Release Of Ankylosis Research Articles

Pre-arthroplastic mandibular distraction osteogenesis for the correction of OSA in TMJ ankylosis: a prospective observational study of 25 cases.

In severe TMJ ankylosis cases, the lack of growth of the mandible creates an anatomically narrow airway with a reduced pharyngeal airway space [PAS] which predisposes these patients towards obstructive apnoea [OSA]. There is evidence in the literature that such patients experience severe discomfort during physiotherapy if such airway abnormalities are not corrected prior to ankylosis release. This eventually leads to non-compliance towards physiotherapy and increases the risk of re-ankylosis. In our study, pre-arthroplastic mandibular distraction osteogenesis [DO] was used to increase the PAS and resolve the underlying OSA prior to releasing the ankylosis. Twenty-five cases of TMJ ankylosis with micrognathia and OSA were included in this prospective observational sleep study. They were further divided into a paediatric group [14 subjects] and an adult group [11 subjects]. All cases presented with a history of onset of ankylosis during childhood [before the completion of craniofacial growth] as result of which there was a lack of forward growth of the mandible. Subjects included in our study underwent initial DO of the mandible followed by a second procedure for distractor removal and ankylosis release. Questionnaires, lateral cephalograms and sleep studies were taken pre-operatively (T0), immediate post-distraction to the desired length (T1) and 12months post the distractor removal and ankylosis release (T2). The parameters studied were PAS width, apnoea hypopnea index [AHI], O2 saturation, mouth opening and mandibular advancement. The paediatric group variables were as follows: mean PAS width which increased from 3.5mm [T0] to 9mm [T2], mean AHI which decreased from 48.04 [T0] to 3.60 [T2], mouth opening which increased from 4.5mm [T0] to 34mm [T2] and mean O2 saturation which increased from 89.86% [T1] to 96.88% [T2]. The adult group variables were as follows: mean PAS width which increased from 5mm [T0] to 11mm [T2], mean AHI which decreased from 31.45 [T0] to 1.43 [T2], mouth opening which increased from 5mm [T0] to 34mm [T2] and mean O2 saturation which increased from 92.01% [T0] to 96.84% [T2]. Statistical analysis revealed that DO of the mandible significantly improved OSA by increasing the PAS which was evident by the lower AHI score. Mouth opening was also significantly improved post ankylosis release and maintained at the T2 interval. Ten subjects followed up beyond the T2 interval [mean 28months post ankylosis release] and their data also revealed positive compliance towards physiotherapy, adequate mouth opening and maintenance of normal AHI. Pre-arthroplastic mandibular DO has proved to be a successful modality for treatment of OSA in TMJ ankylosis patients with stable results at 12months. By resolving the narrow airway and OSA, compliance towards physiotherapy was improved thus reducing the risk of re-ankylosis in the long term.

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.

Temporomandibular Joint Ankylosis Release: 17Years of Experience with 521 Joints.

Various surgical techniques to release temporomandibular joint (TMJ) ankylosis have been described in the literature. The purpose of this paper is to report our Institution's experience regarding the post-surgical outcome of different surgical techniques for the release of ankylosis of the TMJ. The records from our hospital of 386 patients (521 joints) treated for TMJ ankylosis were reviewed. Data analysis included the etiology of TMJ ankylosis, gender distribution, age group, distribution of ankylosis based on location, type, interincisal opening and complications in the perioperative period. Out of 521 joints, 65.02% were unilateral and 73.89% had bony ankylosis. The mean maximal incisal opening preoperative was 5.4mm (SD 3.63mm) and at 1-year follow-up was 36.9mm (SD 3.3mm). There was no permanent facial nerve paralysis. However, transient facial nerve paresis was 14.78%. There was an overall recurrence rate of 8.82%. We conclude that after TMJ ankylosis release with interpositional arthroplasty, reconstruction of the RCU with L ramus osteotomy is the most favorable. This procedure not only causes least complications, but also maintains height of ramus, facilitating surgeries for secondary asymmetry correction.

