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Is aggressive gap arthroplasty essential in the management of temporomandibular joint ankylosis?—a prospective clinical study of 15 cases
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British Journal of Oral and Maxillofacial Surgery 51 (2013) 473–478
Is aggressive gap arthroplasty essential in the management of temporomandibular joint ankylosis?—a prospective clinical study of 15 cases Lokesh Babu a,e , Manoj Kumar Jain b,∗ , C. Ramesh c,f , N. Vinayaka d,g a
Department of Oral and Maxillofacial Surgery, KGF College of Dental Sciences and Hospital, BEML Nagar, K.G.F, Karnataka, India Department of Oral and Maxillofacial Surgery, Sri Hasanamba Dental College and Hospital, Hassan, Karnataka, India c Department of Oral and Maxillofacial Surgery, Indira Gandhi Institute of Dental Sciences, Mahatma Gandhi Medical College and Research Institute Campus, Pillaiyarkuppam, Puducherry 607402, India d Sri Hasanamba Dental College and Hospital, Hassan, Karnataka, India b
Accepted 12 November 2012 Available online 5 December 2012
Abstract The purpose of this three-year, prospective, follow-up study was to evaluate whether aggressive gap arthroplasty is essential in the management of ankylosis of the temporomandibular joint (TMJ). Fifteen patients were treated by the creation of a minimal gap of 5–8 mm and insertion of an interpositional gap arthroplasty using the temporalis fascia. Eleven patients had unilateral coronoidectomy and 4 bilateral coronoidectomy based on Kaban’s protocol. Preoperative assessment included recording of history, clinical and radiological examinations, personal variables, the aetiology of the ankylosis, the side affected, and any other relevant findings. Patients were assessed postoperatively by a surgeon unaware of the treatment given for a minimum of 3 years, which included measurement of the maximal incisal opening, presence of facial nerve paralysis, recurrence, and any other relevant findings. Of the 15 patients (17 joints), 12 had unilateral and three had bilateral involvement, with trauma being the most common cause. The patients were aged between 7 and 29 years (mean (SD) age 20 (8) years). Preoperative maximal incisal opening was 0–2 mm in 8 cases and 2–9 mm in 9. Postoperatively adequate mouth opening of 30–40 mm was achieved in all cases, with no recurrence or relevant malocclusion during 3-year follow up. However, patients will be followed up for 10 years. Aggressive gap arthroplasty is not essential in the management of ankylosis of the TMJ. Minimal gap interpositional arthroplasty with complete removal of the mediolateral ankylotic mass is a feasible and effective method of preventing recurrence. © 2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Temporomandibular joint ankylosis; Minimal gap arthroplasty; Interpositional arthroplasty; Temporalis fascia
Introduction Ankylosis of the temporomandibular joint (TMJ) is a disabling condition that causes problems in mastication,
∗
Corresponding author. Tel.: +91 9972643973. E-mail addresses: [email protected] (L. Babu), [email protected] (M.K. Jain), ramesh [email protected] (C. Ramesh). e Tel.: +91 9845659666. f Tel.: +91 9486910147. g Tel.: +91 9886521748.
