Temporalis Fascia in Temporomandibular Joint Gap Arthroplasty

LETTERS TO THE EDITOR J Oral Maxillofac Surg 69:2075-2077, 2011

THEY DON’T MAKE THEM LIKE THAT ANYMORE To the Editor:—It was with great sorrow that I read of the passing of Dr Robert Walker. I was sad for the usual reasons, but also sad in relation to our specialty. Dr Walker represented a handful of people over the past 100 years who dedicated their personal and professional lives to oral and maxillofacial surgery. It was people like Dr Walker who would not take “no” for an answer and who never wavered in the face of competitive specialties attempting to dictate who we were and what we could do. Dr Walker set up one of the best known training centers that trained some of the best known oral and maxillofacial surgeons (OMSs). Despite his status, he was never too busy to take time to discuss a case or simply exchange pleasantries at an annual meeting. It also saddens me that many young OMSs do not realize “how it used be” and what a struggle it was to gain the ground of our current scope of practice. I feel that many younger OMSs do not realize the price of blood, sweat, and tears that went into gaining things we take for granted such as hospital privileges, emergency room calls, and the ability to rotate through numerous medical and surgical services. It wasn’t always like this! If the true sacrifices were realized by younger OMSs, I don’t think they would have so easily given up emergency room calls, facial trauma, and other less remunerative parts of our specialty. These privileges were hashed out by leaders such as Dr Walker and other tremendously dedicated program directors around the country. We still have many dedicated program directors who continue to train great residents, and we all should strive to duplicate the personal and professional standards that Dr Walker embodied. JOE NIAMTU III, DMD Richmond, Virginia

doi:10.1016/j.joms.2011.05.005

TEMPORALIS FASCIA IN TEMPOROMANDIBULAR JOINT GAP ARTHROPLASTY To the Editor:—The recent report by Bulgannawar et al1 on the treatment of temporomandibular joint (TMJ) ankylosis prompts me to write the following comments. First, although there are many tissues other than the temporalis fascia, some of them mentioned in the report, that have been used in TMJ gap arthroplasty for the surgical treatment of ankylosis, the authors failed to cite the autogenous dermal graft and bank costochondral cartilage. Dermis is easily harvested from many locations in the body, most commonly the buttock, groin, or lower extremity; is

available in any size required (many bony ankyloses of the TMJ are extensive, involving more than just the joint space itself); is readily adaptable simultaneously to multiple contours present in the joint and surrounding structures; and has proved to be efficacious in many studies.2-4 Sailer5 reported on his extensive experience with lyophilized bank cartilage as interpositional material in gap arthroplasty for TMJ ankylosis. Although useful when only 1 plane of interposition is needed between the mandibular condylar stump and the cranial base after resection of the ankylosis, it does not bend or adapt well to multiple surfaces when the ankylosis extends to the medial and lateral aspects of the mandibular condyle, ramus, or coronoid process.6 Second, 3 of the 8 patients included in the report had follow-up periods shorter than 5 years (1 for 4 years, 2 for 11 months). Because there is a high rate of postsurgical recurrence of TMJ ankylosis, any patient followed for shorter than 5 years should not be deemed eligible for inclusion in data to determine surgical success.6 Third, although early initiation of jaw physiotherapy is mentioned, it cannot be emphasized too strongly that reestablishing and maintaining an acceptable range of interincisal opening (⬎30 mm for most patients) is the key to successful restoration of mandibular function, regardless of the surgical technique or the type of interpositional tissue placed into a TMJ gap arthroplasty. That the literature of the previous 100 years is replete with articles describing various surgical techniques and interpositional tissues in the surgical treatment of TMJ ankylosis is glaring testimony that the factors in its development and postsurgical recurrence are, at best, still not well understood. In my practice, in which I have operated on more than 125 patients with TMJ ankylosis, all such patients are followed at least annually and expected to continue daily mandibular opening and rangeof-motion exercises for the remainder of their lives.6 As surgeons, we must always look beyond the operation for additional treatment that is to the ultimate benefit of our patients. Thank you for affording me this opportunity to comment on the work of Bulgannawar et al in their treatment of these most challenging patients. ROGER A. MEYER, DDS, MS, MD Greensboro, Georgia

References 1. Bulgannawar BA, Rai BD, Nair MA, et al: Use of temporalis fascia as an interpositional arthroplasty in temporomandibular joint ankylosis: Analysis of 8 cases. J Oral Maxillofac Surg 69:1031, 2011 2. Meyer RA: Autogenous dermal grafts in the reconstruction of the temporomandibular joint. Oral Maxillofac Clin N Am 1:351, 1989