English

Temperomandibular joint (TMJ) ankylosis is loss of joint movement that results from a union of the mandibular condyle to the base of the skull. Managing airway is considered to be one of the most difficult and challenging procedures when there is a diseased temperomandibular joint as a result of inadequate mouth opening. Although TMJ ankylosis is well known risk factors of difficult airway management, the techniques used are dependent on the expertise of the concerned anesthesiologists and available resources. Techniques used to secure airway in adults may not be ideal for children and sometimes dedicated equipment may not be available. In this case report we described a case of 14-year-old female patient diagnosed with bilateral TMJ ankylosis and who underwent surgery for left side temperomandibular ankylosis release and temperomandibular joint reconstruction under general anesthesia with a blind nasal intubation. Key words: Temporomandibular joint ankylosis, difficulty airway, blind nasal intubation.

Oral and maxillofacial soft tissue reconstruction using local flaps in Sokoto, Northwest Nigeria

Background: Owing to the aesthetics and functional concern, oral and maxillofacial soft tissue reconstruction requires meticulous planning with team approach. The aim of this paper is to present our experience in the use of local flaps in the reconstruction of oral and maxillofacial defects. This was a retrospective study of maxillofacial and oral soft tissue reconstruction using local flaps. Patients and Methods: The study was carried out in the Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital in northwest Nigeria over a 4-year period. Data such as age, sex, diagnosis, types of flaps used, complications and prognosis were collected and analysed with the IBM SPSS Statistics for windows Version 20 (Armonk, NY: IBM Corp). Results: Forty-two out of 64 cases of oral and maxillofacial soft tissue reconstruction (65.6%) met the inclusion criteria for local flap utilisation. They consisted of 27 (64.3%) males and 15 (35.7%) females, with a male:female ratio of 1.8:1. Age ranged from 6 to 72 years with mean ± SD (24.2 ± 17.7). Temporomandibular joint ankylosis (TMJA) release was the main reason for soft tissue flap utilisation as an interpositional material in the maxillofacial region 30 (77.3%). Temporalis myofascial flap 19 (45.2%) was the commonest flap used. Most of our cases had no associated complications 39 (92.9%), only 2 (4.8%) patients had total flap failure. Conclusion: Where free tissue transfer is not feasible, local flaps remain a viable option. Good patient selection is essential to prevent some of the complications associated with their use.

Management of temporomandibular joint ankylosis in Yemeni children by metatarsal bone grafts.

Aim: This study aimed to evaluate temporomandibular joint reconstruction in Yemeni children with metatarsal bone graft after release of ankylosis. Methodology: Ten patients ≤12 years of age, comprising eight unilateral and two bilaterally TMJ ankylosis, were selected for this study. These patients underwent reconstruction with 10 non-vascularized metatarsal grafts. The reconstructed joints were then followed for an average of 1 year. Measures of opening, symmetry, and clinical symptoms relating to the reconstructed joints were assessed. Results: Mean pre-operative interincisal aperture was 8.2mm, and immediate post-operative aperture 23.4mm. At the end of the follow-up period, acceptable results were achieved in 8 out of 10 cases, with adequate mouth opening of 35.6mm in 8 out of 10 patients and overall interincisal aperture of 30.3mm. Re-ankylosis occurred in two bilaterally-treated patients at the end of follow-up. Subjectively, 80% of the patients rated their function as satisfactory and were able to occlude and masticate without any difficulty. Conclusion: Reconstruction of TMJ after release of ankylosis utilizing metatarsal bone graft shows a satisfactory interincisal aperture in 80% of patients.

Simultaneous correction of temporomandibular joint ankylosis, facial asymmetry and obstructive sleep apnoea — the middle path

