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Temporomandibular joint reconstruction and correction of facial deformity in ankylosis
Oral Presentations / O5. TMJ I [-~"~
MAGNETIC RESONANCE IMAGING OF THE TEMPOROMANDIBULAR JOINT IN PATIENTS WITH RHEUMATIC DISEASES. CORRELATION OF CLINICAL SYMPTOMS WITH CONVENTIONAL RADIOGRAPHY AND WITH MAGNETIC RESONANCE IMAGING
L.M.J. Helenius 1, E Tervahartiala2, I. Helenius4, D. Hallikainen2, L. Kivisaari2, C. Lindqvist 1, M. Leirisalo-Repo3. 1Departments of
Oral and Maxillofacial Diseases, 2Radiology, 3Medicine, Division of Rheumatology, 4Hospital for Children and Adolescents, Helsinki University Central Hospital, Helsinki, Finland Temporomandibular joint (TMJ) can be involved in patients with rheumatic diseases. A few studies have investigated clinical and magnetic resonance imaging (MRI) findings in patients with seronegative arthritides or mixed connective tissue disease. The purpose of this study was to investigate correlations between clinical, radiographic and MRI findings in patients with different rheumatic diseases. Sixty-seven patients [16 with rheumatoid arthritis (RA, mean (SD) age 45.9(13.2), two males), 15 with mixed connective tissue disease (MCTD, mean (SD) age 45.1 (13.0), one male), 18 with an kylosing spondylitis (AS, mean (SD) age 43.9(13.0), twelve males), and 18 with spondyloarthropathy (SPA, mean (SD) age 43.4(12.7), ten males] participated in the study. The patients filled in a questionnaire for craniomandibular disorders (CMD), they were clinically examined, and panoramic radiographs (OPTG), lateral panoramic radiographs and MRI of the temporomandibular joint (TMJ) were obtained. MRI showed reduced articular cartilage in 25% (4/16) of IRA, 0% (0/15) of MCTD, 17% (3/18) of AS and 17% (3/18) of SPA patients (N.S.). Condylar changes included erosion, osteophytes and abnormal shape. Disc alterations included perforation, abnormal anterior position, and decreased movement. These abnormalities were most frequent in IRA patients, and least frequent in MCTD and SPA patients. Maximal opening of the mouth correlated with disc perforation (rs=-0.51, 95%CI -0.67 to -0.30) and osteoarthritic changes (rs = -0.47, -0.64 to -0.26) in MRI. Severe condylar erosion in OPTG was significantly associated with MRI findings of condylar erosion (p <0.01), diminished thickness of condylar cartilage, abnormal condylar shape, and abnormal shape of the temporal surface of the TMJ (p<0.001). Abnormalities of the TMJ are common in patients with seronegative arthritides and MCTD. The presence of crepitation, limited motion and/or pain on movement of the mouth often indicate structural damage to the TMJ. For imaging, OPTG and lateral panoramic imaging are usually indicated and also sufficient. However, to obtain a more detailed anatomic picture, MRI is suitable for patients with acute unexplained pain or as part of preoperative work-up. Supported by grants from Helsinki University Central Hospital, the Finnish Dental Foundation, the Finnish Women's Dental Foundation and the Orion Research Foundation.
