- Email: [email protected]
A comparative study of different surgical methods in the treatment of traumatic temporomandibular joint ankylosis
YIJOM-3496; No of Pages 6
Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2016.08.020, available online at http://www.sciencedirect.com
Clinical Paper TMJ Disorders
A comparative study of different surgical methods in the treatment of traumatic temporomandibular joint ankylosis
F. Xu, L. Jiang, C. Man Department of Oral and Maxillofacial Surgery, Stomatological Hospital, Zunyi Medical University, Zunyi, China
F. Xu, L. Jiang, C. Man: A comparative study of different surgical methods in the treatment of traumatic temporomandibular joint ankylosis. Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxx. # 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. Two different surgical methods for the treatment of unilateral traumatic temporomandibular joint (TMJ) ankylosis with a medially displaced residual condyle are described. Eighteen patients with unilateral traumatic TMJ ankylosis and a medially displaced residual condyle, treated between 2008 and 2013, were included in this study. Group A patients (n = 10) were treated with an autogenous coronoid process graft (ACPG) for reconstruction of the mandibular condyle, while group B patients (n = 8) were treated by lateral arthroplasty (LAP); a temporalis myofascial flap (TMF) was used as interpositional material in both groups. The long-term results of the two treatments were compared through postoperative computed tomography and clinical follow-up examinations. The two groups were compared in terms of the recurrence rate, facial pattern change, and improvement in maximum inter-incisal opening (MIO) using SPSS 18.0 software. All patients were followed up for 12–24 months. Two patients in group A (20%) had reankylosis; no reankylosis was observed in group B patients. Compared with the ACPG, LAP improved the facial pattern and MIO significantly (P < 0.05). LAP is a feasible and effective surgical method for the treatment of unilateral traumatic TMJ ankylosis when the displaced residual condyle is bigger than one third of the condylar head.
Temporomandibular joint (TMJ) ankylosis is a severe disease that causes problems such as limited mouth opening and occlusion disorders, and may interfere 0901-5027/000001+06
with mastication and speech. It also has an impact on the development of the mandible, as evidenced in growing patients, resulting in facial deformity
Key words: trauma; temporomandibular joint ankylosis; treatment; recurrence. Accepted for publication 26 August 2016
and potentially sleep apnoea–hypopnoea syndrome (SAHS). The major aetiological factors are trauma and infection. In recent years, due to the widespread use of
# 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Xu F, et al. A comparative study of different surgical methods in the treatment of traumatic temporomandibular joint ankylosis, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.020
YIJOM-3496; No of Pages 6
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Xu et al.
antibiotics, trauma has become the leading cause of TMJ ankylosis.1 A variety of treatments for this condition have been described, including gap arthroplasty, interpositional arthroplasty, and TMJ reconstruction; however, no published consensus has been reached, and recurrence remains the major problem. Gap arthroplasty without interpositional material has gradually been abandoned by many surgeons due to the associated high risk of recurrence.2 The interpositional arthroplasty is a standard procedure that uses autogenous or alloplastic materials between the mandibular ramus and surface of the temporal bone.3 The temporalis myofascial flap (TMF) is the most widely used material, with benefits that include easy harvesting and a lower chance of resorption. However, this flap also presents problems such as donor site morbidity, chronic headache, and trismus. The trismus caused by scar contracture of the temporal muscle can be prevented by ipsilateral coronoidectomy.4 TMJ reconstruction remains a daunting task, because it is difficult to rebuild a structurally and functionally satisfactory neocondyle. A variety of autogenous and alloplastic grafts have been studied; however, no single method has produced uniformly successful results. Recent clinical research supports the use of the autogenous coronoid process graft (ACPG) as a suitable bone resource for condylar reconstruction when it is not involved in the ankylotic mass.5,6 He et al. reported the presence of a medially displaced residual condyle and
disc in 75% of traumatic TMJ ankylosis cases,7 and summarized a surgical method to preserve the residual TMJ structure called the lateral arthroplasty (LAP).8 The aim of the present study was to investigate the feasibility of the LAP and to compare the differences in clinical effects with the ACPG for reconstruction of the condyle in patients with unilateral traumatic TMJ ankylosis. Patients and methods
The present study was approved by the ethics committee of the study university. TMJ ankylosis was classified on the basis of Yang’s criteria9: type A1 represents fibrous ankylosis; types A2 and A3 represent ankylosis with bony fusion on the lateral side of the joint, in the presence of a medially displaced residual condyle and a residual condylar fragment larger than half of the condylar head (type A2) or smaller than half of the condylar head (type A3); type A4 represents bony ankylosis. Eighteen patients (9 female, 9 male) diagnosed with unilateral traumatic TMJ ankylosis who were operated on at a stomatological hospital in Zunyi, China between 2008 and 2013, were included in this retrospective study. The following inclusion criteria were applied: (1) the aetiology was traumatic, (2) the medially displaced residual condyle was bigger than one-third of the condylar head, i.e. type A2 and some type A3 (Fig. 1), (3) the patient agreed to participate. Exclusion criteria were as follows: (1) patient treated previously with
Fig. 1. Preoperative CT scan: the bony mass is located on the left side (red arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of the article.)