digestion, speech, function, cosmesis, and maintenance of oral hygiene.1 It can also cause disturbances of facial growth and acute compromise of the airway, which invariably results in physical and psychological disability.2 It usually results from injury (13–100%); local or systemic infection (10–40%); or systemic disease (10%) such as ankylosing spondylitis, rheumatoid arthritis, and psoriasis3 ; but can also result from operation on the TMJ. The hypothesis has been proposed for traumatic cases that intra-articular haematoma, scarring, and formation of excessive bone gives rise to hypomobility.1–4
0266-4356/$ – see front matter © 2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bjoms.2012.11.004
474
L. Babu et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 473–478
Ankylosis of the TMJ may be classified by using a combination of site (intra-articular or extra-articular), type of tissue involved (bony, fibrous, or fibro-osseous), and extent of fusion (complete or incomplete).3 Tripathy et al. have classified ankylosis as true or false.5 In true ankylosis there is bony or fibrous adhesion between the surfaces of the joint within the capsule, whereas in false ankylosis the problems lie in the surrounding structures.3,5 The aims of treatment are to establish movement of the joint with adequate mouth opening, maintain functional occlusion, reconstruct the joint using biological material, and to prevent recurrence.5–13 There is no published consensus about the best treatment.3 Several techniques have been described,6–20 but there are three basic surgical techniques that have been developed. The first is gap arthroplasty, in which the osseous mass between the articular cavity and the mandibular ramus is resected without interpositional material being inserted. Secondly, interpositional arthroplasty in which a gap is created by resecting the osseous mass into which biological material is interposed, such as a temporal muscle flap, or a nonbiological material such as acrylic, or silastic.6–13 Lastly, the joint can be reconstructed. The osseous mass is resected and the joint reconstructed by autogenous bone grafts or a total joint prosthesis.11–14 The most commonly followed protocol for the management of ankylosis is that given by Kaban et al.,12–13 This includes early surgical intervention, aggressive resection (1.5–2.0 cm), ipsilateral coronoidectomy (if mouth opening less than 35 mm), contralateral coronoidectomy (if mouth opening less than 35 mm after the ipsilateral coronoidectomy), lining of the TMJ with temporalis fascia or cartilage, reconstruction of the ramus with a costochondral graft or distraction osteogenesis, rigid fixation, early mobilisation and aggressive physiotherapy, regular long term follow up, and finally cosmetic surgery after growth has been completed. Various disadvantages have been noted after aggressive resection of the ankylotic mass, among which the most important is reconstruction of the created gap.15,20 Most authorities also agree that ankylosis is less likely to recur when something is interposed between the cut ends of bone, irrespective of the size of the gap arthroplasty (interpositional arthroplasty).15 We therefore organised the present prospective clinical follow-up study to find out whether aggressive gap arthroplasty is essential in the management of ankylosis of the TMJ and how effective minimal gap interpositional arthroplasty with temporal fascia is in its management.
Patients and methods After we had obtained approval from the ethics and research committee, we organised a prospective observational follow up clinical study in the private hospitals of Bangalore, Puducherry and Hassan City. Fifteen patients (18 joints)
Fig. 1. Preoperative mouth opening of 5 mm in a patient with ankylosis of the left temporomandibular joint.
with ankylosis of the TMJ were treated, all by minimal gap interpositional arthroplasty using temporal fascia (5–8 mm vertically) with emphasis on complete lateral to medial excision to permit mobilisation. Preoperative assessment included the patient’s history, and physical and radiographic examinations. We recorded age, sex, aetiology of ankylosis, the side affected, preoperative (Fig. 1) and postoperative maximal incisal opening, recurrence rate, the presence of facial nerve paralysis, and any other relevant findings. The radiographic examination included panoramic radiographs and computed axial tomographic scans with emphasis on the lateral and medial extent of the ankylotic mass (Figs. 2 and 3), and the classification of ankylosis based on Sawhney’s criteria (types 1–4).21 All patients were given cefotaxime 2 g intravenously half an hour before the procedure and were operated on under general anaesthesia with nasoendotracheal intubation. Access to the TMJ was through a preauricular incision with temporal extension, and dissection through the superficial temporal fascia (Fig. 4). The facial nerve was protected by retracting the fascia anteriorly. The capsule was incised and the ankylotic mass exposed. The ankylotic mass was excised with burs and osteotomes to create a gap of 5–8 mm (Fig. 4) with the channel retractor on the medial aspect to prevent injury to vital structures. Trial mouth opening was then attempted. Ipsilateral and (if required) contralateral coronoidectomy was based on the protocol reported by Kaban et al,12,13 and adequate mouth opening was achieved. A pedicled finger-shaped piece of temporal fascia (Fig. 4) was placed in the gap, and secured by sutures to the adjacent soft tissue. The incisions were closed and a pressure dressing was applied. A vacuum suction drain was left in place for 2–3 days. Immediate postoperative care included analgesics and antibiotics. Intermaxillary fixation with arch bars was used for 7–10 days to reduce postoperative pain, to improve healing within the region of the new joint, and to maintain satisfactory occlusion. This was followed by professional and home physiotherapy for 4–6 weeks in all cases after release of the interemaxillary fixation. The physiotherapy included encouraging patients to move the mandible
L. Babu et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 473–478
475
Fig. 2. Sections of coronal computed tomographic scan showing ankylosis of the left temporomandibular joint.
vertically and horizontally by frequent chewing. The other daily exercise was the use of tongue depressors (wooden spatulas) between the upper and lower teeth horizontally to retain the maximum mouth opening that had been achieved intraoperatively. This was to be done 3 times a day for 15 min, and patients were seen weekly for 6 weeks for more than 6 months. Regular follow-up visits were initially every 2 weeks, then at 1, 3, and 6 months, and then at yearly intervals for 3 years.
