- Email: [email protected]
Retrospective Analysis of Use of Buccal Fat Pad as an Interpositional Graft in Temporomandibular Joint Ankylosis: Preliminary Study
J Oral Maxillofac Surg 69:2530-2536, 2011
Retrospective Analysis of Use of Buccal Fat Pad as an Interpositional Graft in Temporomandibular Joint Ankylosis: Preliminary Study Virendra Singh, MDS,* Rahul Dhingra, MDS,† Bindu Sharma, MDS,‡ Amrish Bhagol, MDS,§ and Prashant Kumar, MD储 Purpose: To evaluate the feasibility and usefulness of buccal fat pad as an interpositional graft in the
treatment of temporomandibular joint (TMJ) ankylosis. Materials and Methods: A retrospective study of 10 patients with TMJ ankylosis (9 unilateral and 1 bilateral) was performed with follow-up of 6 months to 2 years. Results: In the present study, patients had a maximum interincisal opening of 32 to 41 mm (mean, 35.1 mm) at the latest follow-up. Mean deviation to the affected side on mouth opening was 1.6 mm (range, 0 to 4 mm), but chewing function was good and all the patients were satisfied. No major occlusal changes were observed and all the patients had satisfactory occlusion at the follow-up periods. No facial paresis of temporal and zygomatic branch of facial nerve was observed in any case. Periodic panoramic radiographs showed well-maintained intra-articular space because of the interposed tissue, with no signs of relapse. Conclusion: The findings of this study showed the short-term successful management of TMJ ankylosis using buccal fat pad as an interpositional graft. © 2011 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 69:2530-2536, 2011
Ankylosis of the temporomandibular joint (TMJ) involves fusion of the mandibular condyle to the base of the skull, which causes distressing conditions, including impaired speech, difficulty in chewing, facial disfigurement, compromise of the airway, and psychological stress.1-3 This is particularly true in young children who are completely unable to open their mouths. Trauma has been reported as 1 of the most common factors, followed by local and systemic infection.3-5
*Professor and Head, Department of Oral and Maxillofacial Surgery, Government Dental College, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, India. †PG Student, Department of Oral and Maxillofacial Surgery, Government Dental College, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, India. ‡PG Student, Department of Oral and Maxillofacial Surgery, Government Dental College, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, India. §Senior Resident, Department of Oral and Maxillofacial Surgery, Government Dental College, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, India.
The goal of managing such a patient should be to establish movement and function in the jaw, prevent relapse, restore appearance, and achieve normal growth and occlusion in the child.6 Surgery is the treatment of choice in patients with TMJ ankylosis.7 Treatment of true ankylosis is controversial, but can be divided into 3 groups: gap arthroplasty, interpositional arthroplasty, and total joint reconstruction using either autogenous or alloplastic materials. Nowa储Assistant Professor, Department of Anesthesia, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, India. Address correspondence and reprint requests to Dr Singh: Department of Oral and Maxillofacial Surgery, Government Dental College, Pt. B.D. Sharma University of Health Sciences, Rohtak124001, Haryana, India; e-mail: [email protected] © 2011 American Association of Oral and Maxillofacial Surgeons
0278-2391/11/6910-0014$36.00/0 doi:10.1016/j.joms.2011.02.022
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days gap arthroplasty is not a preferred choice because of a higher recurrence rate.8 Many materials have been used for insertion at the gap after resection of a bony segment: alloplastic materials (acrylic, proplast–Teflon, Silastic), and autogenous tissues (temporalis muscle flaps, dermis, costochondral grafts, and cartilage).9 Some surgeons are conservative and try to preserve the disc10,11; some are relatively aggressive, using custom-made TMJ total joint prostheses,12,13 and all claim high success rates. None of them achieved uniformly successful results.11 The temporalis muscle flap is the most commonly used interposition material,14,15 because of minimal morbidity of donor site cosmetically and functionally. There is a cartilage covering on the normal condyle surface that separates the condyle from the nearby tissues. However, on the new condyle formed after arthroplasty, there is a freshly wounded bone surface. Fibrosis and ossification occur frequently in this raw surface. The rationale for using fat as an interpositional graft after gap arthroplasty is first to fill the ample tissue in the dead space left within the joint cavity after osteoarthrectomy. Second, it prevents direct contact between the cut bony surface and glenoid fossa. Finally, its vascularity maintains the volume of fat for longer duration without any regressive changes. Buccal fat pad (BFP) graft has most commonly been used as a pedicle flap in oral reconstruction of various defects16 and can also be used as interpositional material in TMJ ankylosis. The present study evaluated the feasibility of the buccal fat pad as an interpositional arthroplasty in the treatment of TMJ ankylosis in 10 patients. This article discusses the short-term successful management of TMJ ankylosis with interpositional arthroplasty using BFP as an interpositional material.
