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Ultrasonography for the volumetric analysis of the buccal fat pad as an interposition material for the management of ankylosis of the temporomandibular joint in adolescent patients
YBJOM-4558; No. of Pages 6
ARTICLE IN PRESS Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
Ultrasonography for the volumetric analysis of the buccal fat pad as an interposition material for the management of ankylosis of the temporomandibular joint in adolescent patients Vishal Bansal a,∗ , Avi Bansal a , Apoorva Mowar a , Sanjay Gupta b a
Department of Oral & Maxillofacial Surgery, Subharti Dental College, Swami Vivekanand Subharti University, NH-58, Meeurt By Pass Road, Meerut (Uttar Pradesh), 250005, India b Healthcare & Imaging Centre. 43, Shivaji Road, Near N.A.S. College, Meerut (Uttar Pradesh), India Accepted 16 June 2015
Abstract The aim of this study was to analyse preoperatively with ultrasound the minimum volume of buccal fat that would be required for interposition of a pad after gap arthroplasty, and to emphasise the value of such a pad in the management of ankylosis of the temporomandibular joint (TMJ) during a short term follow up. Nineteen patients with ankylosis of the TMJ (22 joints) were selected, whose mean (SD) mouth opening was 4.9 (3.7) mm. In 10 joints in which the mean (SD) volume of the buccal fat pad was 0.7 (0.2) ml, the harvested buccal fat was inadequate for interposition, so they were treated with other materials. The remaining 12 joints had a mean (SD) volume of 1.1 (0.3) ml, which gave enough fat for interposition after gap arthroplasty. Investigation with ultrasound at 15 days and 6 months postoperatively showed that the fat pad was viable and the volume had shrunk by 28%. The 6-month postoperative computed tomographic (CT) scan showed little or no heterotopic calcification. We conclude that a buccal fat pad with a preoperative mean (SD) volume of 1.1 (0.3) ml is easy to harvest as interposition material. At a mean follow up of the12 joints after 31 (range 24 - 36) months there was progressive improvement in mouth opening with a mean (SD) of 32.5 (5.0) mm, which established that a pedicled buccal fat pad is a stable, efficient, viable soft tissue barrier in the management of ankylosis of the TMJ. © 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Buccal fat pad; Temporomandibular joint ankylosis; Ultrasonography.
Introduction True ankylosis of the temporomandibular joint (TMJ) is one of the most upsetting articular conditions, which causes not ∗ Corresponding author at: Department of Oral & Maxillofacial Surgery, Subharti Dental College, Swami Vivekanand Subharti University, NH-58, Meeurt By Pass Road, Meerut (Uttar Pradesh) – 250005, India. Tel.: +91-121-2439052/121-2439043x2068; fax: +91 121 2439067/9837233950 (mobile). E-mail address: [email protected] (V. Bansal).
only functional but aesthetic, psychological, and physical disturbances as well. Management of the fused TMJ is still a challenge for maxillofacial surgeons, as they need to maintain a good permanent range of mandibular movements and correct the facial asymmetry.1 Ankylosis of the TMJ is not a single event, and authors have suggested many factors that can cause it.2 The meniscus plays a large part in preventing the adhesion of articular surfaces, but if it is damaged or displaced the condyle and glenoid fossa are more likely to fuse.3
http://dx.doi.org/10.1016/j.bjoms.2015.06.019 0266-4356/© 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Bansal V, et al. Ultrasonography for the volumetric analysis of the buccal fat pad as an interposition material for the management of ankylosis of the temporomandibular joint in adolescent patients. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.06.019
YBJOM-4558; No. of Pages 6
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ARTICLE IN PRESS V. Bansal et al. / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
The main goals of treatment are to establish the range of movement of the mandible and the function of the jaw, and to prevent recurrence, restore appearance, and achieve satisfactory growth potential and functional occlusion for the patient.4,5 Various surgical techniques have been described to achieve these goals, including ramus ostectomy, condylectomy, and gap arthroplasty. The use of an interposition material to minimise the risk of recurrence was suggested with, the idea being to minimise the dead space and preserve a barrier of soft tissue between the 2 raw surfaces and thereby reduce the chance of them reuniting. Various materials such as autogenous (temporalis myofascial flap, fascia lata, dermal graft, auricular graft, and buccal fat pad) and different alloplastic materials (gold foil, tantalum foil, Silastic®, and proplast/Teflon®) have been described and discussed, and all have their own advantages and disadvantages.6 Wolford and Karras7 and Dimitroulis8 discussed using fat from the abdomen or groins for interposition, and Rattan9 was the first to describe the technique of harvesting pedicled buccal fat pad in 2 patients with reankylosis of the TMJ. Advantages of this technique are its close proximity, and the lack of morbidity from a second surgical site. Gaba et al.10 investigated the fate of buccal fat pads with magnetic resonance imaging (MRI) for a year, but were able to assess only actual number of cases have been quoted and is not the percentage. 15 of their 23 joints because of metal artefacts. However, they did not include volumetric analysis and postoperative shrinkage in their study. On English literature search there are no available studies that have evaluated the minimum required amount of buccal fat required for interposition in ankylosis of the TMJ preoperatively, we designed this study using ultrasound (USG) as a diagnostic tool to investigate preoperatively the possibility of harvesting buccal fat in suitable volume, and its efficacy and fate as an interposition material. Computed tomography (CT) was also used after 6 months to rule out any sign of the heterotopic calcification that is responsible for reankylosis.
