient showed bone ankylosis on the femorotibial joint with a 100 flexion, which confirmed knee ankylosis. Arthroplasty was performed with a parapatellar medial approach. After eight months of supervision, the patient was able to perform an active flexion within 1050 and a full extension on the left knee. In our patient, arthroplasty brought a satisfying functional outcome and pain reduction, which was also supported by previous studies with the same procedure on ankylosis patients. Conclusion: Arthroplasty can be considered the main therapy option for joint deformities due to its more satisfying outcomes.

Anaesthetic Management in A Case of Temporomandibular Joint Ankylosis Using A Newer Bronchoscope-Ambu Ascope

We are presenting a case report of anaesthetic management in a case of temporomandibular joint (TMJ) ankylosis with an intraprocedural finding of choanal atresia in a 17yr old male posted for elective lateral gap arthroplasty. Anticipated difficult airway in TMJ ankylosis patients has always made the surgeon to be cautious during airway management, adding on problem like choanal atresia made the intubation even more difficult. Hence, reporting the management of such difficulties with different approach, in which serial dilatation of nostrils using nasogastric tubes and nasal airway, then endotracheal tube was passed through one nostril and bronchoscope through other nostril.

Prevalence and Associated Factors of Facet Joint Ankylosis in Patients With Axial Spondyloarthritis.

To investigate the prevalence of facet joint ankylosis in the whole spine in axial spondyloarthritis (axSpA) using low-dose computed tomography (LDCT), and to identify factors associated with facet joint ankylosis. Whole spine LDCT images from 161 patients with axSpA were examined, and the presence of facet joint ankylosis was assessed (right and left, C2-S1) by 2 readers. Facet joint ankylosis was scored from 0 to 46. Structural damage of vertebral body was assessed using CT Syndesmophyte Score (CTSS). Factors associated with ankylosed facet joint scores for the whole spine were identified using a generalized linear model with a negative binomial distribution. Seventy-nine patients (49%) and 70 patients (43%; reader 1 and reader 2, respectively) had ≥ 1 ankylosed facet joint. Facet joint ankylosis was most common in the thoracic spine. The mean score of facet joint ankylosis for the whole spine was 6.6 (SD 11.2) in reader 1 and 4.2 (SD 8.4) in reader 2. Whole spine facet joint ankylosis score positively correlated with Ankylosing Spondylitis Disease Activity Score (ASDAS) and CTSS. In multivariable analysis, the ankylosed facet joint score was associated with ASDAS, sacroiliitis, CTSS, and a history of uveitis in both readers. Uveitis history, ASDAS, and CTSS were associated with whole spine facet joint ankylosis score in subgroup analysis of only radiographic axSpA. The prevalence of ankylosed facet joints is high in axSpA, especially in the thoracic segment. The whole spine ankylosed facet joint score is significantly associated with a history of uveitis, ASDAS, sacroiliitis, and syndesmophyte score.

Comparative evaluation of temporal fascia and dermal fat graft in the management of temporomandibular joint ankylosis.

Temporomandibular joint (TMJ) ankylosis is a debilitating condition usually afflicting children and young adults, causing long-term functional, aesthetic, and severe psychological impacts on the lives of these patients. To compare the postoperative outcomes after using one of the most commonly employed inter-positional graft, i.e., temporalis fascia, and a recently introduced 'more suitable' graft, i.e., dermal fat. A prospective study in which 20 patients of TMJ ankylosis were randomly assigned into two groups of 10 patients each. Temporalis fascia was used as an inter-positional graft in one group, while dermal fat graft was used in the other group. Post-surgical clinical parameters were evaluated, including interincisal mouth-opening and pain. Interincisal mouth opening at six months was greater in group A (32.1 ± 12.93) as compared to group B (33.8 ± 4.89), but statistically, it was not significant (P = 0.478). The mean pain score in group A was 4.60 ± 1.17, 1.50 ± 0.70, 0.20 ± 0.42 on day 1, 7, and 15, respectively. The mean pain score in group B was 4.10 ± 0.99, 1.30 ± 0.48, 0.20 ± 0.42 on day 1, 7, and 15, respectively. Both the graft materials work well in terms of maximum interincisal opening. For more clarification, a larger sample size with a longer duration of follow-up is needed to validate the study.

