Printer Friendly

A COMPARATIVE STUDY OF GAP and INTERPOSITIONAL ARTHROPLASTY WITH TEMPORALIS MYOFACIAL FLAP FOR TMJ ANKYLOSIS TREATMENT.

Byline: SUNEEL KUMAR PUNJABI, KASHIF ALI CHANNAR, AMBREEN MUNIR and QADEER-UL-HASSAN

ABSTRACT

The objects of this study were to evaluate the effectiveness of gap and interpositional arthroplasty with temporalis myofascial flap in the treatment of the temporomandibular joint (TMJ) ankylosis.

This descriptive case series study consisted of twenty five patients. It was carried out at Oral and Maxillofacial Surgical Department, Liaquat University of Medical and Health Sciences, Jamshoro, Sindh from January 2010 to December 2012. Orthopantomogram (OPG) and 3-D Scan was the standard radiograph and was taken in every case. Nineteen had unilateral and six bilateral TMJ ankylosis.

Most patients were in 2nd decade of life age group (16); followed by 3rd decade (05) and 1st decade of life (04). 18 were female and 7 were male; Major etiological factor was fall (21) followed by forceps delivery (03) and ear infection (01).

Inter-incisal distance (IID)/mouth opening were noted preoperatively, immediately after completion of operation that was 35mm and postoperatively at follow-up. The incidence of TMJ ankylosis varies from country to country and closely related to the social and financial issues of the patients. TMJ ankylosis is challenging problem for the patient, as for the surgeon.

Over the years many modifications were made in TMJ surgery for better results and Gap arthoplasty with temporalis myofascial flap as the interpositional graft is one of common treatment modality which is done at our center.

Key Words: TMJ ankylosis, Arthoplasty, Temporal Myofascial Flap.

INTRODUCTION

Ankylosis of the Temporomandibular joint (TMJ) is disfiguring and distressing condition which usually affects the growing childrens.1

Different factors have been attributed to the condition, such as intracapsular condylar fracture, advanced cases of arthritis, birth trauma from obstetric forceps, ear infection and most common etiological factor is previous trauma, particularly to the chin area in young age.2,3,4

According to Kazanjiian VH5 and Sawhney CP6 ankylosis is divided into two types; true (intra-articular) and false (extraarticular).

True ankylosis has been further divided as type I, II, III and IV. In type I condyle is medially angulated and deformed articular fossa together with a mild-to-moderate amount of new bone formation, Type II no recognizable condyle or fossa but a large mass of new bone is present, Type III ankylosis usually results from a medially displaced fracture dislocation with bone bridging the mandibular ramus to the zygomatic arch, while type IV joint architecture is completely covered by bone with fusion of structures i e; zygomatic arch, glenoid fossa, coronoid fossa, condyle and sigmoid notch.5

The patients with temporomandibular joint ankylosis usually have food intake, digestion, communication, maintaining oral hygiene, rampant caries, facial deformity and psychosocial problems due to limited mouth opening.7

Various radiographs are taken for diagnosis purpose of TMJ ankylosis like; Posterio-anterior View, lateral oblique View, orthopentogram (OPG), CT scan and three dimensional CT scan but recently orthopentogram (OPG), three dimensional CT prior to surgery has been encouraged.8,9

Timing, preference of type of procedure and the policy of treatment vary from one center to another however, the main principles of management of TMJ ankylosis consist of resection of the ankylosed segment, use of interpositional material either alloplastic or allogeneic, and early, aggressive and tenacious postoperative physiotherapy.10

This study was first one done at this center and purpose was to evaluate the results of Gap arthoplasty with interpositional graft among patients operated at the Oral and Maxillofacial surgery Unit, Liaquat University of Medical and Health Sciences, Jamshoro, Sindh.

METHODOLOGY

This descriptive case series study consisted of twenty five patients and was carried out at Oral and Maxillofacial Surgical Unit of Liaquat University of Medical and Health Sciences, Jamshoro, Sindh from January 2010 to December 2012. A detailed history and systematic clinical examination was carried out after taking consent from patient or patient's attendant. Orthopantomogram (OPG) and 3-D Scan were the standard radiographs and were taken in every case.

Only confirmed patients of TMJ ankylosis, irrespective of age and gender, were included in the study and recurrent cases of ankylosis were excluded.

All study subjects were operated under general anesthesia with blind nasotracheal intubation or fiberoptic nasotracheal intubation.