Fig. 1. Coronal computed tomographic image showing bilateral Sawhney’s type III ankylosis of the temporomandibular joint.
know the exact boundaries of the buccal and body parts of the fat pad. The landmarks for calculating the size of the pad were based on its character and its visibility on USG, which could be clearly distinguished from skin, subcutaneous tissue, muscle, and nearby structures. After fibreoptic intubation, we used the Al Kayat Bramley modification of the preauricular approach to expose the ankylotic mass using an aseptic technique. The patients were treated according to Kaban’s protocol. We used a standard technique to harvest the buccal fat pad. We prefer to stand in the 11 o’ clock position if the ankylosis is on the right, and the 1 o’ clock position if it is on the left. Under direct vision a periosteal elevator is inserted anteriorly in the subperiosteal plane at the anterior border of the coronoid process. After exposure and retraction at the level of the coronoid notch, the buccal fat pad is pushed outwards with the finger of the other hand placed intraorally, and bulges into the surgical field. This bulge helps to decide the correct plane of the pad. With the operator on the side being operating on, and under direct vision, the plane is opened using a
Patients and methods Nineteen patients with ankylosis of the TMJ (22 joints) were included in this prospective study. Their mean (SD) age was 11 (range 5- 17) years. It was explained to all the patients that if we failed to harvest enough buccal fat other substances could be used, and they or their parents gave informed consent. All patients were assessed for mouth opening and range of mandibular movement, and had a preoperative orthopantomograph and CT to assess the extent of the ankylotic mass (Fig. 1). All the cases were evaluated preoperatively by a single radiologist for volumetric analysis of the buccal fat pad. The ultrasound machine E-9 was manufactured by General Electonics (Bangalore, India) (Fig. 2). Patients were asked to fill the cheek with air, which helped the radiologist to
Fig. 2. Volumetric analysis of a buccal fat pad from the left cheek.
Please cite this article in press as: Bansal V, et al. Ultrasonography for the volumetric analysis of the buccal fat pad as an interposition material for the management of ankylosis of the temporomandibular joint in adolescent patients. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.06.019
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Fig. 3. Lateral gap osteotomy and sutured buccal fat pad.
blunt haemostat. The buccal fat pad is held with non-toothed forceps and the pedicled fat slowly teased out. Harvest of fat at the surgical site can be further eased by giving it a slight push posterolaterally with the finger of the other hand in the buccal vestibule behind the tuberosity. The gap created is completely filled with the harvested pedicled fat pad, and sutured with 4/0 nylon using a round-bodied needle to the glenoid fossa and medial soft tissue, and ensuring that the fat pad is interposed and completely covering the anterior, posterior, medial, and lateral surfaces of the stump of the ramus and the temporal bone (Fig. 3). Intraoperatively we ensure that the sutured buccal fat pad maintains its position with mandibular movements. After meticulous layered closure with resorbable and silk sutures, a pressure dressing is placed for 48 hours postoperatively. All patients who had interposition of a buccal fat pad alone were given mouth-opening exercises to be done from the first postoperative day. Those who had reconstruction with a costochondral graft started the exercises after 5 days. Patients were recalled for USG evaluation of the fat pad and its volume on the 15th day and 6 months (Fig. 4) postoperatively. A CT was also done at 6 months (Fig. 5) to evaluate any sign of heterotopic calcification.
3
Fig. 4. Ultrasound scan taken 6 months postoperatively to assess the amount of shrinkage of the buccal fat pad.
forces, have a minimal risk of infection, it should obliterate dead space, and should prevent recurrence caused by heterotopic calcification.12 We think that the pedicled buccal fat pad fulfills these requirements adequately. In a study by Stuzin et al13 of 12 fresh cadavers the mean (SD) weight of each fat pad was 9.3 (These values are obtained from the article of Stuzin (Ref. 13) and authors have not mentioned any standard deviation in their article) g, and the volume as measured by water displacement, 9.6 (These values are obtained from the article of Stuzin (Ref. 13) and authors have not mentioned any standard deviation in their article) ml. The difference between right and left was small, and the total mean (SD) weight was within 1.5 (These values are obtained from the article of Stuzin (Ref. 13) and authors have not mentioned any standard deviation in their article) g in all cases.13 In our present study, the mean (SD)
Results The detailed results are shown in Table 1.
Discussion The first interpositional graft was developed by Esmarch in the latter half of the 19th century. (quoted by11 ) The requirements for an ideal material for interposition should be that it is cost- effective, the cosmetic consequences of harvesting it should be minimal, it should be stable under masticatory
Fig. 5. Computed tomographic scan taken 6 months after operation and showing no signs of heterotopic calcification.