Materials and Methods A retrospective study of 10 patients with TMJ ankylosis (9 unilateral and 1 bilateral) who visited the Outpatient Department of Oral and Maxillofacial Surgery, Government Dental College, Rohtak between the period 2008 and 2010 was performed. Informed consent was taken from all the patients or the parents, in case of children, before they entered the study. A detailed history of the age, mode of onset, duration, and gender was recorded. The female-to-male ratio was 6 to 4, with a mean age of 18.1 years (range, 8 to 35 yr). The preoperative maximum interincisal mouth opening (Fig 1) was a range of 0 to 4 mm (mean, 2.8 mm). In terms of etiology, trauma-to-infection ratio was 7 to 3 with mean duration of ankylosis 5 years (ranges, 2 to 15 yr). None of the cases was previously
FIGURE 1. Preoperative mouth opening. Singh et al. Buccal Fat Pad as an Interpositional Graft in TMJ Ankylosis. J Oral Maxillofac Surg 2011.
operated. Both joints were assessed radiographically with orthopantomograms and computed tomograms (axial and coronal view) (Figs 2,3). All patients had routine hematological examinations. This trial was approved by the departmental ethics committee. All surgical procedures were carried out under general anesthesia by nasotracheal intubation using nasal fibroscopy. The joint was exposed through an Al-Kayat Bramley incision and a gap arthroplasty was performed with the help of a surgical bone-cutting device to create a minimum of a 5- to 10-mm gap (Fig 4). Special attention was directed to the medial aspect of the joint to ensure total resection. The glenoid fossa was recontoured as necessary. After excision, the maximal interincisal opening was measured. Ipsilateral coronoidectomy was performed in 6 cases and bilateral coronoidectomy was performed on 4 cases to achieve adequate mouth opening. BFP was used to fill the gap created in the ankylosed joint. For exploration of BFP, the coronoid process was exposed by extending the dissection anteriorly in the subperiosteal plane. A periosteal elevator was inserted at its anterior border for retraction. Coronoidectomy was carried out at this stage when indicated. The main body of BFP and its temporal extension lie in close proximity to the coronoid process and temporalis muscle tendon (Fig 5). An incision was given through the periosteum and fascial envelope of BFP and blunt dissection was performed with a fine curved artery forceps to expose the yellowish-colored buccal fat (Fig 6). Further blunt dissection of tissues surround-
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BUCCAL FAT PAD AS AN INTERPOSITIONAL GRAFT IN TMJ ANKYLOSIS
FIGURE 2. Preoperative orthopantomogram. Singh et al. Buccal Fat Pad as an Interpositional Graft in TMJ Ankylosis. J Oral Maxillofac Surg 2011.
ing the BFP was performed to gently pull out the emergent part and it was herniated into the defect (Fig 7) with a little teasing and application of some external pressure over the cheek. Mechanical suction was avoided once the BFP was exposed. The tensionfree BFP was packed around the TMJ to fill the dead
space and in some cases 1 or 2 sutures were placed just anterior to the external auditory meatus to secure the position of the BFP. Physiotherapy was started from the first postoperative day, which consisted of active and passive exercises. It consisted of active hinge opening and excursive movements combined with manual finger stretching in front of a mirror. The exercise was performed for 2 days, 4 times daily for 5 minutes. After 3 days postoperatively, mouth opening exercise with a mouth prop was started 4 to 5 times daily for 3 to 5 minutes. A mouth gag was applied after 1 week to improve mouth opening and then physiotherapy at
FIGURE 3. Preoperative axial CT scan.
FIGURE 4. Gap created.
Singh et al. Buccal Fat Pad as an Interpositional Graft in TMJ Ankylosis. J Oral Maxillofac Surg 2011.
Singh et al. Buccal Fat Pad as an Interpositional Graft in TMJ Ankylosis. J Oral Maxillofac Surg 2011.
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FIGURE 5. Anatomical relationship of buccal fat pad. Singh et al. Buccal Fat Pad as an Interpositional Graft in TMJ Ankylosis. J Oral Maxillofac Surg 2011.
home was continued with tongue depressors. At 6 weeks postoperatively, the diet was advanced to solid foods. The physical therapy program also included heat, massage, and gum chewing. Patients were instructed to strictly follow the aggressive physiotherapy for at least 1 year. The suction drain was removed after 48 hours if it had stopped draining. Sutures from the preauricular area were removed on the seventh postoperative day and those from the temporal region and the donor site on the 10th day. The patients were assessed for maximum mouth opening, incidence of recurrence (Figs 8,9), and involvement of the facial nerve. To assess any
occlusal changes, clinical photographs of the occlusal status of patients were taken preoperatively and various follow-ups. Any postoperative complication in the form of infection at the operated site was observed.
Results This study evaluated 10 patients with follow-up from 6 months to 2 years (mean, 14.8 mo). Trauma was the most common cause of ankylosis (70%). At the latest follow-up patients had a maximum interincisal opening of 32 to 41 mm (mean, 35.1 mm). Mean
FIGURE 6. Emergence of buccal fat pad.
FIGURE 7. Interposition of buccal fat pad.
Singh et al. Buccal Fat Pad as an Interpositional Graft in TMJ Ankylosis. J Oral Maxillofac Surg 2011.
Singh et al. Buccal Fat Pad as an Interpositional Graft in TMJ Ankylosis. J Oral Maxillofac Surg 2011.
