Printer Friendly

INTERPOSITIONAL TEMPORALIS FASCIA FLAP: HOW EFFECTIVE IS IT IN TMJ ANKYLOSIS TREATMENT.

Byline: MUHAMMAD ASIF SHAHZAD M RAFIQUE CHATHA and AQIB SOHAIL

ABSTRACT

The aim of this study was to evaluate the efficacy of interpositional temporalis fascia flap in the management of TMJ ankylosis by assessing the maximal mouth opening prior and after the proce- dure and prevention of re-ankylosis after interpositioning. This case series study consisted of twenty one patients of TMJ ankylosis unilateral or bilateral irrespective of age and gender. It was carried out at the Oral and Maxillofacial Surgery Department Lahore Medical and Dental College Lahore from December 2010 to September 201. OPG and -D scan were the standard radiographs and were taken in every case. All the patients were treated surgically by temporalis fascia flap interpositional arthro- plasty. Inter-incisal distance (IID) / mouth opening were recorded preoperatively immediately after completion of operation and postoperatively at follow-up. An inter-incisal distance/ mouth opening of at least 5mm was achieved in all cases and showed no recurrence of ankylosis in any of the patients.

Interpositional arthroplasty using temporalis fascia flap is an effective and reliable method to prevent re-ankylosis. Temporalis fascia flap is available at the operative site easy to raise well vascularized reliable and shows better long term results.

Key Words: TMJ ankylosis Interpositional arthroplasty Temporalis fascia flap. INTRODUCTION

TMJ ankylosis can be described as a fusion of joint surface that can cause disabling problems in mastica- tion digestion speech and oral hygiene.12 When occurs during the growing periods it leads to varying degrees of facial deformity and psychological problems.4567

TMJ ankylosis may be classified by combination of location (intra articular or extra articular) type of tissue involved (bony or fibrous) and extent of fusion (com- plete or incomplete). Kazanjian8 classified ankylosis as true or false. Intra articular ankylosis most commonly occurs after trauma or rarely infection whereas extra articular occurs by a large variety of disorders including myogenic neurogenic inflammatory process and bone or soft tissue tumors.28

Various procedures have been described for the treatment of TMJ ankylosis. These include condylec- tomy gap arthroplasty interposition arthroplasty and total joint reconstruction using alloplastic or autogenous materials.9

Timing preference of procedure and policy of treat- ment varies from one center to another. However the main principle of management of TMJ ankylosis consists of resection of ankylosed segment use of interpositional material either autogenous or alloplastic and postop- eratively early and aggressive physiotherapy.1011

The aim of this study was to evaluate the efficacy of interpositional temporalis fascia flap in terms of pre- venting the recurrence of TMJ ankylosis and achieving adequate mouth opening in patients operated at Oral and Maxillofacial Surgery Unit of Lahore Medical and Dental College Lahore.

METHODOLOGY

The current study consisted of twenty one patients and was carried out at Oral and Maxillofacial Surgery Unit of Lahore Medical and Dental College Lahore from December 2010 to September 201.

The study involved only confirmed patients of TMJ ankylosis irrespective of their age and gender. Selection criteria included: Patients with restricted or nil mouth opening radiological evidence of TMJ ankylosis. Patients with evidence of fibrous ankylosis false ankylosis and recurrent cases were excluded.

Preoperative assessment included the clinical his- tory of patients physical and radiological examination. Data was collected regarding the cause of ankylosis facial asymmetry nature of union side affected and the time of onset of ankylosis. Measurement of maximum inter incisal distance/mouth opening were recorded preoperatively. The radiographic examination included orthopentomogram (OPG) and computed tomography (CT) with -D scan to determine the extent and type of ankylosis.

All the patients were treated surgically under gen- eral anesthesia with blind or fiberoptic nasotracheal intubation after taking written and informed consent of the procedure. Al-kayat and Bramely incision was used to gain access to the TMJ in all cases and for joint capsule T shaped incision was used (Fig 1) The ankylosed segment was removed using upper and lower osteotomy cuts and a gap of at least 15 mm was created between the roof of glenoid fossa and mandible (Fig 2). It was followed by ipsilateral coronoidectomy and a passive inter incisal opening of at least 5 mm was achieved. Contra lateral coronoidectomy was performed when necessary in accordance with Kaban's protocol. Finally the temporalis fascia flap of sufficient length was used as interpositional graft material (Fig ). The flap was rotated and sutured to the medial anterior and posterior margins of residual tissue at the site of arthroplasty (Fig 4). Layer wise closure was done and suction drain placed.