Please cite this article in press as: Bansal V, et al. Ultrasonography for the volumetric analysis of the buccal fat pad as an interposition material for the management of ankylosis of the temporomandibular joint in adolescent patients. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.06.019
Age (years)
Preoperative mouth opening (mm)/ unilateral (UL) or bilateral (BL) ankylosis
1
10
7/ UL
Technique of release and method of reconstruction or interposition
Pre- operative volume of buccal fat pad, right cheek (ml)
Pre-operative volume of buccal fat pad left cheek (ml)
Volume of fat interposed 15 days after operation (ml) (A)
Volume of fat interposed 6 months after operation (ml) (B)
% shrinkage of volume of fat interposed from 15 days to 6 months (A-B/A x100)
Follow up (months)
25
1.45
1.23 **
0.27
0.18
33
25
39
1.3 **
0.89
0.18
0.12
33
33
38
1.48 **
0.65
0.51
0.26
49
32
32
0.78*
1.88 **
0.67
0.28
58
25
26
1.03 **
0.76 *
0.29
0.26
10.3
33
32
0.86 **
0.91
0.57
0.51
10.5
36
35
1.23 **
1.29 **
0.87 **
0.68
0.41=right 0.39=left 0.45
21.1=right 9.3=left 2.1
28
39
0.52=right 0.43=left 0.46
33
0.89 **
1.27
0.29
0.2
31
33
30
0.58
0.93 **
0.32
0.23
28.1
29
28
0.93 **
1.39
0.41
0.3
25
29
29
0.52 *
0.63
31
0.44 *
0.45
Not included further in the study -
Not included further in the study -
32
20
Not included further in the study -
26
36
0.64 *
0.48
-
-
-
33
MGC (6-7mm)/ 25 BFP 2 12 0/ UL Gap arthroplasty + 34 CCG + BFP 17 0/ UL Gap arthroplasty + 26 3 CCG + BFP 4 11 4/ BL Bilateral MGC; 31 Left side - BFP & Right side –Temporalis 5 11 2/ BL Bilateral MGC; 25 Right side - BFP; Left side – Temporalis 30 17 3/ UL Gap Arthroplasty 6 + CCG + BFP 7 13 8/BL Bilateral MGC + 29 BFP 8 5 7/ UL Gap Arthroplasty 36 +CCG+BFP 9 14/ UL Gap Arthroplasty 30 9 +CCG+BFP 10 11 0/ UL Gap Arthroplasty 30 + CCG + BFP 11 13 9/ UL Gap Arthroplasty 16 + CCG + BFP Patients in whom the harvested buccal fat pad was too small for interposition: 12 13 5/ UL Gap arthroplasty + 23 SCG 13
10
6/UL
14
9
8/UL
Gap arthroplasty + CCG + TMFP Gap arthroplasty + CCG + TMFP
30
31
ARTICLE IN PRESS
Post-operative mouth opening after 6 months (mm)
Post-operative mouth opening after 15 days (mm)‘
V. Bansal et al. / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
Case No.
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Please cite this article in press as: Bansal V, et al. Ultrasonography for the volumetric analysis of the buccal fat pad as an interposition material for the management of ankylosis of the temporomandibular joint in adolescent patients. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.06.019
Table 1 Clinical and personal details of patients studied.
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Mean (SD) (n=19) 0.89 (0.36) Mean (SD) (n=19) 0.91 (0.34)
9
11
18
19
6/UL
4/UL 7 17
5/UL
10/UL 12 16
*=on operated side, **=on side on which buccal fat pad was interposed, and ***=patients in whom harvested buccal fat pad was insufficient for interposition (no further volumetric analysis and not included in the follow up study). CCG=costochondral graft, SCG=sternoclavicular graft, TMFP=temporalis myofascial flap, UL=unilateral ankylosis, BL=bilateral ankyloses, and MGC=minimal gap created.
28 0.68 37 21
0.79 *
23 0.83 * 35 24
0.93
24 0.9 33 20
0.84 *
25 0.3 35 21
0.28 *
28 0.8 0.74 * 37 23 2/UL 10 15
Gap arthroplasty + CCG + TMFP Gap arthroplasty + auricular cartilage Gap arthroplasty + CCG + TMFP Gap arthroplasty + CCG + TMFP Gap arthroplasty + CCG + TMFP
Post-operative mouth opening after 6 months (mm) Preoperative mouth opening (mm)/ unilateral (UL) or bilateral (BL) ankylosis Age (years) Case No.
Table 1 (Continued )
Technique of release and method of reconstruction or interposition
Post-operative mouth opening after 15 days (mm)‘
Pre- operative volume of buccal fat pad, right cheek (ml)
Pre-operative volume of buccal fat pad left cheek (ml)
Volume of fat interposed 15 days after operation (ml) (A)
Volume of fat interposed 6 months after operation (ml) (B)
% shrinkage of volume of fat interposed from 15 days to 6 months (A-B/A x100)
Follow up (months)
V. Bansal et al. / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
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volume on the right was 0.91 (0.34) ml and on left side it was 0.89 (0.36) ml, which correlates with earlier studies. Another finding was that among the bilateral cases in which the buccal fat was insufficient in 2 joints, the volumes were 0.78 ml and 0.76 ml, respectively. We noticed that the mean (SD) preoperative volume of 1.14 (0.33) ml (range 0.86-1.88 ml) on the side of the harvested fat pad, and in 10 joints in which the amount of fat was insufficient to obliterate the created gap, it was 0.64 (0.22) ml (range 0.28-0.84 ml). From this we can confirm that preoperative volumetric analysis by USG not only reduces the amount of exposure to radiation, but also prevents needless exploration of the buccal fat while planning the management of ankylosis of the TMJ. Our study of 22 joints differed from that of Stuzin et al in several ways.13 We studied live patients while they used fresh cadavers. Our patients had ankylosis of the TMJ that resulted in poor health and undernourishment. Our volumetric analysis was made with US, while they calculated the amount of water displaced by the fat. Our patients had a mean (SD) age of 11 (4) years, while they studied cadavers all of which were older than 60 years. As theirs was a cadaveric study all the fat could be extracted, but we were limited to the body and buccal part of the buccal fat pad that could be assessed by the USG. Babu et al.,14 created