Management Of Ankylosis Research Articles

An evaluation of clinical outcome of total alloplastic temporomandibular joint replacement and costochondral graft in temporomandibular joint ankylosis cases – A retrospective study

Background: The temporomandibular joint (TMJ) ankylosis management incorporates various modalities. Total alloplastic temporomandibular joint replacement (TJR) has opened a new avenue in TMJ reconstruction. Costochondral grafts (CCGs) are the gold standard treatment option. Aim: This study was designed to compare the clinical outcome between total alloplastic TJR and CCG in TMJ ankylosis cases. Materials and Methods: The retrospective data of patients were collected between 2017 and 2020. A total of 12 TJR cases and 8 cases of CCG were included in the study. Maximum mouth opening was recorded in mm and pain score/diet score was recorded on a Visual Analog Score system where 0 was no pain/normal diet and 10 was worse pain/liquid diet. The data were statistically analyzed using the “two-sample t-test (Welch's t-test).” Results: The mean interincisal opening in the TJR group was 32.67 (±2.19) and in the CCG group was 33.71 (±4.77). The pain reduction score was better in the TJR group with 0.5 (±0.90) and the diet score was better in the CCG group with 0.714 (±0.95). Conclusion: The stock TJR devices have a predictable outcome with a good pain reduction score and an acceptable diet score; however, the autogenous CCG is still better in terms of maximum mouth opening. Although failed CCG cases can be taken up for further correction with the TJR.

Management of the palatally displaced maxillary canine. Part 2: exposure and orthodontic alignment

In Part 2 of this article, we highlight the differences between the open and closed exposure techniques in the management of palatally displaced canines (PDCs), the mechanical principles of alignment and the management of ankylosis. CPD/Clinical Relevance: The wide positional variation in the presentation of PDCs requires a degree of clinical flexibility with different exposure techniques and treatment mechanics.

Management of temporomandibular joint ankylosis in children with their surgical risk and benefits

Aim: To Overview and analyse the various treatment options and risk & benefits used for management of ankylosis in growing children. Summary: A Number of technique have been used for the treatment of temporomandibular Ankylosis. Since it is a known challenging problem in paediatric patients. Main aim of our treatment is excision of ankylotic mass followed by recontouring of the joint.

Does no-intraoperative correction of chin deviation prevent costochondral graft overgrowth in pediatric temporomandibular joint ankylosis management - an intermediate outcome study

The use of costochondral graft is controversial for pediatric temporomandibular joint reconstruction due to its unpredictable growth. The height of the cartilage is directly responsible for the growth capacity of costochondral graft. Even after keeping the cartilage in costochondral graft to a recommended height, overgrowth has been reported. Traditionally during costochondral graft fixation, chin deviation is corrected intraoperatively. The investigators hypothesized that this intraoperative manipulation of mandible to correct chin deviation and maintaining the chin in new position causes excessive stress and strain in the muscular functional matrix. The authors believe that this may be the reason for excessive growth trigger on the grafted side. This study intends to prove the hypothesis of no-intraoperative correction of chin deviation can prevent overgrowth of the costochondral graft. We implied this technique in pediatric temporomandibular joint ankylosis patients managed with osteoarthrectomy and reconstructed with costochondral graft. Patients with at least a follow-up of 30-months were included in the study. The study sample consisted of 20 patients. All the patients had adequate growth with improvement in facial asymmetry. The results of the present study supports our hypothesis of no-intraoperative correction of chin deviation as a technique to prevent overgrowth of costochondral graft. We recommend this technique to allow catch-up of growth rather than acceleration of growth. This change in technique needs more research, randomized controlled trial for reliability and long-term results.

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.

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.

Protocol for the management of ankylosis of the temporomandibular joint.

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

TMJ Ankylosis Management: Our Experience.