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BUCCAL FAT PAD AS AN INTERPOSITIONAL GRAFT IN TMJ ANKYLOSIS
FIGURE 8. Postoperative orthopantomogram. Singh et al. Buccal Fat Pad as an Interpositional Graft in TMJ Ankylosis. J Oral Maxillofac Surg 2011.
deviation to the affected side on mouth opening was 1.6 mm (range, 0 to 4 mm), but chewing function was good and all the patients were satisfied. No major postoperative occlusal changes in the form of anterior and contralateral open bite or ipsilateral premature contacts were observed in any of our cases, and all the patients had satisfactory occlusion at the latest follow-up. No facial paresis of temporal and zygomatic branch of facial nerve was observed in any case. No worsening facial asymmetry or any other complication was observed except an ear infection in 1 case at the 1-week follow-up, which subsided after antibiotics. Periodic panoramic radiographs showed well-maintained intra-articular space because of the interposed tissue, with no signs of relapse. The summary of results is presented in Table 1.
FIGURE 9. Postoperative mouth opening. Singh et al. Buccal Fat Pad as an Interpositional Graft in TMJ Ankylosis. J Oral Maxillofac Surg 2011.
Discussion The primary goal of treatment of TMJ ankylosis is to restore the jaw function as well as prevent recurrence. Conventional methods for treatment of ankylosis were mainly dependent on gap arthroplasty and placement of interposition autogenic or alloplastic graft to decrease or prevent fibrous formation and the chances of reankylosis. Surgical method of release and correction has been directed toward the creation of pseudoarthrosis. The simple gap arthroplasty aims to reduce the rate of recurrent ankylosis by increasing the distance between the cut surfaces of the ascending ramus and the cranial base. If the gap is too small, recurrence is more likely. If the gap is large, there is loss of ramus height and no support for the rotating mandible, with a tendency to contralateral open bite and deviation on opening.17 Even after wide gap arthroplasty, the recurrence rates are unacceptably high. Interpositional arthroplasty is widely accepted as the primary surgical treatment for TMJ ankylosis. Credit for originating the interpositional arthroplasty is given to Eschmarc, who in the second half of the 19th century reported the technique of suturing together the muscle components of the pterygomasseteric sling, thus separating the osteotomized parts of the ascending ramus of the mandible. Arthroplasty without interposition requires a gap of 10 to 20 mm6,18,19 and often results in mouth deviation. Therefore, it seems to be better to create a minimal gap (over 5 mm) and then perform interposition to prevent recurrence due to osteoblastic growth between the abraded bone surfaces.6,8 Autogenous tissue has become the preferred and the safest graft material to be used as an reconstruction, particularly in the last 20 years since recognition
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Table 1. TEMPOROMANDIBULAR JOINT ANKYLOSIS: CASE DETAILS Mouth Opening (mm) Serial No.
Age/Gender
Ankylosis
1 2 3
8/m 8/f 12/f
Right Left Left
4 5 6 7 8 9 10
18/m 23/f 18/f 19/f 22/f 35/m 18/m
Left Left Left Bilateral Right Right Left
Duration (y)
Etiology
Coronoidectomy
3 2 5
Infection Trauma Trauma
Ipsilateral Ipsilateral Ipsilateral
0 4 2
3 15 3 7 2 15 5
Infection Infection Trauma Trauma Trauma Trauma Trauma
Ipsilateral Bilateral Bilateral Bilateral Ipsilateral Bilateral Ipsilateral
4 4 0 3 3 4 4
Latest Postoperative
Complication
Follow-Up (m)
34 30 28
32 35 32
8 24 18
28 34 34 34 35 30 35
41 40 36 32 33 35 35
None None Ear infection (cured with antibiotics) None None None None None None None
Preoperative Intraoperative
22 21 15 9 11 6 14
Singh et al. Buccal Fat Pad as an Interpositional Graft in TMJ Ankylosis. J Oral Maxillofac Surg 2011.
of the detrimental effects of alloplastic materials (ie, Silastic, proplast-Teflon) when placed in function in the TMJ. Ear cartilage, fascia, temporalis muscle, pericranium, and dermis have all been used successfully to repair or replace the TMJ disc. All require surgery at a second site, and most result in a separate wound. Temporalis muscle/fascia flap has gained popularity as an interpositional material because it is close at hand, has a local blood supply, and is relatively straightforward. Findings from the study of Su-Gwan15 showed successful use of temporalis muscle and fascia flap in the treatment of unilateral TMJ ankylosis in adults as interpositional material. This separates the cut bony surfaces, but there may be scarring of the muscle.15,20,21 No perfect interpositional material exists at present. All have some drawbacks: muscle flaps tend to contract and become fibrous; fascia is lacking in substance; cartilage may undergo calcification; alloplastic components may fragment; and the debris may result in foreign body reactions.12 Heterotopic ossification (HO) within the TMJ can partially or completely reankylose the joint, causing pain and limiting the range of motion. HO is recognized as a major postoperative complication after gap arthroplasty. The mechanism of HO has been postulated from some aspects of bone growth. Pluripotent cells are induced to differentiate into fibroblasts, chondroblasts, and osteoblasts. They cause the production of collagen and bone. Various factors are related to this process. Also, in fibrotic joints, the decrease in vascularity and the resulting hypoxia in the surrounding tissue might lead to the transformation of the fibrous tissue into cartilage and bone.22 Autologous fat transplantation appears to be a useful adjunct to minimize the occurrence of excessive joint fibrosis and heterotopic calcification, consequently providing improved range of motion.23 Also, the study by Dimitroulis et al,24 on the use of dermal fat graft as an interpositional material in TMJ ankylo-
sis, suggests the radiological presence of fat was within the joint or surrounding the condyle in all 17 operated joints and there was no statistically significant difference in size of fat graft between the time intervals studied. Fat was present in similar quantities within or surrounding all joints regardless of the time lapse since surgery. However, additional donor site morbidity is the main drawback with dermal fat graft. Certainly, the advantages of the pedicled BFP in terms of its availability and proximity to the same surgical site and its own vascularity make it a preferred choice over the dermal fat as interpositional autogenous graft. In the present study, 10 patients with mean follow-up periods of 14.8 months manifested mean maximal interincisal opening of 35 mm, good chewing function, and no signs of recurrence. We found that interposition of BFP in short-term management of temporomandibular ankylosis is an effective and recommended treatment option to restore the jaw function as well as prevent recurrence.