[ - ~ - - ~ TREATMENT OF TMJ DEVELOPMENTAL ABNORMALITIES IN GROWING CHILDREN: THE "EARLY FUNCTIONAL REPOSITIONING" OF THE MANDIBLE W. Cortezzi. Universidade Federal do Rio de Janeiro, Brazil Based on a non-randomized clinical study, the author presents a protocol for the treatment of TMJ ankylosis and condylar hypoplasia in growing children associated with growth arrest. The protocol is based on 2 surgical and 2 clinical steps in sequence. The distinguishing aspect is the last surgical step that was named "early functional repositioning of the mandible". The "early functional repositioning of the mandible" has been defined as the whole repositioning of the mandible aligning skeletal and dental midline and, fundamentally, with maintenance of the biological spaces for the eruption of the teeth. This surgical procedure is done as soon the child presents mouth opening and stretched muscles. From 1982 to 1998, 11 patients with temporomandibular joint ankylosis, mean age of 8.18±4.26 (range from 02 to 13), and 04 patients with condylar hypoplasia, mean age 8.25±4.99 (range from 05 to 13), have been treated with this protocol. The mean follow-up was 29.09±21.73 months (range from 08 to 78) to the temporomandibular joint ankylosis patients and 72±16.97 months (range from 60 to 96) for the condylar hypoplasia patients. The evaluation criteria were: 1 ) Mastigatory function: 2) Facial and mandibular growth and development: 3) Presence or not of relapse: The results for the analyzed parameters were: 1) All patients showed functional improvement. The mean preoperative mouth opening was 5.72±5.51 mm (range from 0 to 12) changed to 36.63±4.52mm
11 (range from 25 to 41) on the final postoperative; 2) All patients showed harmonious facial and mandibular growth and development. 3) We had no relapse. Faced on the results, the author has concluded that this protocol of treatment has been well succeeded. It seems valid to assume that the early functional repositioning of the mandible and this protocol of treatment should be employed in children with temporomandibular ankylosis and condylar hypoplasia associated with growth arrest. The advantages are: 1. It allows the adequate action of the muscles over the bony matrix and, consequently it improves the correct functional remodeling and growth; 2. It produces an immediate improvement in the facial appearance and consequently, restores the child's confidence and self-esteem and full participation in society; 3. It allows the immediate and adequate performance of the orthodontic treatment to improve the malocclusion; 4. After restoring function, form, and esthetics, the relapse may be abolished.
[-0-~
LAI'S ARTHROPLASTY FOR TMJ ANKYLOSlS WITH INTRAORAL APPROACH
E. Ko, M. Chen, E. Huang, S. Lai. Oral and Maxillofacial Surgery Department, Kaohsiung Medical University, Kaohsiung, Taiwan Surgery is the primary treatment of temporomandibular joint ankylosis, which includes gap arthroplasty and interpositional arthroplasty. Various surgical approaches to TMJ include pre-auricular, perimeatal, endaural, post-auricular and submandibular incisions. Possible adverse effects or reported complications are temporary or permanent facial nerve paralysis, sialocele, hemorrhage, scarring etc. We perform arthroplasty with intraoral approach for temporomandibular joint ankylosis. From the year 1989 to 2004, we performed Lai's arthroplasty for the 14 pts with TMJ ankylosis with their consents. This technique has been performed by 4 different surgeons on 16 TMJs of 14 patients (One patient was with bilateral TMJ ankylosis, another patient was performed 2 times arthroplasties due to recurrence). Lai's arthroplasty starts with intraoral incision placed over the buccal shelf. Then reflection of the soft tissue off the mandibular ramus was done. Coronoidectomy was performed and arthroplasty was accomplished at the level of condylar neck. Finally we fixed the coronoid process with stainless steel wire and closed the wound. Advantages of this intraoral approach are excellent cosmetic appearance without facial scar, lower risk of injury to facial nerve or auriculotemoporal nerve, no formation of salivary fistula. Moreover, it is easier to perform arthroplasty with intraoral approach for the cases of extensive ankylosis or for the cases requiring coronoidectomy. Disadvantages are poor access, limited surgical fields, requiring more practice as to be familiar with the procedure. The Increased amounts in dimensions of mouth opening ranges from 9.8 to 41 mm, with the average increased dimension of 23.8 mm. The postoperative dimension of mouth opening was averagely 33.3 mm (excluding the cases of reankylosis). Excellent cosmetic appearance without facial scar and no injury to facial nerve or auriculotemporal nerve was noted. Lai's arthroplasty is a good technique worth-promoting for surgical intervention of TMJ ankylosis.
