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Modification of the temporalis muscle and fascia flap for the management of ankylosis of the temporomandibular joint
J Oral Maxdlofac Surg 54:794-795, 1996
Modification of the Temporalis Muscle and Fascia Flap for the Management of Ankylosis of the Temporomandibular Joint S. OMURA,
DDS, PHD,* AND K. FUJITA,
A variety of grafts have been used for lining the temporomandibular joint (TMJ) after the resection of an ankylotic mass, but no consensus has been reached as to the most suitable material. The temporalis muscle and fascia (TMF) flap has been widely used as an interpositional graft after the release of TMJ ankylosis because of its advantages over other types of materials, including autogenous dermis and cartilage, and alloplastic materials such as Proplast-Teflon and Silastic.’ Among the advantages of the TMF flap are a dependable blood supply and proximity to the recipient site. In the conventional procedure, the fascia lines the glenoid fossa and the muscle faces the condyle. However, theoretically it would be ideal for the fascia to face the condyle as well as the glenoid fossa, because the fascia could reduce friction in the joint. We report a modified TMF flap for use as an interpositional material in the management of severe ankylosis of the TMJ in which the fascia faces both the condyle and the glenoid fossa.
Conventional FIGURE inserted
TMF
flap
fSSCi8
Modified
TMF
flap
I. Diagram showing temporalis muscle and fascia flap into joint (Left: conventional flap, Right: modified flap).
5-O polyglycolic acid so that the muscle is wrapped in the fascia (Figs 1, 2). The flap is turned over the zygomatic arch and inserted into the space after resection of the ankylotic mass (Fig 3). The flap is then secured with several sutures. In this procedure, the fascia faces both the condyle and the glenoid fossa, and the spacebetween the condyle and the glenoid fossa is occupied by the muscle wrapped in the fascia (Fig 1).
The TMF flap is approached by an extended preauricular incision (hemicoronal incision) or a bicoronal incision.2 The flap, which is outlined on the fascia using a skin marker, is fingerlike and extends 6 to 8 cm from the zygomatic arch to provide the proper length for lining the joint. Ten to 15 mm of the distal portion of the elevated flap is folded and sutured with
Discussion Since the first use of a TMF flap in TMJ surgery by Murphy in 1914,? several modifications have been described, but no method that lines both the condyle and the glenoid fossahas been reported. Generally, the flap is turned over the zygomatic arch so that the fascia lines the glenoid fossa and the muscle faces the condyle. In the procedure reported, the distal portion of the TMF flap is folded so that the fascia faces both the condyle and the glenoid fossa. Friction between the condyle and the fascia is considered to be lessthan that between the condyle and the muscle. The modified TMF flap provides smooth movement of the condyle, and its function is closer to that of the original disc
Received from the Department of Oral and Maxillofacial Surgery, School of Medicine, Yokohama City University, Japan. * Assistant Professor. t Professor. Address correspondence and reprint requests to Dr. Omura: Department of Oral and Maxillofacial Surgery, School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama 236, Japan. of Oral and Maxillofacial
TemporaliS
Temporalis fascie
Technique
0 1996 American Association Q278-2391l96l54Q6-QQ23$3.QQlQ
MD, DDS, PHDt
Surgeons
794
OMURA
AND
795
FUJITA
than in the conventional TMF flap. Furthermore, the temporalis muscle wrapped in the fascia is somewhat elastic, so it is suitable as a cushion in the joint. Wrapping the muscle with the fascia also increases the bulk of the flap. Both the elasticity and increased bulk of the flap aid in the prevention of postoperative open bite, which is caused by shortening of the ramus after removal of the ankylotic mass. It is known that some degree of degeneration or atrophy of the temporalis muscle occurs during long follow-up.4.5 In the conventional procedure, fibrous degeneration directly influences mandibular mobility and leads to a limited range of motion or reankylosis. In the new procedure, degeneration of the muscle wrapped in the fascia may not directly influence mandibular mobility, and the risk of reankylosis is reduced. This procedure has been performed in four joints of
FIGURE 3. The flap is turned over the zygomatic into the newly created joint space.
arch and inserted
two patients with severe posttraumatic bony ankylosis, and excellent results have been obtained, without any apparent complications. References
FIGURE 2. Temporalis muscle/fascia harvested for lining of TMJ. Before placement, the distal portion of the flap is folded, wrapping the muscle in fascia.
