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A retrospective study of the costochondral graft in TMJ reconstruction
Int. J. Oral Maxillofac. Surg. 2003; 32: 606–609 doi:10.1054/ijom.2003.0418, available online at http://www.sciencedirect.com
Clinical Paper TMJ Disorders
A retrospective study of the costochondral graft in TMJ reconstruction
N. R. Saeed1, J. N. Kent2 1
Department of Oral & Maxillofacial Surgery, Cheltenham General Hospital, Sandford Road, Cheltenham GL53 7AN, UK; 2Department of Oral & Maxillofacial Surgery, Louisiana State University Medical Centre, 1100 Florida Ave, New Orleans, Louisiana 70119, USA
N. R. Saeed, J. N. Kent: A retrospective study of the costochondral graft in TMJ reconstruction. Int. J. Oral Maxillofac. Surg. 2003; 32: 606–609. 2003 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. A retrospective review of 76 costochondral grafts (57 patients) was undertaken to determine outcome with respect to the extent of previous surgery (none, disc surgery or soft tissue graft, alloplastic disc, alloplastic joint, previous graft) and to initial and preoperative diagnosis. The minimum follow up period was 2 years and for each patient both subjective (pain and dietary interference scores) and objective (interincisal distance) data was recorded. Collectively there was improvement in pain (mean 6.7 to 3.5) and diet (mean 2.2 to 3.0) scores with a moderate increase in interincisal distance (mean 21 to 24 mm). In patients with no previous surgery, arthritic disease or congenital deformity the costochondral graft performed well but in patients with previous alloplastic discs and/or total joints the results were less predictable. A preoperative diagnosis of ankylosis was associated with a high complication and further surgery rate suggesting caution in this group of patients.
Introduction The indications for temporomandibular joint reconstruction are well established and include ankylosis, severe osteoarthritis, rheumatoid arthropathy, neoplastic disease, post-traumatic dysfunction and congenital disease8,15. The aims of such reconstruction are also well defined and include the restoration of mandibular function and form, decreased patient disability and suffering, and the prevention of disease progression13. The method of reconstruction however is controversial and a multitude of techniques both autogenous (fibula, metatarsal, clavicle, iliac and costochondral) and alloplastic (acrylic, synthetic fibres, ulnar head prosthesis, compressible silicone rubber 0901-5027/03/000606+04 $30.00/0
and total joint systems) have been described1,4,6. The most widely accepted autogenous technique involves the costochondral graft and as stated by MI11 the advantages of this graft are its biological compatibility, workability, functional adaptability, and minimal additional detriment to the patient. The growth potential of the costochondral graft makes it the ideal choice in children2,21. Potential problems with the costochondral graft include fracture, further ankylosis, donor site morbidity, and the variable growth behaviour of the graft10. The objective of this study was to evaluate the outcome of costochondral grafting in relation to previous surgical intervention and to a preoperative diag-
Key words: costochondral graft; TMJ; previous surgery; ankylosis. Accepted for publication 12 March 2003
nosis of ankylosis, with the aim of identifying those conditions in which a costochondral graft performs well. Methods and materials A retrospective review of the records of all patients who received costochondral grafts for temporomandibular joint reconstruction under the care of the Louisiana State University Medical Centre from 1986–1997 was undertaken. For each patient a number of variables were recorded, including their demographic details, the initial diagnosis (before any surgery by any surgeon), the preoperative diagnosis, any complications and the follow-up period. The number of previous operations was
2003 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
The costochondral graft in TMJ reconstruction Table 1. Interincisal opening (mm) Opening <10 10–20 21–30 31–40 >40 Total
Preoperative
%
Postoperative
%
11 13 18 10 5 57
19 23 32 17 9 100
4 8 27 18 0 57
7 14 47 32 0 100