[-O-~-] TEMPOROMANDIBULAR JOINT RECONSTRUCTION AND CORRECTION OF FACIAL DEFORMITY IN ANKYLOSlS A.A. Shah. Montmorency College of Dentistry, Defence Housing Authority, Lahore Cantt.54792, Pakistan Early and long standing temporomandibular joint ankylosis in growing patients posses great challenges to Oral & Maxillofacial Surgeons in terms of function, growth and aesthetics. The treatment objectives in such patients include restoration of function, growth and form. The aim of this study was to evaluate the results of reconstruction of temporomandibular joint and correction of facial deformity in a single operation following ankylosis. 40 patients (16 females, 24 males) aged 2-17 years with TMJ ankylosis were treated from 2002 to 2004. Aetiological factors included trauma 30 cases, birth trauma 4, firearm injury 2, infections 2 and unknown 2. Bilateral ankylosis was reported in 8 cases and the rest were unilateral. Pre-operative opening ranged from 2-12 mm. Obstructive sleep apnea symptoms were present in 4 patients. Standard investigations included OPG, lateral Ceph, PA Ceph and 3-D CT scan of TMJ. Joint was approached through Bramly AI-Kayat incision and temporalis muscle with facia was used as an interpositional graft in all cases. Contralateral temporalis myotomy was done in 15 cases and ipsilateral coronoidectomy in 5 patients. TMJ reconstruction and correction of facial deformity was carried out with costochondral rib graft, onlay bone
Int. J. Oral Maxillofac. Surg. 2005; 34 (Supplement 1): $ 1 - $ 1 8 1
12 grafts and orthoganathic surgery. Post-operative physiotherapy started within first 24 hours. Maximum followup period was 2 years. Out of 40 patients, 2 developed re-ankylosis, 3 had costochondral graft overgrowth without altering function and aesthetics. Heterotopic bone formation was seen in 1 patient. Pain reported by 3 patients with 1 complaning of joint noises and none had any interference while eating. Transient facial nerve weakness was reported in 4 patients which recovered over a period of 3 months. The average mouth opening achieved at 40.02 mm. There was significant and satisfactory improvement in function and aesthetics in all patients. Temporomandibular Joint reconstruction and correction of facial deformity in a single operation provides efficiant and satisfactory treatment of early and long standing TMJ ankylosis especially in growing subjects. References [1] Temporomandibularjoint ankylosis: Report of 14 cases. L.C.ManganelloSouza, EB. Mariani: Int.J.Oral MaxilloFac Surg.2003;32:24-29 [2] Treatment of temporomandibular joint ankylosis with temporalis muscle and facia flap: K.Su-Gwan.lnt.J.Oral MaxilloFac Surg.2001;30:189-193. [-O-~--] VARIOUS SURGICAL TECHNIQUES IN TREATMENT OF T M J ANKYLOSIS A.A.F. Mahmoud. Imbaba General Hospital, Cairo, Egypt Comparing between surgical modalities for treatment of T.M.J ankylosis. Thirty patients were complaining of T.M.J ankylosis either unilateral or bilateral had been operated upon for release of their joints. They were divided equally into three main groups. In group (I), patients had been treated by condylectomy, in group (11) patients had been treated by gap arthroplasty with coronoidectomy or coronoidotomy and delayed reconstruction. While in group (111) patients had been treated by gap arthroplasty with immediate reconstruction by allogenic bone graft harvested from ribs, sternoclavicular joints and metatarsus.All patients had been thoroughly investigated both clinically and radiographicaly upto the end of the third postoperative year. One case of recurrence occurred in both groups (l&ll) and no recurrence in group (111). Early reconstruction of T.M.J ankylosis was the best line of treatment in terms of achieving facial symmetry, proper occlusion and good masticatory function with no recurrence. [-6-~
TEMPOROMANDIBULAR JOINT ANKYLOSIS: ANALYSIS OF 65 PATIENTS
S. Ajike 1 , E. Adebayo 2, E. A m a n y i e w e 1 , C. Ononiwu 1 , O. Omisakin 1.
1Ahmadu Bello University Teaching Hospital, Kaduna, Nigeria; 244 Army Reference Hospital, Kaduna, Nigeria To analyze the cases and the problems of management of temporomandibular joint ankylosis at the Oral and Maxillofacial Unit (MFU), Ahmadu Bello University Teaching Hospital, Kaduna, Nigeria between 1990 and 2004. Records of all temporomandibular joint ankylosis at the Oral and Maxillofacial Unit were retrospectively examined over a period of 15 years. These were analyzed with respect to gender, age, site, aetiologic factors, form and type of ankylosis, method of intubation, surgical procedures performed, maximal interincisal opening at followup between 1-6 months and complications. There were 65 patients, 42 (64.6%) males and 23 (35.4%) females; male/female ratio was 1.8:1. The age range was 2 days to 33 years with a mean of 13.5±7.5 years. Duration ranged between 2 days to 19 years. Extraarticular/intraarticular ratio was 1.2:1. The commonest aetiologic factor was infections 49.3%, followed by trauma 46.6% and congenital 3.1%. Tracheostomy (38.1%) was the commonest method of intubation followed by blind intubations (23.8%), fibre-optic laryngoscopy (22.2%) and transtracheal ventilation (15.9%). Various surgical procedures employed were condylectomy (35.0%), angle ostectomy (23.8%), bilateral condylectomy (12.7%), body ostectomy (9.5%), condylectomy and angle ostectomy (9.5%), excision of fibrous band and angle ostectomy (6.3%) and excision of fibrous band (3.2%). Range of maximal interincisal opening (MIO) preoperative, intraoperative, at one month, three months and six months postoperatively ranged 1 mm to 1.5mm, 25mm to 40mm, 13mm to 40mm, 15mm to 35 mm and 15 mm to 45mm respectively. The overall complication was 19.5%. Temporomandibular joint ankylosis is a persisting scourge in sub-Saharan Africa due mainly to poorly managed infections of the head and neck region. Management remains a challenge to the patients and surgeons due to prevailing poverty and poor state of medical
infrastructure in the region. A multisectorial approach is advocated to reduce the prevalence while improved state of medical facilities would enhance surgical management of the condition.