Inter incisal distance (IID)/mouth opening was noted immediately after completion of the procedure and also recorded postoperatively (Fig 5). Patients were routinely administered antibiotics for minimum of 7-10 days. All the patients were advised and guided for active and passive jaw exercises on second postoper- ative day for three to five times in a day. Patients were discharged on the third to fifth postoperative day with instructions and giving them wooden tongue spatulas for active and passive jaw physiotherapy. All patients were followed up for at least of six months. Data was analyzed using SPSS version 17. The qualitative vari- ables in the demographic data like gender and etiol- ogies were presented as proportions and percentages and quantitative variables like age were presented as means and standard deviation. No inferential test applied due to descriptive nature of the study.

TABLE 1: CHARACTERISTICS BEFORE AND AFTER TMJ ANKYLOSIS SURGERY

S. No.###Age###Gender###Joint involvement###Mouth opening###Mouth opening###Coronoidec-

###Preoperatively###Postoperatively###tomy

###01###08###M###Bilateral###06mm###35mm###Bilateral

###02###10###M###Unilateral (R)###05mm###35mm###Ipsilateral

###03###13###F###Unilateral (L)###03mm###35mm###Ipsilateral

###04###18###M###Unilateral (R)###06mm###35mm###Ipsilateral

###05###17###M###Unilateral (R)###08mm###35mm###Ipsilateral

###06###19###M###Bilateral###Nil###35mm###Bilateral

###07###16###F###Bilateral###Nil###35mm###Bilateal

###08###18###M###Unilateral (L)###06mm###35mm###Ipsilateral

###09###14###M###Unilateral (R)###05mm###35mm###Ipsilateral

###10###09###F###Unilateral (R)###03mm###35mm###Ipsilateral

###11###15###F###Unilateral (R)###09mm###35mm###Ipsilateral

###12###19###M###Unilateral (L)###05mm###35mm###No

###13###25###M###Unilateral (L)###09mm###35mm###Ipsilateral

###14###10###F###Unilateral (R)###4mm###35mm###Ipsilateral

###5###19###M###Bilateral###05mm###35mm###Unilateral (R)

###16###8###M###Unilateral (L)###06mm###35mm###Ipsilateral

###17###14###F###Bilateral###06mm###35mm###Bilateral

###18###13###M###Unilateral (L)###08mm###35mm###Ipsilateral

###19###09###M###Unilateral (L)###03mm###35mm###Ipsilateral

###20###12###M###Unilateral (L)###05mm###35mm###Ipsilateral

###21###14###M###Unilateral (R)###06mm###35mm###Ipsilateral

RESULTS

Twenty one patients with TMJ ankylosis were included in our study. 15 were males and 06 females. TMJ ankylosis was unilateral in 16 (76.19%) patients and bilateral in 5 (2.81%) patients. Majority of the patients were in 2nd decade of life (15) followed by 1st decade (05) and rd decade (01). Trauma/fall was the etiological factor in all the cases (21). All the patients showed inter incisal distance/ mouth opening of at least 5mm postoperatively (Table 1).

DISCUSSION

Early ankylosis of TMJ in children can be a de- terrent to normal mandibular growth. Therefore early diagnosis of TMJ ankylosis and early surgical intervention is important. In the clinical studies the most common seen cause of TMJ ankylosis is trauma and infection. Although joint infection has decreased nowadays it is still a cause of disease especially in developing and underdeveloped countries.1 Trauma is an important cause of the disease both in developing and developed west countries in especially 21-0 age group exhibiting a prevalence of 1-86% more often in males.4 Management of TMJ ankylosis requires aggressive surgical intervention without compromise. Various techniques for the management of TMJ anky- losis have been described. Moorthy and Finch1 broadly classified the usual treatment of ankylosis of the tem- poromandibular joint in three groups: a) Condylectomy b) Gap arthroplasty c) Interpositional arthroplasty.