noted and the patients categorized according to the extent of their most invasive procedure (no previous surgery, disc repair/removal or soft tissue disc replacement, alloplastic disc, alloplastic total joint, and previous costochondral graft). Objective assessment was recorded as the interincisal distance (mm) both preoperatively and at each follow up appointment. Subjective data was by analogue scales for pain and dietary interference. In terms of pain a scale of 1–10 was used (1=least, 10=worst) and in terms of dietary interference a 1–4 scale used (1=liquid diet, 2=soft, 3=restricted, 4=normal). Any postcostochondral surgery was noted and the patient’s overall satisfaction recorded on a 1–7 scale (1=markedly worse, 4=no change, and 7=markedly improved). Eighty-nine previously operated patients were identified but 32 excluded due to incomplete data or loss to follow up before 24 months. The 57 patients remaining corresponded to 76 costochondral grafts (20 left, 18 right, 19 bilateral). The male to female ratio was approximately 1:4 (12 males to 45 females) and the ages at the time of surgery ranged from 4 to 67 years with a mean of 34. The minimum follow up period was 2 years with a mean of 53 months (24–161). Surgical exposure was usually via combined preauricular and submandibular incisions. Following complete debridement of the temporomandibular joint the rib graft was shaped and attached to the lateral border of the ramus (or to the posterior border if the graft was straight) by four to six screws. The cartilaginous cap was usually 7–8 mm in length and a soft tissue graft (perichondrium) was placed between the glenoid fossa and rib cartilage. Immediate postoperative physiotherapy was instigated and night-time elastic intermaxillary fixation of 3 months frequently required in order to maintain occlusal and graft stability yet allow joint mobility. The need for compliance with physiotherapy was emphasized to all patients but not formally quantified.
shown in Table 3. The ankylosis encountered was predominately intra-articular and fibrous in nature. The results of surgery with respect to diagnosis are detailed in Table 4 and those patients with arthritis showed the greatest change in pain and diet scores whilst achieving a satisfactory interincisal opening. The only statistically significant finding between the initial diagnosis groups was in patient satisfaction or overall effect (P=0.016) related to patients with arthritic or congenital disease. Seventytwo per cent of patients underwent costochondral grafting for the release of ankylosis and showed improvements in all outcome variables (Table 4). The remaining patients were treated predominantly to relieve pain and/or to remove alloplastic material causing erosion of the joint surfaces and showed a mean decrease in opening (3.7 mm). These patients however were more satisfied with their outcome and this was statistically significant (P=0.008) as was the change in opening (P=0.005) of the ankylosed patients. The number of previous operations varied from 0 to 9 with an average of 3. Tables 5 and 6 detail the outcome of surgery in relation to the extent of surgery. As shown nearly 50% of patients had previous alloplastic discs and total joints removed. The improvement in jaw opening of these patients was minimal and despite improved pain and diet scores many still experienced pain scores of more than 4 out of 10. The most reliable changes in outcome were in those patients with no previous surgical intervention or previous costochondral grafts but the later were small in number. The only significant difference between the groups was in terms of satisfaction or overall effect (P=0.009) mainly related to patients with no previous surgery. Thirty-three complications occurred in 29 patients. These included a minor infection (1), malocclusion (2), graft fracture following overload (1), facial nerve weakness (2), overgrowth (5) and ankylosis (22). Clearly the most striking problem was that of further ankylosis in that 18 of the 22 cases of ankylosis had a preoperative diagnosis of ankylosis. There was no significant donor site
Paired data was analysed using Wilcoxon Signed Ranks test whilst unpaired data was analysed using the Mann–Whitney U test for comparing two groups and the Kruskal–Wallis test when more than two groups were considered. Results Considering the patients, as a total group there was improvement in both diet (mean change from 2.2 to 3.0) and pain (mean change from 6.7 to 3.5) scores and these were both highly significant (P<0.0001). In terms of diet this represents an improvement in 28 (49%) of patients with no change in 28 (49%) patients and one reporting worsening symptoms. In terms of pain an improvement of 3 or more on the visual analogue scale was seen in 31 (54%) of patients with 9 (16%) showing less modest improvement. Only one patient reported worsening pain. The mean interincisal opening improved from 21 to 24 mm but failed to reach significance (P=0.07) and will be discussed later (Table 1). The majority of patients reported an improvement following surgery and the mean overall effect was 5.6. The initial diagnosis (before any surgical intervention) is summarized in Table 2. The immediate preoperative diagnosis was considered as to the presence of ankylosis (physical restricted mouth opening unrelated to pain) as Table 2. Initial diagnosis Diagnosis Arthritis Internal Derangement (ID) Trauma Congenital disease Other Total
Number
%
9 26 15 5 2 57
16 46 26 9 3 100
607
Table 3. Preoperative diagnosis (ankylosis or non-ankylosis) compared to initial diagnosis
Ankylosis Non-ankylosis
Arthritis
ID
3 6
21 5
Initial diagnosis Trauma Congenital 14 1
2 3
Other
Total
1 1
41 (72%) 16 (28%)
608