[
O
•
]
APPLICATION OF ABDOMINAL FAT GRAFTS DURING TOTAL TEMPOROMANDIBULAR JOINT (TMJ) RECONSTRUCTION USING CUSTOM-MADE PROSTHESIS
EE Franco, L.M. Wolford, C. Morales-Ryan. Baylor College of Dentistry,
Texas A & M University Health Science Center, Texas, USA This presentation will illustrate the value of using autogenous fat grafts during TMJ reconstruction with total prosthesis. 194 temporomandibular joints underwent total joint reconstruction using custom-made (TMJ Concepts) prosthesis. The prosthesis was secured with screws to the bone surfaces and then autogenous fat grafts were obtained from the abdomen. The graft was placed around the condylar head of the mandibular shaft into the articulating area. Clinical and radiological evaluations were performed at presurgical T1, immediate postsurgical T2 and longest follow-up T3. Clinical assessment included maximal incisal opening, lateral excursions. Radiological assessment include evaluation of panoramic and TMJ linear tomograms. No patients received radiation therapy after surgery. Maximal incisal opening was improved in all patients. Lateral excursions were decreased in average as expected. No heterotopic bone formation was observed in general. Complications in the donor site were presented in 13 patients including abdominal cyst, hematoma and seroma formation. The application of autogenous fat grafts in total temporomandibular joint reconstruction with custommade prosthesis may decrease heterotopic bone formation with minimal morbidity at the donor site.
06. Other I
[ - G - ~ ZYGOMYCOSlS OF THE OROFACIAL REGION P. Schuetz, M. Valvoda, S. Safer. Department of Oral&Maxillofacial
Surgery, Ministry of Health, Kuwait Department of Oto-rhino-laryngology, Ministry of Health, Kuwait Zygomycosis, also known as phycomycosis or mucormycosis, is infection caused by fungi belonging to the phylum of Zygomycota. Usual human pathogens belong to families Absidia, Mucor, Rhizomucor and Rhizopus. The infection typically occurs in immuno-compromised patients. The main target group consists of poorly controlled diabetes mellitus patients, other risk factors being immunodeficiency, neutropenia, chronic dialysis, bone marrow and solid organ transplants, leukemia, systemic steroids. It can also rarely affect previously healthy individual. The infection happens by inhalation, deglutition or traumatic inoculation of spore. Zygomycetes invading host tissues have tendency to grow inside vascular lumens, which leads to thrombosis and subsequent ischaemic tissue necrosis. In the orofacial system the mucormycosis predominantly affects nasal cavity and paranasal sinuses. Tissue necrosis can lead to palatal perforation or bizarre facial defects. Spread to the orbit is often associated with intracranial complications. Our presentation describes experience with patients treated between 1999 and 2004 The medical records of 7 consecutive patients diagnosed with zygomycosis of the orofacial area were reviewed. We treated 4 females and 3 males aged between 12 and 68 years. With one exception all of them had underlying pathologic condition, mainly diabetes mellitus. Nose or paranasal sinuses were starting point of disease in all cases. All patients received surgical debridement and were treated with Amphotericin B. Two cases presented as acute orbitocellulitis, remaining patients had chronic course of disease characterized mostly by nasal crusting and oral ulcers. Three patients were cured and survived, in two patients the disease was controlled, but they died due to underlying conditions. Two patients were diagnosed only in terminal stage of the disease and died due to intracranial invasion. Diagnosis was confirmed by histopathological examination in all cases. Mycological identification was performed only in the last patient and the causative fungus was Apophysomyces elegans. Orofacial zygomycosis is aggressive, life threatening disease. Only early diagnosis, resting on histopathology examination of biopsy specimen, and subsequent energetic therapy gives patient a chance of survival.
