Piezoelectric osteoarthrectomy for management of ankylosis of the temporomandibular joint
Introduction
The development and success of piezoelectric bone cutting has revolutionised maxillofacial surgery. It uses ultrasonic vibrations and so has selective affinity for hard tissue, and as it causes no heat it avoids any damage to the soft tissue.1 Since its invention it has become one of the widely-practiced methods for creating osteotomies for distraction osteogenesis,2 implant dentistry,3 sinus grafting,3 and orthognathic surgey.4 Though there is a published consensus about the use of piezosurgery in these operations, little has been written about its use in the treatment of ankylosis of the temporomandibular joint (TMJ).
Ankylosis of the TMJ is disabling, and causes problems in mastication, digestion, speech, appearance, and hygiene. Among the various treatments described for it, gap arthroplasty is well-established. The operation consists of aggressive osteoarthrectomy of the ankylotic mass to create a gap of 1.5 cm, followed by aggressive physiotherapy.5 Creating such a gap is also the most important first step for other interpositional treatments. Conventional methods for the release of ankylosis are associated with complications such as bleeding, damage to the facial nerve, and recurrence. Reankylosis is a problem for both the patient and the surgeon, and early healing of the cut ends of bone and aggressive physiotherapy are critical in its prevention.
In this paper we report the use of piezoelectric removal of bone in ankylosis of the TMJ, discuss its advantages over conventional techniques, and report initial results at 6 months’ follow-up. We intend to follow this group for 5 years to record any recurrence caused by regrowth.
Section snippets
Patients and methods
The institutional review board approved the protocol for a prospective observational descriptive study in patients with ankylosis of the TMJ (Fig. 1, Fig. 2) who were operated on using the piezoelectric scalpel in our unit between1 January 2011 and 31 December 2012. Patients treated by gap arthroplasty were included, but those treated by interposition of a costochondral graft or temporalis fascia, or lateral arthroplasty, were excluded. Informed written consent was obtained from all patients.
Surgical technique
A standard preauricular, extended temporal, incision was used in all cases. After exposure of the ankylotic mass, a gap of 1.5 cm was created by cutting the bone perpendicular to the cortical surface from the lateral to the medial side. It is possible to measure the mediolateral thickness of ankylosis on the CT scan (Fig. 2) and use the gradation marks on the piezoscalpel to measure the working depth. Special attention was given to the medial side to avoid any tapering of the cut. The inferior
Results
A total of 35 patients (27 bilateral and 8 unilateral joints that comprised 62 sides) were studied. Of these, two were recurrent. There were 23 male and 12 female patients, whose ages ranged from5 to 28 years (mean (SD) 14 (6) years). There was no bleeding from the maxillary artery or the pterygoid plexus. Mean (SD) blood loss was 43 (5) ml/side. We had no data about the blood loss from the dental drill or saw osteotomy to compare with this group, but thought that there was a substantial
Discussion
Operations for ankylosis of the TMJ are known to be complicated by recurrence. Over a period of 100 years various treatments have been proposed including gap arthroplasty, interposition arthroplasty, reconstruction of the ramal condylar unit with a costochondral graft, and total reconstruction of the joint.5, 6, 7, 8, 9 In addition to recurrence, any intervention used to treat ankylosis is complicated by the presence of the facial nerve, the maxillary artery, the pterygoid plexus, and the
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