EFFECT OF MANDIBULAR DISTRACTION OSTEOGENESIS ON AIRWAY IN PATIENTS WITH TEMPOROMANDIBULAR JOINT ANKYLOSIS

Objectives: The purpose of this study was to clinically and cephalometrically evaluate the pharyngeal airway following mandibular distraction osteogenesis in patients with TMJ ankylosis and retrognathic mandible.
 Materials and Methods: A total of 10 patients were included in this study. These patients were thoroughly evaluated pre-operatively and post-operatively both clinically and radiologically using McNamara analysis allowing comparison of pre-op and post-op findings.
 Results: Out of 10 patients seven were females while three were male (Mean age 13.40 ±5.358 SD). Mean pre-operative UPPER airway width was 6.20±3.155 SD as compared to mean Post-operative upper airway (7.30±2.907 SD) with a statistically significant p-value (0.003). Mean pre-operative LOWER airway width was 4.90±1.969 SD as compared to mean Post-operative lower airway (7.10±2.9282 SD) with a statistically non-significant p-value (0.013). There was a negative correlation between post-operative lower airway and age (r= -0.26, sig=0.48).
 Conclusion: Mandibular distraction Osteogenesis can be used successfully in TMJ ankylosis patients with retrognathic mandible for the improvement of pharyngeal airway dimensions and relief from symptoms of obstructive sleep apnea due to decreased pharyngeal space.

How does changing the vector of transport disc distraction affect the outcomes of surgery in patients of temporomandibular joint ankylosis with obstructive sleep apnea?

Temporomandibular joint ankylosis (TMJA) in children is associated with retrognathia, reduction in pharyngeal airway volume (PAV), and obstructive sleep apnea (OSA). Distraction-osteogenesis (DO) is the proven method in the management of OSA. There is paucity in literature about the effect of distraction vector on PAV. It can be expected that an oblique vector would improve PAV and relieve OSA. Thus, the study was designed to explore the feasibility, advantages, and disadvantages of this modified technique for managing TMJA and OSA simultaneously. The investigators designed a prospective study on patients of TMJA with retrognathia. Ethical approval was obtained (IECPG-547/14.11.2018). In all patients, simultaneous ankylosis release and mandibular distraction were performed. Primary outcome variables were improvement in 3-dimensional (3D) PAV and maximal interincisal opening (MIO). Secondary outcome variables were changed mandibular length, distraction relapse, and re-ankylosis. Paired t-test and multivariate ANOVA were used to assess all the parameters. The study included 13 joints in 8 patients of TMJA with retrognathia (2 unilateral and 6 bilateral ankylosis) with mean age of 14.25 ± 7.37years. Mean distraction performed was 19 ± 4.0mm. There was a statistically significant improvement of PAV by 225% (p = 0.002), a reduction in Epworth's scale (p = 0.017), an increase in MIO (p = 0.001), and an increase in mandibular length. Three patients had re-ankylosis at the 25-month follow-up. The results of the present study conclude that modification of distraction vector improves 3D PAV and MIO in TMJA patients, with the added advantage of a reduction in overall treatment time and improved patient compliance.

Distraction Osteogenesis for Mandibular Ramus lengthening in Temporomandibular Joint Ankylosis Patients simultaneously with Interposition Gap Arthoplasty

Temporomandibular joint ankylosis is the most common cause of facial deformity.1-4The main etiology of TMJ ankylosis include trauma and infection3,5.TraditionallyTemporomandibular joint Ankylosis patients had been managed with different treatment options including Gap arthoplasty6,Interpositiongap arthroplasty ,distraction osteogenesis and total joint replacement.To prevent reankylosis interposition of fascia or muscle had been documented and if reconstruction of the joint was needed Alloplastic(sialistic)or Autogenous graft ( Costochondral bone graft) had been used.6, 7,8,9 Costochondral graft is preferred for reconstruction because morphological it is similar to the condyle of mandibleandhas agrowth capacity.9But thisgraft is unpredictable in nature and different results are reported and documented including facial asymmetry, over growth, graft resorption, graft failure and even reankylosis.9 Distraction osteogenesis is a recent treatment method for the correction of hypo plastic mandible in Temporomandibular joint ankylosis patients. By using distraction osteogenesislarge skeletal movements are possible with little or no relapse commonly seen in other orthognathic corrections. In this study of 30 patients all patients were treated with TMJ Interposition gap arthoplasty (interposition of temporalis fascia) followed by the application of distractors at ramus of mandible. Mean age was14.96±4.17 years. Patient’s minimum and maximum age was 8 and 24 years respectively. Gender distribution shows that 15(50%) of the patients were male and 15(50%) were females. Male to female ratio was 1:1.Mean ramus length before distraction was 38.70±7.28 mm with 28-52 mm range. Mean ramus length after distraction osteogenesis was 49.00±8.01 mm. Mean increase in vertical ramus length was 10.26±2.86 mm. Minimum increase was 5mm and maximum increase in vertical ramus length was 15 mm respectively. In this study we were able to achieve increase in ramus length in all patient and only patient require reoperation due to failure of distractor appliance which was replaced successfully.