TMJ surgery, (2) the aetiology was infection or other, (3) patient unwilling to participate. The relevant patient details are summarized in Table 1. Group A patients were treated with an ACPG for the reconstruction of the mandibular condyle, while group B patients were treated with a LAP; a TMF was used as interpositional material in both groups (thickness 0.5– 1 cm). The advantages and disadvantages of each method were explained to the patient preoperatively, and the method used depended on the patient’s preference. All operations were performed by the same experienced surgeon and all clinical examinations were performed by the same resident.
Table 1. General information for the patients in the two treatment groups.
Patient number
Sex/age (years)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
M/11 F/12 M/13 F/11 M/10 F/18 M/15 F/12 M/15 F/35 M/16 F/15 M/16 F/10 M/23 F/19 M/20 F/37
Age at injury (years)
Time between open operation and presentation with ankylosis (years)
Surgical method/group
Type of ankylosis (Yang’s criteria)
Site of fracture
Preoperative MIO (mm)
10 12 12 10 8 16 13 11 12 35 15 15 15 9 20 18 18 33
1 0.5 1 1 2 2 2 1 3 0.5 1 0.5 1 1 3 1 2 4
ACPG/A ACPG/A ACPG/A ACPG/A ACPG/A ACPG/A ACPG/A ACPG/A ACPG/A ACPG/A LAP/B LAP/B LAP/B LAP/B LAP/B LAP/B LAP/B LAP/B
A2 A2 A2 A2 A2 A2 A3 A2 A2 A2 A2 A2 A3 A2 A2 A2 A2 A2
Right head Right head Right head Left head Left head Right neck Right neck Left head Left head Right head Left neck Right head Left head Right head Left head Right head Left head Right head
5 10 0 13 16 20 5 10 13 8 8 10 9 12 5 0 15 5
MIO, maximum inter-incisal opening; M, male; F, female; ACPG, autogenous coronoid process graft; LAP, lateral arthroplasty.
Please cite this article in press as: Xu F, et al. A comparative study of different surgical methods in the treatment of traumatic temporomandibular joint ankylosis, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.020
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Surgical methods for traumatic TMJ ankylosis
3
Assessment
Assessments included clinical and radiological examinations. The facial pattern and maximum inter-incisal opening (MIO) were recorded before and after surgery. The major radiological examination used was cone beam computed tomography (CBCT), and all patients agreed to CT scans preoperatively and postoperatively. Surgical procedure
Fig. 3. Group B patient (lateral arthroplasty): a medially displaced condylar fragment is observed.
All patients were operated on under general anaesthesia. Blind nasal intubation was successful in 16 patients; the remaining two underwent intubation with the assistance of a fibre-optic endoscope. A modified pre-auricular approach with a temporal extension, which produced a double-layer flap (i.e. the skin flap and the deep temporal flap), was used in order to protect the superficial temporal vessels and the branches of the facial nerve; the superficial temporal fascia was dissected following the plane inferiorly and anteriorly to reach the zygomatic arch. On reaching the capsule, the lateral bony mass was exposed via a T-shaped incision. In group A, aggressive excision of the lateral bony mass and medially displaced residual condylar fragment was performed, creating a gap of about 15– 20 mm between the ramus and surface of the temporal bone, following which an ipsilateral coronoidectomy was done. The bone graft was then trimmed and formed, and an L-shaped titanium miniplate was used to rigidly fix the graft to the ramus (Fig. 2). The TMF was rotated as interpositional material if the disc was disrupted; otherwise the TMF was sutured with the disc. A contralateral coronoidectomy was performed if the intraoperative MIO was less than 35 mm.
In group B, the lateral bony mass was removed with an oscillating saw and a chisel, and then the bony fusion mark between the glenoid fossa and ramus was identified. Guided by the preoperative CT scan, two oblique bony cuts were made over the ankylotic mass without damaging the residual condylar fragment (Figs. 3 and 4). An ipsilateral coronoidectomy was performed, the remainder of the glenoid fossa and ramus were contoured, and the disc was released and sutured, with the TMF filling the dead space (Fig. 5). A contralateral coronoidectomy was performed if the intraoperative MIO was less than 35 mm (Fig. 6). Prophylactic antibiotics were given for 3–5 days postoperative. The drainage was removed 24 h postoperative and the patients were started on a soft diet 2 weeks after the operation. Physiotherapy was started on day 5–7 postoperative to redevelop normal muscle function and prevent hypomobility secondary to fibrous adhesions, and was continued for at least 6 months. All cases were followed up for 12–24 months. The facial pattern and MIO before and after surgery were compared, and CT scans were performed.
Fig. 2. Group A patient (autogenous coronoid process graft): the bone graft was trimmed and formed, and an L-shaped titanium miniplate was used to rigidly fix the graft to the ramus.
Fig. 4. Postoperative CT scan of a group B patient (lateral arthroplasty): the bony mass was completely resected without damaging the medially displaced condylar fragment.
Fig. 5. Group B patient (lateral arthroplasty): the disc was released and sutured with the temporalis myofascial flap to fill the dead space.
Reankylosis was diagnosed in the presence of an MIO of less than 15 mm and/or fibrous/bony fusion observed on CT scan (Fig. 7).