Background: Temporomandibular joint (TMJ) ankylosis is a morbid condition that not only results in hypomobility of the joint but also cause considerable facial asymmetry and obstructive sleep apnoea (OSA). Many approaches have been proposed to correct these. However, the importance of a simple procedure, genioplasty, is often under estimated. Objectives: Providing a single-staged management plan for such patients to release their ankylosis, improve their symmetry and OSA. Methods: 15 patients of TMJ ankylosis age ranging from 15 to 46 years underwent release of TMJ ankylosis with simultaneous advancement genioplasty. Results included achievement of an average of 27 mm of increase in mouth opening, 8.3 mm projection, 7.1 mm translation, 38.25% increase in Pharyngeal Airway space in a mean follow up of 18.5 months (range 6–32 months). Results: Simultaneous genioplasty performed with TMJ ankylosis release serves to improve mouth opening and hence restore function, correct facial asymmetry although not completely, but significantly, reduce episodes of nocturnal desaturation and by increasing the pharyngeal airway space, provides an added advantage of subsequent ease of intubation, if secondary surgery is required. Also, genioplasty does not interfere with subsequent osteotomies. Conclusion: This treatment plan serves as a middle path between single staged addressing only TMJ ankylosis and two staged surgery considering correction of facial asymmetry following ankylosis release.

Quality of life in patients after temporomandibular joint ankylosis release

Quality of life in patients after temporomandibular joint ankylosis release

Fate of the Coronoid Process After Coronoidotomy and Its Effect on the Interincisal Opening: A Clinical and Radiologic Assessment

Coronoidotomy (surgical detachment of the coronoid process from the mandibular ramus) is used to treat several conditions, including coronoid hyperplasia and temporomandibular joint (TMJ) ankylosis. The stability of the outcome, however, is considered questionable because of the risk of reattachment of the coronoid process. This study aims to radiographically and clinically evaluate the long-term anatomic and physiological outcome after coronoidotomy. In 17 patients with unilateral TMJ ankylosis, 25 coronoidotomies were performed as an additional maneuver to relieve trismus after ankylosis release. Radiologic evaluation was performed immediately and 1year postoperatively with panoramic radiography and computed tomography to assess changes at the coronoidotomy site. Clinical assessment included measurement of the interincisal distance at the 1-, 3-, 6-, and 12-month postoperative visits. A sharp osteotomy margin with a 3- to 10-mm gap between the ramus and coronoid process was observed immediately postoperatively in all cases. After 1year, 23 cases (92%) showed partial (n= 5) or complete (n= 18) osseous union to the mandibular ramus, whereas in 2 cases, no evidence of fusion was observed radiographically. The mean interincisal opening achieved at 1year was 33mm. Coronoidotomy is an effective but more straightforward adjunct to arthroplasty than coronoidectomy (surgical excision of the coronoid process) in the management of TMJ ankylosis, with achievement and maintenance of adequate postoperative mouth opening.

Results and outcome predictors after open release of complete ankylosis of the elbow caused by heterotopic ossification

Heterotopic ossification (HO) may lead to complete elbow ankylosis, resulting in severe disability. The prognostic factors that may be valuable in guiding treatment of this condition have not yet been evaluated. The goals of this study were to describe the outcomes of open release for ankylosed elbow caused by HO and to analyse factors associated with clinical outcomes. This retrospective study assessed 41 patients with ankylosed elbows treated by open release surgery. We report final clinical outcomes and analyses of the association between outcomes and clinical variables. Mean patient age was 36.4years; follow-up was 36.1months. Mean arc of motion increased from 0 to 112° post-operatively, mean pronation from 34 to 52°, supination from a mean of 51 to 76°, and Mean Mayo Elbow Performance Score (MEPS) from 42.8 to 84.2. Eight patients experienced recurrence, two of whom underwent a second operation: one for elbow instability and one for revision surgery. Linear regression analysis demonstrated that initial injury type (p = 0.020), articular surface damage (p = 0.001), coma iduringthe initial injury (p = 0.001) and concomitant radial head replacement (p = 0.029) were independent factors affecting the final MEPS. Satisfactory outcomes were achieved, indicating that open release is effective for ankylosed elbows. Our findings demonstrated that initial injury type, articular surface damage, coma and radial head replacement are outcome predictors affecting final outcomes.

