Interpositional Gap Arthroplasty Research Articles

Bilateral fibro-osseous TMJ ankylosis in Marie-Strumpell disease: a case report

Reporting a case of bilateral fibro-osseous TMJ ankylosis in Marie-Strumpell disease. Managed with interposition gap arthroplasty with temporalis myofacial flap. Marie-Strumpell disease or ankylosing spondylitis is a chronic inflammatory disorder affecting predominantly the axial skeleton although peripheral joint involvement may be a significant feature. Temporo-mandibular joint involvement in ankylosing spondylitis varies from 4% to 35%. A 53-year-old male patient reported to our department with a chief complaint of difficulty in opening his mouth and difficulty in eating food. The case was diagnosed as a case of bilateral fibro-osseous TMJ ankylosis associated with ankylosing spondylitis. The individual was managed with aggressive resection of ankylotic segments and inter-position of the temporalis myofascial flap bilaterally with early mobilization and aggressive physiotherapy. Aggressive resection of the ankylotic mass with inter-positional gap arthroplasty with early mobilization and aggressive physiotherapy is a highly effective and safe surgical management option for the management of TMJ ankylosis and with acceptable immediate and long-term outcome with minimum re-ankylosis and have produced satisfactory mandibular movements.

Pedicled Tragal Chondral Flap for Interpositional Gap Arthroplasty in a TMJ Ankyloses.

Interpositional gap arthroplasty has shown good results; however, these techniques could be improved by taking into account the biological bases of the tissue used. Therefore, we suggest the pedicled tragal chondral flap as a safe, simple, and low-morbidity alternative.

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.

Autogenous Fat as an Ideal Interpositional Material in Temporomandibular Joint Surgery.

Interpositional gap arthroplasty has established itself as the the standard surgical treatment of Temporomandibular joint (TMJ) ankylosis. The autogenous tissue has replaced the alloplastic and other xenografts materials owing to its bioavailability, easy uptake, and no additional cost. Commonly used autogenous tissue has been temporalis muscle and fascia, fascia lata, skin graft, auricular and costal cartilage, the masseter and/or medial pterygoid muscle. With the turn of the century, TMJ surgeons started using autogenous fat from the lower abdomen and today it has taken over as the most favored autogenous filler material in TMJ ankylosis surgery or total joint replacement (TMJ-TJR). The use of buccal fat pad (BFP) has increased in the last decade due to its local availability and pedicled nature. This paper will discuss various autogenous tissues used in interposition and bring forth the journey of the autogenous fat as the preferred interpositional material now and rest the case in its favor.

Surgical navigation system for temporomandibular joint ankylosis in a child: a case report

BackgroundComputer-assisted surgical navigation systems were initially introduced for use in neurosurgery and have been applied in craniomaxillofacial surgery for 20 years. The anatomy of the oral and maxillofacial region is relatively complicated and includes critical contiguous organs. A surgical navigation system makes it possible to achieve real-time positioning during surgery and to transfer the preoperative design to the actual operation. Temporomandibular joint ankylosis limits the mouth opening, deforms the face, and causes an increase in dental caries. Although early surgical treatment is recommended, there is controversy regarding the optimal surgical technique. In addition, pediatric treatment is difficult because in children the skull is not as wide as it is in adults. There are few reports of pediatric temporomandibular joint ankylosis surgery performed with a navigation system.Case presentationA 7-year-old Japanese girl presented severe restriction of the opening and lateral movement of her mouth due to a temporomandibular joint bruise experienced 2 years earlier. Computed tomography and magnetic resonance imaging demonstrated left condyle deformation, disappearance of the joint cavity, and a 0.7-mm skull width. We diagnosed left temporomandibular joint ankylosis and performed a temporomandibular joint ankylosis arthroplasty using a surgical navigation system in order to avoid damage to the patient's brain. A preauricular incision was applied, and interpositional gap arthroplasty with temporal muscle was performed. After the surgery, the maximum aperture was 38 mm, and the limitation of the lateral movement was eliminated.ConclusionsA navigation system is helpful for confirming the exact target locations and ensuring safe surgery. In our patient's case, pediatric temporomandibular joint ankylosis surgery was performed using a navigation system without complications.