Statistical analysis
The data analysis was performed using SPSS version 18.0 software (SPSS Inc., Chicago, IL, USA). The Wilcoxon rank sum test was used to determine the significance of the intergroup improvement in MIO. The x2 test was used to determine the significance of the intergroup recurrence rate and facial pattern change. An a level of <0.05 was considered significant. Results
All patients participated in the long-term follow-up study (12–24 months). The
Fig. 6. The intraoperative MIO is 38 mm.
Please cite this article in press as: Xu F, et al. A comparative study of different surgical methods in the treatment of traumatic temporomandibular joint ankylosis, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.020
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Fig. 7. Group A patient (autogenous coronoid process graft): fibrous adhesions can be seen between the ramus and the surface of the temporal bone. (A) Coronal view; (B) sagittal view.
Table 2. Treatment results for the two study groups. Group A B
Follow-up period (months) 12–24 12–24
Recurrence (n)
Mean postoperative MIO (mm)
2/10 0/8 P > 0.05
35.0 37.0 P < 0.05
Facial pattern change 7/10 1/8 P < 0.01
MIO, maximum inter-incisal opening.
results of the treatment in the two groups are summarized in Table 2. Reankylosis was observed in two (20%) patients in group A within 6 months. A further gap arthroplasty with costochondral graft (CCG) was applied in these cases, and successful results were achieved. No reankylosis was observed in group B patients (0%). There was no significant difference in recurrence rate between the two groups (x2 = 1.800, P > 0.05). However, a significant difference in the facial pattern change was observed between the groups (x2 = 7.244, P < 0.01): seven patients (70%) in group A and one (12.5%) in group B showed some degree of mandibular deviation to the operated side on maximum mouth opening after the operation. A significant difference in the MIO improvement was also observed between the groups (Z = 3.630, P < 0.05). These results indicate that in selected cases, i.e. type A2 and some type A3 patients, LAP for the treatment of unilateral traumatic TMJ ankylosis significantly improved the facial pattern and MIO. The most frequent sequela was paralysis of the temporal branch of the facial nerve, which was encountered in three patients (30%) in group A. The patients who experienced this sequela recovered gradually without additional treatment over the course of 2–4 weeks postoperatively. No patient suffered local infection, chronic headache, or permanent facial nerve paralysis. Details of the
postoperative complications are presented in Table 3.
Discussion
Patient age, the severity of the trauma, the pattern of condylar fracture, the duration of immobilization, and the location of the disc play important roles in the development of traumatic TMJ ankylosis.1,10 The intracapsular condylar fracture – especially the mandibular ramus attached to the temporal bone, displaced condylar fragment, and damaged disc and lateral capsule – causes TMJ ankylosis.11 Early diagnosis, appropriate therapeutic interventions, and proper rehabilitation are essential in the treatment of traumatic TMJ ankylosis.6 The protocol for the management of ankylosis recommended by Kaban et al. is as follows12: aggressive resection, ipsilateral coronoidectomy, contralateral coronoidectomy if the intraoperative MIO is less than 35 mm, lining of the TMJ with or without interpositional materials, reconstruction of the ramus with
autogenous or alloplastic grafts, early mobilization, and aggressive physiotherapy. An aggressive resection (15–20 mm) is recommended to prevent ankylosis. However, this has disadvantages of a decreased mandible height, premature occlusion in unilateral cases, and anterior open bite or respiratory problems in bilateral cases.13 The recurrence rate has been shown to be relatively high following treatment by gap arthroplasty without interpositional material. Long-standing ankylosis predisposes to fibrosis of the masticatory muscles; an additional ipsilateral or bilateral coronoidectomy can improve mouth opening.14 In the present study, five patients underwent an ipsilateral coronoidectomy, but the intraoperative MIO was still less than 35 mm, ranging from 20 mm to 30 mm (mean 25.2 mm); a contralateral coronoidectomy was performed in these patients and the MIO increased, ranging from 35 mm to 40 mm (mean 37.6 mm). The ACPG has been studied widely and has the advantages of avoiding a second surgical site and the associated donor site morbidity, easy accessibility, and a good shape and thickness. However, notable bone resorption has been observed in some cases,15 which was also noted in the present study (Fig. 8). Group A patients were treated with the ACPG for reconstruction of the condyle. Three patients suffered temporal facial nerve paralysis, seven experienced a facial pattern change, and two had reankylosis during follow-up (12–24 months). These results suggest that greater attention should be paid to the deep temporal vessels and branches of the facial nerve before grafting, and that a thicker TMF should be prepared as interposition material. The disc plays an important role in preventing ankylosis. Yan et al. found that
Table 3. Postoperative complications in the two treatment groups after 12–24 months of follow-up. Complications Reankylosis Chronic headache Local infection Permanent facial palsy
Group A, n Group B, n 2/10 0/10 0/10 0/10
0/8 0/8 0/8 0/8
Fig. 8. Group A patient (autogenous coronoid process graft): moderate resorption and loss of height of the ramus can be observed.