Abul Hassan et al12 studied the surgical anatomy and blood supply of fascial layers of temporal region. They found that temporalis fascia is supplied solely by the middle temporal artery which is a branch of superficial temporal artery and arises 1- cm below the upper border of zygomatic arch runs always superficial to the arch and enters the temporalis fascia immediately above that layer's attachment to the zygomatic arch. We have used this temporalis fascia in all the patients included in the current study and found this layer to be substantial with robust blood supply and satisfactory arc of rotation to fill in the defect of ostectomy.

Topazian's1 review of gap arthroplasty without interposition reported a recurrence rate as high as 5% pertaining to condylectomy as method of treat- ment. He narrated that the zone of excision should be sufficiently wide to prevent ankylosis and shall produce insignificant change in the vertical height of mandible. Rajgopal and associates14 suggested radical condyle and neck removal as well as coronoidectomy in order to reduce reankylosis. Numerous surgeons agree that the recurrent ankylosis is less likely if material is interposed between the divided bone ends. Controver- sy arises over whether to place alloplastic materials (Proplast Teflon Silastic Methyl methacrylate etc.) or autogenous tissues (fascia lata muscle full thickness skin or cartilage) into the defect.15-19 The alloplastic materials have the problems associated with the use of foreign body as well as those of displacement and extrusion.

Smith and associates20 reported implant erosion into the middle cradial fossa. The histology of these implants displayed an exuberant giant cell inflammation that erodes bone. Such erosions can be treated with an insert of temporalis fascia over the glenoid fossa. The use of biological materials contains the problems of degeneration and fibrosis with time resulting in reankylosis. Demir et al21 used preserved costal cartilage homograft for the treatment of TMJ ankylosis with good functional results and without donor site morbidity and no recurrence over a 4 years follow up. The reliable supply of optimally preserved homologous costal cartilage might not be possible at all set ups. More importantly as the cartilage is no longer considered "immunologically privileged" there will be problems of antigen antibody reaction leading to late resorption of graft that may lead to recurrence of ankylosis in the end.

Huang IY et al22 have quoted the results of studies that suggest that grafted cartilage does evoke transplantation antigens and that the rejec- tion response is merely delayed by the physical barrier that the matrix interposes between the chondrocytes and the cells of immune surveillance system of the recipient host. The temporalis fascia flap however is an axial flap which is available at the operative site and is easy to raise and quick to execute. We have used this vascularized flap as it shows fewer chances of subsequent absorption and fibrosis. The follow up of patients did not show relapse or recurrence of ankylosis in the long run.

It is recommended that TMJ ankylosis should be dealt with early aggressive surgical intervention using temporalis fascia flap interpositional arthroplasty with ipsilateral or contralateral coronoidectomy followed by early mobilization of the joint. It results not only in satisfactory mouth opening and jaw function but also ensures in reduction of re-ankylosis.

CONCLUSION

Interpositional arthroplasty using the locally avail- able temporalis fascia flap is an effective and reliable method to prevent recurrence of ankylosis. Advantages of this vascularized flap include close proximity to the TMJ without involving an additional surgical site ad- equate blood supply autogenous origin easy to raise and quick to execute. It obviates the disadvantages of alloplastic materials as well as non vascularized autogenous tissues.

REFERENCES

1 Moorthy AP Finch LD. Interpositional arthroplasty for anky- losis of the temporomandibular joint. Oral Surg Oral Med Oral Pathol 198; 55: 545-52.

2 Kaban LB Perrott DH Fisher K. A protocol for management of temporomandibular joint ankylosis. J Oral Maxillofac Surg 1990; 48: 145-51.

Chidzonga MM. Temporomandibular joint ankylosis: review of thirty-two cases. Br J Oral Maxillofac Surg 1999; 7: 12-6.

4 Roychoudhury A Parkash H Trikha A. Functional restoration by gap arthroplasty in temporomandibular joint ankylosis: a report of 50 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999; 87: 166-9.