a minimal gap, and found that this, with interposition of temporalis muscle, gave satisfactory results. We also did a minimal gap arthroplasty (6-7 mm) with interposition of the buccal fat pad in 7 joints (Topazian’s15 stage I classification).15,16 Postoperatively, there was a progressive increase in the range of movement and little or no signs of heterotopic calcification on CT 6 months postoperatively. The benefit of this technique can be seen in the early mobilisation of the joint without an additional donor site. This helped us to realise that interposition material has an important role, and it is not just important to create a large gap when treating ankylosis of the TMJ. Gaba et al.,10 reported the problem of artefacts during the postoperative phase at 6 months when they were evaluating the buccal fat pad with MRI. We also noticed metal artefacts when we used MRI. However, we do not have the same problem with USG, and regard it as a more reliable, less invasive diagnostic tool. The percentage of shrinkage of interposed free fat varies from 20% in the frontal sinus to 33% in posterior lumbar surgery. These variations seem to be the result of loadbearing in the lumbar region.10 We noticed that the mean shrinkage was 28%, which may be because the buccal fat pad becomes fibrosed under the influence of masticatory forces. Dimitroulis described the use of free abdominal fat as an interpositional material in patients with ankylosis of the TMJ, and reported shrinkage of 50% in an MRI study and 29% on clinical evaluation of the joint during second-stage surgery.8 Improved mouth opening, from 4.9 (4.5) mm to 32.5 (5.0) mm, at a mean follow up of 31 (range 24 – 36) months with
Please cite this article in press as: Bansal V, et al. Ultrasonography for the volumetric analysis of the buccal fat pad as an interposition material for the management of ankylosis of the temporomandibular joint in adolescent patients. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.06.019
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little or no sign of heterotopic calcification on CT postoperatively suggests to us that the buccal fat pad has the properties of an ideal interpositional material. Comparable mean (SD) mouth opening (34.1 (2.4) mm) was noted in patients who had had a temporalis myofascial flap inserted. We know of no other reports of the use of USG in volumetric analysis of buccal fat pads, both before and after operation.
Conflict of Interest We have no conflict of interest. Ethics statement/confirmation of patients’ permission The institutional ethics committee approved the protocol. Written informed consent was obtained from the patients or their parents for publication in print and electronic form. References 1. Su-Gwan K. Treatment of temporomandibular joint ankylosis with temporalis muscle and fascia flap. Int J Oral Maxillofac Surg 2001;30:189–93. 2. 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 2011;69:1031–5. 3. Arakeri G, Kusanale A, Zaki GA, et al. Pathogenesis of post-traumatic ankylosis of the temporomandibular joint: a critical review. Br J Oral Maxillofac Surg 2012;50:8–12. 4. Singh V, Dhingra R, Sharma B, et al. Retrospective analysis of use of buccal fat pad as an interpositional graft in temporomandibular joint ankylosis: preliminary study. J Oral Maxillofac Surg 2011;69:2530–6.
5. Mehrotra D, Pradhan R, Mohammad S, et al. Random control trial of dermis-fat graft and interposition of temporalis fascia in the management of temporomandibular ankylosis in children. Br J Oral Maxillofac Surg 2008;46:521–6. 6. Danda AK, Ramkumar S, Chinnaswami R. Comparison of gap arthroplasty with and without a temporalis muscle flap for the treatment of ankylosis. J Oral Maxillofac Surg 2009;67:1425–31. 7. Wolford LM, Karras SC. Autologous fat transplantation around temporomandibular joint total joint prosthesis: preliminary outcomes. J Oral Maxillofac Surg 1997;55:245–52. 8. Dimitroulis G. A critical review of interpositional grafts following temporomandibular joint discectomy with an overview of the dermis-fat graft. Int J Oral Maxillofac Surg 2011;40:561–8. 9. Rattan V. A simple technique for use of buccal pad of fat in temporomandibular joint reconstruction. J Oral Maxillofac Surg 2006;64:1447–51. 10. Gaba S, Sharma RK, Rattan V, et al. The long-term fate of pedicled buccal pad fat used for interpositional arthroplasty in TMJ ankylosis. J Plast Reconstr Aesthet Surg 2012;65:1468–73. 11. Dimitroulis G. The interpositional dermis-fat graft in the management of temporomandibular joint ankylosis. Int J Oral Maxillofac Surg 2004;33:755–60. 12. Li ZB, Li Z, Shang ZJ, et al. Potential role of disc repositioning in preventing postsurgical recurrence of traumatogenic temporomandibular joint ankylosis: a retrospective review of 17 consecutive cases. Int J Oral Maxillofac Surg 2006;35:219–23. 13. Stuzin JM, Wagstrom L, Kawamoto HK, et al. The anatomy and clinical applications of the buccal fat pad. Plast Reconstr Surg 1990;85: 29–37. 14. Babu L, Jain MK, Ramesh C, et al. Is aggressive gap arthroplasty essential in the management of temporomandibular joint ankylosis?-a prospective clinical study of 15 cases. Br J Oral Maxillofac Surg 2013;51:473–8. 15. Topazian RG. Comparison of gap and interpositional arthroplasty in the treatment of temporomandibular joint ankylosis. J Oral Surgery 1966;24:405. 16. Chossegros C, Guyot L, Cheynet F, et al. Comparison of different materials for interposition arthroplasty in treatment of temporomandibular joint ankylosis surgery: long-term follow-up in 25 cases. Br J Oral Maxillofac Surg 1997;35:157–60.