References 1. Posnick JC, Goldstein JA: Surgical management of temporomandibular joint ankylosis in the pediatric population. Plast Reconstr Surg 91:791, 1993 2. López EN, Dogliotti PL: Treatment of temporomandibular joint ankylosis in children: Is it necessary to perform mandibular distraction simultaneously? J Craniofac Surg 15:879, 2004 3. Chidzonga MM: Temporomandibular joint ankylosis: review of thirty-two cases. Br J Oral Maxillofac Surg 37:123, 1999 4. Qudah MA, Qudeimat MA, Al-Maaita J: Treatment of TMJ ankylosis in Jordanian children—A comparison of two surgical techniques. J Craniomaxillofac Surg 33:30, 2005 5. Rao K, Kumar S, Kumar V, et al: The role of simultaneous gap arthroplasty and distraction osteogenesis in the management of temporo-mandibular joint ankylosis with mandibular deformity in children. J Craniomaxillofac Surg 32:38, 2004 6. Rowe NL: Ankylosis of the temporomandibular joint. Parts 1, 2 and 3. J R Coll Surg Edinb 27:67, 167, 1982 7. Smith-Danvelle JB: Temporomandibular ankylosis. J Oral Surg 8:297, 1950
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BUCCAL FAT PAD AS AN INTERPOSITIONAL GRAFT IN TMJ ANKYLOSIS
8. Topazian RC: Comparison of gap and interposition arthroplasty in the treatment of temporomandibular joint Ankylosis. J Oral Surg 24:33, 1966 9. Dimitroulis G: The interpositional dermis-fat graft in the management of temporomandibular joint ankylosis. Int J Oral Maxillofac Surg 33:755, 2004 10. 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 35:219, 2006 11. Long X, Li X, Cheng Y, et al: Preservation of disc for treatment of traumatic temporomandibular joint ankylosis. J Oral Maxillofac Surg 63:897, 2005 12. Mercuri LG, Anspach WE III: Principles for the revision of total alloplastic TMJ prostheses. Int J Oral Maxillofac Surg 32:353, 2003 13. Wolford LM, Pitta MC, Reiche-Fischel O, et al: TMJ Concepts/ Techmedica custom-made TMJ total joint prosthesis: 5-year follow-up study. Int J Oral Maxillofac Surg 32:268, 2003 14. Herbosa EG, Rotskoff KS: Composite temporalis pedicle flap as an interpositional graft in temporomandibular joint arthroplasty: A preliminary report. J Oral Maxillofac Surg 48:1049, 1990 15. Su-Gwan K: Treatment of TMJ ankylosis with temporalis muscle and fascia flap. Int J Oral Maxillofac Surg 30:189, 2001 16. Tideman H, Bosanquet A, Scott J: Use of the buccal fat pad as a pedicled graft. J Oral Maxillofac Surg 44:435, 1986
17. 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 36:909, 2007 18. Topazian RG: Etiology of ankylosis of the temporomandibular joint: Analysis of 44 cases. J Oral Surg Anesth Hosp 22:227, 1964 19. Lello GE: Surgical correction of temporomandibular joint ankylosis. J Craniomaxofac Surg 18:19, 1990 20. Mani V, Panda AK: Versatility of temporalis myofascial flap in maxillofacial reconstruction—Analysis of 30 cases. Int J Oral Maxillofac Surg 32:368, 2003 21. Smith JA, Sandler NA, Ozaki WH, et al: Subjective and objective assessment of the temporalis myofascial flap in previously operated temporomandibular joints. J Oral Maxillofac Surg 57: 1058, 1999 22. Triffit JT: Initiation and enhancement of bone formation: A review. Acta Orthop Scand 58:673, 1987 23. Wolford LM, Karras SC: Autologous fat transplantation around temporomandibular joint total joint prostheses: preliminary treatment outcomes. J Oral Maxillofac Surg 55:245, 1997 24. Dimitroulis G, Trost N, Morrison W: The radiological fate of dermis-fat grafts in the human temporomandibular joint using magnetic resonance imaging. Int J Oral Maxillofac Surg 37:249, 2008
Retrospective Analysis of Use of Buccal Fat Pad as an Interpositional Graft in Temporomandibular Joint Ankylosis: Preliminary Study Virendra Singh, MDS,* Rahul Dhingra, MDS,† Bindu Sharma, MDS,‡ Amrish Bhagol, MDS,§ and Prashant Kumar, MD储 Purpose: To evaluate the feasibility and usefulness of buccal fat pad as an interpositional graft in the
treatment of temporomandibular joint (TMJ) ankylosis. Materials and Methods: A retrospective study of 10 patients with TMJ ankylosis (9 unilateral and 1 bilateral) was performed with follow-up of 6 months to 2 years. Results: In the present study, patients had a maximum interincisal opening of 32 to 41 mm (mean, 35.1 mm) at the latest follow-up. Mean deviation to the affected side on mouth opening was 1.6 mm (range, 0 to 4 mm), but chewing function was good and all the patients were satisfied. No major occlusal changes were observed and all the patients had satisfactory occlusion at the follow-up periods. No facial paresis of temporal and zygomatic branch of facial nerve was observed in any case. Periodic panoramic radiographs showed well-maintained intra-articular space because of the interposed tissue, with no signs of relapse. Conclusion: The findings of this study showed the short-term successful management of TMJ ankylosis using buccal fat pad as an interpositional graft. © 2011 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 69:2530-2536, 2011