Saeed and Kent
Table 4. Mean change in outcome variables with respect to initial and preoperative diagnosis (preop=preoperative, postop=postoperative). Pain scale 1–10 (1=least, 10=worst), dietary interference scale 1–4 (1=liquid diet, 4=normal), overall effect scale 1–7 (1=markedly worse, 4=no change, 7=markedly improved) Diagnosis Arthritis ID Trauma Congenital Other Ankylosis Non-ankylosis
Preop
Diet Postop
Change
Preop
Pain Postop
Change
Preop
2.6 1.9 2.4 2.6 3.0 2.1 2.6
3.5 2.7 2.9 3.2 3.5 2.8 3.5
0.9 0.8 0.5 0.6 0.5 0.7 0.9
7.1 8.4 4.8 3.4 3.0 6.7 7.1
2.4 5.0 2.3 1.2 3.0 3.7 3.2
4.7 3.4 2.5 2.2 0.0 3.0 3.9
23.6 22.1 16.7 23.0 20.0 16.6 33.2
complications recorded. Twenty-four patients have undergone further surgery (11 cases 2 further procedures) including resurfacing (cleavage or soft tissue graft) in 23 cases, graft removal in 5 cases, osteotomy in 4 cases and total alloplastic joint replacement in 3 cases. Discussion The rationale for using the costochondral graft in TMJ reconstruction has been summarized by MI11 and is based on a biological anatomical reconstruction with minimal detriment to the patient. Certainly in children the growth potential of the costochondral graft makes it the ideal choice but complications including graft fracture, infection, overgrowth, donor site morbidity16 and especially recurrent ankylosis are well described. The patients in this series showed significant improvements in pain (mean 6.7 to 3.5) and diet (mean 2.2 to 3.0) scores with a moderate increase in interincisal distance (mean 21 to 24 mm) and patient satisfaction. Only 32% of patients achieved an interincisal opening of Table 5. Extent of previous surgery Extent of surgery
Number
%
16 10
28% 18%
8 20 3
14% 35% 5%
57
100%
None Disc surgery/soft tissue graft Alloplastic disc Alloplastic total joint Previous costochondral graft Total
30 mm or more but 69% had an opening of at least 20 mm. Only 38% achieved an increase of opening of more than 5 mm. In patients with an initial diagnosis (before any surgery) of congenital deformity or arthritis the costochondral graft performed well with results similar to those reported previously18. An immediate preoperative diagnosis of ankylosis was associated with improvements in opening but many of these patients also developed recurrent ankylosis requiring further surgery. Patients without previous surgical intervention also showed good functional results despite less than ideal opening. In contrast patients with previous alloplastic discs or total joints had significant pain scores following treatment and in particular those with previous alloplastic joints reported minimal improvement. The retrospective nature of this study meant it was difficult to collate data on lateral excursion movements of the mandible and a radiological review was not possible. Both these issues would need to be considered in an ideal review. Our results are similar to those reported elsewhere8,17 but L et al.9 in a survey of 60 patients achieved a mean interincisal opening of 33.2 mm. They also reported good or excellent mandibular function in 56% of patients but no specific data on pain or dietary interference was given. Only two of the patients appear to have undergone previous surgery. N & B14 reviewed six patients and achieved a mean postoperative opening of 38.5 mm and K et al.5 reported a mean post-
Opening (mm) Postop Change 26.3 24.3 21.5 26.6 25.0 23.3 29.5
2.7 2.2 4.8 3.6 5.0 6.7 3.7
Overall effect 6.3 5.1 5.3 6.8 6.0 5.3 6.3
operative opening of 37.5 mm on 14 patients but with only one year follow up. No data on pain or dietary interference was given but the authors reported pain in only two of 18 joints. In contrast the patients in this study represent those treated in a specialist unit often having failed treatment elsewhere and with nearly 75% having undergone previous surgery (mean of three previous invasive procedures). The mouth opening achieved in our patients is disappointing as is the high further ankylosis rate despite intensive physiotherapy and wide surgical excision following the protocol described by K5. A number of factors may have contributed to this including previous multiple surgeries, long standing disease, a lack of synovial fluid, muscle atrophy and poor patient compliance (many returning to initial units) all limiting joint and muscle rehabilitation and increasing scar formation. There is no doubt that costochondral graft reconstruction of the temporomandibular joint can produce excellent results but the incidence of pain and especially recurrent ankylosis and complications is greater when used in the multiply operated patient7. Total prosthetic joint replacement of the temporomandibular joint3,19,20 may produce better results in such cases although MI12 suggests a staged approach using autogenous tissues. In spite of the potential problems with the costochondral graft we believe it should be preferred in the growing child and as initial reconstruction in many adult deformities.