Please cite this article in press as: Bansal V, et al. Ultrasonography for the volumetric analysis of the buccal fat pad as an interposition material for the management of ankylosis of the temporomandibular joint in adolescent patients. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.06.019
ARTICLE IN PRESS Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
Ultrasonography for the volumetric analysis of the buccal fat pad as an interposition material for the management of ankylosis of the temporomandibular joint in adolescent patients Vishal Bansal a,∗ , Avi Bansal a , Apoorva Mowar a , Sanjay Gupta b a
Department of Oral & Maxillofacial Surgery, Subharti Dental College, Swami Vivekanand Subharti University, NH-58, Meeurt By Pass Road, Meerut (Uttar Pradesh), 250005, India b Healthcare & Imaging Centre. 43, Shivaji Road, Near N.A.S. College, Meerut (Uttar Pradesh), India Accepted 16 June 2015
Abstract The aim of this study was to analyse preoperatively with ultrasound the minimum volume of buccal fat that would be required for interposition of a pad after gap arthroplasty, and to emphasise the value of such a pad in the management of ankylosis of the temporomandibular joint (TMJ) during a short term follow up. Nineteen patients with ankylosis of the TMJ (22 joints) were selected, whose mean (SD) mouth opening was 4.9 (3.7) mm. In 10 joints in which the mean (SD) volume of the buccal fat pad was 0.7 (0.2) ml, the harvested buccal fat was inadequate for interposition, so they were treated with other materials. The remaining 12 joints had a mean (SD) volume of 1.1 (0.3) ml, which gave enough fat for interposition after gap arthroplasty. Investigation with ultrasound at 15 days and 6 months postoperatively showed that the fat pad was viable and the volume had shrunk by 28%. The 6-month postoperative computed tomographic (CT) scan showed little or no heterotopic calcification. We conclude that a buccal fat pad with a preoperative mean (SD) volume of 1.1 (0.3) ml is easy to harvest as interposition material. At a mean follow up of the12 joints after 31 (range 24 - 36) months there was progressive improvement in mouth opening with a mean (SD) of 32.5 (5.0) mm, which established that a pedicled buccal fat pad is a stable, efficient, viable soft tissue barrier in the management of ankylosis of the TMJ. © 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Buccal fat pad; Temporomandibular joint ankylosis; Ultrasonography.
Introduction True ankylosis of the temporomandibular joint (TMJ) is one of the most upsetting articular conditions, which causes not ∗ Corresponding author at: Department of Oral & Maxillofacial Surgery, Subharti Dental College, Swami Vivekanand Subharti University, NH-58, Meeurt By Pass Road, Meerut (Uttar Pradesh) – 250005, India. Tel.: +91-121-2439052/121-2439043x2068; fax: +91 121 2439067/9837233950 (mobile). E-mail address: [email protected] (V. Bansal).
only functional but aesthetic, psychological, and physical disturbances as well. Management of the fused TMJ is still a challenge for maxillofacial surgeons, as they need to maintain a good permanent range of mandibular movements and correct the facial asymmetry.1 Ankylosis of the TMJ is not a single event, and authors have suggested many factors that can cause it.2 The meniscus plays a large part in preventing the adhesion of articular surfaces, but if it is damaged or displaced the condyle and glenoid fossa are more likely to fuse.3
http://dx.doi.org/10.1016/j.bjoms.2015.06.019 0266-4356/© 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Bansal V, et al. Ultrasonography for the volumetric analysis of the buccal fat pad as an interposition material for the management of ankylosis of the temporomandibular joint in adolescent patients. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.06.019
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The main goals of treatment are to establish the range of movement of the mandible and the function of the jaw, and to prevent recurrence, restore appearance, and achieve satisfactory growth potential and functional occlusion for the patient.4,5 Various surgical techniques have been described to achieve these goals, including ramus ostectomy, condylectomy, and gap arthroplasty. The use of an interposition material to minimise the risk of recurrence was suggested with, the idea being to minimise the dead space and preserve a barrier of soft tissue between the 2 raw surfaces and thereby reduce the chance of them reuniting. Various materials such as autogenous (temporalis myofascial flap, fascia lata, dermal graft, auricular graft, and buccal fat pad) and different alloplastic materials (gold foil, tantalum foil, Silastic®, and proplast/Teflon®) have been described and discussed, and all have their own advantages and disadvantages.6 Wolford and Karras7 and Dimitroulis8 discussed using fat from the abdomen or groins for interposition, and Rattan9 was the first to describe the technique of harvesting pedicled buccal fat pad in 2 patients with reankylosis of the TMJ. Advantages of this technique are its close proximity, and the lack of morbidity from a second surgical site. Gaba et al.10 investigated the fate of buccal fat pads with magnetic resonance imaging (MRI) for a year, but were able to assess only actual number of cases have been quoted and is not the percentage. 15 of their 23 joints because of metal artefacts. However, they did not include volumetric analysis and postoperative shrinkage in their study. On English literature search there are no available studies that have evaluated the minimum required amount of buccal fat required for interposition in ankylosis of the TMJ preoperatively, we designed this study using ultrasound (USG) as a diagnostic tool to investigate preoperatively the possibility of harvesting buccal fat in suitable volume, and its efficacy and fate as an interposition material. Computed tomography (CT) was also used after 6 months to rule out any sign of the heterotopic calcification that is responsible for reankylosis.
