Interpositional dermatofat graft for the treatment of ankylosis of the temporomandibular joint (2023)

Clinical Article
temporomandibular disorders

Intermediate dermatofatty graft in the treatment of temporomandibular joint ankylosis
  • Treatment of pediatric ankylosis

    2023, Journal of Oral Biology and Craniofacial Research

    Temporomandibular joint (TMJ) ankylosis is one of the most debilitating pathological conditions of the face and jaw, characterized by the replacement of the normal architecture of the temporomandibular joint (TMJ) by fibrous or bony tissue. The incidence of TMJ is more common in the pediatric population [first and second decade of life] and is frequently associated with maxillofacial trauma. Comprehensive management includes a thorough evaluation of the associated anatomy of the ankylotic mass and other relevant details, such as the presence or absence of obstructive sleep apnea. Categorizing patients based on these variables helps select an appropriate surgical procedure. Various resective and reconstructive surgical techniques are discussed; along with its merits and demerits. Long-term physiotherapy, long-term clinical follow-up and adequate family counseling are fundamental pillars for success. In this review, the authors present an algorithmic approach to the evaluation and treatment of pediatric temporomandibular joint syndrome. Appropriate evidence-based recommendations are made to select the optimal surgical procedure.

  • Results of total alloplastic joint reconstruction in temporomandibular ankylosis

    2022, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology

    The aim of this study was to evaluate the subjective and objective outcomes in patients with temporomandibular joint (TMJ) ankylosis treated with alloplastic TMJ (TMJ) reconstruction.

    All patients diagnosed with TMJ ankylosis who underwent TMJ reconstruction in our service between 2010 and 2019 were retrospectively reviewed. Patients were divided into 2 cohorts: bone and fibrous ankylosis. The subjective variables evaluated were facial and headache pain, temporomandibular joint pain, jaw function, diet, and disability. The objective variables evaluated were the maximum interincisal opening and the lateral excursions. The Mann-Whitney test was used to analyze subjective variables and the unpaired t test to analyze objective variables. P<0.05 was considered statistically significant.

    Twenty-eight patients met the inclusion criteria (21 women, 7 men). The mean age at surgery was 42 years and the mean number of previous TMJ surgeries was 3. A total of 52 TMJ surgeries were performed on the 28 patients and the mean follow-up was 46 months. All subjective variables improved significantly and the mean maximum interincisal opening increased from 16.9 mm to 37.25 mm.

    The results of the study indicate that TMJR is an effective and reliable method of treating osseous and fibrous ankylosis of TMJ.

  • Treatment of heterotopic ossification of the temporomandibular joint: a new protocol with multimodal therapy based on a review of the literature and presentation of a single case.

    2022, Journal of Oral and Maxillofacial Surgery

    The aim of this study was to establish a treatment protocol for TMJ heterotopic ossification (HO) cases, particularly those that do not respond to current TMJ-HO protocols. Furthermore, we demonstrate the success of this protocol in a unique case of recurrent HO, where several TMJ-HO protocols failed in the context of an improvised explosive device (IED) blast on a wounded warrior.

    An electronic literature search was performed through PubMed and Web of Science. Twenty-five studies were identified to provide supporting evidence for a current proposed protocol for the treatment of refractory TMJ HO. The authors present a case report of a wounded warrior with HO ankylosis of the bilateral temporomandibular joints during an IED burst and demonstrate the successful application of our surgical and pharmacotherapeutic protocol.

    Based on the literature review, our proposed protocol consists of pharmacotherapy with celecoxib and etidronate, with weekly forced dilation (Brisement) and home physiotherapy with TheraBite Jaw Motion Rehab System. Surgically, the temporomandibular joint should be treated with a two-stage reconstruction using initial polymethylmethacrylate spacers and posterior total joint replacement with custom prostheses, fat grafting, and three-dimensionally navigated HO total resection. This protocol was used successfully in our patient with refractory ankylosed temporomandibular joint after IED burst, and the patient's maximum incisal opening recovered and remained stable 2 years after surgery without recurrent HO.