5 Smith JA Sandler NA Ozaki WH Braun TW. Subjective and objective assessment of the temporalis myofascial flap in pre- viously operated temporomandibular joints. J Oral Maxillofac Surg 1999; 57: 1058-65.

6 Brusati R Raffaini M Sesenna E Bozetti A. The temporalis muscle flap in temporomandibular joint surgery. J Craniomax- illofac Surg 1990; 18: 52-8.

7 Su-Gwan K. Treatment of temporomandibular joint ankylosis with temporalis muscle and fascia flap. Int J Oral Maxillofac Surg 2001; 0: 189-9.

8 Balaji SM. Modified temporalis anchorage in craniomandibular reankylosis. Int J Oral Maxillofac Surg 200; 2: 480-85. 9 Tuncel U Ozgenel GY. Use of Human Amniotic Membrane as an Interpositional Material in Treatment of Temporomandibular Joint Ankylosis. J Oral Maxillofac Surg 2011; 69: 58-66.

10 Bayat M Badri A Moharamnejad N. Treatment of temporo- mandibular joint ankylosis: gap and interpositional arthroplasty with temporalis muscle flap. J Oral Maxillofac Surg 2009; 1: 207-12.

11 Yazdani J Ali Ghavimi M Pourshahidi S Ebrahimi H. Compar- ison of clinical efficacy of temporalis myofascial flap and dermal graft as interpositional material in treatment of temporoman- dibular joint ankylosis. J Craniofac Surg 2010; 21: 1218-20.

12 Abul-Hassan S. Hussain MD Grace Von Dras Ascher AMI and Robert D. Acland MD. Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg 1986; 77: 17-28.

1 Topazian R.G. Etiology of ankylosis of temporomandibular joint: analysis of 44 cases. J Oral Surg 1964; 22: 227-2.

14 Rajgopal A Banerjee P.K Baluria V and Sural A. Temporoman- dibular joint ankylosis: A report of 15 cases. J Oral Maxillofacial Surg 198; 11: 7-42.

15 Saeed N Hensher R McLeod N Kent J. Reconstruction of the temporomandibular joint autogenous compared with alloplastic. Br J Oral Maxillofac Surg 2010; 40: 296-9.

16 Erol B Tanrikulu R GAlrgA1/4n B. A clinical study on ankylosis of the temporomandibular joint. J Craniomaxillofac Surg 2006; 4: 100-6. 17 Zhi K Ren W Zhou H Gao L Zhao L et al. Management of temporomandibular joint ankylosis: 11 years' clinical experience. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009; 108: 687-92.

18 Babu L Jain MK Ramesh C Vinakaya N. Is aggressive gap arthroplasty essential in the management of temporomandibular ankylosis A prospective clinical study of 15 cases. Br J Oral Maxillofac Surg. 201; 51: 47-8.

19 Tripathy S Yaseen M Singh NN Bariar LM. Interposition ar- throplasty in post-traumatic temporomandibular joint ankylosis: A retrospective study. Indian J Plast Surg 2009; 42: 182-7.

20 Smith RM Goldwasser MS and Sabol Sr. Erosion of Teflon Proplast implant into the middle cranial fossa. J Oral Maxillofac Surg 199; 51: 1268-72.

21 Demir Z Velidedeoglu H Sahin U Kurtay A. Coskunfirat OK. Preserved costal cartilage homograft application for the treat- ment of temporomandibular joint ankylosis. Plast Reconstr Surg 2001; 108: 44-51.

22 Huang IY Lai ST Shen YH Worthington P. Interpositional arthroplasty using autogenous costal cartilage graft for tem- poromandibular joint ankylosis in adults. Int J Oral Maxillofac Surg 2007; 6: 909-15.
COPYRIGHT 2014 Asianet-Pakistan
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2014 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Publication:Pakistan Oral and Dental Journal
Article Type:Report
Geographic Code:9PAKI
Date:Dec 31, 2014
Words:2496
Previous Article:ANGULAR CHEILITIS: CASE REPORTS AND LITERATURE REVIEW.
Next Article:CONGENITAL MALFORMATIONS ASSOCIATED WITH CLEFT LIP AND PALATE.
Topics:

Terms of use | Privacy policy | Copyright © 2019 Farlex, Inc. | Feedback | For webmasters