Ankylosis of the temporomandibular joint (TMJ) involves fusion of the mandibular condyle to the base of the skull, which causes distressing conditions, including impaired speech, difficulty in chewing, facial disfigurement, compromise of the airway, and psychological stress.1-3 This is particularly true in young children who are completely unable to open their mouths. Trauma has been reported as 1 of the most common factors, followed by local and systemic infection.3-5
*Professor and Head, Department of Oral and Maxillofacial Surgery, Government Dental College, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, India. †PG Student, Department of Oral and Maxillofacial Surgery, Government Dental College, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, India. ‡PG Student, Department of Oral and Maxillofacial Surgery, Government Dental College, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, India. §Senior Resident, Department of Oral and Maxillofacial Surgery, Government Dental College, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, India.
The goal of managing such a patient should be to establish movement and function in the jaw, prevent relapse, restore appearance, and achieve normal growth and occlusion in the child.6 Surgery is the treatment of choice in patients with TMJ ankylosis.7 Treatment of true ankylosis is controversial, but can be divided into 3 groups: gap arthroplasty, interpositional arthroplasty, and total joint reconstruction using either autogenous or alloplastic materials. Nowa储Assistant Professor, Department of Anesthesia, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, India. Address correspondence and reprint requests to Dr Singh: Department of Oral and Maxillofacial Surgery, Government Dental College, Pt. B.D. Sharma University of Health Sciences, Rohtak124001, Haryana, India; e-mail: [email protected] © 2011 American Association of Oral and Maxillofacial Surgeons
0278-2391/11/6910-0014$36.00/0 doi:10.1016/j.joms.2011.02.022
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SINGH ET AL
days gap arthroplasty is not a preferred choice because of a higher recurrence rate.8 Many materials have been used for insertion at the gap after resection of a bony segment: alloplastic materials (acrylic, proplast–Teflon, Silastic), and autogenous tissues (temporalis muscle flaps, dermis, costochondral grafts, and cartilage).9 Some surgeons are conservative and try to preserve the disc10,11; some are relatively aggressive, using custom-made TMJ total joint prostheses,12,13 and all claim high success rates. None of them achieved uniformly successful results.11 The temporalis muscle flap is the most commonly used interposition material,14,15 because of minimal morbidity of donor site cosmetically and functionally. There is a cartilage covering on the normal condyle surface that separates the condyle from the nearby tissues. However, on the new condyle formed after arthroplasty, there is a freshly wounded bone surface. Fibrosis and ossification occur frequently in this raw surface. The rationale for using fat as an interpositional graft after gap arthroplasty is first to fill the ample tissue in the dead space left within the joint cavity after osteoarthrectomy. Second, it prevents direct contact between the cut bony surface and glenoid fossa. Finally, its vascularity maintains the volume of fat for longer duration without any regressive changes. Buccal fat pad (BFP) graft has most commonly been used as a pedicle flap in oral reconstruction of various defects16 and can also be used as interpositional material in TMJ ankylosis. The present study evaluated the feasibility of the buccal fat pad as an interpositional arthroplasty in the treatment of TMJ ankylosis in 10 patients. This article discusses the short-term successful management of TMJ ankylosis with interpositional arthroplasty using BFP as an interpositional material.