Surgical management of ankyloses of the temporomandibular joint by a piezoelectric device

IntroductionPiezosurgery is commonly used in different field of craniomaxillofacial surgery; since its introduction it has become one of the widely adopted technique for performing osteotomies in orthognathic surgery, distraction osteogenesis and dentoalveolar surgery. Little has been written regarding ultrasonic system for temporomandibular joint surgery (TMJ). In this prospective study we describe the use of piezoelectric device for ankylosis of the TMJ. Materials and methodsWe enrolled in this study 19 patients, 10 males and 9 females, mean (SD) age 24.6 (7.6) years, affected by unilateral ankylosis of TMJ who were surgically managed between January 2009 and December 2014 by interpositional arthroplasty with temporomyofascial muscle flap. We adopted in all cases a preauricular approach with temporal extension. The ankylotic block was removed with piezoelectric device in 9 patients and using traditional rotary bur in 10 cases. We investigated and compared the following parameters as surgical outcomes: intraoperative bleeding, duration of operation, incidence of infection, postoperative swelling and hematoma, mouth opening, nerve impairment and rate of recurrence. ResultsWe noticed a substantial reduction in bleeding with the piezoelectric bone cutter when compared to traditional mechanical surgery (103 ml versus 117 ml; p < 0.05); however, we did not report any severe bleeding from the pterygoid plexus or maxillary artery. Operating time was longer in the piezo group (101 min versus 88 min; p < 0.05). There was a lower incidence of postoperative hematoma and swelling following piezoosteotomy. However, regarding postoperative nerve impairment and infection we did not observe any differences between the two groups. At one year follow-up mean (SD) mouth opening was 34 (4.3) mm. We did not report recurrence of the disease. ConclusionPiezoelectric bone removal for the release of ankylosis of the TMJ is associated with minimal bleeding and few postoperative complications. We believe that piezosurgery allows surgeons to achieve better results compared to a traditional surgery. It is a possible alternative due to the clinical benefits demonstrated.

Zurich pediatric distractor for ramal condylar unit distraction in temporomandibular joint ankylosis

Temporomandibular joint (TMJ) Ankylosis is an extremely disabling condition characterized by difficulty or inability to open the mouth resulting in facial asymmetry, malocclusion and dental problems. Surgical excision of the ankylosed mass is the only treatment option available to gain mouth opening. The loss in vertical height of ramus following release of ankylosis is difficult to manage in both unilateral and bilateral TMJ ankylosis. Out of all the methods to restore this height Distraction Osteogenesis (DO) is gaining popularity because of predictable gain in the length without any associated morbidity. Recurrent bilateral TMJ ankylosis in a 32 year old male was treated by osteoarthrectomy and temporal fascia interpositioning arthroplasty. Bilateral reconstruction of ramal condylar unit (RCU) was carried out by Zurich paediatric distractor (KLS Martin, Tuttlingen Germany). Following a latency period of 7 days distraction was carried out at a rate of 1mm/day for 8 days. Distractors were removed after 12 weeks of consolidation period. The case was followed up for 12 months during which the mouth opening was maintained at 38 mm and there was no anterior open bite.

Use of oral mucoperiosteal and pterygo-masseteric muscle flaps as interposition material in surgery of temporomandibular joint ankylosis: a comparative study.

Background:The most common complication of surgery for the release of temporomandibular joint (TMJ) ankylosis is relapse of the ankylosis. To prevent re-ankylosis, a variety of interpositional materials have been used.Aim:The aim was to compare the surgical outcome of oral mucoperiosteal flap, not hitherto used as interpositional material, with pterygo-masseteric muscles flap after surgical release of TMJ ankylosis.Subjects and Methods:This was a prospective randomized study of all consecutive patients treated for the release of complete TMJ bony ankylosis, from January 2003 to December 2012, at the Oral and Maxillofacial unit of our institution. The patients were randomized into two groups: The pterygo-masseteric group comprises 22 patients while the oral mucoperiosteal group had 23 patients. Information on demographics, clinical characteristics, and postoperative complications over a 5 year follow-up period were obtained, and analyzed using the statistical package for social sciences (Statistical Package for the Social Sciences version 13, Chicago, IL, USA). A P < 0.05 was considered significant.Results:The age of the patients ranged from 15 to 28 mean 20.3 (3.35) years while the duration of ankylosis ranged from 2 to 16 mean 5.1 (3.4) years. The baseline demographic (gender; P = 0.92; side; P = 0.58) and clinical characteristics in terms of etiology (P = 0.60) and age (P = 0.52) were comparable in both treatment groups. All the patients presented with complete bony TMJ ankylosis with a preoperative inter-incisal distance of <0.5 cm. The intraoperative mouth opening achieved ranged from 4 cm to 5 cm, mean 4.6 (0.27) cm and this was not different for either group (P = 0.51). The patients were followed up postoperatively for a period ranging from 3 to 5 years, mean 3.4 (0.62) years. The mouth opening decreased, over the period of postoperative review, from the initial range of 4–5 cm to 2.9–3.6 cm, and this was not different in both groups (P = 0.18).Conclusion:This study suggests that oral mucoperiosteal flap could be an option in the choice of interpositional materials in surgery of TMJ ankylosis.