    Our treatment regimen in this case deviated from the standard TMJ Concepts HO protocol, as it included a multimodal drug therapy with celecoxib and etidronate. Based on our review of the literature and our experience, we recommend that clinicians use our protocol for the management of all cases of craniofacial OH, particularly those cases of recurrent OH where conventional therapies fail and/or involve a high pressure blast trauma.

  • Analysis of the maximum bite force and masticatory efficiency in cases of unilateral TMJ ankylosis treated with interposition buccal fat arthroplasty

    2022, British Journal of Oral and Maxillofacial Surgery

    There is limited knowledge of masticatory function after resolution of temporomandibular joint (TMJ) ankylosis. In this study, masticatory function was assessed by measuring maximum voluntary bite force (MVBF) and masticatory efficiency in 30 patients with unilateral temporomandibular ankylosis treated with buccal interpositional fat arthroplasty (BFP). Eighteen subjects older than 12 years were included in Study Group A and 12 subjects younger than 12 years in Study Group B. Patients in both study groups completed at least one year of postoperative follow-up. Control groups C (older than 12 years, n=18) and D (less than 12 years, n=12) consisted of normal subjects of equivalent age, sex, and weight. Mean MVBF was measured between occluded molars using a strain gauge transducer. Chewing efficiency was measured with two different colored sticks of chewing gum. These were chewed for 5, 10, 20, 30, and 50 puffs. Compared with normal subjects, study groups (A and B) were able to generate 64.7% (p=0.004*) and 89.8% (p=0.121) MVBF, respectively. Global masticatory efficiency was 88.7% in Group A and 92.9% in Group B (p=0.014* and p=0.138, respectively) compared to healthy subjects. The study showed that BFP interposition arthroplasty effectively restores masticatory function.

  • Strategies to reduce rechylosis in patients with TMJ ankylosis

    2021, British Journal of Oral and Maxillofacial Surgery

    The aim of the study was to define a protocol to prevent recurrent ankylosis after surgical treatment of temporomandibular ankylosis (TMJ). The investigators designed a retrospective study of all TMJA patients treated with different treatment modalities from 2013 to 2019. The investigators noted that complete removal of the ankylotic mass, primarily on the medial side; Using a piezoelectric scalpel for a clean, smooth osteotomy with copious irrigation to remove bone chips and mud; minor trauma to local tissue; Drawing of the parallel osteotomy and inferior osteotomy at the narrowest point, which generally corresponds to the condylar neck; Coronoidectomy (with mouth opening < 30 mm), fat deposits; absence of intraoperative correction of pre-existing mental deviation in treatment with costochondral graft; patient motivation; and aggressive physical therapy and the use of vacuum drainage are important to prevent recurrence of ankylosis, regardless of treatment modality. A total of 114 patients (n=152 joints), [bilateral (n=38), unilateral (n=76)] were retrospectively evaluated. Interpositional fat arthroplasty was performed in n=43, CCG was used for reconstruction in n=30, and total joint replacement (TJR) was performed in n=41 patients. Reankylosis was observed in n = 3 (2.6%) patients (2 in CCG and 1 patient in interposition arthroplasty). Follow-up ranged from 12 to 80 months. The results conclude that following the proposed good practice protocol is effective in reducing scopeilosis.

  • Outcome of standard total joint replacement with fat grafting in adult patients with temporomandibular joint ankylosis

    2021, Journal of Oral and Maxillofacial Surgery

    There is no uniform treatment protocol for temporomandibular ankylosis (TMJ) in adults. The aim of the study was to evaluate the outcome of total joint replacement (TJR) in conjunction with fat grafting around the joint in adult patients with TMJ. The specific objective was to find out if RTJ can be a definitive treatment for TMJ in adults.

    Investigators conducted a prospective study in adult TMJ patients treated with osteoarthrectomy for ankylosis and temporomandibular joint (TMJ) with fat grafting. In some unilateral cases, orthognathic correction of facial asymmetry was performed at the same time. Follow-up visits were made at regular intervals to assess the primary outcome variables of maximum incisal opening (MIO) and scopeilosis. Secondary outcome variables included demographics, etiology, duration of ankylosis (DOA), correlation between pre- and postoperative DOA and MIO, occlusion and bleeding complications, facial nerve palsy, periprosthetic joint infection. , dislocation and implant failure.

