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Bony ankylosis of the temporo-mandibular joint with micrognathai: Case report
BONY ANKYLOSIS OF THE TEMPORO-MANDIBULAR WITH M I C R O G N A T H I A : CASE R E P O R T
JOINT
By A. LAPIDOT, M.D., B.D.S}
Hadassah Medical School, Jerusalem, Israel CASE REPORT
AN Arab (Druse), aged 18, was referred for consultation in view of not having been able to open his mouth since the age of 4 and because of his facial deformity. A concise history was not available, but it would appear that when he was a few years old he sustained a traumatic facial injury which was neglected. He subsequently was unable to open his mouth and since had fed on a liquid diet and " slops." The patient had been operated on several times and spent lengthy periods in hospitals.
A
B
C FIG. I A, B, C, Original deformity and degree of malocclusion.
On examination he was found to be underdeveloped in stature and to weigh 46 kg. (92 lb.). His intellect was quite normal. In the right pre-auricular region there was a scar 3½ in. in length. The facial deformity was as shown in Fig. I, A and B. He was completely unable to open his mouth, with his anterior teeth in an almost edge-to-edge bite and with gross malocclusion (Fig. I, c). Sensation over the entire peripheral distribution of the trigeminal nerve was normal. Intra-oral examination was limited; however, it was noted that the left lower arch was in linguoversion and the right lower arch was edentulous as from the first premolar. Extra-oral radiographs revealed an absence of the right condylar head and neck in place of which there was clear evidence of bony ankylosis between the ascending ramus and the base of the skull. On the left side the condylar head could be outlined. The pattern of the bone in the rami of the mandible appeared normal. In the right mandible the teeth backward from and including the first premolar were missing. There was a full complement of posterior teeth in the left mandible with a vertically unerupted third molar. Examination of the auditory system was negative. Treatmem.--(I) It was decided as a first-stage operation to perform an osteotomy in the right ascending ramus and an arthroplasty. The patient was prepared for operation, and in September 1958 under blind nasal-intratracheal intubation and anamthesia the i Now Fellow-Trainee, Head and Neck Surgery, Washington University Medical School, St Louis, Missouri. 26~
266
BRITISH JOURNAL OF PLASTIC SURGERY
right ascending ramus was exposed by a submandibular approach and horizontally fractured above the lingula by the use of burrs. Sufficient bone was removed at the fracture site to obtain a space between the bone ends of nearly 2 cm. A vertical incision through the mid-portion of masseter enabled rotation medially of its anterior portion, which was sutured to the internal pterygoid muscle. At this stage a gag was inserted in the mouth and an opening of I cm. was obtained. It must be stated that prior to operation under general anmsthesia, there was no movement whatever of the mandible using the mouth gag. The wound was closed in layers. No teeth in the mandible were sacrificed. On the following day exercises were started with a wooden wedge placed between the incisal edges of the teeth. The patient was instructed in oral hygiene and told to chew gum and on the seventh day after admission he was discharged.
A
B FI~. 2 A, B, C, Post-operative appearance and result.
C
(2) A month later the patient was readmitted for the purpose of inserting a bone graft in the anterolateral aspect of the mandible. The outer aspect of the mandible from molar to molar region was exposed by a submandibular approach and the outer cortical plate removed. A bone graft, decorticated from the left iliac crest, was applied to the mandible together with bone chips. The wound was closed in layers and a through drain inserted for forty-eight hours. Recovery was uneventful except for a discharging sinus on the left side in the suture line, which persisted for twenty days and resolved under antibiotic therapy. Thirteen days after admission the patient was discharged from hospital. The post-operative result is seen in Fig. 2, A, B, and c. (3) Mouth exercises were continued and the opening improved to 2½ cm. In October 1959 a left condylectomy was carried out. There was transient paresis of the temporal branch of the facial nerve but the opening continued to improve and finally registered 3 cm. between the incisal edges of the anterior teeth. The weight one and a half years after the first-stage operation reached 54 kg. (lO8 lb.). DISCUSSION A not u n c o m m o n complication of neglected trauma to the t e m p o r o - m a n d i b u l a r joint in early childhood is ankylosis and the accompanying u n d e r d e v e l o p m e n t of the mandible due to the injury to the condylar growth centrel I f only one joint is affected the opposite joint, consequent to non-function, undergoes fibrosis.
BONY
ANKYLOSIS
OF
THE TEMPORO-MANDIBULARJOINT WITH MICROGNATHIA 267
In the creation of a new false joint to mobilise the mandible, several foreign bodies have been used at the osteotomy site to prevent union (fascia lata, cartilage, vitallium) with varying success as some of these tissues may resorb and the foreign bodies may act as irritants. Smith (195o) advocates a method which I have followed with good results. No tissue or material other than local tissue is necessary provided sufficient bone is removed. With regard to the bone graft, it would appear that if only cancellous bone is used, the operative oedema hmmatoma is not within " n o n - g i v i n g " confines in a more richly vascular field, hence it is more readily resorbed, there is less risk of infection, and the " t a k e " is better. T h e chronological sequence of the operations was designed for maximal functional and cosmetic effect. At this stage there would be no contraindication to further cosmetic improvement by a buccal-epithelial inlay if one wanted to " gild the lily." I should like to thank Mr A. Weldon Moule, F.D.S.R.C.S., of Manchester, England, my former consultant and teacher, for his advice and interest in this case; Dr B. Hirshowitz, F.R.C.S, of Haifa, for his very sound criticism, inspiration, and most able assistance at two of the operations ; Dr J. Birkhahn for his excellent amesthesia; Dr Vdeinreb and Mrs Solomon, Anatomy Department, Jerusalem Medical School, for the photographs, and Mr Meir Cohen for the radiographs. REFERENCE SMITH, J. (195o). J. Oral Surg., 8, 297.