Fig. 1. Coronal computed tomographic image showing bilateral Sawhney’s type III ankylosis of the temporomandibular joint.
know the exact boundaries of the buccal and body parts of the fat pad. The landmarks for calculating the size of the pad were based on its character and its visibility on USG, which could be clearly distinguished from skin, subcutaneous tissue, muscle, and nearby structures. After fibreoptic intubation, we used the Al Kayat Bramley modification of the preauricular approach to expose the ankylotic mass using an aseptic technique. The patients were treated according to Kaban’s protocol. We used a standard technique to harvest the buccal fat pad. We prefer to stand in the 11 o’ clock position if the ankylosis is on the right, and the 1 o’ clock position if it is on the left. Under direct vision a periosteal elevator is inserted anteriorly in the subperiosteal plane at the anterior border of the coronoid process. After exposure and retraction at the level of the coronoid notch, the buccal fat pad is pushed outwards with the finger of the other hand placed intraorally, and bulges into the surgical field. This bulge helps to decide the correct plane of the pad. With the operator on the side being operating on, and under direct vision, the plane is opened using a
Patients and methods Nineteen patients with ankylosis of the TMJ (22 joints) were included in this prospective study. Their mean (SD) age was 11 (range 5- 17) years. It was explained to all the patients that if we failed to harvest enough buccal fat other substances could be used, and they or their parents gave informed consent. All patients were assessed for mouth opening and range of mandibular movement, and had a preoperative orthopantomograph and CT to assess the extent of the ankylotic mass (Fig. 1). All the cases were evaluated preoperatively by a single radiologist for volumetric analysis of the buccal fat pad. The ultrasound machine E-9 was manufactured by General Electonics (Bangalore, India) (Fig. 2). Patients were asked to fill the cheek with air, which helped the radiologist to
Fig. 2. Volumetric analysis of a buccal fat pad from the left cheek.
Please cite this article in press as: Bansal V, et al. Ultrasonography for the volumetric analysis of the buccal fat pad as an interposition material for the management of ankylosis of the temporomandibular joint in adolescent patients. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.06.019
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ARTICLE IN PRESS V. Bansal et al. / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
Fig. 3. Lateral gap osteotomy and sutured buccal fat pad.
blunt haemostat. The buccal fat pad is held with non-toothed forceps and the pedicled fat slowly teased out. Harvest of fat at the surgical site can be further eased by giving it a slight push posterolaterally with the finger of the other hand in the buccal vestibule behind the tuberosity. The gap created is completely filled with the harvested pedicled fat pad, and sutured with 4/0 nylon using a round-bodied needle to the glenoid fossa and medial soft tissue, and ensuring that the fat pad is interposed and completely covering the anterior, posterior, medial, and lateral surfaces of the stump of the ramus and the temporal bone (Fig. 3). Intraoperatively we ensure that the sutured buccal fat pad maintains its position with mandibular movements. After meticulous layered closure with resorbable and silk sutures, a pressure dressing is placed for 48 hours postoperatively. All patients who had interposition of a buccal fat pad alone were given mouth-opening exercises to be done from the first postoperative day. Those who had reconstruction with a costochondral graft started the exercises after 5 days. Patients were recalled for USG evaluation of the fat pad and its volume on the 15th day and 6 months (Fig. 4) postoperatively. A CT was also done at 6 months (Fig. 5) to evaluate any sign of heterotopic calcification.
3
Fig. 4. Ultrasound scan taken 6 months postoperatively to assess the amount of shrinkage of the buccal fat pad.
forces, have a minimal risk of infection, it should obliterate dead space, and should prevent recurrence caused by heterotopic calcification.12 We think that the pedicled buccal fat pad fulfills these requirements adequately. In a study by Stuzin et al13 of 12 fresh cadavers the mean (SD) weight of each fat pad was 9.3 (These values are obtained from the article of Stuzin (Ref. 13) and authors have not mentioned any standard deviation in their article) g, and the volume as measured by water displacement, 9.6 (These values are obtained from the article of Stuzin (Ref. 13) and authors have not mentioned any standard deviation in their article) ml. The difference between right and left was small, and the total mean (SD) weight was within 1.5 (These values are obtained from the article of Stuzin (Ref. 13) and authors have not mentioned any standard deviation in their article) g in all cases.13 In our present study, the mean (SD)
Results The detailed results are shown in Table 1.
Discussion The first interpositional graft was developed by Esmarch in the latter half of the 19th century. (quoted by11 ) The requirements for an ideal material for interposition should be that it is cost- effective, the cosmetic consequences of harvesting it should be minimal, it should be stable under masticatory
Fig. 5. Computed tomographic scan taken 6 months after operation and showing no signs of heterotopic calcification.