EFFECTS OF TEMPOROMANDIBULAR JOINT ANKYLOSIS ON DENTITION AND RAMUS HEIGHT

Objective:To determine dentition related problems in patients with TMJ ankylosis and to establish effect of TMJ ankylosis on ramus height.Material and method:This descriptive study was conducted at Khyber College of Dentistry, Peshawar Pakistan, from July 2020 to July 2021. Medical records and Cone beam computed tomography of 20 patients with the diagnosis of temporomandibular joint ankylosis were included in the study.Results: Most of the patients presented with unilateral TMJ ankylosis (n=15, 75%) In unilateral ankylosis, the affected side ramus and body (4.89cm, 7.63cm respectively) were less than the non-affected sides (5.54cm, 8.15cm) respectively. Dentition crowding with malposed teeth was present in all bilateral TMJ ankylosis patients and 9 patients in unilateral cases. Conclusion:This study established the effect of TMJ ankylosis on the dentition and ramus height. The height of the ramus was deficient on the affected side and the erupted teeth were crowded in most of the patients.

Abstract No.: ABS3164 : Awake fiberoptic intubation in paediatric patients with temporomandibular joint ankylosis

Background and Aims:Endotracheal Intubation in temporomandibular joint (TMJ) ankylosis is considered as difficult airway manaegment. Fibreoptic intubation is the gold standard for TMJ ankylosis.Methods:In the present study 30 patients aged 5 -14 yrs were enroled for awake fiberoptic intubation [Table 1]. The procdure of awake fiberoptic intubation was explained to them. Patients were preoxygentaion for 5 min using nasal airway. All patient xyolcaine jelly was inserted in more patent nostril and nostril and 1% inj xylocaine was injected trans-tracheal. Following this trachea was intubated using fiber optic intubation. The correct placement of tracheal tube was confirmed with chest auscultation and and endtidal carbondioxide monitoring.Table 1Age of the patients enroled for awake fiberoptic intubation in temporomandibular joint ankylosis n Age 5-7 years18 8-10 years8 10-14 years 4Results:Out of 30 patients,three patients could not be intubated and tracheostomy was done in one patient and in two patients surgery was postponed. In these 2 patients surgery which was done after two weeks using fiberoptic intubation successfully using spontaneous ventilation with oxygen in sevoflurane.Conclusion:The use of awake fiberoptic intubation after explaining to patients and parents resulted in successful outcome in patients of TM ankylosis.

Longitudinal changes in electromyographic activity of masseter and anterior temporalis muscles before and after alloplastic total joint replacement in patients with temporomandibular ankylosis: a prospective study

The purpose of the study was to evaluate the longitudinal changes in electromyographic (EMG) activity of the masseter and temporalis muscles before and after temporomandibular joint (TMJ) total joint replacement (TJR) in ankylosis patients. A prospective longitudinal study was designed on patients undergoing unilateral or bilateral TMJ-TJR. EMG activity at rest and maximal voluntary contraction (MVC) was recorded for the muscles preoperatively (T0), and at one-week (T1) and six-month (T2) follow up. The study sample was composed of 10 (male: female 2.3:1) patients undergoing TMJ-TJR. The number of unilateral and bilateral cases was three and seven, respectively. In both unilateral and bilateral cases a statistically significant reduction in EMG activity of the masseter and anterior temporalis muscles was observed at T1. At T2, EMG activity of the muscles was found to be approaching the preoperative value. In unilateral cases, when the affected side at T0, T1, and T2 was compared with T0 for the unaffected side, statistically significant differences were seen for the masseter. In the case of the temporalis, similar results were seen except at T2 for the postural rest position. The results indicate that re-attachment of the masseter and temporalis muscles occurs progressively post TMJ-TJR.

Role of Magnetic Resonance Imaging in Temporomandibular Joint Ankylosis - An Evaluative Study.

