Ramus-condyle Unit Reconstruction Research Articles

Transport Distraction Osteogenesis for Reconstruction of Ramus-Condyle Unit following Release of Temporomandibular Joint ankylosis

Introduction: Temporomandibular joint (TMJ) is a structurally complex joint. TMJ deficiency and deformity can result from different causes. Ankylosis of the TMJ is considered the most common cause leading to severe form of deformity and shortening of the ramus / condyle unit which can affect both, function and esthetic and is difficult to treat. Different surgical procedures have been used to treat this deficiency, with variable degrees of success rates. Distraction osteogenesis is a well-established technique that is used to treat different maxillofacial deformities. A recent use in reconstruction of the deficiency or ramus-condyle unit is developed Aim: The objective of this study was to evaluate the use of transport distraction osteogenesis in restoring the deficient condyle/ramus unit of patients with unilateral or bilateral TMJ ankylosis to correct the resultant deformity. Materials and Methods: Ten patients with TMJ ankylosis underwent Transport condylar ramus distraction osteogenesis to reconstruct the condyle after release and gap arthroplasty. The distractors used were extraoral submerged ones. Results: Five males and five females were included. Their age ranged from 2 to 46 years with an average of 21.2years. The follow-up period ranged from 15 to 60 months with an average of 30.2 months. Successful treatment was achieved in seven cases. Complications were mild in two, moderate in four and severe in three. Conclusions: Transport condylar distraction osteogenesis is a valuable treatment option for TMJ ankylosis. It has a considerable complication rate that must be considered its choice and discussed thoroughly with the patient/guardian.

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.

Can costochondral grafts fulfil ramus-condyle unit reconstruction goals in children with temporomandibular joint ankylosis?

The purpose of this study was to analyse whether costochondral grafts (CCG) fulfil temporomandibular joint (TMJ) reconstructive goals in children with TMJ ankylosis. A total of 23 patients (12 male, 11 female, aged 3–16 years) with unilateral or bilateral TMJ ankylosis operated on between January 2014 to April 2018 were included in the study. Maximal incisal opening (MIO), frequency of reankylosis, and growth of CCG, were evaluated at one month and six months for one year, and after that once yearly. Mouth opening changes with time were assessed by the Friedman test and growth was compared at follow up and analysed using the paired t test. Mean (range) follow up was 18 (12–48) months. Study results revealed follow up MIO at 12 months was highly significant (p=0.001). Out of 27 CCG studied, only one graft had undergone re-ankylosis. Based on the predetermined criteria using condylion to gnathion (Co–Gn) measurement in the posteroanterior cephalogram, CCG were categorised into optimum, sub-optimum, and overgrowth. However, long-standing TMJ ankylosis cases still displayed mandibular asymmetry at the end of the study, even with “optimal growth” radiographically. Overall comparison between the immediate postoperative and last follow up Co-Gn measurements in either unilateral or bilateral cases was not significant. CCG with functional matrix maintained the growth of the mandible and MIO in TMJ ankylosis. It can be concluded that CCG partially fulfils reconstructive goals; however, patients need to be followed up till the end of puberty for a substantive conclusion.

Evaluation of Success of Transport Disc Distraction Osteogenesis and Costochondral Graft for Ramus Condyle Unit Reconstruction in Pediatric Temporomandibular Joint Ankylosis