MAGNETIC RESONANCE IMAGING OF THE TEMPOROMANDIBULAR JOINT IN PATIENTS WITH RHEUMATIC DISEASES. CORRELATION OF CLINICAL SYMPTOMS WITH CONVENTIONAL RADIOGRAPHY AND WITH MAGNETIC RESONANCE IMAGING
L.M.J. Helenius 1, E Tervahartiala2, I. Helenius4, D. Hallikainen2, L. Kivisaari2, C. Lindqvist 1, M. Leirisalo-Repo3. 1Departments of
Oral and Maxillofacial Diseases, 2Radiology, 3Medicine, Division of Rheumatology, 4Hospital for Children and Adolescents, Helsinki University Central Hospital, Helsinki, Finland Temporomandibular joint (TMJ) can be involved in patients with rheumatic diseases. A few studies have investigated clinical and magnetic resonance imaging (MRI) findings in patients with seronegative arthritides or mixed connective tissue disease. The purpose of this study was to investigate correlations between clinical, radiographic and MRI findings in patients with different rheumatic diseases. Sixty-seven patients [16 with rheumatoid arthritis (RA, mean (SD) age 45.9(13.2), two males), 15 with mixed connective tissue disease (MCTD, mean (SD) age 45.1 (13.0), one male), 18 with an kylosing spondylitis (AS, mean (SD) age 43.9(13.0), twelve males), and 18 with spondyloarthropathy (SPA, mean (SD) age 43.4(12.7), ten males] participated in the study. The patients filled in a questionnaire for craniomandibular disorders (CMD), they were clinically examined, and panoramic radiographs (OPTG), lateral panoramic radiographs and MRI of the temporomandibular joint (TMJ) were obtained. MRI showed reduced articular cartilage in 25% (4/16) of IRA, 0% (0/15) of MCTD, 17% (3/18) of AS and 17% (3/18) of SPA patients (N.S.). Condylar changes included erosion, osteophytes and abnormal shape. Disc alterations included perforation, abnormal anterior position, and decreased movement. These abnormalities were most frequent in IRA patients, and least frequent in MCTD and SPA patients. Maximal opening of the mouth correlated with disc perforation (rs=-0.51, 95%CI -0.67 to -0.30) and osteoarthritic changes (rs = -0.47, -0.64 to -0.26) in MRI. Severe condylar erosion in OPTG was significantly associated with MRI findings of condylar erosion (p <0.01), diminished thickness of condylar cartilage, abnormal condylar shape, and abnormal shape of the temporal surface of the TMJ (p<0.001). Abnormalities of the TMJ are common in patients with seronegative arthritides and MCTD. The presence of crepitation, limited motion and/or pain on movement of the mouth often indicate structural damage to the TMJ. For imaging, OPTG and lateral panoramic imaging are usually indicated and also sufficient. However, to obtain a more detailed anatomic picture, MRI is suitable for patients with acute unexplained pain or as part of preoperative work-up. Supported by grants from Helsinki University Central Hospital, the Finnish Dental Foundation, the Finnish Women's Dental Foundation and the Orion Research Foundation.
[ - ~ - - ~ TREATMENT OF TMJ DEVELOPMENTAL ABNORMALITIES IN GROWING CHILDREN: THE "EARLY FUNCTIONAL REPOSITIONING" OF THE MANDIBLE W. Cortezzi. Universidade Federal do Rio de Janeiro, Brazil Based on a non-randomized clinical study, the author presents a protocol for the treatment of TMJ ankylosis and condylar hypoplasia in growing children associated with growth arrest. The protocol is based on 2 surgical and 2 clinical steps in sequence. The distinguishing aspect is the last surgical step that was named "early functional repositioning of the mandible". The "early functional repositioning of the mandible" has been defined as the whole repositioning of the mandible aligning skeletal and dental midline and, fundamentally, with maintenance of the biological spaces for the eruption of the teeth. This surgical procedure is done as soon the child presents mouth opening and stretched muscles. From 1982 to 1998, 11 patients with temporomandibular joint ankylosis, mean age of 8.18±4.26 (range from 02 to 13), and 04 patients with condylar hypoplasia, mean age 8.25±4.99 (range from 05 to 13), have been treated with this protocol. The mean follow-up was 29.09±21.73 months (range from 08 to 78) to the temporomandibular joint ankylosis patients and 72±16.97 months (range from 60 to 96) for the condylar hypoplasia patients. The evaluation criteria were: 1 ) Mastigatory function: 2) Facial and mandibular growth and development: 3) Presence or not of relapse: The results for the analyzed parameters were: 1) All patients showed functional improvement. The mean preoperative mouth opening was 5.72±5.51 mm (range from 0 to 12) changed to 36.63±4.52mm
11 (range from 25 to 41) on the final postoperative; 2) All patients showed harmonious facial and mandibular growth and development. 3) We had no relapse. Faced on the results, the author has concluded that this protocol of treatment has been well succeeded. It seems valid to assume that the early functional repositioning of the mandible and this protocol of treatment should be employed in children with temporomandibular ankylosis and condylar hypoplasia associated with growth arrest. The advantages are: 1. It allows the adequate action of the muscles over the bony matrix and, consequently it improves the correct functional remodeling and growth; 2. It produces an immediate improvement in the facial appearance and consequently, restores the child's confidence and self-esteem and full participation in society; 3. It allows the immediate and adequate performance of the orthodontic treatment to improve the malocclusion; 4. After restoring function, form, and esthetics, the relapse may be abolished.