Temporomandibular joint (TMJ) ankylosis is an extremely disabling affliction that causes problems in mastication, digestion, speech, appearance and hygiene. Surgery of TMJ ankylosis needs careful evaluation and planning to yield predictable results. Temporomandibular joint ankylosis is very common among young children. The aim of treatment is not only to treat the movement of the joint but also to prevent relapse. In this series, 18 cases of temporomandibular joint ankylosis were treated at our institute from January 2012 to January 2017 with osteoarthrectomy and interpositional arthroplasty. Patients were in the age range of 5-57years, with 11 males and 7 females and including 8 unilateral and 10 bilateral cases. Duration of ankylosis ranged from less than 2years to more than 6years. Seven of the patients were secondarily taken up for correction of their deformities with either orthognathic surgery or distraction osteogenesis. Good mouth opening was achieved in all the patients with a mean follow-up period of 12months. The early post-operative mouth opening ranged from 24 to 37mm. The late post-operative mouth opening ranged from 20 to 33mm. There was a stress on aggressive physiotherapy for a minimum of 6months in all our patients. Interpositional arthroplasty using vascularized temporalis fascia flap is a very reliable method to prevent recurrence of ankylosis, and it also avoids the disadvantages of alloplastic materials as well as nonvascularized autogenous tissues.

Coronoid process and residual ankylotic mass as an autograft in the management of ankylosis of the temporomandibular joint in young adolescent patients: a retrospective clinical investigation

The aim of this non-randomised investigation was to assess the feasibility of using autogenous grafts (such as coronoid process and the resected ankylotic mass) in reconstruction of the condyle after gap arthroplasty for ankylosis of the temporomandibular joint (TMJ). Sixteen patients (23 joints) operated on between 2007 and 2009 were studied and postoperative measurements of maximum interincisal opening, bite force, range of movement, and infection were recorded. After a mean (SD) follow up of 55 (2.25) months mouth opening improved from 3 (3.84) mm to 33 (1.66) mm in patients treated with coronoid graft, while in patients treated with an ankylotic mass after a mean (SD) follow up of 58 (1.58) months it increased from 4 (2.64) mm to 26 (8.04) mm. Bite force six months postoperatively ranged from 18.25kg/cm2 – 27.5kg/cm2 after reconstruction with the coronoid process and 18.5kg/cm2 – 23.25kg/cm2 after reconstruction with the ankylotic mass. One patient developed reankylosis postoperatively and another developed infection, in both of which the ankylotic mass had been used. Both were managed successfully. Both the ankylotic mass and the coronoid process gave satisfactory results and seem to be options for reconstruction. However, the coronoid process graft was better than residual ankylotic mass in terms of masticatory efficiency, bite force, and range of movement.

Ultrasonography for the volumetric analysis of the buccal fat pad as an interposition material for the management of ankylosis of the temporomandibular joint in adolescent patients

The aim of this study was to analyse preoperatively with ultrasound the minimum volume of buccal fat that would be required for interposition of a pad after gap arthroplasty, and to emphasise the value of such a pad in the management of ankylosis of the temporomandibular joint (TMJ) during a short term follow up. Nineteen patients with ankylosis of the TMJ (22 joints) were selected, whose mean (SD) mouth opening was 4.9 (3.7) mm. In 10 joints in which the mean (SD) volume of the buccal fat pad was 0.7 (0.2) ml, the harvested buccal fat was inadequate for interposition, so they were treated with other materials. The remaining 12 joints had a mean (SD) volume of 1.1 (0.3) ml, which gave enough fat for interposition after gap arthroplasty. Investigation with ultrasound at 15 days and 6 months postoperatively showed that the fat pad was viable and the volume had shrunk by 28%. The 6-month postoperative computed tomographic (CT) scan showed little or no heterotopic calcification. We conclude that a buccal fat pad with a preoperative mean (SD) volume of 1.1 (0.3) ml is easy to harvest as interposition material. At a mean follow up of the12 joints after 31 (range 24 - 36) months there was progressive improvement in mouth opening with a mean (SD) of 32.5 (5.0) mm, which established that a pedicled buccal fat pad is a stable, efficient, viable soft tissue barrier in the management of ankylosis of the TMJ.

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.

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.