Results All 15 patients (17 joints) were treated with a minimum gap of 5–8 mm vertically and interpositional arthroplasty
with the emphasis on complete removal of the mediolateral ankylotic mass to permit mobilisation. Unilateral coronoidectomy was done for 11 patients and bilateral coronoidectomy for 4. Twelve had unilateral, and 3 had bilateral, involvement with a male: female ratio of 2:1. The patients were aged between 7 and 29 (mean (SD), 20 (8)) years. Most cases were post-traumatic except 2 in whom the aetiology was infection, and 1 in whom it was congenital. Three patients were Sawhney’s type 3 and rest were type 2 (Table 1). Preoperative mouth opening (maximal incisal opening) was 0–2 mm in 5 cases and 3–9 mm in the other 10. Adequate mouth opening of 30–40 mm was achieved postoperatively (Fig. 5) in all cases. The postoperative period was uneventful with no major complications. The mouth opening improved up to 35 mm in most cases during the first year, and patients
Fig. 3. Lateral three-dimensional computed tomography scan showing ankylosis of the left temporomandibular joint.
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L. Babu et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 473–478
Table 1 Clinical variables, aetiology, involvement, Sawhney’s grading, and preoperative and postoperative mouth opening of all the patients. Case no.
Age (years)
Sex
Aetiology and involvement
Preoperative mouth opening (mm)
Sawhney’s criteria (type)
Postoperative mouth opening (mm) (3 years’ follow up)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
23 18 15 07a 13 22 18a 20a 16 29 14 20 25 26 28a
Female Male Female Male Male Male Male Female Male Female Male Female Male Male Male
Trauma, unilateral Trauma, unilateral Trauma, unilateral Trauma, bilateral Trauma, unilateral Trauma, unilateral Trauma, unilateral Congenital, bilateral Trauma, unilateral Trauma, unilateral Trauma, unilateral Infection, unilateral Infection, unilateral Trauma, unilateral Trauma, bilateral
5 3 5 0 2 4 1 3 5 3 2 8 7 9 1
2 2 2 3 2 2 2 3 2 2 2 2 2 2 3
34 31 35 31 31 33 30 34 33 35 32 40 37 37 40
a
Treated by bilateral coronoidectomy; the rest were treated by unilateral coronoidectomy.
were followed up for a minimum of 3 years. Postoperatively adequate mouth opening of 30–40 mm was achieved in all cases with no recurrence, and any malocclusion could be managed by orthodontics.
Fig. 5. Postoperative mouth opening of 34 mm at 3 years’ follow up.
Discussion
Fig. 4. Intraoperative picture of minimal interpositional arthroplasty using temporalis fascia with complete removal of the mediolateral ankylotic mass.
Trauma or local or systemic infections are the main causes of ankylosis of the TMJ.1,4,15,20 In 12 of our 15 the cause was trauma, which is similar to those reported in many other studies, probably because these patients were referred from rural areas with no easy access to maxillofacial services after injuries. Management of ankylosis is difficult,12 and rates of relapse postoperatively are as high as 50%.22 Many authors have recommended that a gap of 15–20 mm should be left between the recontoured fossa and the mandible to prevent reankylosis after gap arthroplasty.3,22 However, this has the disadvantage of generating a pseudoarticulation with shortening of the mandibular ramus, premature occlusion on the affected side with a contralateral open bite in unilateral cases.2 In bilateral cases this may result in gagging of the posterior teeth, anterior open bite and, more seriously, respiratory embarrassment.23 Recurrences develop even after wide gap arthroplasty.20
L. Babu et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 473–478
In all our cases, therefore, a vertical gap of only 5–8 mm was created between the cut ends of bone with emphasis on complete lateral to medial excision to permit mobilisation. We hoped that this zone of excision would be sufficiently wide to prevent reankylosis but also to produce little change in the vertical height of the mandible and avoid the need to reconstruct the ramus of mandible. Most authorities agree that recurrence of ankylosis is less likely when something is interposed between the cut ends of bone (interpositional arthroplasty).1,5 A review of gap arthroplasty without interposition reported a recurrence rate of 53%.15 However, we know of no perfect interpositional material at present. All have drawbacks.20 Several materials have been used including temporal fascia, temporalis or masseter muscle, fascia lata, dermis, full-thickness skin, autologous costochondral cartilage,5 and dislocated articular disc.15 Non-biological options include insertion of T-plates,5 silicone,9 silastic, acrylic, proplast, and teflon.20 Interpositional arthroplasty using alloplastic materials has the disadvantages of possible fragmentation with foreign body reaction, instability, infection, and extrusion.20 Autogenous materials used as interpositional inserts all have some donor site morbidity. Muscle flaps tend to contract