The costochondral graft (CCG) is considered the reference standard for pediatric temporomandibular joint reconstruction. It has the disadvantages of unpredictable growth, donor site morbidity, and the need for intermaxillary fixation. It has been reported that transport disk distraction osteogenesis (TDDO) can result in the formation of a neocondyle and disc. We performed a randomized trial to measure and compare clinically relevant outcomes of ramus-condyle unit (RCU) reconstruction using CCG and TDDO for pediatric temporomandibular joint ankylosis (TMJA). In the present randomized controlled trial (block randomization with a variable block size), pediatric patients with unilateral, nonrecurrent TMJA aged 3 to 16years who had presented to our unit from December 2015 to June 2017 were enrolled. Instead of temporalis myofascial flap interposition, a buccal fat pad was used to fill the gap created by osteoarthrectomy. The primary outcome parameter was mouth opening. A mouth opening of at least 25mm at the median follow-up point was considered success. The secondary outcome parameters were occlusion, laterotrusion, protrusion, reankylosis, neocondyle, chin deviation, facial asymmetry, midline shift, and neo-disc formation. Data were analyzed using the independent t test and rank sum test. A total of 24 patients were enrolled in the CCG and TDDO groups (n=12 in each group). Trauma (40.9%) was the most common etiology with a slight male preponderance (59.09%). The mean age was 10.32±2.85years. The average distraction achieved in the TDDO group was 10.42mm. The median follow-up duration was 31.5months (range, 24 to 39months). The mean preoperative maximal incisal opening had improved from 8.5±4.1 and 9.5±7.1mm in the CCG and TDDO groups preoperatively to 35.7±2.7 and 34.4±8.9mm, respectively, at the median follow-up point (P<.005). RCU reconstruction with both modalities resulted in improvement in all the parameters; however, the intergroup comparison showed statistically non-significant differences. No reankylosis or open bite was found. The 3-hour delayed gadolinium-enhanced magnetic resonance imaging scan showed successful neo-disc formation. Similar success can be achieved in RCU reconstruction using either CCG or TDDO for pediatric TMJA. Both techniques have some advantages and disadvantages. RCU reconstruction using CCG or TDDO results in formation of a neocondyle, maintenance of occlusion, and correction of facial asymmetry.

Guidelines for Single-Stage Correction of TMJ Ankylosis, Facial Asymmetry and OSA in Adults.

Treatment for TMJ Ankylosis aims at restoring joint function, improving the patient's aesthetic appearance and quality of life and preventing re-ankylosis. Mouth opening is achieved by gap arthroplasty with various options of interpositional materials. Ramus-condyle unit (RCU) reconstruction maintains the height of the ramus and prevents secondary occlusal problems. Advancement genioplasty corrects chin deformities as well as increases the posterior airway space (N-PAS) by the forward pull exerted on geniohyoid and genioglossus. This prospective single-centre study on 43 joints in 25 adultpatients with TMJ Ankylosisaimed at providing a single-staged management plan of ankylosis release, RCU reconstruction and extended advancement centering genioplasty. Interpositional arthroplasty was done using temporalis myofascial flap, abdominal dermis fat or buccal fat pad. RCU reconstruction was done either by vertical ramus osteotomy or L osteotomy. Follow-up ranged from 12 to20months (mean 14.4). Average mouth opening at maximum follow-up was 34.36mm with re-ankylosis in no case. Cephalometric parameters showed increase in point P to Pog, decrease inN perpendicular to Pog, angle N-A-Pog, Cg-ANS to Cg-Menton, neck-chin angle and labiomental angle. N-PAS increased, and average 50% improvement in AHI was seen in all patients with OSA. Most common complications involved transient paraesthesia of temporal and zygomatic branches of facial nerve. Based on the findings of the above study, we propose treatment guidelines for treatment of TMJ ankylosis in adult patients with AHI < 20.

Sternoclavicular Joint Graft in Temporomandibular Joint Reconstruction for Ankylosis.

Background:Temporomandibular joint ankylosis is one of the most distressing clinical condition resulting in loss of jaw function and impairment of growth. Ankylosis is a greek word meaning “Stiff Joint”. It is observed that in humans the Sternoclavicular joint and Temporomandibular joint are similar morphologically and histologically as they are the only two synovial joints covered with fibrocartilage. This similarity of the joints have encouraged the surgeons to use SCG as an alternative to costochondral grafts.Aims:The purpose of this article was to evaluate the feasibility of using sternoclavicular graft for TMJ reconstruction in TMJ ankylosis patients and to also assess this technique in restoration of mandibular movement, function and growth of the mandible.Settings and Design:This retrospective study was conducted in 10 patients with unilateral TMJ ankylosiswho had undergone Interpositional arthroplasty with temporalis fascia and reconstruction of ramus condyle unit with sternoclavicular graft.Methods and Material:Ten patients(8 male and 2 female) with unilateral TMJ ankylosis within the growth period were included in the study. Clinical parameters assessed were maximal incisor opening, lateral excursion and protrusive movements.,ramus height,wound infection, donor sitemorbidity, evidence of neurological deficit in both donor and recipient site. Pre and post operative radiographic analysis of graft in relation to glenoid fossa and ramus of mandible was also done and donor site regeneration was also assessed.Statistical Analysis Used:The data were analysed using SPSS version 20 (IBM Corporation, SPPSInc; Chicago, IL, USA). Paired T test was used to compare the pre operative and post operativelaterotrusive, protrusive movements and the height of the ramus of the mandible. Repeated measures ANOVA was used to analyse the mouth opening pre operatively ,immediate post operatively and a after 5- year follow up.Results:The mean post operative mouth opening achieved was 28.9+_7.57mm with reankylosis in two patients. The mean laterotrusive and protrusive movements were 5.2 +_2.82mm and 2.2 +_.78 mm respectively postoperatively on a five year follow up. There was a 6.2 +_2.57mm increase in ramus height. The sternoclavicular graft had integrated and remodelled satisfactorily in eight patients. There was no change in the body length or midline deviation. Regarding the healing of the donor site there was a complete regeneration of clavicle within one year, however there was a incidence of clavicle fracture in one patient. The shoulder movements were normal in all patients.Conclusions:The reconstruction of TMJ with SCG has proved to be successful in this study. With an impressive success rate, the sternoclavicular graft could become a versatile and viable alternative to the surgeons in reconstruction of TMJ as it is relatively simple to carry out with minimal complications and good results.