    The study sample consisted of 41 patients (54 joints) (bilateral, n=13; unilateral, n=28 [right side, n=12; left side, n=16]). The number of recurrent cases was 15. Trauma as an etiology of ankylosis was observed in n=30 (73.2%), infection in n=7 (17.1%), unknown in n=3 (7.3%) and ankylosing spondylitis in n=1 (2.4%) cases. The mean DOA was 11.95 years. Paired t-test revealed a statistically significant difference between preoperative and follow-up IOM (p<0.001). None of the cases presented scopeilosis in the follow-up period. Pearson's correlation revealed a statistically negative correlation between DOA and postoperative OMI.

    The result of this study suggests that a TJR TMJ in conjunction with fat grafting around the joints provides adequate mouth opening without signs or symptoms of reankylosis. Standard TMJ TJR with fat grafting can be considered as a definitive treatment modality in adult TMJ with minimal comorbidity.

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  • The aim of this study was to provide a systematic review of the efficacy of discopexy in the treatment of disorders of the internal temporomandibular joint (TMJ).

    We searched MEDLINE through PubMed, SCOPUS, Web of Science, and the Cochrane Central Register of Controlled Trials, as well as gray literature accessed through Google Scholar, Openthesis, and handsearching from early to July 2019. 2020. The search strategy returned 363 potentially relevant studies. After title and abstract screening, 41 full-text articles were checked for eligibility and 7 studies were included in the meta-analysis.

    There was an overall decrease in visual analogue scale (VAS) pain score of 4.59 cm (95% confidence interval [CI], 2.03-7.16; p<0.001) during the follow-up period and an overall increase of 10 mm (95% CI, 6.93–13.01; p<0.001) in mouth opening after temporomandibular joint surgery with discopexy.

    Available evidence has shown an overall decrease in VAS pain score and improvement in mouth opening after TMJ discopexy surgery. Changes in maximum interincisal opening were greater after arthroscopic disc reduction than after the open hinge procedure.

  • Investigation article

    New method for removing a buccal fat pad for interposition after cleft temporomandibular joint arthroplasty

    British Journal of Oral and Maxilofacial Surgery, Band 54, Ausgabe 4, 2016, S. 469-470

  • Investigation article

    Coronoid process and residual ankylotic mass as autograft in the treatment of temporomandibular joint ankylosis in young adolescent patients: a retrospective clinical study

    British Journal of Oral and Maxilofacial Surgery, Band 54, Ausgabe 3, 2016, S. 280-285

    The objective of this nonrandomized study was to evaluate the feasibility of using autografts (such as coronoid process and resected ankylotic mass) in condyle reconstruction after cleft arthroplasty for temporomandibular joint (TMJ) ankylosis. Sixteen patients (23 joints) operated on between 2007 and 2009 were examined, and postoperative measures of maximum interincisal opening, bite force, range of motion, and infection were recorded. After a mean (SD) follow-up of 55 (2.25) months, mouth opening improved from 3 (3.84) mm to 33 (1.66) mm in patients treated with coronoid grafting, while in treated patients with ankylotic mass increased from 4 (2.64) mm to 26 (8.04) mm after a mean (SD) follow-up of 58 (1.58) months. The bite force six months after surgery was in the range of 18.25 kg/cm2– 27,5kg/cm2after reconstruction with coronoid process and 18.5 kg/cm2– 23,25kg/cm2after reconstruction with an ankylotic mass. One patient developed scopeilosis and another developed postoperative infection where the ankylotic mass had been used. Both were successfully passed. Both the ankylotic mass and the coronoid process gave satisfactory results and appear to be options for reconstruction. However, the coronoid process graft was superior to the residual ankylotic mass in terms of masticatory efficiency, bite force, and range of motion.

  • Autologous fat grafts in the temporomandibular joint (TMJ) have shown positive clinical effects in the prevention of adhesions after surgery. However, the survival rate of transplanted fat has not yet been determined. The aim of this study was to evaluate the long-term survival of free fat grafts in the temporomandibular joint using magnetic resonance imaging (MRI).