Analysis for different functional results of TMJ ankylosis management by comparing ramus-condyle unit reconstruction using vertical ramus osteotomy and interpositional gap arthroplasty

The objective of the present study was to analyze the functional results of temporomandibular joint (TMJ) range; that is, trismus index, lateral excursion, protrusion, retrusion, occlusion, masticatory efficiency), reestablishment of the anatomic relationship of the TMJ, aesthetics to improve quality of life, and complications in terms of ramus shortening on the affected side, deviation, facial asymmetry, neurologic deficits, and reankylosis. Sixteen patients with unilateral bony ankylosis were included and randomly divided into 2 groups with 8 patients in each group. Group I was treated with interpositional gap arthroplasty followed by reconstruction of the ramus-condyle unit using vertical ramus osteotomy. Group II was treated with interpositional gap arthroplasty. In both groups, a pedicled flap made up of fascia, temporalis muscle, and pericranium was used as an interpositional material. The functional range of the mandible was analyzed pre- and postoperatively. Group I improved significantly more than group II in terms of TMJ range; that is, trismus index, lateral excursion, protrusion, retrusion, reestablishment of the normal anatomic relationship of the TMJ, aesthetics, and masticatory efficiency. The reestablishment of anatomic relationship showed better result in mastication significantly. No reankylosis was reported in any of the groups. The functional results and aesthetics with TMJ reconstruction are significantly better.

Modified Temporalis Myofascial Flap for Management of Temporomandibular Joint Ankylosis: JAIN Technique.

One of the management modalities of temporomandibular joint ankylosis is interpositional gap arthroplasty. The most commonly used interpositioning material is temporalis myofascial flap owing to its close proximity to operating site. However, sometimes this flap becomes insufficient in terms of length. Hence, we propose a technique of temporalis myofascial flap lengthening. The technique described in the manuscript increases the length of the flap by 1½-fold. This increases the reach of the flap till the medial aspect of the created gap avoiding bone-to-bone contact during movement of the jaw. This technique can be easily and effectively used to ensure proper interpositioning during management of temporomandibular joint ankylosis to avoid recurrence.

Re-Contouring Interpositional Gap Arthroplasty with Ramus Height Preservation for Treatment of Temporomandibular Joint Ankylosis: Case Report (New Technique)

Background: Ankylosis of the temporomandibular joint (TMJ) is an intracapsular union between the mandibular condylar disc and the temporal articular surface that restricts mandibular functions. The management of TMJ ankylosis requires minimally invasive methods. Objectives: This study aims to present a new surgical method for restoring ramus height as much as possible after condylectomy of the TMJ due to ankylosis. Case Prsentation: Two patients with TMJ ankylosis participated in this investigation. Patients’ preoperative maximal mouth openings were 3 mm and 9 mm. A new method was used to separate the bony fusion between the condyle and the glenoid fossa. Then, the condylar head on the mandibular ramus was recontoured, and finally the temporalis musculofascial flap was employed as an interpositional graft. Patients were followed for six months. Both surgeries were performed at the Department of Oral and Maxillofacial Surgery of Taleghani Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran. Results: Both patients had an average maximal mouth opening of 35-40 mm postoperatively. Conclusion: In patients who have TMJ ankylosis the excessive bone between the condyle and the zygomatic arch can be removed by releasing the ankylotic site followed by routine gap arthroplasty so that the ramus becomes shorter than the other side. With this method, however, the condylar head is also recontoured, thus preserving more ramus length than with other techniques; future orthognatic surgery or distraction osteogenesis (DO), if necessary, will also be easier.

Retrospective analysis of a TMJ ankylosis protocol with a 9 year follow up

ObjectiveTemporomandibular joint ankylosis (TMJa) is a debilitating condition that causes difficulty in mastication, speech and mouth opening. Its treatment poses surgical and rehabilitative challenges along with a high incidence of reankylosis. This study was designed to assess the long-term outcomes with a new two phase physiotherapy protocol following conservative resection of the ankylotic mass. Materials and methods143 patients who were treated for TMJa were initially recruited, among whom 98 were inducted into the study and retrospectively evaluated using clinical records and 3-dimensional computed tomography. All the patients underwent a minimal pre auricular incision and conservative interpositional gap arthroplasty with collagen membrane. This was followed by the new two phase physiotherapy protocol with the use of a bite block. The primary outcome measures were the maximum interincisal distance, vertical ramus height and complications. The patients were followed up at monthly intervals during the first year, quarterly intervals during the second year, and at intervals of 6 months during subsequent follow-up years. The mean follow up period was 6.38 ± 2.36 years after ankylotic release. Paired student t test was used for statistical analysis. ResultsThe mean scores for mouth opening at T1, T2 and T3 were statistically significantly different at all intervals (p < 0.0005). The mean scores for ramal length were statistically significantly different at T1 and T2 interval (p < 0.0005) and insignificant at T2 and T3 interval. No reankylosis was observed in patients who followed the physiotherapy protocol. ConclusionsIn the management of TMJa, the success of the conservative surgical technique with interpositional arthroplasty is less dependent on the longevity and rigidity of the interpositional material but more indebted to the patient compliance in following the proposed physiotherapy protocol.