Comparison of vertical ramus osteotomy and l osteotomy for ramus condyle unit reconstruction in temporomandibular joint ankylosis

Comparison of vertical ramus osteotomy and l osteotomy for ramus condyle unit reconstruction in temporomandibular joint ankylosis

Novel technique for harvesting the sternoclavicular graft.

Originally introduced for mandibular reconstruction more than 40 years ago, the sternoclavicular graft (SCG) has gained widespread popularity for the reconstruction of the ramus-condyle unit (RCU) owing to its anatomic and histological likeness to the normal mandibular condyle. Conventional longitudinal osteotomy design for its harvest has been fraught with considerable complications at the donor site including fracture clavicle and major neurovascular injury. In an attempt to alleviate these ill effects, a new technique for procuring the sternoclavicular graft is presented. A split-thickness cortico-cancellous graft was harvested form the sternal end of the clavicle along with the articular disk with the osteotomy cut oriented parallel to the coronal plane, with limited soft tissue dissection. Donor site complications were assessed in terms of incidence of clavicle fracture, neurovascular injury, pleural tear and radiographic healing as seen in the six-month postoperative chest radiograph. 17 patients suffering from unilateral temporomandibular joint ankylosis underwent SCG harvesting for RCU reconstruction following osteoarthrectomy. No adverse events were seen in the intra- and post-operative period in any patient and satisfactory radiographic osseous healing was observed after six months. The proposed harvest technique for SCG results in reduced donor site morbidity and favourable healing and greater patient comfort.

Ramus Condyle Unit Reconstruction Using Vertical Ramus Osteotomy in Temporomandibular Joint Ankylosis.

Treatment of bony Temporomandibular Joint (TMJ) Ankylosis includes release of the ankylosis and creation of a gap with or without insertion of interposing material and complete reconstruction of the joint using e.g. costochondral, autogenous coronoid/ankylosed mass, sternoclavicular, clavicular bone grafts etc. As these are non-pedicled grafts, there is eventual resorption with subsequent decrease in height of the ramus, facial asymmetry, deviated mouth opening and reankylosis. The authors have applied the method of vertical ramus osteotomy (VRO) on the posterior border of the mandibular ramus for reconstruction of the ramus condyle unit (RCU) as a pedicled graft along with Myofascial Temporalis Interposition for the correction of TMJ Ankylosis. Ten patients of TMJ Ankylosis were included in this study. All ten patients were treated using VRO for the RCU reconstruction with posterior border of mandibular ramus after Gap Arthroplasty. Temporalis myofascial flap was used as an interpositional material in all patients. Patients were followed from 20 to 30months (mean 24months). As a result of successful procedure the post-operative maximal mouth opening of 32-45mm (mean 37mm) was achieved. No patient experienced pain and infection at surgical site. None of the patients had graft rejection and reankylosis at follow-up. The results showed that VRO on the posterior border of the mandibular ramus seems to be an alternative and promising method for RCU reconstruction in patients with TMJ Ankylosis.