Table 6. Mean change in outcome variables with respect to previous surgery (preop=preoperative, postop=postoperative). Analogue scales as previous Previous surgery None Disc surgery/soft tissue graft Alloplastic disc Alloplastic total joint Previous costochondral graft
Preop
Diet Postop
Change
Preop
Pain Postop
Change
Preop
2.5 1.7 2.4 2.4 2.0
3.2 3.0 3.0 2.7 3.7
0.7 1.3 0.6 0.3 1.7
4.0 7.6 8.1 8.2 4.0
1.5 3.7 4.6 4.7 1.3
2.5 3.9 3.5 3.5 2.7
18.8 22.5 23.6 22.3 17.3
Opening (mm) Postop Change 22.6 23.7 24.6 24.1 30.0
3.8 1.2 1.0 1.8 12.7
Overall effect 6.0 5.2 6.0 5.0 7.0
The costochondral graft in TMJ reconstruction Acknowledgments. We would like to thank Christopher Foy (medical statistician) and the staff of the Oral & Maxillofacial Unit at the Louisiana State University Medical Centre.
References 1. C MR, M KF, H N. The compressible silicone rubber prosthesis in temporomandibular joint disease. Br J Oral Maxillofac Surg 1993: 31: 376– 384. 2. F AA, G BJ, P S. Long term follow up of a mandibular costochondral graft. Oral Surg Oral Med Oral Pathol 1984: 58: 257–268. 3. H CH, W LM. Treatment outcomes for temporomandibular joint reconstruction after proplast-teflon implant failure. J Oral Maxillofac Surg 1993: 51: 352–358. 4. H R. Temporomandibular joint replacement. Br J Hosp Med 1995: 53: 455–456. 5. K LB, P DH, F K. A protocol for management of temporomandibular joint ankylosis. J Oral Maxillofac Surg 1990: 48: 1145–1151. 6. K JN, M DJ. Controversies in disc and condyle replacement for partial and total temporomandibular joint reconstruction. In: Worthington P, Evans JR, eds: Controversies in Oral & Maxillofacial Surgery. Philadelphia: WB Saunders 1994: 397–435. 7. K JN, Z J. Comparative Study of TMJ Reconstruction with Cos-
8.
9.
10.
11.
12.
13.
14.
15.
tochondral Grafts. J Oral Maxillofac Surg 1995: 53: 127. L C, J J, P P, T A. Adaptation of autogenous costochondral grafts used for temporomandibular joint reconstruction: A long term clinical and radiologic follow up. J Oral Maxillofac Surg 1988: 46: 465–470. L C, P A, T A, H G. Autogenous costochondral grafts in temporomandibular joint arthroplasty. A survey of 66 arthroplasties in 60 patients. J Maxillofac Surg 1986: 14: 143–149. L JO, H DC, L DM. Hyperplasia of a costochondral graft in an adult. J Oral Maxillofac Surg 1993: 51: 1392–1394. MI RB. The case for autogenous reconstruction of the adult temporomandibular joint. In: Worthington P, Evans JR, eds: Controversies in Oral & Maxillofacial Surgery. Philadelphia: WB Saunders 1994: 356–380. MI RB. The use of autogenous tissues for temporomandibular joint reconstruction. J Oral Maxillofac Surg 2000: 58: 63–69. M LG. The use of alloplastic prostheses for temporomandibular joint reconstruction. J Oral Maxillofac Surg 2000: 58: 70–75. N CL, B JD. Costochondral grafting for posttraumatic temporomandibular joint reconstruction: A review of six cases. J Oral Maxillofac Surg 1989: 47: 1030–1038. O G, G SA, C PW. Costochondral grafting in condylar replacement and mandibular reconstruc-
16.