Management of recurrent ankylosis in arthrogryposis: new solutions to a rare problem

Arthrogryposis is a rare condition that comprises contracture of the joints, muscular weakness, and fibrosis. Restricted mouth opening caused by coronoid hyperplasia has been reported but to our knowledge, ankylosis of the temporomandibular joint (TMJ) has not. Standard management of ankylosis includes creation of a gap arthroplasty and possible reconstruction with autogenous or alloplastic materials. We describe management of a patient with arthrogryposis who developed ankylosis for a second time after satisfactory gap arthroplasty and total replacement of the TMJ with a custom-made prosthesis. The original prosthesis was removed, the ankylosis resected, and the prosthesis replaced. This has given an excellent outcome at 12 months.

Aetiology and presentation of ankylosis of the temporomandibular joint: report of 23 cases from Abuja, Nigeria

Several studies have reviewed the management of ankylosis of the temporomandibular joint (TMJ), but only a few focused on the aetiology and clinical features. We retrospectively studied the aetiology and clinical features of patients with ankylosis of the TMJ who presented to the Maxillofacial Unit, National Hospital, Abuja, Nigeria, between 2004 and 2009. There were 13 male and 10 female patients, M:F ratio 1.3:1, age range 6–62, mean (SD) 20 (13) years. The aetiological factors were trauma ( n = 11) that comprised falls ( n = 6), untreated fractures of the zygomatic arch ( n = 4) and myositis ossificans ( n = 1); infection ( n = 9), that comprised cancrum oris ( n = 3) and ear infection ( n = 6); congenital or unknown ( n = 2), and coronoid hyperplasia ( n = 1). The maximum interincisal distance at presentation ranged from 0 to 25 mm (mean (SD) 6.7 (7.2) mm). Seventeen had facial deformities. The diagnoses recorded were as follows: left extracapsular ankylosis, ( n = 8); right intracapsular bony ankylosis, ( n = 6); left intracapsular bony ankylosis, ( n = 4); bilateral intracapsular bony ankylosis, ( n = 4), and bilateral intracapsular fibrous ankylosis ( n = 1). Extreme poverty was the main predisposing factor. There is a need for a concerted effort among healthcare providers, policy makers, and the world in general to eradicate poverty and improve healthcare to limit the incidence of ankylosis of the TMJ.

Histological fate of abdominal dermis–fat grafts implanted in the temporomandibular joint of the rabbit following condylectomy

The histological fate of abdominal dermis-fat grafts implanted into the temporomandibular joint (TMJ) following condylectomy was studied. 21 rabbits underwent left TMJ discectomies and condylectomies; 6 were controls (Group A; no graft used); 15 (Group B) had autogenous abdominal grafts transplanted into the left TMJ. Animals were killed after 4, 12 and 20 weeks. Specimens of the TMJ were histologically and histomorphometrically evaluated. At 4 weeks, fat necrosis was clear in all specimens. The dermis component survived and formed cysts with no necrosis. By 12 weeks, viable fat deposits appeared with no evidence of necrotic fat. At 20 weeks, large amounts of viable fat were present in Group B specimens. Group A had no fat, although the missing condyles regenerated. In the presence of viable fat, Group B showed little condyle regeneration 20 weeks after condylectomy. Non-vascularised fat grafts do not survive transplantation, but stimulate neoadipogenesis. The fate of the dermis component of the graft is independent of the fat component. Fat in the joint space disrupts the regeneration of a new condylar head. Neoadipogensis inhibits growth of new bone and cartilage. This has clinical implications for TMJ ankylosis management and preventing heterotopic bone formation around prosthetic joints.

One stage management of ankylosis of the temporomandibular joint with a custom-made total joint replacement system

Alloplastic joint prostheses have been used in the treatment of severe diseases of the temporomandibular joint (TMJ) for many years. Treatment of ankylosis of the TMJ has been difficult, with many surgical approaches being used that traditionally involved multistage procedures, long treatment times, and increasing expense. We report a single stage technique for replacement of an ankylosed joint using a custom-made prosthesis, and discuss the technical aspects of the procedure, including our use of a custom-made acrylic glenoid fossa template.

Chemical versus mechanical procedure in temporomandibular joint ankylosis management

Background and Objectives: A variety of techniques for the management of craniomandibular ankylosis have been described however, no single technique has proved entirely satisfactory. These techniques pose a significant challenge due to a high incidence of recurrence. The aim of this study was to evaluate and compare between chemical and mechanical procedures in the treatment of temporomandibular joint (TMJ) ankylosis.