Please cite this article in press as: Xu F, et al. A comparative study of different surgical methods in the treatment of traumatic temporomandibular joint ankylosis, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.020
YIJOM-3496; No of Pages 6
Surgical methods for traumatic TMJ ankylosis when the disc remained in the normal position, neither fibrous nor fibro-osseous calluses were observed.16 Using a sheep model, Miyamoto et al. showed that the presence of an intact disc can prevent the development of ankylosis.17,18 Sarma and Dave analysed 60 patients and found that the ankylosed condyle was divided into two parts19: the non-adhesive part demonstrated a medially displaced condylar fragment, and the bony-adhesive part presented new bone formation. In 1998, Nitzan et al. reported a modified gap arthroplasty and applied it in four patients.20 The procedure involved resection of the lateral bony mass and preservation of the medially displaced condylar fragment, leaving a large gap between the glenoid fossa and the ramus, and the results were excellent. On the basis of that study, He et al. raised the concept of the ‘lateral arthroplasty’ (LAP), confirming that the medially displaced residual condylar fragment, as well as maintaining the normal function of the mandible, can also promote the development of the mandible in growing patients.8 The key point in the LAP procedure is preservation of the functional condylar fragment. Group B patients were treated by LAP. Only patients whose medially displaced condylar fragment was bigger than onethird of the condylar head could apply for this procedure. This amount is necessary to keep the structure stable and to sustain the pressure from the implanted graft, thereby preventing malocclusion and a shortage of mandibular ramus caused by resorption. In the present study, LAP for the treatment of unilateral traumatic TMJ ankylosis improved the occlusion, facial pattern, and MIO significantly compared with the ACPG. No patient experienced temporal facial nerve paralysis or had reankylosis during the follow-up period of 12–24 months. The LAP has several advantages. First of all, the medially displaced condylar fragment can be preserved, which is very important for growing patients. Recent research has shown that aggressive excision of the bony mass is not necessary, as the bony mass is not a neoplastic process capable of continued growth.21 Second, the disc is sutured with the TMF as interpositional material, and it is well known that the disc has an important role in preventing ankylosis.16–18 Third, compared with ACPG, internal fixation is not needed, which avoids the possibility of hardware loosening or a foreign body reaction. Finally, less bone resorption was observed in LAP patients than in ACPG patients, owing to the good blood supply.
A limitation of the LAP is that it can only be applied to patients whose medially displaced condylar fragment is bigger than one third of the condylar head; if this is less than one-third, it cannot provide sufficient strength for the TMJ loading force and resorption will ultimately occur. In conclusion, the LAP is a feasible and effective surgical method for the treatment of unilateral traumatic TMJ ankylosis in selected cases, i.e. type A2 and some type A3 patients. Funding
This study was supported by the Foundation of Guizhou Science and Technology Department (grant LKZ[2013]09) and the Foundation for Doctor Start-up of Zunyi Medical University (grant F-458). Competing interests
None declared.
7.
8.
9.
10.
11.
12.
Ethical approval
This study was approved by the Ethics Committee of Zunyi Medical University, Zunyi, China.
13.
Patient consent
Written patient consent was obtained to publish the clinical photographs. References 1. Yan YB, Liang SX, Shen J, Zhang JC, Zhang Y. Current concepts in the pathogenesis of traumatic temporomandibular joint ankylosis. Head Face Med 2014;10:35. 2. Danda AK, Ramkumar S, Chinnaswami R. Comparison of gap arthroplasty with and without a temporalis muscle flap for the treatment of ankylosis. J Oral Maxillofac Surg 2009;67:1425–31. 3. Su-Gwan K. Treatment of temporomandibular joint ankylosis with temporalis muscle and fascia flap. Int J Oral Maxillofac Surg 2001;30:189–93. 4. Shimizu M, Kurita K, Matsuura H, Ishimaru JI, Goss AN. The role of muscle grafts in temporomandibular joint ankylosis: shortterm experimental study in sheep. Int J Oral Maxillofac Surg 2006;35:842–9. 5. Zhang W, Gu B, Hu J, Guo B, Feng G, Zhu S. Retrospective comparison of autogenous costochondral graft and coronoid process graft in the management of unilateral ankylosis of the temporomandibular joint in adults. Br J Oral Maxillofac Surg 2014;52:928–33. 6. Hu W, Thadani S, Mukul SK, Sood R. Autogenous coronoid process as free graft