[-0-~
LAI'S ARTHROPLASTY FOR TMJ ANKYLOSlS WITH INTRAORAL APPROACH
E. Ko, M. Chen, E. Huang, S. Lai. Oral and Maxillofacial Surgery Department, Kaohsiung Medical University, Kaohsiung, Taiwan Surgery is the primary treatment of temporomandibular joint ankylosis, which includes gap arthroplasty and interpositional arthroplasty. Various surgical approaches to TMJ include pre-auricular, perimeatal, endaural, post-auricular and submandibular incisions. Possible adverse effects or reported complications are temporary or permanent facial nerve paralysis, sialocele, hemorrhage, scarring etc. We perform arthroplasty with intraoral approach for temporomandibular joint ankylosis. From the year 1989 to 2004, we performed Lai's arthroplasty for the 14 pts with TMJ ankylosis with their consents. This technique has been performed by 4 different surgeons on 16 TMJs of 14 patients (One patient was with bilateral TMJ ankylosis, another patient was performed 2 times arthroplasties due to recurrence). Lai's arthroplasty starts with intraoral incision placed over the buccal shelf. Then reflection of the soft tissue off the mandibular ramus was done. Coronoidectomy was performed and arthroplasty was accomplished at the level of condylar neck. Finally we fixed the coronoid process with stainless steel wire and closed the wound. Advantages of this intraoral approach are excellent cosmetic appearance without facial scar, lower risk of injury to facial nerve or auriculotemoporal nerve, no formation of salivary fistula. Moreover, it is easier to perform arthroplasty with intraoral approach for the cases of extensive ankylosis or for the cases requiring coronoidectomy. Disadvantages are poor access, limited surgical fields, requiring more practice as to be familiar with the procedure. The Increased amounts in dimensions of mouth opening ranges from 9.8 to 41 mm, with the average increased dimension of 23.8 mm. The postoperative dimension of mouth opening was averagely 33.3 mm (excluding the cases of reankylosis). Excellent cosmetic appearance without facial scar and no injury to facial nerve or auriculotemporal nerve was noted. Lai's arthroplasty is a good technique worth-promoting for surgical intervention of TMJ ankylosis.