17.
18.
19.
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21.
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tion. J Oral Maxillofac Surg 1988: 46: 177–182. O K, N K, O E. Chest wall deformities and thoracic scoliosis after costal cartilage graft harvesting. Plast Reconstr Surg 1997: 99: 1030–1036. P C, F E, B M. The use of costochondral grafts in arthroplasty of the temporomandibular joint. J Craniomaxillofac Surg 1987: 15: 345–354. P JC. Surgical management of temporomandibular joint ankylosis in the pediatric population. Plast Reconstr Surg 1993: 91: 791–798. S NR, ML NMH, H R. Temporomandibular joint replacement in rheumatoid induced disease. Brit J Oral Maxilllofac Surg 2001: 39: 71–75. S B, H R, P D. Total prosthetic replacement of the TMJ: experience with two systems 1988–1997. Brit J Oral Maxillofac Surg 2000: 38: 360–369. W-C K E, H CS, C YR. Temporomandibular joint reconstruction in children using costochondral grafts. J Oral Maxillofac Surg 1999: 57: 789–798.
Address: Mr N. R. Saeed Department of Oral & Maxillofacial Surgery The John Radcliffe Hospital Headington Oxford OX3 9DU Tel: 01865 851151 Fax: 01865 222040 E-mail: [email protected]
Clinical Paper TMJ Disorders
A retrospective study of the costochondral graft in TMJ reconstruction
N. R. Saeed1, J. N. Kent2 1
Department of Oral & Maxillofacial Surgery, Cheltenham General Hospital, Sandford Road, Cheltenham GL53 7AN, UK; 2Department of Oral & Maxillofacial Surgery, Louisiana State University Medical Centre, 1100 Florida Ave, New Orleans, Louisiana 70119, USA
N. R. Saeed, J. N. Kent: A retrospective study of the costochondral graft in TMJ reconstruction. Int. J. Oral Maxillofac. Surg. 2003; 32: 606–609. 2003 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. A retrospective review of 76 costochondral grafts (57 patients) was undertaken to determine outcome with respect to the extent of previous surgery (none, disc surgery or soft tissue graft, alloplastic disc, alloplastic joint, previous graft) and to initial and preoperative diagnosis. The minimum follow up period was 2 years and for each patient both subjective (pain and dietary interference scores) and objective (interincisal distance) data was recorded. Collectively there was improvement in pain (mean 6.7 to 3.5) and diet (mean 2.2 to 3.0) scores with a moderate increase in interincisal distance (mean 21 to 24 mm). In patients with no previous surgery, arthritic disease or congenital deformity the costochondral graft performed well but in patients with previous alloplastic discs and/or total joints the results were less predictable. A preoperative diagnosis of ankylosis was associated with a high complication and further surgery rate suggesting caution in this group of patients.