Using the Gap Arthroplasty to Treat Temporomandibular Joint Ankylosis may Result in Greater Mandibular Range of Motion Than Treating the Ankylosis Using Ankylosis Resection and Ramus–Condyle Reconstruction With Costochondral Grafting

Operative management of temporomandibular joint ankylosis: A systematic review and meta-analysis. Katsnelson A, Markewicz MR, Keith DA, Dodson TR. J Oral Maxillofac Surg 2012;70:531-6. O. Ross Beirne, DMD, PhD Does surgical treatment of patients with temporomandibular joint ankylosis using the gap arthroplasty result in greater range of mandibular movement than using ankylosis resection and ramus–condyle unit reconstruction with costochondral grafts? Supported in part by the Massachusetts General Hospital Department of Oral and Maxillofacial Surgery Education and Research Fund, the Center for Applied Clinical Investigation, and the Massachusetts General Physicians Organization Systematic review with meta-analysis Level 2: Limited-quality, patient oriented evidence Grade B: Inconsistent or limited-quality patient-oriented evidence

Reconstruction of ramus-condyle unit with transport distraction osteogenesis: Report of eight cases and review of literature

Background/AimsThis report and review of literature aimed to assess the feasibility of condylar distraction in humans and its esthetic and functional outcome. MethodsWe present a case series of eight TMJ ankylosis patients, where after a gap arthroplasty, ramus condyle unit was reconstructed using transport distraction to analyze its feasibility, esthetic and functional outcome and success. ResultsAll patients had satisfactory mouth opening, and minimal pain in their follow-up period. ConclusionCondylar transport distraction osteogenesis holds promise for successful TMJ reconstruction and should be the method of choice as it does not involve secondary surgery or need for an alloplast.

Operative Management of Temporomandibular Joint Ankylosis: A Systematic Review and Meta-Analysis

Two common treatments of temporomandibular joint ankylosis are gap arthroplasty and ankylosis resection and reconstruction of the ramus-condyle unit with a costochondral graft. The purpose of the present study was to answer the following clinical question: "Among patients with temporomandibular joint ankylosis, do those patients who undergo gap arthroplasty, compared with those who undergo ankylosis resection and ramus-condyle unit reconstruction with a costochondral graft have better postoperative mandibular range of motion?" A systematic search of the published data was performed to identify eligible studies. The primary predictor variable was treatment type (ie, gap arthroplasty or ankylosis resection and ramus-condyle unit reconstruction). The main outcome was the change in maximal incisal opening postoperatively. A random effects model was used to compute the pooled weighted mean difference between the pre- and postoperative maximal incisal opening in both treatment groups. Four studies met the inclusion criteria. Those undergoing gap arthroplasty had a significantly greater maximal incisal opening than the group undergoing ankylosis resection and ramus-condyle unit reconstruction. The weighted mean difference between the 2 groups was 2.4 mm (95% confidence interval 0.9 to 4.0; P = .002). Subjects with temporomandibular joint ankylosis who underwent gap arthroplasty had significantly better postoperative maximal incisal opening than those undergoing ankylosis resection and ramus-condyle unit reconstruction with a costochondral graft.

Efficacy of Temporomandibular Joint Ankylosis Surgical Treatment

The purpose of the present study was to answer the following clinical question: of the patients with temporomandibular joint ankylosis, do those treated with ankylosis resection and ramus-condyle unit reconstruction with a prosthetic total joint (total joint replacement [TJR]) have improved jaw function and decreased pain compared with those treated with ankylosis resection and interpositional arthroplasty (IA)? Using a retrospective study design, the investigators enrolled a sample derived from the population of patients presenting to the Massachusetts General Hospital (Boston, MA) and the University of Oslo Faculty of Dentistry from 1998 to 2008 for the evaluation and management of temporomandibular joint ankylosis. The primary predictor variable was treatment (ie, TJR or IA). The outcome variables were the maximal interincisal opening and pain. Data analyses were performed using bivariate and multiple regression methods. The final study sample included 36 subjects with a mean age of 40 +/- 13.1 years, and 25 were women (69%). Of the 36 patients, 14 (39%) and 22 (61%) were in the TJR and IA groups, respectively. The changes in the maximal interincisal opening in the TJR and IA groups were 9.4 +/- 6.7 and 18 +/- 9.7 mm (P = .02). After adjusting for institutional location, number of previous operations, laterality (unilateral versus bilateral operation), age, and etiology, the difference in the maximal interincisal opening between the 2 treatment groups was not significant (P = .06). The changes between preoperative and postoperative pain scores were insignificant between the groups (P = .16). Ankylosis resection and ramus-condyle unit reconstruction with a prosthetic total joint and IA produced comparable outcomes in terms of mandibular range of motion and pain.