[-O-~-] TEMPOROMANDIBULAR JOINT RECONSTRUCTION AND CORRECTION OF FACIAL DEFORMITY IN ANKYLOSlS A.A. Shah. Montmorency College of Dentistry, Defence Housing Authority, Lahore Cantt.54792, Pakistan Early and long standing temporomandibular joint ankylosis in growing patients posses great challenges to Oral & Maxillofacial Surgeons in terms of function, growth and aesthetics. The treatment objectives in such patients include restoration of function, growth and form. The aim of this study was to evaluate the results of reconstruction of temporomandibular joint and correction of facial deformity in a single operation following ankylosis. 40 patients (16 females, 24 males) aged 2-17 years with TMJ ankylosis were treated from 2002 to 2004. Aetiological factors included trauma 30 cases, birth trauma 4, firearm injury 2, infections 2 and unknown 2. Bilateral ankylosis was reported in 8 cases and the rest were unilateral. Pre-operative opening ranged from 2-12 mm. Obstructive sleep apnea symptoms were present in 4 patients. Standard investigations included OPG, lateral Ceph, PA Ceph and 3-D CT scan of TMJ. Joint was approached through Bramly AI-Kayat incision and temporalis muscle with facia was used as an interpositional graft in all cases. Contralateral temporalis myotomy was done in 15 cases and ipsilateral coronoidectomy in 5 patients. TMJ reconstruction and correction of facial deformity was carried out with costochondral rib graft, onlay bone
Int. J. Oral Maxillofac. Surg. 2005; 34 (Supplement 1): $ 1 - $ 1 8 1
12 grafts and orthoganathic surgery. Post-operative physiotherapy started within first 24 hours. Maximum followup period was 2 years. Out of 40 patients, 2 developed re-ankylosis, 3 had costochondral graft overgrowth without altering function and aesthetics. Heterotopic bone formation was seen in 1 patient. Pain reported by 3 patients with 1 complaning of joint noises and none had any interference while eating. Transient facial nerve weakness was reported in 4 patients which recovered over a period of 3 months. The average mouth opening achieved at 40.02 mm. There was significant and satisfactory improvement in function and aesthetics in all patients. Temporomandibular Joint reconstruction and correction of facial deformity in a single operation provides efficiant and satisfactory treatment of early and long standing TMJ ankylosis especially in growing subjects. References [1] Temporomandibularjoint ankylosis: Report of 14 cases. L.C.ManganelloSouza, EB. Mariani: Int.J.Oral MaxilloFac Surg.2003;32:24-29 [2] Treatment of temporomandibular joint ankylosis with temporalis muscle and facia flap: K.Su-Gwan.lnt.J.Oral MaxilloFac Surg.2001;30:189-193. [-O-~--] VARIOUS SURGICAL TECHNIQUES IN TREATMENT OF T M J ANKYLOSIS A.A.F. Mahmoud. Imbaba General Hospital, Cairo, Egypt Comparing between surgical modalities for treatment of T.M.J ankylosis. Thirty patients were complaining of T.M.J ankylosis either unilateral or bilateral had been operated upon for release of their joints. They were divided equally into three main groups. In group (I), patients had been treated by condylectomy, in group (11) patients had been treated by gap arthroplasty with coronoidectomy or coronoidotomy and delayed reconstruction. While in group (111) patients had been treated by gap arthroplasty with immediate reconstruction by allogenic bone graft harvested from ribs, sternoclavicular joints and metatarsus.All patients had been thoroughly investigated both clinically and radiographicaly upto the end of the third postoperative year. One case of recurrence occurred in both groups (l&ll) and no recurrence in group (111). Early reconstruction of T.M.J ankylosis was the best line of treatment in terms of achieving facial symmetry, proper occlusion and good masticatory function with no recurrence. [-6-~
TEMPOROMANDIBULAR JOINT ANKYLOSIS: ANALYSIS OF 65 PATIENTS
S. Ajike 1 , E. Adebayo 2, E. A m a n y i e w e 1 , C. Ononiwu 1 , O. Omisakin 1.
1Ahmadu Bello University Teaching Hospital, Kaduna, Nigeria; 244 Army Reference Hospital, Kaduna, Nigeria To analyze the cases and the problems of management of temporomandibular joint ankylosis at the Oral and Maxillofacial Unit (MFU), Ahmadu Bello University Teaching Hospital, Kaduna, Nigeria between 1990 and 2004. Records of all temporomandibular joint ankylosis at the Oral and Maxillofacial Unit were retrospectively examined over a period of 15 years. These were analyzed with respect to gender, age, site, aetiologic factors, form and type of ankylosis, method of intubation, surgical procedures performed, maximal interincisal opening at followup between 1-6 months and complications. There were 65 patients, 42 (64.6%) males and 23 (35.4%) females; male/female ratio was 1.8:1. The age range was 2 days to 33 years with a mean of 13.5±7.5 years. Duration ranged between 2 days to 19 years. Extraarticular/intraarticular ratio was 1.2:1. The commonest aetiologic factor was infections 49.3%, followed by trauma 46.6% and congenital 3.1%. Tracheostomy (38.1%) was the commonest method of intubation followed by blind intubations (23.8%), fibre-optic laryngoscopy (22.2%) and transtracheal ventilation (15.9%). Various surgical procedures employed were condylectomy (35.0%), angle ostectomy (23.8%), bilateral condylectomy (12.7%), body ostectomy (9.5%), condylectomy and angle ostectomy (9.5%), excision of fibrous band and angle ostectomy (6.3%) and excision of fibrous band (3.2%). Range of maximal interincisal opening (MIO) preoperative, intraoperative, at one month, three months and six months postoperatively ranged 1 mm to 1.5mm, 25mm to 40mm, 13mm to 40mm, 15mm to 35 mm and 15 mm to 45mm respectively. The overall complication was 19.5%. Temporomandibular joint ankylosis is a persisting scourge in sub-Saharan Africa due mainly to poorly managed infections of the head and neck region. Management remains a challenge to the patients and surgeons due to prevailing poverty and poor state of medical
infrastructure in the region. A multisectorial approach is advocated to reduce the prevalence while improved state of medical facilities would enhance surgical management of the condition.