Surgical approach to the TMJ was Al-Kayat and Bramley and for joint capsule T-shaped incision used, after approaching to joint ankylotic mass was cut and at least 10mm gap created between the ramus and base of skull and finally temporalis myofascial flap was used as interpositional graft material.

Inter-incisal distance (IID)/mouth opening were noted immediately after completion of the operation and recorded, postoperatively. Patients were routinely administered antibiotics for minimum 7-10 days.

All patients were advised and guided for active and passive jaw exercises three to five times in a day. Patients were discharged on the 5th or 7th postoperative day with instructions and giving them wooden spatula for active and passive jaw physiotherapy with minimum inter-incisal mouth opening of 30 to 35mm. Every patient was reviewed up to six months.

DATA ANALYSIS PROCEDURE

Data were analyzed in statistical program for social sciences (SPSS) version 11.0. The frequency and percentage was computed for qualitative variables, like gender, etiologies. Mean+- standard deviation was computed for qualitative variables, like age. No inferential test applied due to descriptive statistics.

RESULTS

Twenty five patients presented with TMJ ankylosis, nineteen had unilateral and six bilateral TMJ ankylosis.

Most patients were in 2nd decade of life age group (16); followed by 3rd decade (05) and 1st decade of life (04). 18 were female and 7 were male; Major etiological factor was fall (21) followed by forceps delivery (03) and ear infection (01). Table 1 shows the results.

Table 1 showing the characteristics before and after

TMJ ankylosis Surgery

DISCUSSION

There was not only the speech impairment issue with TMJ ankylosis but failure to treat properly could result in difficulties with mastication, poor oral hygiene, rampant caries, facial and mandibular growth disturbances and airway compromise which is constant threat to the patient's life.11,12

According to Sawhney CP6 and Li13 TMJ ankylosis is a quite common condition of younger age group, condylar fractures of mandible were main etiological factor.

In the present study 72% patients were female (n=18) and 28% were male (n=07). These results are similar to the studies conducted by Cheema7 and Tanrikulu14 but differ with the studies of Vasconcelos15 where gender was equally divided.

Some researchers have stated that the frequency of TMJ ankylosis in developing countries like Pakistan16,

TABLE 1: CHARACTERISTICS BEFORE AND AFTER TMJ ANKYLOSIS SURGERY

S.###Age###Gender###Etiology###Joint In-###Mouth Opening###Mouth Open-###Coronoid-

No.###volvement###Preoperatively###ing Postopera-###ectomy

###tively

01###11###F###fall###Unilateral###10mm###Less than 35mm###Ipsilateral

02###13###F###fall###Unilateral###11mm###Less than 35mm###Ipsilateral

03###11###F###fall###Unilateral###11mm###Less than 35mm###No

04###12###F###fall###Unilateral###12mm###Less than 35mm###No

05###14###F###Ear Infection###Unilateral###10mm###Less than 35mm###Ipsilateral

06###16###F###fall###Unilateral###10mm###Less than 35mm###Ipsilateral

07###18###F###fall###Unilateral###10mm###Less than 35mm###Ipsilateral

08###19###M###fall###Bilateral###10mm###Less than 35mm###Ipsilateral

09###11###M###Forceps Delivery###Bilateral###10mm###Less than 35mm###Ipsilateral

10###13###M###fall###Unilateral###10mm###Less than 35mm###Ipsilateral

11###14###F###fall###Unilateral###10mm###Less than 35mm###Ipsilateral

12###22###F###fall###Unilateral###10mm###Less than 35mm###Ipsilateral

13###27###F###fall###Bilateral###10mm###Less than 35mm###Ipsilateral

14###28###F###fall###Bilateral###15mm###Less than 35mm###Bilateral

15###25###M###fall###Unilateral###11mm###Less than 35mm###Ipsilateral

16###24###F###fall###Bilateral###09mm###Less than 35mm###Bilateral

17###09###F###Forceps Delivery###Bilateral###13mm###Less than 35mm###Ipsilateral

18###13###M###fall###Unilateral###11mm###Less than 35mm###Ipsilateral

19###11###M###Forceps Delivery###Bilateral###12mm###Less than 35mm###Bilateral

20###12###M###fall###Unilateral###10mm###Less than 35mm###Ipsilateral

21###08###F###fall###Unilateral###10mm###Less than 35mm###Ipsilateral

22###16###F###fall###Unilateral###12mm###Less than 35mm###Bilateral

23###09###F###fall###Unilateral###10mm###Less than 35mm###Ipsilateral

24###10###F###fall###Unilateral###10mm###Less than 35mm###Ipsilateral

25###11###F###fall###Unilateral###08mm###Less than 35mm###Ipsilateral

China17, and Africa18 is greater than seen in developed countries.