and become fibrous; cartilage may calcify; and thin grafts such as skin, dermis, and auricular cartilage may not maintain the height of the ramus adequately, and may perforate under pressure from the condyle.20 One study concluded that the deep temporal fascia is supplied by the middle temporal artery, a branch of the superficial temporal artery. A temporal fascial (vascularised) flap is a locally available axial pattern flap that has fewer chances of absorption and fibrosis.24 We used a pedicled temporal fascia flap as interpositional material, as we found this flap to be relatively simple and easy to raise, the donor site was close at hand, and it was always available.8,12,20 Aggressive physiotherapy should be given postoperatively to disrupt and prevent adhesions, to prevent soft tissue from contracting, and to redevelop normal muscle function. A waiting period of 5–7 days allows early healing of the surrounding tissues. The potential problem with early mobilisation is that it may provoke bleeding and create a haematoma, which delays healing.2 We started active physiotherapy within 7–10 days of operation, and this was continued for more than 6 months. The incidence of injury to the facial nerve is low and varies from 9% to 18%, and symptoms usually disappear within 6 months.2 However, we had no instances of paralysis of the facial nerve. We achieved maximal incisal opening of 30–40 mm in all the cases with a follow-up period of 3 years and with no recurrence. We think that a gap of 10–20 mm in gap arthroplasty, which is thought to prevent reankylosis, may not be required. The limitations of this study include the small sample size, the fact that it is not a comparative study, and that we have a relatively short period of follow up.
477
To conclude, aggressive gap arthroplasty is not essential in the management of ankylosis of the TMJ. Minimum gap interpositional arthroplasty with complete removal of the mediolateral ankylotic mass is a feasible and effective way of preventing recurrence. A prospective, comparative study with a larger sample size would give definitive results.
Conflict of interest None.
References 1. Akama MK, Guthua S, Chindia ML, et al. Management of bilateral temporomandibular joint ankylosis in children: case report. East Afr Med J 2009;86:45–8. 2. Vasconcelos BC, Porto GG, Bessa-Nogueira RV, et al. Surgical treatment of temporomandibular joint ankylosis: follow-up of 15 cases and literature review. Med Oral Patol Oral Cir Bucal 2009;14:E34–8. 3. Sidebottom AJ, Salha R. Management of the temporomandibular joint in rheumatoid disorders. Br J Oral Maxillofac Surg 2012;(May) [Epub ahead of print]. 4. Erol B, Tanrikulu R, Görgün B. A clinical study on ankylosis of the temporomandibular joint. J Craniomaxillofac Surg 2006;34:100–6. 5. Tripathy S, Yaseen M, Singh NN, et al. Interposition arthroplasty in post-traumatic temporomandibular joint ankylosis: a retrospective study. Indian J Plast Surg 2009;42:182–7. 6. Li ZB, Li Z, Shang ZJ, et al. Potential role of disc repositioning in preventing postsurgical recurrence of traumatogenic temporomandibular joint ankylosis: a retrospective review of 17 consecutive cases. Int J Oral Maxillofac Surg 2006;35:219–23. 7. Paterson AW, Shepherd JP. Fascia lata interpositional arthroplasty in the treatment of temporomandibular joint ankylosis caused by psoriatic arthritis. Int J Oral Maxillofac Surg 1992;21:137–9. 8. Pogrel MA, Kaban LB. The role of a temporalis fascia and muscle flap in temporomandibular joint surgery. J Oral Maxillofac Surg 1990;48:14–9. 9. Schliephake H, Schmelzesien R, Maschek H, et al. Long-term results of the use of silicone sheets after diskectomy in the temporomandibular joint: clinical, radiographic and histopathologic findings. Int J Oral Maxillofac Surg 1999;28:323–9. 10. Dean A, Alamillos F. Mandibular distraction in temporomandibular joint ankylosis. Plast Reconstr Surg 1999;104:2021–31. 11. Saeed N, Hensher R, McLeod N, et al. Reconstruction of the temporomandibular joint autogenous compared with alloplastic. Br J Oral Maxillofac Surg 2002;40:296–9. 12. Kaban LB, Perrott DH, Fisher K. A protocol for management of temporomandibular joint ankylosis. J Oral Maxillofac Surg 1990;48:1145–52. 13. Kaban LB, Bouchard C, Troulis MJ. A protocol for management of temporomandibular joint ankylosis in children. J Oral Maxillofac Surg 2009;67:1966–78. 14. Mercuri LG, Ali FA, Woolson R. Outcomes of total alloplastic replacement with periarticular autogenous fat grafting for management of reankylosis of the temporomandibular joint. J Oral Maxillofac Surg 2008;66:1794–803. 15. 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. 16. Gunaseelan R. Condylar reconstruction in extensive ankylosis of temporomandibular joint in adults using resected segment as autograft. A new technique. Int J Oral Maxillofac Surg 1997;26:405–7. 17. Schwartz HC, Relle RJ. Distraction osteogenesis for temporomandibular joint reconstruction. J Oral Maxillofac Surg 2008;66:718–23.