JOINT
By A. LAPIDOT, M.D., B.D.S}
Hadassah Medical School, Jerusalem, Israel CASE REPORT
AN Arab (Druse), aged 18, was referred for consultation in view of not having been able to open his mouth since the age of 4 and because of his facial deformity. A concise history was not available, but it would appear that when he was a few years old he sustained a traumatic facial injury which was neglected. He subsequently was unable to open his mouth and since had fed on a liquid diet and " slops." The patient had been operated on several times and spent lengthy periods in hospitals.
A
B
C FIG. I A, B, C, Original deformity and degree of malocclusion.
On examination he was found to be underdeveloped in stature and to weigh 46 kg. (92 lb.). His intellect was quite normal. In the right pre-auricular region there was a scar 3½ in. in length. The facial deformity was as shown in Fig. I, A and B. He was completely unable to open his mouth, with his anterior teeth in an almost edge-to-edge bite and with gross malocclusion (Fig. I, c). Sensation over the entire peripheral distribution of the trigeminal nerve was normal. Intra-oral examination was limited; however, it was noted that the left lower arch was in linguoversion and the right lower arch was edentulous as from the first premolar. Extra-oral radiographs revealed an absence of the right condylar head and neck in place of which there was clear evidence of bony ankylosis between the ascending ramus and the base of the skull. On the left side the condylar head could be outlined. The pattern of the bone in the rami of the mandible appeared normal. In the right mandible the teeth backward from and including the first premolar were missing. There was a full complement of posterior teeth in the left mandible with a vertically unerupted third molar. Examination of the auditory system was negative. Treatmem.--(I) It was decided as a first-stage operation to perform an osteotomy in the right ascending ramus and an arthroplasty. The patient was prepared for operation, and in September 1958 under blind nasal-intratracheal intubation and anamthesia the i Now Fellow-Trainee, Head and Neck Surgery, Washington University Medical School, St Louis, Missouri. 26~
266
BRITISH JOURNAL OF PLASTIC SURGERY
right ascending ramus was exposed by a submandibular approach and horizontally fractured above the lingula by the use of burrs. Sufficient bone was removed at the fracture site to obtain a space between the bone ends of nearly 2 cm. A vertical incision through the mid-portion of masseter enabled rotation medially of its anterior portion, which was sutured to the internal pterygoid muscle. At this stage a gag was inserted in the mouth and an opening of I cm. was obtained. It must be stated that prior to operation under general anmsthesia, there was no movement whatever of the mandible using the mouth gag. The wound was closed in layers. No teeth in the mandible were sacrificed. On the following day exercises were started with a wooden wedge placed between the incisal edges of the teeth. The patient was instructed in oral hygiene and told to chew gum and on the seventh day after admission he was discharged.
A
B FI~. 2 A, B, C, Post-operative appearance and result.
C
(2) A month later the patient was readmitted for the purpose of inserting a bone graft in the anterolateral aspect of the mandible. The outer aspect of the mandible from molar to molar region was exposed by a submandibular approach and the outer cortical plate removed. A bone graft, decorticated from the left iliac crest, was applied to the mandible together with bone chips. The wound was closed in layers and a through drain inserted for forty-eight hours. Recovery was uneventful except for a discharging sinus on the left side in the suture line, which persisted for twenty days and resolved under antibiotic therapy. Thirteen days after admission the patient was discharged from hospital. The post-operative result is seen in Fig. 2, A, B, and c. (3) Mouth exercises were continued and the opening improved to 2½ cm. In October 1959 a left condylectomy was carried out. There was transient paresis of the temporal branch of the facial nerve but the opening continued to improve and finally registered 3 cm. between the incisal edges of the anterior teeth. The weight one and a half years after the first-stage operation reached 54 kg. (lO8 lb.). DISCUSSION A not u n c o m m o n complication of neglected trauma to the t e m p o r o - m a n d i b u l a r joint in early childhood is ankylosis and the accompanying u n d e r d e v e l o p m e n t of the mandible due to the injury to the condylar growth centrel I f only one joint is affected the opposite joint, consequent to non-function, undergoes fibrosis.
BONY
ANKYLOSIS
OF
THE TEMPORO-MANDIBULARJOINT WITH MICROGNATHIA 267
In the creation of a new false joint to mobilise the mandible, several foreign bodies have been used at the osteotomy site to prevent union (fascia lata, cartilage, vitallium) with varying success as some of these tissues may resorb and the foreign bodies may act as irritants. Smith (195o) advocates a method which I have followed with good results. No tissue or material other than local tissue is necessary provided sufficient bone is removed. With regard to the bone graft, it would appear that if only cancellous bone is used, the operative oedema hmmatoma is not within " n o n - g i v i n g " confines in a more richly vascular field, hence it is more readily resorbed, there is less risk of infection, and the " t a k e " is better. T h e chronological sequence of the operations was designed for maximal functional and cosmetic effect. At this stage there would be no contraindication to further cosmetic improvement by a buccal-epithelial inlay if one wanted to " gild the lily." I should like to thank Mr A. Weldon Moule, F.D.S.R.C.S., of Manchester, England, my former consultant and teacher, for his advice and interest in this case; Dr B. Hirshowitz, F.R.C.S, of Haifa, for his very sound criticism, inspiration, and most able assistance at two of the operations ; Dr J. Birkhahn for his excellent amesthesia; Dr Vdeinreb and Mrs Solomon, Anatomy Department, Jerusalem Medical School, for the photographs, and Mr Meir Cohen for the radiographs. REFERENCE SMITH, J. (195o). J. Oral Surg., 8, 297.