Introduction The indications for temporomandibular joint reconstruction are well established and include ankylosis, severe osteoarthritis, rheumatoid arthropathy, neoplastic disease, post-traumatic dysfunction and congenital disease8,15. The aims of such reconstruction are also well defined and include the restoration of mandibular function and form, decreased patient disability and suffering, and the prevention of disease progression13. The method of reconstruction however is controversial and a multitude of techniques both autogenous (fibula, metatarsal, clavicle, iliac and costochondral) and alloplastic (acrylic, synthetic fibres, ulnar head prosthesis, compressible silicone rubber 0901-5027/03/000606+04 $30.00/0
and total joint systems) have been described1,4,6. The most widely accepted autogenous technique involves the costochondral graft and as stated by MI11 the advantages of this graft are its biological compatibility, workability, functional adaptability, and minimal additional detriment to the patient. The growth potential of the costochondral graft makes it the ideal choice in children2,21. Potential problems with the costochondral graft include fracture, further ankylosis, donor site morbidity, and the variable growth behaviour of the graft10. The objective of this study was to evaluate the outcome of costochondral grafting in relation to previous surgical intervention and to a preoperative diag-
Key words: costochondral graft; TMJ; previous surgery; ankylosis. Accepted for publication 12 March 2003
nosis of ankylosis, with the aim of identifying those conditions in which a costochondral graft performs well. Methods and materials A retrospective review of the records of all patients who received costochondral grafts for temporomandibular joint reconstruction under the care of the Louisiana State University Medical Centre from 1986–1997 was undertaken. For each patient a number of variables were recorded, including their demographic details, the initial diagnosis (before any surgery by any surgeon), the preoperative diagnosis, any complications and the follow-up period. The number of previous operations was
2003 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
The costochondral graft in TMJ reconstruction Table 1. Interincisal opening (mm) Opening <10 10–20 21–30 31–40 >40 Total
Preoperative
%
Postoperative
%
11 13 18 10 5 57
19 23 32 17 9 100
4 8 27 18 0 57
7 14 47 32 0 100
noted and the patients categorized according to the extent of their most invasive procedure (no previous surgery, disc repair/removal or soft tissue disc replacement, alloplastic disc, alloplastic total joint, and previous costochondral graft). Objective assessment was recorded as the interincisal distance (mm) both preoperatively and at each follow up appointment. Subjective data was by analogue scales for pain and dietary interference. In terms of pain a scale of 1–10 was used (1=least, 10=worst) and in terms of dietary interference a 1–4 scale used (1=liquid diet, 2=soft, 3=restricted, 4=normal). Any postcostochondral surgery was noted and the patient’s overall satisfaction recorded on a 1–7 scale (1=markedly worse, 4=no change, and 7=markedly improved). Eighty-nine previously operated patients were identified but 32 excluded due to incomplete data or loss to follow up before 24 months. The 57 patients remaining corresponded to 76 costochondral grafts (20 left, 18 right, 19 bilateral). The male to female ratio was approximately 1:4 (12 males to 45 females) and the ages at the time of surgery ranged from 4 to 67 years with a mean of 34. The minimum follow up period was 2 years with a mean of 53 months (24–161). Surgical exposure was usually via combined preauricular and submandibular incisions. Following complete debridement of the temporomandibular joint the rib graft was shaped and attached to the lateral border of the ramus (or to the posterior border if the graft was straight) by four to six screws. The cartilaginous cap was usually 7–8 mm in length and a soft tissue graft (perichondrium) was placed between the glenoid fossa and rib cartilage. Immediate postoperative physiotherapy was instigated and night-time elastic intermaxillary fixation of 3 months frequently required in order to maintain occlusal and graft stability yet allow joint mobility. The need for compliance with physiotherapy was emphasized to all patients but not formally quantified.