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18. Huang IY, Lai ST, Shen YH, et al. Interpositional arthroplasty using autogenous costal cartilage graft for temporomandibular joint ankylosis in adults. Int J Oral Maxillofac Surg 2007;36:909–15. 19. Rao K, Kumar S, Kumar V, et al. The role of simultaneous gap arthroplasty and distraction osteogenesis in the management of temporomandibular joint ankylosis with mandibular deformity in children. J Craniomaxillofac Surg 2004;32:38–42. 20. Chossegros C, Guyot L, Cheynet F, et al. Comparison of different materials for interposition arthroplasty in treatment of temporomandibular joint ankylosis surgery: long term follow-up in 25 cases. Br J Oral Maxillofac Surg 1997;35:157–60.
21. Sawhney CP. Bony ankylosis of the temporomandibular joint: follow-up of 70 patients treated with arthroplasty and acrylic spacer interposition. Plast Reconstr Surg 1986;77:29–40. 22. Lei Z. Auricular cartilage graft interposition after temporomandibular joint ankylosis surgery in children. J Oral Maxillofac Surg 2002;60:985–7. 23. El-Sheikh MM. Temporomandibular joint ankylosis: the Egyptian experience. Ann R Coll Surg Engl 1999;81:12–8. 24. Mani V, Panda AK. Versatility of temporalis myofascial flap in maxillofacial reconstruction – analysis of 30 cases. Int J Oral Maxillofac Surg 2003;32:368–72.
British Journal of Oral and Maxillofacial Surgery 51 (2013) 473–478
Is aggressive gap arthroplasty essential in the management of temporomandibular joint ankylosis?—a prospective clinical study of 15 cases Lokesh Babu a,e , Manoj Kumar Jain b,∗ , C. Ramesh c,f , N. Vinayaka d,g a
Department of Oral and Maxillofacial Surgery, KGF College of Dental Sciences and Hospital, BEML Nagar, K.G.F, Karnataka, India Department of Oral and Maxillofacial Surgery, Sri Hasanamba Dental College and Hospital, Hassan, Karnataka, India c Department of Oral and Maxillofacial Surgery, Indira Gandhi Institute of Dental Sciences, Mahatma Gandhi Medical College and Research Institute Campus, Pillaiyarkuppam, Puducherry 607402, India d Sri Hasanamba Dental College and Hospital, Hassan, Karnataka, India b
Accepted 12 November 2012 Available online 5 December 2012
Abstract The purpose of this three-year, prospective, follow-up study was to evaluate whether aggressive gap arthroplasty is essential in the management of ankylosis of the temporomandibular joint (TMJ). Fifteen patients were treated by the creation of a minimal gap of 5–8 mm and insertion of an interpositional gap arthroplasty using the temporalis fascia. Eleven patients had unilateral coronoidectomy and 4 bilateral coronoidectomy based on Kaban’s protocol. Preoperative assessment included recording of history, clinical and radiological examinations, personal variables, the aetiology of the ankylosis, the side affected, and any other relevant findings. Patients were assessed postoperatively by a surgeon unaware of the treatment given for a minimum of 3 years, which included measurement of the maximal incisal opening, presence of facial nerve paralysis, recurrence, and any other relevant findings. Of the 15 patients (17 joints), 12 had unilateral and three had bilateral involvement, with trauma being the most common cause. The patients were aged between 7 and 29 years (mean (SD) age 20 (8) years). Preoperative maximal incisal opening was 0–2 mm in 8 cases and 2–9 mm in 9. Postoperatively adequate mouth opening of 30–40 mm was achieved in all cases, with no recurrence or relevant malocclusion during 3-year follow up. However, patients will be followed up for 10 years. Aggressive gap arthroplasty is not essential in the management of ankylosis of the TMJ. Minimal gap interpositional arthroplasty with complete removal of the mediolateral ankylotic mass is a feasible and effective method of preventing recurrence. © 2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Temporomandibular joint ankylosis; Minimal gap arthroplasty; Interpositional arthroplasty; Temporalis fascia
Introduction Ankylosis of the temporomandibular joint (TMJ) is a disabling condition that causes problems in mastication,
∗
Corresponding author. Tel.: +91 9972643973. E-mail addresses: [email protected] (L. Babu), [email protected] (M.K. Jain), ramesh [email protected] (C. Ramesh). e Tel.: +91 9845659666. f Tel.: +91 9486910147. g Tel.: +91 9886521748.