[
O
•
]
APPLICATION OF ABDOMINAL FAT GRAFTS DURING TOTAL TEMPOROMANDIBULAR JOINT (TMJ) RECONSTRUCTION USING CUSTOM-MADE PROSTHESIS
EE Franco, L.M. Wolford, C. Morales-Ryan. Baylor College of Dentistry,
Texas A & M University Health Science Center, Texas, USA This presentation will illustrate the value of using autogenous fat grafts during TMJ reconstruction with total prosthesis. 194 temporomandibular joints underwent total joint reconstruction using custom-made (TMJ Concepts) prosthesis. The prosthesis was secured with screws to the bone surfaces and then autogenous fat grafts were obtained from the abdomen. The graft was placed around the condylar head of the mandibular shaft into the articulating area. Clinical and radiological evaluations were performed at presurgical T1, immediate postsurgical T2 and longest follow-up T3. Clinical assessment included maximal incisal opening, lateral excursions. Radiological assessment include evaluation of panoramic and TMJ linear tomograms. No patients received radiation therapy after surgery. Maximal incisal opening was improved in all patients. Lateral excursions were decreased in average as expected. No heterotopic bone formation was observed in general. Complications in the donor site were presented in 13 patients including abdominal cyst, hematoma and seroma formation. The application of autogenous fat grafts in total temporomandibular joint reconstruction with custommade prosthesis may decrease heterotopic bone formation with minimal morbidity at the donor site.
06. Other I
[ - G - ~ ZYGOMYCOSlS OF THE OROFACIAL REGION P. Schuetz, M. Valvoda, S. Safer. Department of Oral&Maxillofacial
Surgery, Ministry of Health, Kuwait Department of Oto-rhino-laryngology, Ministry of Health, Kuwait Zygomycosis, also known as phycomycosis or mucormycosis, is infection caused by fungi belonging to the phylum of Zygomycota. Usual human pathogens belong to families Absidia, Mucor, Rhizomucor and Rhizopus. The infection typically occurs in immuno-compromised patients. The main target group consists of poorly controlled diabetes mellitus patients, other risk factors being immunodeficiency, neutropenia, chronic dialysis, bone marrow and solid organ transplants, leukemia, systemic steroids. It can also rarely affect previously healthy individual. The infection happens by inhalation, deglutition or traumatic inoculation of spore. Zygomycetes invading host tissues have tendency to grow inside vascular lumens, which leads to thrombosis and subsequent ischaemic tissue necrosis. In the orofacial system the mucormycosis predominantly affects nasal cavity and paranasal sinuses. Tissue necrosis can lead to palatal perforation or bizarre facial defects. Spread to the orbit is often associated with intracranial complications. Our presentation describes experience with patients treated between 1999 and 2004 The medical records of 7 consecutive patients diagnosed with zygomycosis of the orofacial area were reviewed. We treated 4 females and 3 males aged between 12 and 68 years. With one exception all of them had underlying pathologic condition, mainly diabetes mellitus. Nose or paranasal sinuses were starting point of disease in all cases. All patients received surgical debridement and were treated with Amphotericin B. Two cases presented as acute orbitocellulitis, remaining patients had chronic course of disease characterized mostly by nasal crusting and oral ulcers. Three patients were cured and survived, in two patients the disease was controlled, but they died due to underlying conditions. Two patients were diagnosed only in terminal stage of the disease and died due to intracranial invasion. Diagnosis was confirmed by histopathological examination in all cases. Mycological identification was performed only in the last patient and the causative fungus was Apophysomyces elegans. Orofacial zygomycosis is aggressive, life threatening disease. Only early diagnosis, resting on histopathology examination of biopsy specimen, and subsequent energetic therapy gives patient a chance of survival.