Modified Cut for Gap Arthroplasty in Temporomandibular Joint Ankylosis.

Temporomandibular joint ankylosis is a debilitating disease affecting the function, esthetics and psychology of the patient. Treatment of this condition aims at establishing not only the function and esthetics but also aims to prevent reankylosis. Among the different treatment modalities, interpositional gap arthroplasty followed by aggressive jaw physiotherapy is considered most effective. This is achieved by making two horizontal osteotomy cuts at a distance of 10–15 mm in the TMJ region. The gap is then interposed with an autogenous or alloplastic graft material. However, during the application of a jaw stretcher intraoperatively with the surgical site open and with the jaw wide open, a bony contact was seen to occur between the posterior aspect of the upper and lower osteotomy cuts. Taking this into consideration, the lower osteotomy cut is modified by making the posterior one-third cut divergent. This eliminates the bony contact during maximum mouth opening and thus prevents the chances of reankylosis as well.

Evaluation of Temporomandibular Disorders in Contralateral Joint after Unilateral Interpositional Gap Arthroplasty for Temporomandibular Joint Ankylosis

Interpositional gap arthroplasty is the standard treatment for temporomandibular joint (TMJ) ankylosis. There are fewer studies evaluating the contralateral normal TMJ in case of a unilateral TMJ ankylosis after the release. We hypothesised that temporomandibular disorders (TMD) of some degree will appear in the contralateral normal joint due to uneven functional load. Twenty-two patients of unilateral TMJ ankylosis underwent interpositional gap arthroplasty by a single surgeon using a standard technique. The interpositional material used was autogenous pedicled buccal fat pad. They were evaluated clinically and radiologically for the development of TMDs in the contralateral normal TMJ. The clinical assessment was done using the Axis I tool of Diagnostic Criteria – Temporomandibular Disorders (DC-TMD) wherein the following parameters were assessed: (a) myalgia, (b) arthralgia, (c) degenerative joint disease, (d) disc displacements, (e) headaches attributed to TMD, and (f) subluxation. Radiographic assessment in terms of morphological changes in contralateral condyle was made between the pre- and post-operative CBCT. The Mimics 18.0 software package (Materialise, Leuven, Belgium) was used to create 3D reconstructions and to calculate change in volume of condyles. Discrete categorical data were represented in the form of either a number or a percentage. The normality of quantitative data was checked by measures of Kolmogorov-Smirov Tests of Normality. For comparison of normally time related variables, paired t test was applied. Median was calculated for extremes of data. The statistical analysis was carried out using SPSS statistics software (Version 22.0). Age range was 5-60 years; M:F was 11:11. Follow-up period ranged from 2 years to 12 years. At the longest follow-up, none of the patients developed TMD in the contralateral joint and only 1 patient developed subluxation of the normal condyle. There was significant improvement in lateral and contralateral excursions. No significant morphological changes were found in the contralateral condyle though there was an increase in contralateral condylar volume. We concluded that unilateral interpositional arthroplasty did not lead to contralateral TMD. There was significant improvement in lateral excursions following ankylosis release. There was increase in volume of the contralateral condyle after release of ankylosis. This may be attributed to functional adaptation of the joint.

Gap Arthroplasty or Interpositional Arthroplasty for the Management of TMJ Ankylosis? A Prospective Randomized Comparative Multicenter Clinical Trial.

The main aim of this study is to compare the gap arthroplasty with interpositional gap arthroplasty for the management of TMJ ankylosis. A prospective randomized multicenter clinical trial had been performed, on 60 patients diagnosed with TMJ ankylosis from August 2005 to June 2015. Patients were equally divided into two groups: Group I patients were treated with gap arthroplasty, while patients in Group II were treated with interpositional arthroplasty. The mean age in Group I was 27.9years and in Group II was 25.6years. Trauma was the common etiological factor in both the groups. The mean postoperative mouth opening after 1month, 6months and 24months was found to better in Group II. Open bite after 24months was present in six patients in Group I and in one case in Group II. Permanent facial nerve palsy was present in one patient in both the groups. Frey's syndrome was present in one patient from Group I and none from Group II. Reoccurrence occurred in eight cases from Group I (26.6%) and none from Group II. This study concluded that interpositional arthroplasty is better than gap arthroplasty in terms of mouth opening and reankylosis.