IntroductionTemporomandibular joint (TMJ) ankylosis is a pathologic condition where the mandible is fused to the fossa by bony or fibrotic tissues. Haemorrhage is one of the major complications during TMJ surgery especially in ankyloses due to altered anatomy. The aim of the study was to analyse the proximity of the vasculature to the TMJ region in TMJ ankylosis patients using magnetic resonance imaging (MRI)Materials and Methods:Noncontrast-enhanced MRI images of seven patients were assessed. The distance between maxillary artery and neck of condyle/ankylotic mass was measured using coronal sections and distance between the internal carotid artery (ICA), internal jugular vein (IJV) and medial edge of condyle/bony mass were measured using axial sections.Results:The mean distance of internal maxillary artery (IMA) to medial edge of ankylotic mass was 1 ± 0.57 mm and 2 ± 1.2 mm-left and right condylar regions respectively (range: 0–4 mm).The mean distance from lateral aspect of ankylotic mass to IMA was 8.2 ± 1.4 mm and 8.7 ± 2.8 mm–right and left condylar regions respectively (range: 3–11 mm).The mean distance from medial edge of condyle to ICA was 18.8 ± 1.3 mm and 18.2 ± 1.1 mm-right and left condylar regions respectively (range: 17 mm–20 mm).The mean distance from the medial edge of condyle to IJV was 16.4 ± 1.1 mm and 14.5 ± 2.9 mm-right and left condylar regions (range: 11 mm–19 mm).Discussion:These measurements were used as a guide to plan the steps during surgery in order to minimise the intraoperative haemorrhagic complications. Hence, MRI may be considered as a valuable tool in assessing the juxtaposition of vascular bed to TMJ region, though contrast MRI and a larger sample is needed to standardise.

Perioperative trigeminocardiac reflex in patients undergoing surgical treatment of temporomandibular joint ankylosis: A study.

Purpose:The behavior of trigeminocardiac reflex (TCR) is limited to few case reports only in maxillofacial surgery, especially for temporomandibular joint (TMJ) ankylosis cases. The present study aims to find out the incidence of bradycardia due to TCR during intraoperative forceful mouth opening in TMJ ankylosis patients.Materials and Methods:A prospective, unicentric observational study was conducted selecting those patients who were planned for osteoarthrectomy with interpositional gap arthroplasty under general anesthesia. Sixty cases of TMJ ankylosis were randomly selected from December 2018 to-03-2020. Predictor variables were patient age, gender, and type of ankylosis, and outcome variables were pulse rate, mean arterial blood pressure (MABP), and oxygen saturation level (SPO2). Data were recorded at baseline and during intraoperative mouth opening via heister jaw stretcher. A Chi-square test was used for testing the association between variables. P values were considered statistically significant at <0.05.Results:The sample size of 60 subjects has been divided into two age groups (10–19) years and (20–40) years. The mean standard deviation age of the patients was 18.32 ± 6.81 years. About 63.3% were male. Out of 60 cases, 14 patients developed bradycardia. The frequency of bradycardia was found 23.3%. According to logistic regression analysis, age and type of ankylosis were the significant predictors of bradycardia.Conclusion:We conclude that bradycardia due to TCR in TMJ ankylosis patients is not an uncommon entity. Incidences are more prevalent in the age group of 10–19 years and type IV bony ankylosis. Male had a high incidence of bradycardia though P value was nonsignificant.

Do simultaneous mandibular advancement and temporomandibular joint prosthesis impact the upper airway in TMJ ankylosis patients?

BackgroundAnkylosis of the temporomandibular joint (TMJ) is a pathological disorder which results in patients’ limited or even complete failure of mouth opening. When TMJ ankylosis occurs during the growing age, moderate to severe micrognathia might be the proposed scenario of such cases, accompanied by obstructive sleep apnea and hypopnea syndrome (OSAHS). TMJ reconstruction using total TMJ prostheses with mandibular advancement (MA) can simultaneously improve the function and aesthetic profile of such patients. The purpose of this study was to determine whether the upper airway can be improved after TMJ reconstruction with total TMJ prostheses combined with or without MA in TMJ ankylosis patients.MethodsFourteen patients with pre-(T1) and post-(T2) operative CT scans were included. Patients were divided into two groups according to the operation with or without MA (MA/WoMA). The changes of the upper airway and jaw bones were comparatively analyzed within and between the two groups.ResultsIn MA Group, the volume of the total upper airway (Vt) and palatopharynx (V1), together with the surface area (SA) of the total upper airway (SAt) and palatopharynx (SA1) increased significantly after the operation by 41.4%, 43.2%, 36.3% and 36.6%, respectively. In WoMA Group, V1, SAt and SA1 increased significantly by 21.0%, 19.0% and 23.1% following surgery. The changes of Point B (P<0.01), Y-axis angle (P<0.01), SNB (P<0.01), and ANB (P<0.01) were significantly greater in MA Group than in WoMA Group. Comparing both groups, the maxilla, and mandible were more backward in MA Group than in WoMA group before the operation, but there was no significant difference of the final position of the maxilla and mandible after the operation between both groups.ConclusionsRelease of TMJ ankylosis and condylar reconstruction using total joint prostheses simultaneously with MA could significantly improve the total volume and other various parameters of the upper airway, while, only the dimension of the palatopharynx increased in cases without MA.