Please cite this article in press as: Bansal V, et al. Ultrasonography for the volumetric analysis of the buccal fat pad as an interposition material for the management of ankylosis of the temporomandibular joint in adolescent patients. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.06.019
Age (years)
Preoperative mouth opening (mm)/ unilateral (UL) or bilateral (BL) ankylosis
1
10
7/ UL
Technique of release and method of reconstruction or interposition
Pre- operative volume of buccal fat pad, right cheek (ml)
Pre-operative volume of buccal fat pad left cheek (ml)
Volume of fat interposed 15 days after operation (ml) (A)
Volume of fat interposed 6 months after operation (ml) (B)
% shrinkage of volume of fat interposed from 15 days to 6 months (A-B/A x100)
Follow up (months)
25
1.45
1.23 **
0.27
0.18
33
25
39
1.3 **
0.89
0.18
0.12
33
33
38
1.48 **
0.65
0.51
0.26
49
32
32
0.78*
1.88 **
0.67
0.28
58
25
26
1.03 **
0.76 *
0.29
0.26
10.3
33
32
0.86 **
0.91
0.57
0.51
10.5
36
35
1.23 **
1.29 **
0.87 **
0.68
0.41=right 0.39=left 0.45
21.1=right 9.3=left 2.1
28
39
0.52=right 0.43=left 0.46
33
0.89 **
1.27
0.29
0.2
31
33
30
0.58
0.93 **
0.32
0.23
28.1
29
28
0.93 **
1.39
0.41
0.3
25
29
29
0.52 *
0.63
31
0.44 *
0.45
Not included further in the study -
Not included further in the study -
32
20
Not included further in the study -
26
36
0.64 *
0.48
-
-
-
33
MGC (6-7mm)/ 25 BFP 2 12 0/ UL Gap arthroplasty + 34 CCG + BFP 17 0/ UL Gap arthroplasty + 26 3 CCG + BFP 4 11 4/ BL Bilateral MGC; 31 Left side - BFP & Right side –Temporalis 5 11 2/ BL Bilateral MGC; 25 Right side - BFP; Left side – Temporalis 30 17 3/ UL Gap Arthroplasty 6 + CCG + BFP 7 13 8/BL Bilateral MGC + 29 BFP 8 5 7/ UL Gap Arthroplasty 36 +CCG+BFP 9 14/ UL Gap Arthroplasty 30 9 +CCG+BFP 10 11 0/ UL Gap Arthroplasty 30 + CCG + BFP 11 13 9/ UL Gap Arthroplasty 16 + CCG + BFP Patients in whom the harvested buccal fat pad was too small for interposition: 12 13 5/ UL Gap arthroplasty + 23 SCG 13
10
6/UL
14
9
8/UL
Gap arthroplasty + CCG + TMFP Gap arthroplasty + CCG + TMFP
30
31
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Post-operative mouth opening after 6 months (mm)
Post-operative mouth opening after 15 days (mm)‘
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Case No.
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Please cite this article in press as: Bansal V, et al. Ultrasonography for the volumetric analysis of the buccal fat pad as an interposition material for the management of ankylosis of the temporomandibular joint in adolescent patients. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.06.019
Table 1 Clinical and personal details of patients studied.
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Mean (SD) (n=19) 0.89 (0.36) Mean (SD) (n=19) 0.91 (0.34)
9
11
18
19
6/UL
4/UL 7 17
5/UL
10/UL 12 16
*=on operated side, **=on side on which buccal fat pad was interposed, and ***=patients in whom harvested buccal fat pad was insufficient for interposition (no further volumetric analysis and not included in the follow up study). CCG=costochondral graft, SCG=sternoclavicular graft, TMFP=temporalis myofascial flap, UL=unilateral ankylosis, BL=bilateral ankyloses, and MGC=minimal gap created.
28 0.68 37 21
0.79 *
23 0.83 * 35 24
0.93
24 0.9 33 20
0.84 *
25 0.3 35 21
0.28 *
28 0.8 0.74 * 37 23 2/UL 10 15
Gap arthroplasty + CCG + TMFP Gap arthroplasty + auricular cartilage Gap arthroplasty + CCG + TMFP Gap arthroplasty + CCG + TMFP Gap arthroplasty + CCG + TMFP
Post-operative mouth opening after 6 months (mm) Preoperative mouth opening (mm)/ unilateral (UL) or bilateral (BL) ankylosis Age (years) Case No.
Table 1 (Continued )
Technique of release and method of reconstruction or interposition
Post-operative mouth opening after 15 days (mm)‘
Pre- operative volume of buccal fat pad, right cheek (ml)
Pre-operative volume of buccal fat pad left cheek (ml)
Volume of fat interposed 15 days after operation (ml) (A)
Volume of fat interposed 6 months after operation (ml) (B)
% shrinkage of volume of fat interposed from 15 days to 6 months (A-B/A x100)
Follow up (months)
V. Bansal et al. / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
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volume on the right was 0.91 (0.34) ml and on left side it was 0.89 (0.36) ml, which correlates with earlier studies. Another finding was that among the bilateral cases in which the buccal fat was insufficient in 2 joints, the volumes were 0.78 ml and 0.76 ml, respectively. We noticed that the mean (SD) preoperative volume of 1.14 (0.33) ml (range 0.86-1.88 ml) on the side of the harvested fat pad, and in 10 joints in which the amount of fat was insufficient to obliterate the created gap, it was 0.64 (0.22) ml (range 0.28-0.84 ml). From this we can confirm that preoperative volumetric analysis by USG not only reduces the amount of exposure to radiation, but also prevents needless exploration of the buccal fat while planning the management of ankylosis of the TMJ. Our study of 22 joints differed from that of Stuzin et al in several ways.13 We studied live patients while they used fresh cadavers. Our patients had ankylosis of the TMJ that resulted in poor health and undernourishment. Our volumetric analysis was made with US, while they calculated the amount of water displaced by the fat. Our patients had a mean (SD) age of 11 (4) years, while they studied cadavers all of which were older than 60 years. As theirs was a cadaveric study all the fat could be extracted, but we were limited to the body and buccal part of the buccal fat pad that could be assessed by the USG. Babu et al.,14 created a minimal gap, and found that this, with interposition of temporalis muscle, gave satisfactory results. We also did a minimal gap arthroplasty (6-7 mm) with interposition of the buccal fat pad in 7 joints (Topazian’s15 stage I classification).15,16 Postoperatively, there was a progressive increase in the range of movement and little or no signs of heterotopic calcification on CT 6 months postoperatively. The benefit of this technique can be seen in the early mobilisation of the joint without an additional donor site. This helped us to realise that interposition material has an important role, and it is not just important to create a large gap when treating ankylosis of the TMJ. Gaba et al.,10 reported the problem of artefacts during the postoperative phase at 6 months when they were evaluating the buccal fat pad with MRI. We also noticed metal artefacts when we used MRI. However, we do not have the same problem with USG, and regard it as a more reliable, less invasive diagnostic tool. The percentage of shrinkage of interposed free fat varies from 20% in the frontal sinus to 33% in posterior lumbar surgery. These variations seem to be the result of loadbearing in the lumbar region.10 We noticed that the mean shrinkage was 28%, which may be because the buccal fat pad becomes fibrosed under the influence of masticatory forces. Dimitroulis described the use of free abdominal fat as an interpositional material in patients with ankylosis of the TMJ, and reported shrinkage of 50% in an MRI study and 29% on clinical evaluation of the joint during second-stage surgery.8 Improved mouth opening, from 4.9 (4.5) mm to 32.5 (5.0) mm, at a mean follow up of 31 (range 24 – 36) months with
Please cite this article in press as: Bansal V, et al. Ultrasonography for the volumetric analysis of the buccal fat pad as an interposition material for the management of ankylosis of the temporomandibular joint in adolescent patients. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.06.019
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little or no sign of heterotopic calcification on CT postoperatively suggests to us that the buccal fat pad has the properties of an ideal interpositional material. Comparable mean (SD) mouth opening (34.1 (2.4) mm) was noted in patients who had had a temporalis myofascial flap inserted. We know of no other reports of the use of USG in volumetric analysis of buccal fat pads, both before and after operation.
Conflict of Interest We have no conflict of interest. Ethics statement/confirmation of patients’ permission The institutional ethics committee approved the protocol. Written informed consent was obtained from the patients or their parents for publication in print and electronic form. References 1. Su-Gwan K. Treatment of temporomandibular joint ankylosis with temporalis muscle and fascia flap. Int J Oral Maxillofac Surg 2001;30:189–93. 2. 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 2011;69:1031–5. 3. Arakeri G, Kusanale A, Zaki GA, et al. Pathogenesis of post-traumatic ankylosis of the temporomandibular joint: a critical review. Br J Oral Maxillofac Surg 2012;50:8–12. 4. Singh V, Dhingra R, Sharma B, et al. Retrospective analysis of use of buccal fat pad as an interpositional graft in temporomandibular joint ankylosis: preliminary study. J Oral Maxillofac Surg 2011;69:2530–6.
5. Mehrotra D, Pradhan R, Mohammad S, et al. Random control trial of dermis-fat graft and interposition of temporalis fascia in the management of temporomandibular ankylosis in children. Br J Oral Maxillofac Surg 2008;46:521–6. 6. Danda AK, Ramkumar S, Chinnaswami R. Comparison of gap arthroplasty with and without a temporalis muscle flap for the treatment of ankylosis. J Oral Maxillofac Surg 2009;67:1425–31. 7. Wolford LM, Karras SC. Autologous fat transplantation around temporomandibular joint total joint prosthesis: preliminary outcomes. J Oral Maxillofac Surg 1997;55:245–52. 8. Dimitroulis G. A critical review of interpositional grafts following temporomandibular joint discectomy with an overview of the dermis-fat graft. Int J Oral Maxillofac Surg 2011;40:561–8. 9. Rattan V. A simple technique for use of buccal pad of fat in temporomandibular joint reconstruction. J Oral Maxillofac Surg 2006;64:1447–51. 10. Gaba S, Sharma RK, Rattan V, et al. The long-term fate of pedicled buccal pad fat used for interpositional arthroplasty in TMJ ankylosis. J Plast Reconstr Aesthet Surg 2012;65:1468–73. 11. Dimitroulis G. The interpositional dermis-fat graft in the management of temporomandibular joint ankylosis. Int J Oral Maxillofac Surg 2004;33:755–60. 12. Li ZB, Li Z, Shang ZJ, et al. Potential role of disc repositioning in preventing postsurgical recurrence of traumatogenic temporomandibular joint ankylosis: a retrospective review of 17 consecutive cases. Int J Oral Maxillofac Surg 2006;35:219–23. 13. Stuzin JM, Wagstrom L, Kawamoto HK, et al. The anatomy and clinical applications of the buccal fat pad. Plast Reconstr Surg 1990;85: 29–37. 14. Babu L, Jain MK, Ramesh C, et al. Is aggressive gap arthroplasty essential in the management of temporomandibular joint ankylosis?-a prospective clinical study of 15 cases. Br J Oral Maxillofac Surg 2013;51:473–8. 15. Topazian RG. Comparison of gap and interpositional arthroplasty in the treatment of temporomandibular joint ankylosis. J Oral Surgery 1966;24:405. 16. Chossegros C, Guyot L, Cheynet F, et al. Comparison of different materials for interposition arthroplasty in treatment of temporomandibular joint ankylosis surgery: long-term follow-up in 25 cases. Br J Oral Maxillofac Surg 1997;35:157–60.
Please cite this article in press as: Bansal V, et al. Ultrasonography for the volumetric analysis of the buccal fat pad as an interposition material for the management of ankylosis of the temporomandibular joint in adolescent patients. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.06.019