Recurrence of temporomandibular joint ankylosis: Fascia lata a good alternative. A case report

Recurrence of temporomandibular joint (TMJ) ankylosis is a known complication. Studies have contributed to the various treatment options in recurrent ankylosis. The causes of reankylosis of TMJ, to our experience is due to inadequate gap arthroplasty, insufficient interpositional material, adhesion and elongation of the coronoid process. It has been reported in the literature that the incidence varies with choice of treatment modality, severity of ankylosis, site (unilateral/bilateral), and the surgeons skill. The patient's compliance to the post-treatment physiotherapy is the main reason for reankylosis. Here, we present a case of left TMJ reankylosis in a 22-year-old female, previously treated by interpositional gap arthroplasty using temporalis muscle, and had developed recurrence after ˜ 1 year of treatment, then it was successfully treated with gap arthroplasty using fascia lata as interpositional material.

Interpositional Gap Arthroplasty by Versatile Pedicled Temporalis Myofascial Flap in the Management of Temporomandibular Joint Ankylosis- A Case Series Study.

Temporomandibular Joint (TMJ) ankylosis is a situation in which the mandibular condyle is fused to the glenoid fossa by bone or fibrous tissue. The management of TMJ ankylosis has a complicated chore and it is challenging for the maxillofacial surgeon because of technical hitches and high rate of re-ankylosis. Interpositional gap arthroplasty is one of the modalities for its management. A range of inter-positional materials have been used to avert recurrence after gap arthroplasty in TMJ ankylosis. The aim of this series was to evaluate the effectiveness of the temporomyofacial flap in the treatment of TMJ ankylosis as an interpositional gap arthroplasty. A total of 10 cases with unilateral TMJ ankylosis were treated by interpositional gap arthroplasty by pedicled temporalis myofacial flap and evaluated with a follow-up of 6 months to 5 years (Mean 3.3 years) for the functional stability of TMJ. All the patients were successfully treated. There were no signs of recurrence in any patients up to last follow up visit. The result showed that temporalis myofascial flap is a preferable choice for inter-positional gap arthroplasty which proves its versatility as an inter-positional material.

Fate of Costochondral Graft in Temporomandibular Joint Reconstruction: A Histological Study.

To asses the fate of the costochondral graft (CCG) used to stimulate mandibular growth in the management of Temporomandibular joint (TMJ) reconsrtuction in ankylosis-histologically. Ten patients who had undergone CCG grafting for TMJ ankylosis between 1994-2009 in the department of Oral & Maxillofacial Surgery, Tamil Nadu Govt Dental College and Hospital, Chennai and had come back with reankylosis, were surgically explored and the graft along with the ankylotic mass was excised and evaluated histologically. There is no documented human study and clinically it is not possible. Histological evaluation revealed the presence of osseous tissue, fibrous tissue and osteocytes but no evidence of any chondroid tissue. Our study showing the absence of chondroid tissue raises the question on the rationale of CCG in TMJ reconstruction when other interpositional gap arthroplasty can achieve a disease free joint.

Costochondral Graft as Interpositional material for TMJ Ankylosis in Children: A Clinical Study.

TMJ ankylosis is one of the most disruptive anomaly that affects the masticatory system. The inability to move the mandible has significant functional ramification, such as the inability to eat a normal diet. Additionally, speech is affected, making it difficult for some individuals to communicate and express themselves to others. As there are several biologic and anatomic similarities to the mandibular condyles, autogenous costochondral grafts have been considered to be the most acceptable tissue for temporomandibular joint reconstruction. In addition donor site complications are infrequent and regeneration of the rib usually occurs within a year post operatively in children. The aim of this study was to evaluate the function of costochondral grafts to replace the mandibular condyles and to assess the position, growth, overgrowth, function, success, failure and resorption of costochondral grafts. Ten TMJ ankylosis patients were operated in the Department of Oral and Maxillofacial Surgery at Institute of Dental Sciences, Bareilly. Out of the 10 cases 6 were male patients and 4 female patients in age group of ≤14years; of which 8 patients were of unilateral TMJ ankylosis and 2 were of bilateral TMJ ankylosis. All ten patients underwent interpositional gap arthroplasty with reconstruction of the condyle by costochondral graft. All patients with costochondral grafts had improved mandibular symmetry and growth with adequate mouth opening. This study indicates that using costochondral grafts to reconstruct TMJ ankylosis in children provides a good result.