    89 patients (117 joints) with free fat grafts placed in the temporomandibular joints after a modified TMJ disc anchor were included in our study. They were divided into the following groups based on the time interval between temporomandibular joint surgery and the last MRI examination: 1-3 months, 4-6 months, 7-12 months, 13-24 months, and >24 months. Signal intensity changes and volume retention were assessed using magnetic resonance imaging.

    The volume retention rate of the transplanted free fat showed that the size varied exactly around 50%, although it decreased very slowly with long-term follow-up. Almost half of the joints showed lower signal intensity of the transplanted fat on MRI at 6 months and recovered to normal 6 months later compared to the day after the operation.

    Free fat transplanted into the temporomandibular joint cavity could remain alive for a long time with a survival rate of about 48.44%. However, the survival mechanism was still unknown, which we need to explore and study in the future.

  • Investigation article

    Retrospective Comparison of Autologous Cosotochondral Graft and Coronoid Process in the Treatment of Unilateral Ankylosis of the Temporomandibular Joint in Adults

    British Journal of Oral and Maxillofacial Surgery, Band 52, Ausgabe 10, 2014, S. 928-933

    We retrospectively compared the clinical outcomes of autologous coronoid grafts (n = 32) and costochondral grafts (n = 28) in condylar reconstruction for the treatment of unilateral temporomandibular joint (TMJ) ankylosis in adults. Preoperative and postoperative assessments included diet scores, cone beam computed tomography (CT), maximum interincisal opening, lateral excursion, and mandibular deviation during mouth opening. There were no significant differences between the 2 groups in preoperative and postoperative measurements regarding incisal opening, lateral excursion, mandibular deviation, diet scores, or recurrence rate, but incisal opening scores Postoperatively, lateral excursion and diet improved significantly before the operation. After costochondral transplantation, 3 patients developed multiple intraoperative tears and 6 had transient pain at the donor site. The anterior branch of the facial nerve was temporarily affected in 5 patients after costochondral transplantation and in 3 after coronoid process transplantation, and all recovered between 3 and 6 months. There was no recurrence after coronoid process transplantation and one after costochondral transplantation. The clinical results in both groups were satisfactory and comparable. Therefore, autotransplantation of the coronoid process may be a good alternative for condylar reconstruction in patients with temporomandibular joint ankylosis.

  • Investigation article

    Quantifying the outcome of surgical treatment of TMJ ankylosis: a systematic review and meta-analysis

    Journal of Craneo-Maxillofacial Surgery, Band 44, Ausgabe 1, 2016, S. 6-15

    Temporomandibular joint ankylosis results in a restricted mouth opening due to a fibrous or bony (non-neoplastic) connection of the mandibular head to the acetabulum. Early surgical treatment is recommended, but the optimal surgical technique is debated. Our aim was to quantify the effect of different surgical procedures on maximum (interincisal) mouth opening.

    The systematic literature search (1960-2015) was based on PubMed, Web of Science, and Cochrane Library. Pooled mean differences and 95% confidence intervals between preoperative and postoperative maximum mouth opening (in mm) were calculated using random-effects meta-analysis. Surgical procedures were grouped according to their increasing complexity: slit arthroplasty, interposition arthroplasty, and reconstructive arthroplasty.

    We identified 38 articles (1993-2015), including 1215 patients undergoing surgery; 84% of the cases were caused by trauma and 8% by infection.

    Separation arthroplasty (n=463), interposition arthroplasty (n=409), and repair arthroplasty (n=293) resulted in an improved maximum mouth opening of 26.2 mm (95% CI, 24.1 -28.2), 26.7 mm (95% CI, 24.6 to 28.8), or 30.6 mm (95% CI, 28.7 to 32.5), and 28.7 mm overall (95% CI, 26.7 to 29.2). The combined mean maximum postoperative mouth opening ranged from 33.0 to 36.1 mm.

    Maximum mouth opening improved more after reconstructive arthroplasty and less after gap arthroplasty. However, the maximum postoperative mouth opening was similar for all techniques.

Copyright © 2004 International Association of Oral and Maxillofacial Surgeons. Issued by Elsevier Ltd. All rights reserved.

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