shown in Table 3. The ankylosis encountered was predominately intra-articular and fibrous in nature. The results of surgery with respect to diagnosis are detailed in Table 4 and those patients with arthritis showed the greatest change in pain and diet scores whilst achieving a satisfactory interincisal opening. The only statistically significant finding between the initial diagnosis groups was in patient satisfaction or overall effect (P=0.016) related to patients with arthritic or congenital disease. Seventytwo per cent of patients underwent costochondral grafting for the release of ankylosis and showed improvements in all outcome variables (Table 4). The remaining patients were treated predominantly to relieve pain and/or to remove alloplastic material causing erosion of the joint surfaces and showed a mean decrease in opening (3.7 mm). These patients however were more satisfied with their outcome and this was statistically significant (P=0.008) as was the change in opening (P=0.005) of the ankylosed patients. The number of previous operations varied from 0 to 9 with an average of 3. Tables 5 and 6 detail the outcome of surgery in relation to the extent of surgery. As shown nearly 50% of patients had previous alloplastic discs and total joints removed. The improvement in jaw opening of these patients was minimal and despite improved pain and diet scores many still experienced pain scores of more than 4 out of 10. The most reliable changes in outcome were in those patients with no previous surgical intervention or previous costochondral grafts but the later were small in number. The only significant difference between the groups was in terms of satisfaction or overall effect (P=0.009) mainly related to patients with no previous surgery. Thirty-three complications occurred in 29 patients. These included a minor infection (1), malocclusion (2), graft fracture following overload (1), facial nerve weakness (2), overgrowth (5) and ankylosis (22). Clearly the most striking problem was that of further ankylosis in that 18 of the 22 cases of ankylosis had a preoperative diagnosis of ankylosis. There was no significant donor site
Paired data was analysed using Wilcoxon Signed Ranks test whilst unpaired data was analysed using the Mann–Whitney U test for comparing two groups and the Kruskal–Wallis test when more than two groups were considered. Results Considering the patients, as a total group there was improvement in both diet (mean change from 2.2 to 3.0) and pain (mean change from 6.7 to 3.5) scores and these were both highly significant (P<0.0001). In terms of diet this represents an improvement in 28 (49%) of patients with no change in 28 (49%) patients and one reporting worsening symptoms. In terms of pain an improvement of 3 or more on the visual analogue scale was seen in 31 (54%) of patients with 9 (16%) showing less modest improvement. Only one patient reported worsening pain. The mean interincisal opening improved from 21 to 24 mm but failed to reach significance (P=0.07) and will be discussed later (Table 1). The majority of patients reported an improvement following surgery and the mean overall effect was 5.6. The initial diagnosis (before any surgical intervention) is summarized in Table 2. The immediate preoperative diagnosis was considered as to the presence of ankylosis (physical restricted mouth opening unrelated to pain) as Table 2. Initial diagnosis Diagnosis Arthritis Internal Derangement (ID) Trauma Congenital disease Other Total
Number
%
9 26 15 5 2 57
16 46 26 9 3 100
607
Table 3. Preoperative diagnosis (ankylosis or non-ankylosis) compared to initial diagnosis
Ankylosis Non-ankylosis
Arthritis
ID
3 6
21 5
Initial diagnosis Trauma Congenital 14 1
2 3
Other
Total
1 1
41 (72%) 16 (28%)
608
Saeed and Kent
Table 4. Mean change in outcome variables with respect to initial and preoperative diagnosis (preop=preoperative, postop=postoperative). Pain scale 1–10 (1=least, 10=worst), dietary interference scale 1–4 (1=liquid diet, 4=normal), overall effect scale 1–7 (1=markedly worse, 4=no change, 7=markedly improved) Diagnosis Arthritis ID Trauma Congenital Other Ankylosis Non-ankylosis
Preop
Diet Postop
Change
Preop
Pain Postop
Change
Preop
2.6 1.9 2.4 2.6 3.0 2.1 2.6
3.5 2.7 2.9 3.2 3.5 2.8 3.5
0.9 0.8 0.5 0.6 0.5 0.7 0.9
7.1 8.4 4.8 3.4 3.0 6.7 7.1
2.4 5.0 2.3 1.2 3.0 3.7 3.2
4.7 3.4 2.5 2.2 0.0 3.0 3.9
23.6 22.1 16.7 23.0 20.0 16.6 33.2