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for reconstruction of mandibular condyle in patients with temporomandibular ankylosis. Oral Maxillofac Surg 2014;18:313–23. He D, Yang C, Chen M, Zhang X, Qiu Y, Yang X, et al. Traumatic temporomandibular joint ankylosis: our classification and treatment experience. J Oral Maxillofac Surg 2011;69:1600–7. He D, Yang C, Chen M, Yang X, Li L, Jiang Q. Surgical treatment of traumatic temporomandibular joint ankylosis with medially displaced residual condyle: surgical methods and long-term results. J Oral Maxillofac Surg 2011;69:2412–8. Yang C. Temporomandibular joint ankylosis. In: Wei-Liu Q, editor. Oral and maxillofacial surgery. Shanghai: Shanghai Science and Technology Press; 2008. p. 869. Laskin DM. Role of the meniscus in the etiology of posttraumatic temporomandibular joint ankylosis. Int J Oral Surg 1978;7:340–5. Long X. The relationship between temporomandibular joint ankylosis and condylar fractures. Chin J Dent Res 2012;15:17–20. Kaban LB, Perrott DH, Fisher K. A protocol for management of temporomandibular joint ankylosis. J Oral Maxillofac Surg 1990;48:1145–51. Babu L, Jain MK, Ramesh C, Vinayaka N. Is aggressive gap arthroplasty essential in the management of temporomandibular joint ankylosis? A prospective clinical study of 15 cases. Br J Oral Maxillofac Surg 2013;51:473–8. Gu¨ven O. Treatment of temporomandibular joint ankylosis by a modified fossa prosthesis. J Craniomaxillofac Surg 2004;32:236– 42. Liu Y, Li J, Hu J, Zhu S, Luo E, Hsu Y. Autogenous coronoid process pedicled on temporal muscle grafts for reconstruction of the mandible condylar in patients with temporomandibular joint ankylosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:203–10. Yan YB, Zhang Y, Gan YH, An JG, Li JM, Xiao E. Surgical induction of TMJ bony ankylosis in growing sheep and the role of injury severity of the glenoid fossa on the development of bony ankylosis. J Craniomaxillofac Surg 2013;41:476–86. Miyamoto H, Kurita K, Ogi N, Ishimaru J, Goss AN. The effect of an intra-articular bone fragment in the genesis of temporomandibular joint ankylosis. Int J Oral Maxillofac Surg 2000;29:290–5. Miyamoto H, Kurita K, Ogi N, Ishimaru JI, Goss AN. The role of the disk in sheep temporomandibular joint ankylosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:151–8. Sarma UC, Dave PK. Temporomandibular joint ankylosis: an Indian experience. Oral Surg Oral Med Oral Pathol 1991;72:660–4. Nitzan DW, Bar-Ziv J, Shteyer A. Surgical management of temporomandibular joint
Please cite this article in press as: Xu F, et al. A comparative study of different surgical methods in the treatment of traumatic temporomandibular joint ankylosis, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.020
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ankylosis type III by retaining the displaced condyle and disc. J Oral Maxillofac Surg 1998;56:1133–8. 21. Salins PC. New perspectives in the management of cranio-mandibular ankylosis. Int J Oral Maxillofac Surg 2000;29:337–40.
Address: Cheng Man Department of Oral and Maxillofacial Surgery Stomatological Hospital Zunyi Medical University
Zunyi Guizhou 563000 China. Fax: +86 851 28638920 E-mail: [email protected]
Please cite this article in press as: Xu F, et al. A comparative study of different surgical methods in the treatment of traumatic temporomandibular joint ankylosis, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.020
Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2016.08.020, available online at http://www.sciencedirect.com
Clinical Paper TMJ Disorders
A comparative study of different surgical methods in the treatment of traumatic temporomandibular joint ankylosis
F. Xu, L. Jiang, C. Man Department of Oral and Maxillofacial Surgery, Stomatological Hospital, Zunyi Medical University, Zunyi, China
F. Xu, L. Jiang, C. Man: A comparative study of different surgical methods in the treatment of traumatic temporomandibular joint ankylosis. Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxx. # 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. Two different surgical methods for the treatment of unilateral traumatic temporomandibular joint (TMJ) ankylosis with a medially displaced residual condyle are described. Eighteen patients with unilateral traumatic TMJ ankylosis and a medially displaced residual condyle, treated between 2008 and 2013, were included in this study. Group A patients (n = 10) were treated with an autogenous coronoid process graft (ACPG) for reconstruction of the mandibular condyle, while group B patients (n = 8) were treated by lateral arthroplasty (LAP); a temporalis myofascial flap (TMF) was used as interpositional material in both groups. The long-term results of the two treatments were compared through postoperative computed tomography and clinical follow-up examinations. The two groups were compared in terms of the recurrence rate, facial pattern change, and improvement in maximum inter-incisal opening (MIO) using SPSS 18.0 software. All patients were followed up for 12–24 months. Two patients in group A (20%) had reankylosis; no reankylosis was observed in group B patients. Compared with the ACPG, LAP improved the facial pattern and MIO significantly (P < 0.05). LAP is a feasible and effective surgical method for the treatment of unilateral traumatic TMJ ankylosis when the displaced residual condyle is bigger than one third of the condylar head.
Temporomandibular joint (TMJ) ankylosis is a severe disease that causes problems such as limited mouth opening and occlusion disorders, and may interfere 0901-5027/000001+06
with mastication and speech. It also has an impact on the development of the mandible, as evidenced in growing patients, resulting in facial deformity
Key words: trauma; temporomandibular joint ankylosis; treatment; recurrence. Accepted for publication 26 August 2016
and potentially sleep apnoea–hypopnoea syndrome (SAHS). The major aetiological factors are trauma and infection. In recent years, due to the widespread use of
# 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Xu F, et al. A comparative study of different surgical methods in the treatment of traumatic temporomandibular joint ankylosis, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.020
YIJOM-3496; No of Pages 6
2
Xu et al.