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.

Temporomandibular Joint Ankylosis:Evaluation of surgical outcomes

The study reviews surgical outcomes of 45 temporomandibular joint (TMJ) ankylosis patients that were treated in the maxillofacial and oral surgery unit of the University of the Western Cape, in South Africa.The aim of the study was to evaluate the outcomes of our protocol and to compare the outcomes unilateral and bilateral TMJ ankylosiscases. In this study the outcomes of TMJ ankylosiswere evaluated by using the following three parameters; preoperative maximal interincisal opening (preop MIO), intraoperative maximal interincisal opening (OP MIO) and the outcome Maximal interincisal opening (outcome MIO). The patient progress since surgery is calculated by subtracting Op MIO from the outcome MIO, and parameter is called postoperative change (Pop MIO). While the overall change is measured by subtracting preop MIO from the outcome MIO, and variable is called Overall change in MIO (OC MIO). The study showed that surgical release of TMJ ankylosis improved mouth opening by a mean OC MIO of 18.5mm. The study also showed that there was no difference in outcomes between unilateral and bilateral cases. Gap arthroplasty showed better outcomes than reconstruction with costochondral graft.

Treatment of Facial Asymmetry and Temporomandibular Joint Ankylosis by Distraction Osteogenesis: A Case Report

Facial asymmetry and functional problems due to dentofacial discrepancy and soft tissue disparities are commonly managed by orthognathic surgery and augmentation procedures. Distraction osteogenesis is a relatively new technique of bone generation and reconstruction. A patient reported with the chief complaint of asymmetry of face and deviated chin; had temporomandibular joint ankylosis. Distraction device was applied with simultaneous release of ankylosis by gap arthroplasty. For management of mandibular deformity and discrepancy of the dentition, orthodontic therapy was done using MBT 0.022” prescription. Distraction was stopped when the midline of upper central incisor coincided with the midline of lower central incisor followed by stabilization period of ten weeks. The functional and esthetic results achieved were acceptable.&#x0D;

Role of Computed Tomographic Angiography in Treatment of Patients With Temporomandibular Joint Ankylosis

To evaluate the use of preoperative computed tomographic angiography (CTA) and selective embolization as an ancillary tool for the treatment of patients with temporomandibular joint (TMJ) ankylosis. The present study was a case series of subjects with bilateral TMJ ankylosis who had undergone preoperative CTA and surgical release with immediate reconstruction. The indications for CTA were either an intimate association between the vessels and the ankylotic mass on the facial computed tomography (CT) scan or a history of multiple previous TMJ operations. In cases in which intimate anatomic association was present between the branches of the maxillary artery and the ankylotic masses, preoperative selective embolization was performed. All subjects underwent a standard approach to ankylosis release with immediate reconstruction and were followed up for up to 6 months postoperatively. The demographic and operative variables were recorded for each subject. Five subjects (mean age, 36.4 years; 3 females) with bilateral TMJ ankylosis underwent release and had undergone preoperative CTA for vascular assessment. Three subjects underwent preoperative embolization. The total operating time ranged from 5.9 to 10.3 hours. The intraoperative blood loss ranged from 150 to 3,750 mL. One patient who had undergone unilateral embolization required an intraoperative transfusion because of bleeding on the nonembolized side. No adverse cardiac, renal, or neurologic events developed secondary to the blood loss. In all 5 subjects, the preoperative maximal incisor opening was less than 15 mm, increased to more than 35 mm intraoperatively, and was 30 mm or more at 6 months or longer of follow-up. In select cases, CTA can be a useful adjunct in the treatment of patients with TMJ ankylosis.