Usually treatment of TMJ ankylosis is divided into three main categories i.e, gap arthroplasty, interpositional arthroplasty, and total joint reconstruction with or auto or alloplastic materials.15 Every procedure has its advantages and disadvantages. Gap arthroplasty is simpler and less time consuming procedure as compared to other two procedures.19 Study conducted by Roychoudhury et al with the sample size of 50 patients treated with gap arthroplasty showed 30 mm postoperative mean of MIO and one patient had reankylosis.20

Many materials like skin grafts, temporalis muscle or temporalis fascia, cartilage (homologous), silastic sheets, silicone or acrylic implants have been used since long time as interpositioning materials.14,21

The overall choice of interpositioning material, easy availability and material which causes minimal donor site morbidity. Silastic is one of alloplastic material used as interpositional graft, the risk of foreign body reaction and extrusion exists while dermis autogenous material causes donor site morbidity.19,24 Third method used in the treatment of TMJ ankylosis is reconstruction with TMJ prosthesis.

Many studies have shown that Condylar replacement alone is not sufficient for reconstruction of temporomandibular joint because there are chances of eroding glenoid fossa and extensive heterotopic bone formation within the joint.22 Total joint replacement must be used, including ramus and fossa components but this method has also some side effects namely hardware loosening, foreign body reaction, and heterotopic bone formation around alloplastic devices.22,23

In TMJ ankylosis postoperative rehabilitation is equally important and attention must be paid to prevent failure. Early mobilization or postoperative jaw exercises, use of analgesic and anti-inflammatory medications are necessary to reduce the postoperative pain. They play major role in prevention of reankylosis.21

CONCLUSION

The incidence of TMJ ankylosis varies from country to country and is closely related to the social and financial issues of the patients.

TMJ ankylosis is challenging problem for the patient, for their parents as well as for the surgeon.

Over the years many modifications have been made in TMJ surgery for better results and Gap arthoplasty with temporalis myofascial flap as the interpositional graft is one of the common treatment modality which is done at this center.

REFERNCES

1 Roychoudhury A, Parkash H, Trikha A. Functional restoration by gap arthroplasty in temporomandibular joint ankylosis. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 1999; 87: 166-69.

2 Silver CM, Motamed M, Carlotti AE. Arthroplasty of the temporomandibular joint with use of vitalium condyle prosthesis. J Oral Surg 1977; 35: 909-913.

3 Obiechina AE, Arotiba JT, Fasola AO. Ankylosis of the temporomandibular joint as a complication of forceps delivery: report of a case. West Afr J Med 1999; 18: 144-146.

4 Ansari SR, Iqbal S, Aslam S. Surgical correction of TMJ ankylosis. A study on the incidence and evaluation of success rates of various surgical procedures. Pak Oral Dent J 2003; 23(2): 105-12.

5 Kazanjiian VH. Ankylosis of the temporomandibular joint. Surg, Gynecol, Obstet 1938; 67: 333-48.

6 Sawhney CP. Bony ankylosis of the temporomandibular joint: Follow up of 70 patients treated with Arthroplasty and acrylic spacer interposition. Plast Reconst Surg 1986; 77: 29-38.

7 Cheema SA. Temporal fascia as interpositioning material in cases of temporomandibular ankylosis. J Coll Physicians Surg Pak 2005; 15(2): 89-91.

8 de Bont LG, van der Kuijl B, Stegenga B, Vencken LM, Boering G. Computed tomography in differential diagnosis of temporomandibular joint disorders. Int J Oral Maxillofac Surg 1993; 22: 200-209.

9 Gorgu M, Erdogan B, Akoz T, Kosar U, Dag F. Threedimensional computed tomography in evaluation of ankylosis of the temporomandibular joint. Scand J Plast Reconst Surg 2000; 34: 117-120.

10 Orhan Gu Ven. Treatment of temporomandibular joint ankylosis by a modified fossa prosthesis. J Crani Maxillofac Surg. 2004; 32: 236-42.