digestion, speech, function, cosmesis, and maintenance of oral hygiene.1 It can also cause disturbances of facial growth and acute compromise of the airway, which invariably results in physical and psychological disability.2 It usually results from injury (13–100%); local or systemic infection (10–40%); or systemic disease (10%) such as ankylosing spondylitis, rheumatoid arthritis, and psoriasis3 ; but can also result from operation on the TMJ. The hypothesis has been proposed for traumatic cases that intra-articular haematoma, scarring, and formation of excessive bone gives rise to hypomobility.1–4
0266-4356/$ – see front matter © 2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bjoms.2012.11.004
474
L. Babu et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 473–478
Ankylosis of the TMJ may be classified by using a combination of site (intra-articular or extra-articular), type of tissue involved (bony, fibrous, or fibro-osseous), and extent of fusion (complete or incomplete).3 Tripathy et al. have classified ankylosis as true or false.5 In true ankylosis there is bony or fibrous adhesion between the surfaces of the joint within the capsule, whereas in false ankylosis the problems lie in the surrounding structures.3,5 The aims of treatment are to establish movement of the joint with adequate mouth opening, maintain functional occlusion, reconstruct the joint using biological material, and to prevent recurrence.5–13 There is no published consensus about the best treatment.3 Several techniques have been described,6–20 but there are three basic surgical techniques that have been developed. The first is gap arthroplasty, in which the osseous mass between the articular cavity and the mandibular ramus is resected without interpositional material being inserted. Secondly, interpositional arthroplasty in which a gap is created by resecting the osseous mass into which biological material is interposed, such as a temporal muscle flap, or a nonbiological material such as acrylic, or silastic.6–13 Lastly, the joint can be reconstructed. The osseous mass is resected and the joint reconstructed by autogenous bone grafts or a total joint prosthesis.11–14 The most commonly followed protocol for the management of ankylosis is that given by Kaban et al.,12–13 This includes early surgical intervention, aggressive resection (1.5–2.0 cm), ipsilateral coronoidectomy (if mouth opening less than 35 mm), contralateral coronoidectomy (if mouth opening less than 35 mm after the ipsilateral coronoidectomy), lining of the TMJ with temporalis fascia or cartilage, reconstruction of the ramus with a costochondral graft or distraction osteogenesis, rigid fixation, early mobilisation and aggressive physiotherapy, regular long term follow up, and finally cosmetic surgery after growth has been completed. Various disadvantages have been noted after aggressive resection of the ankylotic mass, among which the most important is reconstruction of the created gap.15,20 Most authorities also agree that ankylosis is less likely to recur when something is interposed between the cut ends of bone, irrespective of the size of the gap arthroplasty (interpositional arthroplasty).15 We therefore organised the present prospective clinical follow-up study to find out whether aggressive gap arthroplasty is essential in the management of ankylosis of the TMJ and how effective minimal gap interpositional arthroplasty with temporal fascia is in its management.