Management of Bilateral Temporomandibular Joint Ankylosis and Class 2 Malocclusion in a Patient With Nager Syndrome

Nager syndrome is a rare hereditary syndrome characterized by severe mandibulofacial and pre-axial upper limb anomalies. Patients with Nager syndrome often exhibit syndromic Pierre-Robin sequence secondary to their hypoplastic mandible and require mandibular distraction osteogenesis to prevent dependence on a tracheostomy or gastric tube. This procedure, however, has been associated with temporomandibular joint (TMJ) ankylosis. TMJ ankylosis is a highly debilitating condition that dramatically impairs patients’ function and can result in facial asymmetry in affected children during periods of rapid facial growth. Surgical intervention is warranted in patients who fail physiotherapy; however, there is no gold standard treatment for surgically correcting TMJ ankylosis in patients with Nager syndrome. Herein, we detail the surgical management of TMJ ankylosis and class 2 malocclusion in a patient with Nager syndrome.

Autogenous Grafts for Condylar Reconstruction in the Treatment of Temporomandibular Joint Ankylosis

Background: Temporomandibular joint (TMJ) ankylosis is distinguished by complexity or failure to open the mouth, leading to facial asymmetry, and malaligned teeth due to fusion of temporal bone with mandibular condyle. Objective: The present review aimed to discuss the different options of condylar reconstruction in TMJ ankylosis patients by autogenous grafts as reported in previous studies. Materials and Methods: A wide-ranging electronic search was performed by the following electronic databases: PubMed (Central), Hinari, and Google Scholar. A total of 25 full-text articles were found to meet the inclusion criteria and were reviewed for qualitative analysis in this study. Results: Surgery with or without condylar reconstruction is the only treatment alternative for TMJ ankylosis patients. Removal of ankylotic mass followed by condylar reconstruction with different existing autogenous grafts such as costochondral (CCG), sternoclavicular (SCG), coronoid, and metatarsal are done by surgeons. However, the costochondral graft is a preference by most surgeons due to its easy accessibility and adaptation. Distraction osteogenesis (DO) provides fewer complications with excellent efficient results in TMJ reconstruction. Conclusions: Up till now, any of the autogenous grafts for condylar reconstruction are not ideal for rebuilding the TMJ complex anatomy. CCG is still now the main choice for surgeons to reconstruct the TMJ in pediatric patients. DO has become popular recently.

Growth Outcome and Jaw Functions Are Better After Gap Arthroplasty Plus Costochondral Graft Reconstruction Than Gap Arthroplasty Alone in Pediatric Temporomandibular Joint Ankylosis Patients: A Cluster Randomized Controlled Trial

It is not known if the muscle matrix that becomes functional after gap arthroplasty (GA) in temporomandibular joint ankylosis (TMJA), induces growth of the mandible or the reconstructive arthroplasty with costochondral graft (CCG) is responsible for growth. The study aimed to evaluate the mandibular growth and functional outcome with the use of CCG/GA in the management of pediatric TMJA. The investigators designed a cluster randomized controlled trial on pediatric (3 to 16 years) TMJA patients. Treatment applied (CCG and GA), was the primary predictor variable. Patients were divided into CCG and GA groups. The primary outcome variable was growth. Secondary outcome variables included etiology and duration of ankylosis, maximal incisal opening (MIO), reankylosis, occlusion, laterotrusion, chin deviation, facial asymmetry, occlusal tilt, and complications. The distance condylion (Co) to gnathion (Gn) was used to measure mandibular length. Ramal height was measured from Co- gonion (Go). Lower facial height was measured from the anterior nasal spine to Gn. Generalized estimating equations were used to calculate the regression coefficient adjusted for the cluster. The patient was considered as a cluster and the unit of analysis was joint. Fifty-six {n=28 in each group, (n=33 joint in the CCG group and n=31 joints in GA group)} patients were analyzed. The median follow-up was 33-months (31.93 ± 15.24) in the CCG group and 32-months (32.85 ± 17.84) in the GA group. Intergroup comparison between the CCG and GA group showed a statistically significant difference in mandibular length (CCG=77.51 ± 9.31 and GA=66.66 ± 8.32 mm, P < .001), ramal height (CCG=44.21 ± 7.3 and GA=31.87 ± 8.4 mm, P < .001), and statistically insignificant difference in lower facial height (CCG=52.53 ± 6.1 and GA=50.19 ± 6.3 mm, P=0.14) at follow-up. Statistically, significant improvement was seen in MIO in both groups (<.001). The results of the present study concluded that growth and jaw functions were better in reconstructive arthroplasty with CCG than GA in pediatric TMJA.