antibiotics, trauma has become the leading cause of TMJ ankylosis.1 A variety of treatments for this condition have been described, including gap arthroplasty, interpositional arthroplasty, and TMJ reconstruction; however, no published consensus has been reached, and recurrence remains the major problem. Gap arthroplasty without interpositional material has gradually been abandoned by many surgeons due to the associated high risk of recurrence.2 The interpositional arthroplasty is a standard procedure that uses autogenous or alloplastic materials between the mandibular ramus and surface of the temporal bone.3 The temporalis myofascial flap (TMF) is the most widely used material, with benefits that include easy harvesting and a lower chance of resorption. However, this flap also presents problems such as donor site morbidity, chronic headache, and trismus. The trismus caused by scar contracture of the temporal muscle can be prevented by ipsilateral coronoidectomy.4 TMJ reconstruction remains a daunting task, because it is difficult to rebuild a structurally and functionally satisfactory neocondyle. A variety of autogenous and alloplastic grafts have been studied; however, no single method has produced uniformly successful results. Recent clinical research supports the use of the autogenous coronoid process graft (ACPG) as a suitable bone resource for condylar reconstruction when it is not involved in the ankylotic mass.5,6 He et al. reported the presence of a medially displaced residual condyle and
disc in 75% of traumatic TMJ ankylosis cases,7 and summarized a surgical method to preserve the residual TMJ structure called the lateral arthroplasty (LAP).8 The aim of the present study was to investigate the feasibility of the LAP and to compare the differences in clinical effects with the ACPG for reconstruction of the condyle in patients with unilateral traumatic TMJ ankylosis. Patients and methods
The present study was approved by the ethics committee of the study university. TMJ ankylosis was classified on the basis of Yang’s criteria9: type A1 represents fibrous ankylosis; types A2 and A3 represent ankylosis with bony fusion on the lateral side of the joint, in the presence of a medially displaced residual condyle and a residual condylar fragment larger than half of the condylar head (type A2) or smaller than half of the condylar head (type A3); type A4 represents bony ankylosis. Eighteen patients (9 female, 9 male) diagnosed with unilateral traumatic TMJ ankylosis who were operated on at a stomatological hospital in Zunyi, China between 2008 and 2013, were included in this retrospective study. The following inclusion criteria were applied: (1) the aetiology was traumatic, (2) the medially displaced residual condyle was bigger than one-third of the condylar head, i.e. type A2 and some type A3 (Fig. 1), (3) the patient agreed to participate. Exclusion criteria were as follows: (1) patient treated previously with
Fig. 1. Preoperative CT scan: the bony mass is located on the left side (red arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of the article.)
TMJ surgery, (2) the aetiology was infection or other, (3) patient unwilling to participate. The relevant patient details are summarized in Table 1. Group A patients were treated with an ACPG for the reconstruction of the mandibular condyle, while group B patients were treated with a LAP; a TMF was used as interpositional material in both groups (thickness 0.5– 1 cm). The advantages and disadvantages of each method were explained to the patient preoperatively, and the method used depended on the patient’s preference. All operations were performed by the same experienced surgeon and all clinical examinations were performed by the same resident.
Table 1. General information for the patients in the two treatment groups.
Patient number
Sex/age (years)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
M/11 F/12 M/13 F/11 M/10 F/18 M/15 F/12 M/15 F/35 M/16 F/15 M/16 F/10 M/23 F/19 M/20 F/37
Age at injury (years)
Time between open operation and presentation with ankylosis (years)
Surgical method/group
Type of ankylosis (Yang’s criteria)
Site of fracture
Preoperative MIO (mm)
10 12 12 10 8 16 13 11 12 35 15 15 15 9 20 18 18 33
1 0.5 1 1 2 2 2 1 3 0.5 1 0.5 1 1 3 1 2 4
ACPG/A ACPG/A ACPG/A ACPG/A ACPG/A ACPG/A ACPG/A ACPG/A ACPG/A ACPG/A LAP/B LAP/B LAP/B LAP/B LAP/B LAP/B LAP/B LAP/B
A2 A2 A2 A2 A2 A2 A3 A2 A2 A2 A2 A2 A3 A2 A2 A2 A2 A2
Right head Right head Right head Left head Left head Right neck Right neck Left head Left head Right head Left neck Right head Left head Right head Left head Right head Left head Right head
5 10 0 13 16 20 5 10 13 8 8 10 9 12 5 0 15 5
MIO, maximum inter-incisal opening; M, male; F, female; ACPG, autogenous coronoid process graft; LAP, lateral arthroplasty.
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Surgical methods for traumatic TMJ ankylosis
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Assessment
Assessments included clinical and radiological examinations. The facial pattern and maximum inter-incisal opening (MIO) were recorded before and after surgery. The major radiological examination used was cone beam computed tomography (CBCT), and all patients agreed to CT scans preoperatively and postoperatively. Surgical procedure
Fig. 3. Group B patient (lateral arthroplasty): a medially displaced condylar fragment is observed.