Materials and Methods A retrospective study of 10 patients with TMJ ankylosis (9 unilateral and 1 bilateral) who visited the Outpatient Department of Oral and Maxillofacial Surgery, Government Dental College, Rohtak between the period 2008 and 2010 was performed. Informed consent was taken from all the patients or the parents, in case of children, before they entered the study. A detailed history of the age, mode of onset, duration, and gender was recorded. The female-to-male ratio was 6 to 4, with a mean age of 18.1 years (range, 8 to 35 yr). The preoperative maximum interincisal mouth opening (Fig 1) was a range of 0 to 4 mm (mean, 2.8 mm). In terms of etiology, trauma-to-infection ratio was 7 to 3 with mean duration of ankylosis 5 years (ranges, 2 to 15 yr). None of the cases was previously
FIGURE 1. Preoperative mouth opening. Singh et al. Buccal Fat Pad as an Interpositional Graft in TMJ Ankylosis. J Oral Maxillofac Surg 2011.
operated. Both joints were assessed radiographically with orthopantomograms and computed tomograms (axial and coronal view) (Figs 2,3). All patients had routine hematological examinations. This trial was approved by the departmental ethics committee. All surgical procedures were carried out under general anesthesia by nasotracheal intubation using nasal fibroscopy. The joint was exposed through an Al-Kayat Bramley incision and a gap arthroplasty was performed with the help of a surgical bone-cutting device to create a minimum of a 5- to 10-mm gap (Fig 4). Special attention was directed to the medial aspect of the joint to ensure total resection. The glenoid fossa was recontoured as necessary. After excision, the maximal interincisal opening was measured. Ipsilateral coronoidectomy was performed in 6 cases and bilateral coronoidectomy was performed on 4 cases to achieve adequate mouth opening. BFP was used to fill the gap created in the ankylosed joint. For exploration of BFP, the coronoid process was exposed by extending the dissection anteriorly in the subperiosteal plane. A periosteal elevator was inserted at its anterior border for retraction. Coronoidectomy was carried out at this stage when indicated. The main body of BFP and its temporal extension lie in close proximity to the coronoid process and temporalis muscle tendon (Fig 5). An incision was given through the periosteum and fascial envelope of BFP and blunt dissection was performed with a fine curved artery forceps to expose the yellowish-colored buccal fat (Fig 6). Further blunt dissection of tissues surround-
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BUCCAL FAT PAD AS AN INTERPOSITIONAL GRAFT IN TMJ ANKYLOSIS
FIGURE 2. Preoperative orthopantomogram. Singh et al. Buccal Fat Pad as an Interpositional Graft in TMJ Ankylosis. J Oral Maxillofac Surg 2011.
ing the BFP was performed to gently pull out the emergent part and it was herniated into the defect (Fig 7) with a little teasing and application of some external pressure over the cheek. Mechanical suction was avoided once the BFP was exposed. The tensionfree BFP was packed around the TMJ to fill the dead
space and in some cases 1 or 2 sutures were placed just anterior to the external auditory meatus to secure the position of the BFP. Physiotherapy was started from the first postoperative day, which consisted of active and passive exercises. It consisted of active hinge opening and excursive movements combined with manual finger stretching in front of a mirror. The exercise was performed for 2 days, 4 times daily for 5 minutes. After 3 days postoperatively, mouth opening exercise with a mouth prop was started 4 to 5 times daily for 3 to 5 minutes. A mouth gag was applied after 1 week to improve mouth opening and then physiotherapy at
FIGURE 3. Preoperative axial CT scan.
FIGURE 4. Gap created.
Singh et al. Buccal Fat Pad as an Interpositional Graft in TMJ Ankylosis. J Oral Maxillofac Surg 2011.
Singh et al. Buccal Fat Pad as an Interpositional Graft in TMJ Ankylosis. J Oral Maxillofac Surg 2011.
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SINGH ET AL
FIGURE 5. Anatomical relationship of buccal fat pad. Singh et al. Buccal Fat Pad as an Interpositional Graft in TMJ Ankylosis. J Oral Maxillofac Surg 2011.
home was continued with tongue depressors. At 6 weeks postoperatively, the diet was advanced to solid foods. The physical therapy program also included heat, massage, and gum chewing. Patients were instructed to strictly follow the aggressive physiotherapy for at least 1 year. The suction drain was removed after 48 hours if it had stopped draining. Sutures from the preauricular area were removed on the seventh postoperative day and those from the temporal region and the donor site on the 10th day. The patients were assessed for maximum mouth opening, incidence of recurrence (Figs 8,9), and involvement of the facial nerve. To assess any
occlusal changes, clinical photographs of the occlusal status of patients were taken preoperatively and various follow-ups. Any postoperative complication in the form of infection at the operated site was observed.
Results This study evaluated 10 patients with follow-up from 6 months to 2 years (mean, 14.8 mo). Trauma was the most common cause of ankylosis (70%). At the latest follow-up patients had a maximum interincisal opening of 32 to 41 mm (mean, 35.1 mm). Mean
FIGURE 6. Emergence of buccal fat pad.
FIGURE 7. Interposition of buccal fat pad.
Singh et al. Buccal Fat Pad as an Interpositional Graft in TMJ Ankylosis. J Oral Maxillofac Surg 2011.
Singh et al. Buccal Fat Pad as an Interpositional Graft in TMJ Ankylosis. J Oral Maxillofac Surg 2011.