Autogenous Reconstructive Modalities of TMJ Ankylosis-A Retrospective Analysis of 45 Cases.

The study reports the authors' experience in managing temporomandibular joint (TMJ) ankylosis in Chennai, India (1995-2006) and compares the surgical modalities used. Forty-five patients (67 joints) were reviewed in this retrospective study. Pre- and post-operative assessment included history, radiological, physical examination, and range of mouth opening. Age, gender, aetiology, joint(s) affected, surgical modality, complications and follow-up periods were evaluated. Various types (fibrous, fibroosseous and bony) of TMJ ankylosis were diagnosed. Trauma was the commonest aetiology. The patients' age range was 2-50years, 51.1% were males and the follow-up period ranged from 14 to 96months. Average mouth opening was significantly increased to 32mm 12months post-operatively. Mouth opening was compared following different interpositional materials like temporalis interpositioning (33mm), costochondral graft (30.6mm) and autograft (30mm). Minor and major complications were encountered in 37.4% of cases, including 6.7% recurrence rate. Early release of TMJ ankylosis; reconstruction of the ramus height with distraction osteogenesis or bone grafting combined with interpositional arthroplasty, followed by vigorous physiotherapy is a successful strategy for the management of TMJ ankylosis.

Clinical application of transport distraction osteogenesis arthroplasty in the treatment of temporomandibular joint bony ankylosis

To explore the clinical application of transport distraction osteogenesis arthroplasty (TDOAP) in the treatment of temporomandibular joint (TMJ) bony ankylosis. From December 1999 to December 2011, a total of 73 patients (89 sides of TMJ) underwent TDOAP were included. There were 39 males and 34 females with a mean age of 19.6 years (range: 3 - 60). Among them, 27 patients were recurrence cases and 30 cases were accompanied with micrognathia and obstructive sleep apnea-hypopnea syndrome (OSAHS). The mean preoperative degree of mouth opening was 6.6 mm (range: 1 - 20). After a release of ankylosis, a transport disc was performed and fixed to ramus with a distractor. Distraction began at Days 4 - 8 postoperation. The distraction rhythm and rate were 0.25 mm four times daily. Distraction stopped when planning distance was achieved. And a distractor was maintained in place for 3-6 months after completion of distraction and then removed. Active postoperative training of mouth opening was implemented. The mean distance of distraction was 15.3 mm (range: 12 - 23). The range of mouth opening of 65 patients increased to normal and bone formation in gaps were perfect. The mean follow-up period was 44.8 months (range: 18 - 102). Eight cases were recurrent. And 1/37 over 15 years old and 7/36 under 15 years old had recurrence. TDOAP is an effective treatment for TMJ ankylosis. A pediatric patient, especially recurrent, should be operated after adolescence to decrease recurrence. Micrognathia and OSAHS should be also considered during the treatment of ankylosis.

New protocol to prevent TMJ reankylosis and potentially life threatening complications in triad patients

The management of patients with the triad of temporomandibular joint (TMJ) ankylosis, micrognathia and obstructive sleep apnea syndrome is challenging for the oral and maxillofacial surgeon because it involves achieving the desired oral opening, correction of micrognathia, and correction of the obstructed airway. Seven of the authors’ triad patients, in whom only the release of ankylosis was performed, developed bradycardia and respiratory distress during postoperative jaw physiotherapy, leading to their non-compliance for active jaw physiotherapy and subsequent reankylosis. This paper suggests a new surgical protocol for the management of patients with the triad, to achieve correction of the obstructed airway, relief of the respiratory distress symptoms, correction of micrognathia and restricted mouth opening. It also provides a logical reason for the occurrence of bradycardia following ankylosis release and its potential role in TMJ reankylosis. It emphasizes that the occurrence of bradycardia in triad patients during jaw exercises is dictated by the severity of their apnea–hypopnea index and the degree of narrowing of their posterior airway space. The recognition and prevention of this by the new protocol is discussed in 7 patients.