Patients and methods After we had obtained approval from the ethics and research committee, we organised a prospective observational follow up clinical study in the private hospitals of Bangalore, Puducherry and Hassan City. Fifteen patients (18 joints)
Fig. 1. Preoperative mouth opening of 5 mm in a patient with ankylosis of the left temporomandibular joint.
with ankylosis of the TMJ were treated, all by minimal gap interpositional arthroplasty using temporal fascia (5–8 mm vertically) with emphasis on complete lateral to medial excision to permit mobilisation. Preoperative assessment included the patient’s history, and physical and radiographic examinations. We recorded age, sex, aetiology of ankylosis, the side affected, preoperative (Fig. 1) and postoperative maximal incisal opening, recurrence rate, the presence of facial nerve paralysis, and any other relevant findings. The radiographic examination included panoramic radiographs and computed axial tomographic scans with emphasis on the lateral and medial extent of the ankylotic mass (Figs. 2 and 3), and the classification of ankylosis based on Sawhney’s criteria (types 1–4).21 All patients were given cefotaxime 2 g intravenously half an hour before the procedure and were operated on under general anaesthesia with nasoendotracheal intubation. Access to the TMJ was through a preauricular incision with temporal extension, and dissection through the superficial temporal fascia (Fig. 4). The facial nerve was protected by retracting the fascia anteriorly. The capsule was incised and the ankylotic mass exposed. The ankylotic mass was excised with burs and osteotomes to create a gap of 5–8 mm (Fig. 4) with the channel retractor on the medial aspect to prevent injury to vital structures. Trial mouth opening was then attempted. Ipsilateral and (if required) contralateral coronoidectomy was based on the protocol reported by Kaban et al,12,13 and adequate mouth opening was achieved. A pedicled finger-shaped piece of temporal fascia (Fig. 4) was placed in the gap, and secured by sutures to the adjacent soft tissue. The incisions were closed and a pressure dressing was applied. A vacuum suction drain was left in place for 2–3 days. Immediate postoperative care included analgesics and antibiotics. Intermaxillary fixation with arch bars was used for 7–10 days to reduce postoperative pain, to improve healing within the region of the new joint, and to maintain satisfactory occlusion. This was followed by professional and home physiotherapy for 4–6 weeks in all cases after release of the interemaxillary fixation. The physiotherapy included encouraging patients to move the mandible
L. Babu et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 473–478
475
Fig. 2. Sections of coronal computed tomographic scan showing ankylosis of the left temporomandibular joint.
vertically and horizontally by frequent chewing. The other daily exercise was the use of tongue depressors (wooden spatulas) between the upper and lower teeth horizontally to retain the maximum mouth opening that had been achieved intraoperatively. This was to be done 3 times a day for 15 min, and patients were seen weekly for 6 weeks for more than 6 months. Regular follow-up visits were initially every 2 weeks, then at 1, 3, and 6 months, and then at yearly intervals for 3 years.
Results All 15 patients (17 joints) were treated with a minimum gap of 5–8 mm vertically and interpositional arthroplasty
with the emphasis on complete removal of the mediolateral ankylotic mass to permit mobilisation. Unilateral coronoidectomy was done for 11 patients and bilateral coronoidectomy for 4. Twelve had unilateral, and 3 had bilateral, involvement with a male: female ratio of 2:1. The patients were aged between 7 and 29 (mean (SD), 20 (8)) years. Most cases were post-traumatic except 2 in whom the aetiology was infection, and 1 in whom it was congenital. Three patients were Sawhney’s type 3 and rest were type 2 (Table 1). Preoperative mouth opening (maximal incisal opening) was 0–2 mm in 5 cases and 3–9 mm in the other 10. Adequate mouth opening of 30–40 mm was achieved postoperatively (Fig. 5) in all cases. The postoperative period was uneventful with no major complications. The mouth opening improved up to 35 mm in most cases during the first year, and patients
Fig. 3. Lateral three-dimensional computed tomography scan showing ankylosis of the left temporomandibular joint.
476
L. Babu et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 473–478
Table 1 Clinical variables, aetiology, involvement, Sawhney’s grading, and preoperative and postoperative mouth opening of all the patients. Case no.
Age (years)
Sex
Aetiology and involvement
Preoperative mouth opening (mm)
Sawhney’s criteria (type)
Postoperative mouth opening (mm) (3 years’ follow up)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
23 18 15 07a 13 22 18a 20a 16 29 14 20 25 26 28a
Female Male Female Male Male Male Male Female Male Female Male Female Male Male Male
Trauma, unilateral Trauma, unilateral Trauma, unilateral Trauma, bilateral Trauma, unilateral Trauma, unilateral Trauma, unilateral Congenital, bilateral Trauma, unilateral Trauma, unilateral Trauma, unilateral Infection, unilateral Infection, unilateral Trauma, unilateral Trauma, bilateral
5 3 5 0 2 4 1 3 5 3 2 8 7 9 1
2 2 2 3 2 2 2 3 2 2 2 2 2 2 3
34 31 35 31 31 33 30 34 33 35 32 40 37 37 40
a
Treated by bilateral coronoidectomy; the rest were treated by unilateral coronoidectomy.
were followed up for a minimum of 3 years. Postoperatively adequate mouth opening of 30–40 mm was achieved in all cases with no recurrence, and any malocclusion could be managed by orthodontics.