I. Pogrel MA, Kaban LB: The role of a temporalis fascia and muscle flap in temporomandibular joint surgery. J Oral Maxillofac Surg 48:14, 1990 2. Pogrel MA, Perrott DH, Kaban LB: Bicoronal flap approach to the temporomandibular joints. Int J Oral Maxillofac Surg 20:219, 1991 3. Murphy JB: Arthroplasty for intra-articular bony and fibrous ankylosis of temporomandibular articulation. JAMA 62: 1783, 1914 4. Albert TW, Merrill RG: Temporalis myofascial flap for reconstruction of the temporomandibular joint. Oral Maxillofac Clin North Am I :341, 1989 5. Umeda H, Kaban LB, Pogrel MA, et al: Long-term viability of the temporalis muscle/fascia flap used for temporomandibular joint reconstruction. J Oral Maxillofac Surg 51:530, 1993
Modification of the Temporalis Muscle and Fascia Flap for the Management of Ankylosis of the Temporomandibular Joint S. OMURA,
DDS, PHD,* AND K. FUJITA,
A variety of grafts have been used for lining the temporomandibular joint (TMJ) after the resection of an ankylotic mass, but no consensus has been reached as to the most suitable material. The temporalis muscle and fascia (TMF) flap has been widely used as an interpositional graft after the release of TMJ ankylosis because of its advantages over other types of materials, including autogenous dermis and cartilage, and alloplastic materials such as Proplast-Teflon and Silastic.’ Among the advantages of the TMF flap are a dependable blood supply and proximity to the recipient site. In the conventional procedure, the fascia lines the glenoid fossa and the muscle faces the condyle. However, theoretically it would be ideal for the fascia to face the condyle as well as the glenoid fossa, because the fascia could reduce friction in the joint. We report a modified TMF flap for use as an interpositional material in the management of severe ankylosis of the TMJ in which the fascia faces both the condyle and the glenoid fossa.
Conventional FIGURE inserted
TMF
flap
fSSCi8
Modified
TMF
flap
I. Diagram showing temporalis muscle and fascia flap into joint (Left: conventional flap, Right: modified flap).
5-O polyglycolic acid so that the muscle is wrapped in the fascia (Figs 1, 2). The flap is turned over the zygomatic arch and inserted into the space after resection of the ankylotic mass (Fig 3). The flap is then secured with several sutures. In this procedure, the fascia faces both the condyle and the glenoid fossa, and the spacebetween the condyle and the glenoid fossa is occupied by the muscle wrapped in the fascia (Fig 1).
The TMF flap is approached by an extended preauricular incision (hemicoronal incision) or a bicoronal incision.2 The flap, which is outlined on the fascia using a skin marker, is fingerlike and extends 6 to 8 cm from the zygomatic arch to provide the proper length for lining the joint. Ten to 15 mm of the distal portion of the elevated flap is folded and sutured with
Discussion Since the first use of a TMF flap in TMJ surgery by Murphy in 1914,? several modifications have been described, but no method that lines both the condyle and the glenoid fossahas been reported. Generally, the flap is turned over the zygomatic arch so that the fascia lines the glenoid fossa and the muscle faces the condyle. In the procedure reported, the distal portion of the TMF flap is folded so that the fascia faces both the condyle and the glenoid fossa. Friction between the condyle and the fascia is considered to be lessthan that between the condyle and the muscle. The modified TMF flap provides smooth movement of the condyle, and its function is closer to that of the original disc
Received from the Department of Oral and Maxillofacial Surgery, School of Medicine, Yokohama City University, Japan. * Assistant Professor. t Professor. Address correspondence and reprint requests to Dr. Omura: Department of Oral and Maxillofacial Surgery, School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama 236, Japan. of Oral and Maxillofacial
TemporaliS
Temporalis fascie
Technique
0 1996 American Association Q278-2391l96l54Q6-QQ23$3.QQlQ
MD, DDS, PHDt
Surgeons
794
OMURA
AND
795
FUJITA
than in the conventional TMF flap. Furthermore, the temporalis muscle wrapped in the fascia is somewhat elastic, so it is suitable as a cushion in the joint. Wrapping the muscle with the fascia also increases the bulk of the flap. Both the elasticity and increased bulk of the flap aid in the prevention of postoperative open bite, which is caused by shortening of the ramus after removal of the ankylotic mass. It is known that some degree of degeneration or atrophy of the temporalis muscle occurs during long follow-up.4.5 In the conventional procedure, fibrous degeneration directly influences mandibular mobility and leads to a limited range of motion or reankylosis. In the new procedure, degeneration of the muscle wrapped in the fascia may not directly influence mandibular mobility, and the risk of reankylosis is reduced. This procedure has been performed in four joints of
FIGURE 3. The flap is turned over the zygomatic into the newly created joint space.
arch and inserted
two patients with severe posttraumatic bony ankylosis, and excellent results have been obtained, without any apparent complications. References
FIGURE 2. Temporalis muscle/fascia harvested for lining of TMJ. Before placement, the distal portion of the flap is folded, wrapping the muscle in fascia.
I. Pogrel MA, Kaban LB: The role of a temporalis fascia and muscle flap in temporomandibular joint surgery. J Oral Maxillofac Surg 48:14, 1990 2. Pogrel MA, Perrott DH, Kaban LB: Bicoronal flap approach to the temporomandibular joints. Int J Oral Maxillofac Surg 20:219, 1991 3. Murphy JB: Arthroplasty for intra-articular bony and fibrous ankylosis of temporomandibular articulation. JAMA 62: 1783, 1914 4. Albert TW, Merrill RG: Temporalis myofascial flap for reconstruction of the temporomandibular joint. Oral Maxillofac Clin North Am I :341, 1989 5. Umeda H, Kaban LB, Pogrel MA, et al: Long-term viability of the temporalis muscle/fascia flap used for temporomandibular joint reconstruction. J Oral Maxillofac Surg 51:530, 1993