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 5–8mm 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 0–2mm in 8 cases and 2–9mm in 9. Postoperatively adequate mouth opening of 30–40mm 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.

Use of the suture anchor in interpositional arthroplasty of temporomandibular joint ankylosis

The purpose of this article is to demonstrate the use of a mini suture anchor to attach the temporal myofascial flap to the head of the mandibular condyle in interpositional arthroplasty for the treatment of temporomandibular joint (TMJ) ankylosis. A 29-year-old patient, with unilateral posttraumatic temporomandibular joint osseous ankylosis and pre-operative maximal interincisal distance of 9mm, was treated by the interpositional gap arthroplasty using the temporal myofascial flap. After rotation, the flap and the TMJ capsule were attached to the lateral pole of the condyle by a non-absorbable mini suture anchor. The surgery was uneventful. On the first post-operative day, the range of motion was considerably improved, with a maximal interincisal distance of 26mm, a mandibular protrusion of 1mm and a lateral mandibular excursion of 4mm to the left and 7mm to the right. On the 20th post-operative day, the maximal interincisal distance was 30mm, protrusion 4mm, the lateral excursion to the right 7mm and to the left 5mm. On the third post-operative month, the maximal interincisal distance reached 40mm. The mini suture anchor demonstrated to be a good tool for the fixation of the temporalis myofascial flap to the condyle, also allowing with the same suture to attach the capsular tissue to the lateral surface of the condyle. The bone-anchored suture permits the restoration of a more physiologic TMJ anatomy. The treatment of TMJ ankylosis should be comprehensive; physiotherapy plays an important role in the rehabilitation period to restore the normal function.

Continuous ropivacaine infusion vs transdermal fentanyl for providing postoperative analgesia following temporomandibular joint interpositional gap arthroplasty

AimThe purpose of this study was to evaluate the postoperative pain control and mouth opening in patients undergoing temporomandibular joint interpositional gap arthroplasty by either placing an epidural catheter in the incision wound and infusing ropivacaine 0.25% or by using a transdermal fentanyl patch.Materials and Methods:The study was prospective, randomized and double blind. Eighty patients belonging to American Society of Anesthesiologists grade I and II, 18–32 years of age, scheduled for temporomandibular joint interpositional gap arthroplasty were randomized into 2 groups; ropivacaine group (G rop): to receive 0.25% ropivacaine infusion and transdermal fentanyl group (G tf): to receive transdermal fentanyl patch. For postoperative pain (Visual Analog Score [VAS]) and analgesic requirements were assessed 2, 4 and 8 h after surgery and each morning, until and 4 days after surgery.Results:Time to first analgesic requirement was found to be significantly (P < 0.0001) higher in G rop (49 ± 6.7) as compared with G tf (32 ± 9.1) VAS were also significantly lower in G rop throughout the postoperative period. Postoperatively, mouth opening was better in G rop as compared with G tf, which was statistically significant.Conclusion:It was concluded that by placing an epidural catheter at the incision wound and continuously infusing with ropivacaine 0.25% effectively controls the postoperative pain in patients undergoing temporomandibular joint interpositional gap arthroplasty and provides better postoperative mouth opening.

Temporomandibular joint interpositional gap arthroplasty under intravenous (I.V) conscious sedation

Ankylosis may be defined as the fusion of joint surfaces. Temporomandibular joint (TMJ) ankylosis is a condition that may cause chewing, digestion, speech, esthetic and psychological disorders. It is a devastating disorder resulting in inability to open the mouth. As a result of this, General anaesthesia, is very difficult to administer because laryngeal inlet is not directly visualized. Even the blind nasal intubation is difficult because of small mandible and tongue fall following relaxation. There are various techniques to overcome these challenges. At times these techniques fail and tracheostomy has to be done. All the risks associated with difficult intubation, and general anaesthesia can be avoided if the surgery is done under conscious sedation. Conscious sedation, a simple but safe and effective method of anaesthesia is described here, which allows successful temporomandibular joint interpositional gap arthroplasty.