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BUCCAL FAT PAD AS AN INTERPOSITIONAL GRAFT IN TMJ ANKYLOSIS
FIGURE 8. Postoperative orthopantomogram. Singh et al. Buccal Fat Pad as an Interpositional Graft in TMJ Ankylosis. J Oral Maxillofac Surg 2011.
deviation to the affected side on mouth opening was 1.6 mm (range, 0 to 4 mm), but chewing function was good and all the patients were satisfied. No major postoperative occlusal changes in the form of anterior and contralateral open bite or ipsilateral premature contacts were observed in any of our cases, and all the patients had satisfactory occlusion at the latest follow-up. No facial paresis of temporal and zygomatic branch of facial nerve was observed in any case. No worsening facial asymmetry or any other complication was observed except an ear infection in 1 case at the 1-week follow-up, which subsided after antibiotics. Periodic panoramic radiographs showed well-maintained intra-articular space because of the interposed tissue, with no signs of relapse. The summary of results is presented in Table 1.
FIGURE 9. Postoperative mouth opening. Singh et al. Buccal Fat Pad as an Interpositional Graft in TMJ Ankylosis. J Oral Maxillofac Surg 2011.
Discussion The primary goal of treatment of TMJ ankylosis is to restore the jaw function as well as prevent recurrence. Conventional methods for treatment of ankylosis were mainly dependent on gap arthroplasty and placement of interposition autogenic or alloplastic graft to decrease or prevent fibrous formation and the chances of reankylosis. Surgical method of release and correction has been directed toward the creation of pseudoarthrosis. The simple gap arthroplasty aims to reduce the rate of recurrent ankylosis by increasing the distance between the cut surfaces of the ascending ramus and the cranial base. If the gap is too small, recurrence is more likely. If the gap is large, there is loss of ramus height and no support for the rotating mandible, with a tendency to contralateral open bite and deviation on opening.17 Even after wide gap arthroplasty, the recurrence rates are unacceptably high. Interpositional arthroplasty is widely accepted as the primary surgical treatment for TMJ ankylosis. Credit for originating the interpositional arthroplasty is given to Eschmarc, who in the second half of the 19th century reported the technique of suturing together the muscle components of the pterygomasseteric sling, thus separating the osteotomized parts of the ascending ramus of the mandible. Arthroplasty without interposition requires a gap of 10 to 20 mm6,18,19 and often results in mouth deviation. Therefore, it seems to be better to create a minimal gap (over 5 mm) and then perform interposition to prevent recurrence due to osteoblastic growth between the abraded bone surfaces.6,8 Autogenous tissue has become the preferred and the safest graft material to be used as an reconstruction, particularly in the last 20 years since recognition
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SINGH ET AL
Table 1. TEMPOROMANDIBULAR JOINT ANKYLOSIS: CASE DETAILS Mouth Opening (mm) Serial No.
Age/Gender
Ankylosis
1 2 3
8/m 8/f 12/f
Right Left Left
4 5 6 7 8 9 10
18/m 23/f 18/f 19/f 22/f 35/m 18/m
Left Left Left Bilateral Right Right Left
Duration (y)
Etiology
Coronoidectomy
3 2 5
Infection Trauma Trauma
Ipsilateral Ipsilateral Ipsilateral
0 4 2
3 15 3 7 2 15 5
Infection Infection Trauma Trauma Trauma Trauma Trauma
Ipsilateral Bilateral Bilateral Bilateral Ipsilateral Bilateral Ipsilateral
4 4 0 3 3 4 4
Latest Postoperative
Complication
Follow-Up (m)
34 30 28
32 35 32
8 24 18
28 34 34 34 35 30 35
41 40 36 32 33 35 35
None None Ear infection (cured with antibiotics) None None None None None None None
Preoperative Intraoperative
22 21 15 9 11 6 14
Singh et al. Buccal Fat Pad as an Interpositional Graft in TMJ Ankylosis. J Oral Maxillofac Surg 2011.
of the detrimental effects of alloplastic materials (ie, Silastic, proplast-Teflon) when placed in function in the TMJ. Ear cartilage, fascia, temporalis muscle, pericranium, and dermis have all been used successfully to repair or replace the TMJ disc. All require surgery at a second site, and most result in a separate wound. Temporalis muscle/fascia flap has gained popularity as an interpositional material because it is close at hand, has a local blood supply, and is relatively straightforward. Findings from the study of Su-Gwan15 showed successful use of temporalis muscle and fascia flap in the treatment of unilateral TMJ ankylosis in adults as interpositional material. This separates the cut bony surfaces, but there may be scarring of the muscle.15,20,21 No perfect interpositional material exists at present. All have some drawbacks: muscle flaps tend to contract and become fibrous; fascia is lacking in substance; cartilage may undergo calcification; alloplastic components may fragment; and the debris may result in foreign body reactions.12 Heterotopic ossification (HO) within the TMJ can partially or completely reankylose the joint, causing pain and limiting the range of motion. HO is recognized as a major postoperative complication after gap arthroplasty. The mechanism of HO has been postulated from some aspects of bone growth. Pluripotent cells are induced to differentiate into fibroblasts, chondroblasts, and osteoblasts. They cause the production of collagen and bone. Various factors are related to this process. Also, in fibrotic joints, the decrease in vascularity and the resulting hypoxia in the surrounding tissue might lead to the transformation of the fibrous tissue into cartilage and bone.22 Autologous fat transplantation appears to be a useful adjunct to minimize the occurrence of excessive joint fibrosis and heterotopic calcification, consequently providing improved range of motion.23 Also, the study by Dimitroulis et al,24 on the use of dermal fat graft as an interpositional material in TMJ ankylo-
sis, suggests the radiological presence of fat was within the joint or surrounding the condyle in all 17 operated joints and there was no statistically significant difference in size of fat graft between the time intervals studied. Fat was present in similar quantities within or surrounding all joints regardless of the time lapse since surgery. However, additional donor site morbidity is the main drawback with dermal fat graft. Certainly, the advantages of the pedicled BFP in terms of its availability and proximity to the same surgical site and its own vascularity make it a preferred choice over the dermal fat as interpositional autogenous graft. In the present study, 10 patients with mean follow-up periods of 14.8 months manifested mean maximal interincisal opening of 35 mm, good chewing function, and no signs of recurrence. We found that interposition of BFP in short-term management of temporomandibular ankylosis is an effective and recommended treatment option to restore the jaw function as well as prevent recurrence.