Fig. 5. Postoperative mouth opening of 34 mm at 3 years’ follow up.
Discussion
Fig. 4. Intraoperative picture of minimal interpositional arthroplasty using temporalis fascia with complete removal of the mediolateral ankylotic mass.
Trauma or local or systemic infections are the main causes of ankylosis of the TMJ.1,4,15,20 In 12 of our 15 the cause was trauma, which is similar to those reported in many other studies, probably because these patients were referred from rural areas with no easy access to maxillofacial services after injuries. Management of ankylosis is difficult,12 and rates of relapse postoperatively are as high as 50%.22 Many authors have recommended that a gap of 15–20 mm should be left between the recontoured fossa and the mandible to prevent reankylosis after gap arthroplasty.3,22 However, this has the disadvantage of generating a pseudoarticulation with shortening of the mandibular ramus, premature occlusion on the affected side with a contralateral open bite in unilateral cases.2 In bilateral cases this may result in gagging of the posterior teeth, anterior open bite and, more seriously, respiratory embarrassment.23 Recurrences develop even after wide gap arthroplasty.20
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In all our cases, therefore, a vertical gap of only 5–8 mm was created between the cut ends of bone with emphasis on complete lateral to medial excision to permit mobilisation. We hoped that this zone of excision would be sufficiently wide to prevent reankylosis but also to produce little change in the vertical height of the mandible and avoid the need to reconstruct the ramus of mandible. Most authorities agree that recurrence of ankylosis is less likely when something is interposed between the cut ends of bone (interpositional arthroplasty).1,5 A review of gap arthroplasty without interposition reported a recurrence rate of 53%.15 However, we know of no perfect interpositional material at present. All have drawbacks.20 Several materials have been used including temporal fascia, temporalis or masseter muscle, fascia lata, dermis, full-thickness skin, autologous costochondral cartilage,5 and dislocated articular disc.15 Non-biological options include insertion of T-plates,5 silicone,9 silastic, acrylic, proplast, and teflon.20 Interpositional arthroplasty using alloplastic materials has the disadvantages of possible fragmentation with foreign body reaction, instability, infection, and extrusion.20 Autogenous materials used as interpositional inserts all have some donor site morbidity. Muscle flaps tend to contract and become fibrous; cartilage may calcify; and thin grafts such as skin, dermis, and auricular cartilage may not maintain the height of the ramus adequately, and may perforate under pressure from the condyle.20 One study concluded that the deep temporal fascia is supplied by the middle temporal artery, a branch of the superficial temporal artery. A temporal fascial (vascularised) flap is a locally available axial pattern flap that has fewer chances of absorption and fibrosis.24 We used a pedicled temporal fascia flap as interpositional material, as we found this flap to be relatively simple and easy to raise, the donor site was close at hand, and it was always available.8,12,20 Aggressive physiotherapy should be given postoperatively to disrupt and prevent adhesions, to prevent soft tissue from contracting, and to redevelop normal muscle function. A waiting period of 5–7 days allows early healing of the surrounding tissues. The potential problem with early mobilisation is that it may provoke bleeding and create a haematoma, which delays healing.2 We started active physiotherapy within 7–10 days of operation, and this was continued for more than 6 months. The incidence of injury to the facial nerve is low and varies from 9% to 18%, and symptoms usually disappear within 6 months.2 However, we had no instances of paralysis of the facial nerve. We achieved maximal incisal opening of 30–40 mm in all the cases with a follow-up period of 3 years and with no recurrence. We think that a gap of 10–20 mm in gap arthroplasty, which is thought to prevent reankylosis, may not be required. The limitations of this study include the small sample size, the fact that it is not a comparative study, and that we have a relatively short period of follow up.
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To conclude, aggressive gap arthroplasty is not essential in the management of ankylosis of the TMJ. Minimum gap interpositional arthroplasty with complete removal of the mediolateral ankylotic mass is a feasible and effective way of preventing recurrence. A prospective, comparative study with a larger sample size would give definitive results.
Conflict of interest None.
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