All patients were operated on under general anaesthesia. Blind nasal intubation was successful in 16 patients; the remaining two underwent intubation with the assistance of a fibre-optic endoscope. A modified pre-auricular approach with a temporal extension, which produced a double-layer flap (i.e. the skin flap and the deep temporal flap), was used in order to protect the superficial temporal vessels and the branches of the facial nerve; the superficial temporal fascia was dissected following the plane inferiorly and anteriorly to reach the zygomatic arch. On reaching the capsule, the lateral bony mass was exposed via a T-shaped incision. In group A, aggressive excision of the lateral bony mass and medially displaced residual condylar fragment was performed, creating a gap of about 15– 20 mm between the ramus and surface of the temporal bone, following which an ipsilateral coronoidectomy was done. The bone graft was then trimmed and formed, and an L-shaped titanium miniplate was used to rigidly fix the graft to the ramus (Fig. 2). The TMF was rotated as interpositional material if the disc was disrupted; otherwise the TMF was sutured with the disc. A contralateral coronoidectomy was performed if the intraoperative MIO was less than 35 mm.
In group B, the lateral bony mass was removed with an oscillating saw and a chisel, and then the bony fusion mark between the glenoid fossa and ramus was identified. Guided by the preoperative CT scan, two oblique bony cuts were made over the ankylotic mass without damaging the residual condylar fragment (Figs. 3 and 4). An ipsilateral coronoidectomy was performed, the remainder of the glenoid fossa and ramus were contoured, and the disc was released and sutured, with the TMF filling the dead space (Fig. 5). A contralateral coronoidectomy was performed if the intraoperative MIO was less than 35 mm (Fig. 6). Prophylactic antibiotics were given for 3–5 days postoperative. The drainage was removed 24 h postoperative and the patients were started on a soft diet 2 weeks after the operation. Physiotherapy was started on day 5–7 postoperative to redevelop normal muscle function and prevent hypomobility secondary to fibrous adhesions, and was continued for at least 6 months. All cases were followed up for 12–24 months. The facial pattern and MIO before and after surgery were compared, and CT scans were performed.
Fig. 2. Group A patient (autogenous coronoid process graft): the bone graft was trimmed and formed, and an L-shaped titanium miniplate was used to rigidly fix the graft to the ramus.
Fig. 4. Postoperative CT scan of a group B patient (lateral arthroplasty): the bony mass was completely resected without damaging the medially displaced condylar fragment.
Fig. 5. Group B patient (lateral arthroplasty): the disc was released and sutured with the temporalis myofascial flap to fill the dead space.
Reankylosis was diagnosed in the presence of an MIO of less than 15 mm and/or fibrous/bony fusion observed on CT scan (Fig. 7).
Statistical analysis
The data analysis was performed using SPSS version 18.0 software (SPSS Inc., Chicago, IL, USA). The Wilcoxon rank sum test was used to determine the significance of the intergroup improvement in MIO. The x2 test was used to determine the significance of the intergroup recurrence rate and facial pattern change. An a level of <0.05 was considered significant. Results
All patients participated in the long-term follow-up study (12–24 months). The
Fig. 6. The intraoperative MIO is 38 mm.
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Fig. 7. Group A patient (autogenous coronoid process graft): fibrous adhesions can be seen between the ramus and the surface of the temporal bone. (A) Coronal view; (B) sagittal view.
Table 2. Treatment results for the two study groups. Group A B
Follow-up period (months) 12–24 12–24
Recurrence (n)
Mean postoperative MIO (mm)
2/10 0/8 P > 0.05
35.0 37.0 P < 0.05
Facial pattern change 7/10 1/8 P < 0.01
MIO, maximum inter-incisal opening.
results of the treatment in the two groups are summarized in Table 2. Reankylosis was observed in two (20%) patients in group A within 6 months. A further gap arthroplasty with costochondral graft (CCG) was applied in these cases, and successful results were achieved. No reankylosis was observed in group B patients (0%). There was no significant difference in recurrence rate between the two groups (x2 = 1.800, P > 0.05). However, a significant difference in the facial pattern change was observed between the groups (x2 = 7.244, P < 0.01): seven patients (70%) in group A and one (12.5%) in group B showed some degree of mandibular deviation to the operated side on maximum mouth opening after the operation. A significant difference in the MIO improvement was also observed between the groups (Z = 3.630, P < 0.05). These results indicate that in selected cases, i.e. type A2 and some type A3 patients, LAP for the treatment of unilateral traumatic TMJ ankylosis significantly improved the facial pattern and MIO. The most frequent sequela was paralysis of the temporal branch of the facial nerve, which was encountered in three patients (30%) in group A. The patients who experienced this sequela recovered gradually without additional treatment over the course of 2–4 weeks postoperatively. No patient suffered local infection, chronic headache, or permanent facial nerve paralysis. Details of the
postoperative complications are presented in Table 3.