11 Lapenz EN, Dogliotti PL, Mariana SM. Treatment of temporomandibular joint ankylosis by arthroplasty and mandibular distraction in children: our protocol of treatment. Rev Soc Bras Cir Craniomaxilofac 2006; 9: 14-18.

12 Posnick JC, Goldstein JA. Surgical management of temporomandibular joint ankylosis in the pediatric population. Plast Reconstr Surg. 1993; 91: 791-98.

13 Li ZB, Li Z, Shang ZJ, Zhao JH, Dong YJ. 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.

14 Tanrikulu R, Erol B, Gorgun B, Soker M. The contribution to success of various methods of treatment of temporomandibular joint ankylosis (a statistical study containing 24 cases). Turk J pediatr 2005; 47: 261-65.

15 Vasconcelos BCE, Bessa-Nogueira RV, Cypriano RV. Treatment of temporomandibular joint ankylosis by gap arthroplasty. Med Oral Pathol Oral Cir Bucal 2006; 11: 66-69.

16 Warraich RA, Cheema SA. Temporomandibular joint ankylosisA preventable entity? Ann KE Med Coll 2001; 7: 168-69.

17 Long X, Li X, Cheng Y, Yang X, Qin L, Qiao Y, et al. Preservation of disc for treatment of traumatic temporomandibular joint ankylosis. J Oral Maxillofac Surg 2005; 63(7): 897-902.

18 Ferretti C, Bryant R, Becker P, Lawrence C. Temporomandibular joint morphology following post-traumatic ankylosis in 26 patients. Int J Oral Maxillofac Surg 2005; 34: 376-81.

19 Kaban LB, Perrott DH, Fisher K. A protocol for management of temporomandibular joint ankylosis. J Oral Maxillofac Surg 1990; 48: 1145-51.

20 Roychoudhury A, Parkash H, Trikha A. Functional restoration by gap arthroplasty in temporomandibular joint ankylosis. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 1999; 87: 166-69.

21 Mansoor N, Khan M, Mehboob B, DIN B. Gap Vs Interpositional arthroplasty in the management of temporomandibular joint ankylosis. Pak Oral Dent J. 2013; 33: 8-12.

22 Westermark A, Koppel D, Leiggener C. Condylar replacement alone is not sufficient for prosthetic reconstruction of the temporomandibular joint. Int J Oral Maxillofac Surg. 2006; 35: 488-92.

23 Sembronio S, Albiero AM, Polini F, Robiony M, Politi M. Intraoral endoscopically assisted treatment of temporomandibular joint ankylosis: preliminary report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007; 104: e7-10.

24 Bayat M, Badri A, Moharamnejad N. Treatment of temporomandibular joint ankylosis: gap and interpositional arthroplasty with temporalis muscle flap. Oral Maxillofac Surg. 2009; 13: 207-12.

For Correspondence: 1Dr Suneel Kumar Punjabi, Assistant Professor, Department of Oral and Maxillofacial Surgery, Liaquat University of Medical and Health Sciences, Jamshoro, Sindh

Res: 307, 3rd floor, Citizen Plaza near Aga Khan Hospital, Main Jamshoro Road, Hyderabad, Sindh Cell: 0333-3603176

Assistant Professor Department of Oral and Maxillofacial Surgery

Associate Professor Department of General Surgery

Associate Professor Department of Oral and Maxillofacial Surgery Email: drsunilpanjabi@yahoo.com
COPYRIGHT 2013 Asianet-Pakistan
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2013 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Title Annotation:temporomandibular joint
Author:Punjabi, Suneel Kumar; Channar, Kashif Ali; Munir, Ambreen; Qadeer-Ul-Hassan
Publication:Pakistan Oral and Dental Journal
Article Type:Report
Geographic Code:9PAKI
Date:Dec 31, 2013
Words:2429
Previous Article:TREATMENT OUTCOMES OF RECONSTRUCTION WITH ILIAC BONE GRAFT AND RIB GRAFT IN PATIENTS WITH MANDIBULAR DEFECTS.
Next Article:FREQUENCY AND MANAGEMENT OF TEMPOROMANDIBULAR JOINT ANKYLOSIS: A STUDY CONDUCTED OVER THE PERIOD OF 13 YEARS.
Topics:

Terms of use | Privacy policy | Copyright © 2021 Farlex, Inc. | Feedback | For webmasters