complications recorded. Twenty-four patients have undergone further surgery (11 cases 2 further procedures) including resurfacing (cleavage or soft tissue graft) in 23 cases, graft removal in 5 cases, osteotomy in 4 cases and total alloplastic joint replacement in 3 cases. Discussion The rationale for using the costochondral graft in TMJ reconstruction has been summarized by MI11 and is based on a biological anatomical reconstruction with minimal detriment to the patient. Certainly in children the growth potential of the costochondral graft makes it the ideal choice but complications including graft fracture, infection, overgrowth, donor site morbidity16 and especially recurrent ankylosis are well described. The patients in this series showed significant improvements in pain (mean 6.7 to 3.5) and diet (mean 2.2 to 3.0) scores with a moderate increase in interincisal distance (mean 21 to 24 mm) and patient satisfaction. Only 32% of patients achieved an interincisal opening of Table 5. Extent of previous surgery Extent of surgery
Number
%
16 10
28% 18%
8 20 3
14% 35% 5%
57
100%
None Disc surgery/soft tissue graft Alloplastic disc Alloplastic total joint Previous costochondral graft Total
30 mm or more but 69% had an opening of at least 20 mm. Only 38% achieved an increase of opening of more than 5 mm. In patients with an initial diagnosis (before any surgery) of congenital deformity or arthritis the costochondral graft performed well with results similar to those reported previously18. An immediate preoperative diagnosis of ankylosis was associated with improvements in opening but many of these patients also developed recurrent ankylosis requiring further surgery. Patients without previous surgical intervention also showed good functional results despite less than ideal opening. In contrast patients with previous alloplastic discs or total joints had significant pain scores following treatment and in particular those with previous alloplastic joints reported minimal improvement. The retrospective nature of this study meant it was difficult to collate data on lateral excursion movements of the mandible and a radiological review was not possible. Both these issues would need to be considered in an ideal review. Our results are similar to those reported elsewhere8,17 but L et al.9 in a survey of 60 patients achieved a mean interincisal opening of 33.2 mm. They also reported good or excellent mandibular function in 56% of patients but no specific data on pain or dietary interference was given. Only two of the patients appear to have undergone previous surgery. N & B14 reviewed six patients and achieved a mean postoperative opening of 38.5 mm and K et al.5 reported a mean post-
Opening (mm) Postop Change 26.3 24.3 21.5 26.6 25.0 23.3 29.5
2.7 2.2 4.8 3.6 5.0 6.7 3.7
Overall effect 6.3 5.1 5.3 6.8 6.0 5.3 6.3
operative opening of 37.5 mm on 14 patients but with only one year follow up. No data on pain or dietary interference was given but the authors reported pain in only two of 18 joints. In contrast the patients in this study represent those treated in a specialist unit often having failed treatment elsewhere and with nearly 75% having undergone previous surgery (mean of three previous invasive procedures). The mouth opening achieved in our patients is disappointing as is the high further ankylosis rate despite intensive physiotherapy and wide surgical excision following the protocol described by K5. A number of factors may have contributed to this including previous multiple surgeries, long standing disease, a lack of synovial fluid, muscle atrophy and poor patient compliance (many returning to initial units) all limiting joint and muscle rehabilitation and increasing scar formation. There is no doubt that costochondral graft reconstruction of the temporomandibular joint can produce excellent results but the incidence of pain and especially recurrent ankylosis and complications is greater when used in the multiply operated patient7. Total prosthetic joint replacement of the temporomandibular joint3,19,20 may produce better results in such cases although MI12 suggests a staged approach using autogenous tissues. In spite of the potential problems with the costochondral graft we believe it should be preferred in the growing child and as initial reconstruction in many adult deformities.
Table 6. Mean change in outcome variables with respect to previous surgery (preop=preoperative, postop=postoperative). Analogue scales as previous Previous surgery None Disc surgery/soft tissue graft Alloplastic disc Alloplastic total joint Previous costochondral graft
Preop
Diet Postop
Change
Preop
Pain Postop
Change
Preop
2.5 1.7 2.4 2.4 2.0
3.2 3.0 3.0 2.7 3.7
0.7 1.3 0.6 0.3 1.7
4.0 7.6 8.1 8.2 4.0
1.5 3.7 4.6 4.7 1.3
2.5 3.9 3.5 3.5 2.7
18.8 22.5 23.6 22.3 17.3
Opening (mm) Postop Change 22.6 23.7 24.6 24.1 30.0
3.8 1.2 1.0 1.8 12.7
Overall effect 6.0 5.2 6.0 5.0 7.0
The costochondral graft in TMJ reconstruction Acknowledgments. We would like to thank Christopher Foy (medical statistician) and the staff of the Oral & Maxillofacial Unit at the Louisiana State University Medical Centre.
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Address: Mr N. R. Saeed Department of Oral & Maxillofacial Surgery The John Radcliffe Hospital Headington Oxford OX3 9DU Tel: 01865 851151 Fax: 01865 222040 E-mail: [email protected]