References 1. Posnick JC, Goldstein JA: Surgical management of temporomandibular joint ankylosis in the pediatric population. Plast Reconstr Surg 91:791, 1993 2. López EN, Dogliotti PL: Treatment of temporomandibular joint ankylosis in children: Is it necessary to perform mandibular distraction simultaneously? J Craniofac Surg 15:879, 2004 3. Chidzonga MM: Temporomandibular joint ankylosis: review of thirty-two cases. Br J Oral Maxillofac Surg 37:123, 1999 4. Qudah MA, Qudeimat MA, Al-Maaita J: Treatment of TMJ ankylosis in Jordanian children—A comparison of two surgical techniques. J Craniomaxillofac Surg 33:30, 2005 5. Rao K, Kumar S, Kumar V, et al: The role of simultaneous gap arthroplasty and distraction osteogenesis in the management of temporo-mandibular joint ankylosis with mandibular deformity in children. J Craniomaxillofac Surg 32:38, 2004 6. Rowe NL: Ankylosis of the temporomandibular joint. Parts 1, 2 and 3. J R Coll Surg Edinb 27:67, 167, 1982 7. Smith-Danvelle JB: Temporomandibular ankylosis. J Oral Surg 8:297, 1950
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8. Topazian RC: Comparison of gap and interposition arthroplasty in the treatment of temporomandibular joint Ankylosis. J Oral Surg 24:33, 1966 9. Dimitroulis G: The interpositional dermis-fat graft in the management of temporomandibular joint ankylosis. Int J Oral Maxillofac Surg 33:755, 2004 10. 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 35:219, 2006 11. Long X, Li X, Cheng Y, et al: Preservation of disc for treatment of traumatic temporomandibular joint ankylosis. J Oral Maxillofac Surg 63:897, 2005 12. Mercuri LG, Anspach WE III: Principles for the revision of total alloplastic TMJ prostheses. Int J Oral Maxillofac Surg 32:353, 2003 13. Wolford LM, Pitta MC, Reiche-Fischel O, et al: TMJ Concepts/ Techmedica custom-made TMJ total joint prosthesis: 5-year follow-up study. Int J Oral Maxillofac Surg 32:268, 2003 14. Herbosa EG, Rotskoff KS: Composite temporalis pedicle flap as an interpositional graft in temporomandibular joint arthroplasty: A preliminary report. J Oral Maxillofac Surg 48:1049, 1990 15. Su-Gwan K: Treatment of TMJ ankylosis with temporalis muscle and fascia flap. Int J Oral Maxillofac Surg 30:189, 2001 16. Tideman H, Bosanquet A, Scott J: Use of the buccal fat pad as a pedicled graft. J Oral Maxillofac Surg 44:435, 1986
17. 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 36:909, 2007 18. Topazian RG: Etiology of ankylosis of the temporomandibular joint: Analysis of 44 cases. J Oral Surg Anesth Hosp 22:227, 1964 19. Lello GE: Surgical correction of temporomandibular joint ankylosis. J Craniomaxofac Surg 18:19, 1990 20. Mani V, Panda AK: Versatility of temporalis myofascial flap in maxillofacial reconstruction—Analysis of 30 cases. Int J Oral Maxillofac Surg 32:368, 2003 21. Smith JA, Sandler NA, Ozaki WH, et al: Subjective and objective assessment of the temporalis myofascial flap in previously operated temporomandibular joints. J Oral Maxillofac Surg 57: 1058, 1999 22. Triffit JT: Initiation and enhancement of bone formation: A review. Acta Orthop Scand 58:673, 1987 23. Wolford LM, Karras SC: Autologous fat transplantation around temporomandibular joint total joint prostheses: preliminary treatment outcomes. J Oral Maxillofac Surg 55:245, 1997 24. Dimitroulis G, Trost N, Morrison W: The radiological fate of dermis-fat grafts in the human temporomandibular joint using magnetic resonance imaging. Int J Oral Maxillofac Surg 37:249, 2008