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3. McIntosh RB: Costochondral and dermal grafts in temporomandibular joint reconstruction. Oral Maxillofac Surg Clin North Am 1:363, 1989 4. Georgiade N, Altany F, Pickrell K: An experimental and clinical evaluation of autogenous dermal grafts used in treatment of temporomandibular joint ankylosis. Plast Reconstr Surg 19:321, 1957 5. Sailer HF: Transplantation of Lyophilized Cartilage in Maxillofacial Surgery. Basel, S Karger, 1983 6. Meyer RA: Costal cartilage for treatment of temporomandibular joint ankylosis. Plast Reconstr Surg 109:2168, 2002

doi:10.1016/j.joms.2011.04.016

USE OF TEMPORALIS FASCIA AS AN INTERPOSITIONAL ARTHROPLASTY IN TEMPOROMANDIBULAR JOINT ANKYLOSIS: ANALYSIS OF 8 CASES To the Editor:—We thank Dr Meyer for his comments and the editor for providing the opportunity to respond. First, the purpose of this study was to evaluate the versatility of the temporalis fascia in temporomandibular joint ankylosis. Various interposition arthroplasty materials have been proposed, with their advantages and disadvantages.1 We agree that the use of an autogenous dermal graft and a bank costochondral graft as interpositional arthroplasty is not mentioned in our article. Harvesting dermal graft requires a second surgical site, and the use of bank costochondral cartilage in India is difficult because of its unavailability. Second, all patients are periodically followed. Three of 8 patients had a follow-up shorter than 5 years; 1 patient with 4-year follow-up was seen 5 years 6 months postoperatively and the mouth opening was 34 mm, and 2 patients with 11-month follow-up were seen at 2 years 5 months postoperatively and their mouth openings were 36 and 38 mm, respectively. Third, the primary objectives in the management of ankylosis surgery are 1) to establish jaw movement and jaw function by surgical release of the ankylosis and 2) to prevent relapse by interpositional grafting, early jaw mobilization, intensive physiotherapy,2 and strict follow-up to prevent postoperative adhesions.3 The key to the success of ankylosis surgery is to restore form and function. Form includes the esthetic correction of the facial deformity and occlusal corrections. Function includes adequate mouth opening without signs of re-ankylosis. In our study we emphasized restoring function first and form at a later date. Based on this, the emphasis was placed on adequate mouth opening. This was achieved postoperatively and is an indication of good function and no re-ankylosis. BIPIN ASHOK BULGANNAWAR, MDS BHAGAVAN DAS RAI, MDS MANJU ANANTHKRISHAN NAIR, MDS RAVI KALOLA, MDS Debari, Udaipur, Rajasthan, India

References 1. Yazdani J, Ghavimi A, Pourshahidi S, et al: Comparison of clinical efficacy of temporalis myofascial flap and dermal graft as interpositional material in treatment of temporomandibular joint ankylosis. J Craniofac Surg 21:1218, 2010 2. Dimitroulis G: The interpositional dermis-fat graft in the management of temporomandibular joint ankylosis. Int J Oral Maxillofac Surg 33:755, 2004

3. Su-Gwan K: Treatment of temporomandibular joint ankylosis with temporalis muscle and fascia flap. Int J Oral Maxillofac Surg 30:189, 2001

doi:10.1016/j.joms.2011.04.019

THE “MISSING” ANTERIOR LOOP To the Editor:—I write in response to a recent report by Benninger et al1 and would like to state my support for their findings. This is because one must remember that the anterior loop is a phenomenon usually seen in panoramic radiographs, and this can be attributed to seeing a 3-dimensional structure as a 2-dimensional shadow. Therefore, there is a possibility that the loop seen on panoramic radiographs might, in fact, be the result of variation in the division of the inferior alveolar nerve, as rightly pointed out by Benninger et al.1 To recapitulate, the inferior alveolar nerve comprises 2 large nerves that are spirally twisted around each other but separately wrapped in perineural sheaths.2 The point of division has always been a matter of debate, with some studies suggesting the presence of a loop anteriorly and then backward before branching out as the mental nerve. The findings from Benninger et al1 are in agreement with those reported by Gustinna-Wadu et al,3 who also discovered in their cadaveric dissection that frequent anatomic variations are present in the intrabony course of the inferior alveolar nerve, and the branching to mental and incisive nerve might occur more posteriorly than generally anticipated. I would like to draw the attention of the authors to an additional finding from Gustinna-Wadu et al.3 They reported that the mandibular canal is not a well-corticated structure.3 In fact, they likened the radiographic “cortex” of the mandibular canal as the effect of “wire netting” on the trabecular bone. When the distance between the “wire netting” is short, it will be seen as a sclerotic margin radiographically. About 2 years ago, a study was performed in our institution to determine the radiographic visualization of the anterior loop in subjects of different age groups. We discovered that the visualization becomes worse as the age of the subjects increases.4 We found that the anterior loop was not visualized in 72.7% of the subjects aged 40 to 49 years or in 85% of the subjects aged older than 50 years. On the basis of the present (on older cadavers) and previous studies cited,1-4 I would like to hypothesize that an increase in age, with its accompanying increase in cortical porosity and the percentage of Haversian canals showing resorption, in addition to the chemical processing that preserves the cadavers, allows the inferior alveolar nerve and its intrabony branches some degrees of shrinkage or displacement, resulting in intrabony movement and displacement of the anterior loop. As a result, the anterior loop, if it was ever present earlier, might no longer be seen during dissection or detected radiographically because of the change in position. In summary, however, is that perhaps the findings of Benninger et al1 and others, such as the findings from Rosenquist5 might have been the truth all this while, and the anterior loop is perhaps merely a radiographic phenomenon, such as suggested by Bavitz et al.6 WEI CHEONG NGEOW, BDS (Mal), FFDRCSIre (OS), FDSRCS (Eng), MDSc (Mal), PhD (Sheffield) Faculty of Dentistry, University of Malaya Kuala Lumpur, Malaysia