O.663 TMJ prosthesis: a critical appraisal of literature and case

Temporomandibular joint (TMJ) ankylosis can be surgically managed by a number of approaches. This systematic review compared the clinical outcomes among various treatment options, i.e., gap arthroplasty (GA), interpositional gap arthroplasty (IGA), reconstruction arthroplasty (RA) and distraction osteogenesis (DO).PubMed, Ovid, Embase, Web of Science, Scopus and Cochrane central register of controlled trials were searched till April 2018. Randomized controlled trials, cohort studies and retrospective studies in subjects with acquired TMJ ankylosis reporting re-ankylosis with a follow-up period of ≥12 months were included.Twenty-six studies with 1197 subjects were included. The higher recurrence rate was observed with GA compared to both IGA and RA (p < 0.05). Comparable results were obtained with IGA, RA and DO (p > 0.05). Among interpositional materials, alloplastic materials showed higher recurrence rate compared to autogenous materials (p < 0.05). However, for reconstruction, both autogenous grafts and alloplastic prosthetic implants gave similar results (p > 0.05). The highest improvements in MMO (maximum mouth opening) resulted with IGA but the differences regarding post-operative changes in MMO were clinically similar in all other groups.IGA with autogenous material and reconstruction using either autogenous grafts or total joint replacement by alloplastic prosthetic implants provide similar clinical outcomes for TMJ ankylosis management.

O.647 Interpositional arthroplasty in TMJ ankylosis

Temporomandibular joint (TMJ) ankylosis can be surgically managed by a number of approaches. This systematic review compared the clinical outcomes among various treatment options, i.e., gap arthroplasty (GA), interpositional gap arthroplasty (IGA), reconstruction arthroplasty (RA) and distraction osteogenesis (DO).PubMed, Ovid, Embase, Web of Science, Scopus and Cochrane central register of controlled trials were searched till April 2018. Randomized controlled trials, cohort studies and retrospective studies in subjects with acquired TMJ ankylosis reporting re-ankylosis with a follow-up period of ≥12 months were included.Twenty-six studies with 1197 subjects were included. The higher recurrence rate was observed with GA compared to both IGA and RA (p < 0.05). Comparable results were obtained with IGA, RA and DO (p > 0.05). Among interpositional materials, alloplastic materials showed higher recurrence rate compared to autogenous materials (p < 0.05). However, for reconstruction, both autogenous grafts and alloplastic prosthetic implants gave similar results (p > 0.05). The highest improvements in MMO (maximum mouth opening) resulted with IGA but the differences regarding post-operative changes in MMO were clinically similar in all other groups.IGA with autogenous material and reconstruction using either autogenous grafts or total joint replacement by alloplastic prosthetic implants provide similar clinical outcomes for TMJ ankylosis management.

Management of ankylosis in the young child

Ankylosis and fibrous adhesions causing limited range of motion of the pediatric mandible can be a challenging problem for the oral and maxillofacial surgeon to remedy. The causes of limited range of motion in the pediatric population may be congenital, post-traumatic, neoplastic, or iatrogenic. It is important to differentiate between the many causes of trismus in the pediatric patient. Critical to the treatment planning is a detailed evaluation and diagnosis of the limited range of motion. Untreated ankylosis or recurrence can cause problems with mastication, speech, growth, and airway impairment. Treatments that have been described for ankylosis and/or adhesions include coronoidectomy, gap arthroplasty, costochondral rib reconstruction, prosthetic joint replacement, or distraction osteogenesis with transport techniques. However, controversies exist because outcome studies are sparse when one looks carefully at the many surgical options. This session will outline evaluation, differential diagnosis, and current surgical approaches for both ankylosis and fibrous adhesions of the pediatric mandible. Particular attention will be given to the controversial management of this difficult problem. References Posnick JC, Goldstein JA: Surgical management of the temporomandibular joint ankylosis in the pediatric population. Plast Reconstr Surg 91:791, 1993 Ridson F: Ankylosis of the temporomandibular joint. J Am Dent Assoc 21, 1933 Kaban LB, Perrott DH, Fisher K: A protocol for management of temporomandibular joint ankylosis. J Oral Maxillofac Surg 48:1145, 1990