Discussion
Patient age, the severity of the trauma, the pattern of condylar fracture, the duration of immobilization, and the location of the disc play important roles in the development of traumatic TMJ ankylosis.1,10 The intracapsular condylar fracture – especially the mandibular ramus attached to the temporal bone, displaced condylar fragment, and damaged disc and lateral capsule – causes TMJ ankylosis.11 Early diagnosis, appropriate therapeutic interventions, and proper rehabilitation are essential in the treatment of traumatic TMJ ankylosis.6 The protocol for the management of ankylosis recommended by Kaban et al. is as follows12: aggressive resection, ipsilateral coronoidectomy, contralateral coronoidectomy if the intraoperative MIO is less than 35 mm, lining of the TMJ with or without interpositional materials, reconstruction of the ramus with
autogenous or alloplastic grafts, early mobilization, and aggressive physiotherapy. An aggressive resection (15–20 mm) is recommended to prevent ankylosis. However, this has disadvantages of a decreased mandible height, premature occlusion in unilateral cases, and anterior open bite or respiratory problems in bilateral cases.13 The recurrence rate has been shown to be relatively high following treatment by gap arthroplasty without interpositional material. Long-standing ankylosis predisposes to fibrosis of the masticatory muscles; an additional ipsilateral or bilateral coronoidectomy can improve mouth opening.14 In the present study, five patients underwent an ipsilateral coronoidectomy, but the intraoperative MIO was still less than 35 mm, ranging from 20 mm to 30 mm (mean 25.2 mm); a contralateral coronoidectomy was performed in these patients and the MIO increased, ranging from 35 mm to 40 mm (mean 37.6 mm). The ACPG has been studied widely and has the advantages of avoiding a second surgical site and the associated donor site morbidity, easy accessibility, and a good shape and thickness. However, notable bone resorption has been observed in some cases,15 which was also noted in the present study (Fig. 8). Group A patients were treated with the ACPG for reconstruction of the condyle. Three patients suffered temporal facial nerve paralysis, seven experienced a facial pattern change, and two had reankylosis during follow-up (12–24 months). These results suggest that greater attention should be paid to the deep temporal vessels and branches of the facial nerve before grafting, and that a thicker TMF should be prepared as interposition material. The disc plays an important role in preventing ankylosis. Yan et al. found that
Table 3. Postoperative complications in the two treatment groups after 12–24 months of follow-up. Complications Reankylosis Chronic headache Local infection Permanent facial palsy
Group A, n Group B, n 2/10 0/10 0/10 0/10
0/8 0/8 0/8 0/8
Fig. 8. Group A patient (autogenous coronoid process graft): moderate resorption and loss of height of the ramus can be observed.
Please cite this article in press as: Xu F, et al. A comparative study of different surgical methods in the treatment of traumatic temporomandibular joint ankylosis, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.020
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Surgical methods for traumatic TMJ ankylosis when the disc remained in the normal position, neither fibrous nor fibro-osseous calluses were observed.16 Using a sheep model, Miyamoto et al. showed that the presence of an intact disc can prevent the development of ankylosis.17,18 Sarma and Dave analysed 60 patients and found that the ankylosed condyle was divided into two parts19: the non-adhesive part demonstrated a medially displaced condylar fragment, and the bony-adhesive part presented new bone formation. In 1998, Nitzan et al. reported a modified gap arthroplasty and applied it in four patients.20 The procedure involved resection of the lateral bony mass and preservation of the medially displaced condylar fragment, leaving a large gap between the glenoid fossa and the ramus, and the results were excellent. On the basis of that study, He et al. raised the concept of the ‘lateral arthroplasty’ (LAP), confirming that the medially displaced residual condylar fragment, as well as maintaining the normal function of the mandible, can also promote the development of the mandible in growing patients.8 The key point in the LAP procedure is preservation of the functional condylar fragment. Group B patients were treated by LAP. Only patients whose medially displaced condylar fragment was bigger than onethird of the condylar head could apply for this procedure. This amount is necessary to keep the structure stable and to sustain the pressure from the implanted graft, thereby preventing malocclusion and a shortage of mandibular ramus caused by resorption. In the present study, LAP for the treatment of unilateral traumatic TMJ ankylosis improved the occlusion, facial pattern, and MIO significantly compared with the ACPG. No patient experienced temporal facial nerve paralysis or had reankylosis during the follow-up period of 12–24 months. The LAP has several advantages. First of all, the medially displaced condylar fragment can be preserved, which is very important for growing patients. Recent research has shown that aggressive excision of the bony mass is not necessary, as the bony mass is not a neoplastic process capable of continued growth.21 Second, the disc is sutured with the TMF as interpositional material, and it is well known that the disc has an important role in preventing ankylosis.16–18 Third, compared with ACPG, internal fixation is not needed, which avoids the possibility of hardware loosening or a foreign body reaction. Finally, less bone resorption was observed in LAP patients than in ACPG patients, owing to the good blood supply.
A limitation of the LAP is that it can only be applied to patients whose medially displaced condylar fragment is bigger than one third of the condylar head; if this is less than one-third, it cannot provide sufficient strength for the TMJ loading force and resorption will ultimately occur. In conclusion, the LAP is a feasible and effective surgical method for the treatment of unilateral traumatic TMJ ankylosis in selected cases, i.e. type A2 and some type A3 patients. Funding
This study was supported by the Foundation of Guizhou Science and Technology Department (grant LKZ[2013]09) and the Foundation for Doctor Start-up of Zunyi Medical University (grant F-458). Competing interests
None declared.
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Ethical approval
This study was approved by the Ethics Committee of Zunyi Medical University, Zunyi, China.
13.
Patient consent
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Address: Cheng Man Department of Oral and Maxillofacial Surgery Stomatological Hospital Zunyi Medical University
Zunyi Guizhou 563000 China. Fax: +86 851 28638920 E-mail: [email protected]
Please cite this article in press as: Xu F, et al. A comparative study of different surgical methods in the treatment of traumatic temporomandibular joint ankylosis, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.08.020