One stage treatment of temporomandibular joint complete bony ankylosis using total joint replacement

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Abstract

Introduction

Temporomandibular joint ankylosis is a joint disorder due to bone or fibrous adhesion of the joint components that cause loss of function. There are many causes, such as trauma, infections and systemic diseases. To date, no uniform treatment protocol has been established.

Materials and methods

We enrolled in the study patients that underwent single stage alloplastic total joint replacement for complete bony ankylosis. The subjective and objective variables were as follow: TMJ pain, diet, jaw function, quality of life, maximum interincisal opening (MIO) and occlusion. The minimum follow-up was 12 months.

Results

12 patients met the inclusion criteria. Six patients underwent bilateral or monolateral total joint reconstruction with stock prosthesis, six patients underwent bilateral total joint reconstruction with custom made prosthesis. The mean preoperative MIO was 7.9 mm. The mean MIO reordered at 12-month follow-up was 26.5 mm (P < 0,0001). The occlusion was unchanged in 9 patients out of 12. In two patients the occlusion was changed by means of custom prosthesis design. In one patient occlusion worsened with less stable functional contact. Quality of life and diet relevantly improved in all cases.

Conclusions

Single stage resection and reconstruction with total alloplastic TMJ reconstruction is an effective and reliable method to reestablish stable long-term mandibular function in ankylotic patients.

Introduction

Temporomandibular joint (TMJ) ankylosis is a joint disorder which refers to bone or fibrous adhesion of the anatomic joint components and the ensuing loss of function (Gundlach, 2010).

The main causes of TMJ ankylosis are trauma, infections and systemic diseases (Kaban et al., 1990, Chidzonga, 1999, Arakeri et al., 2012, Al-Moraissi et al., 2015).

Surgical treatment of TMJ ankylosis remains a significant clinical challenge and, to date, no uniform treatment protocol has been established (Arakeri et al., 2012, Zhu et al., 2013, Mercuri et al., 2008).

Gap arthroplasty with or without interpositional material, gap arthroplasty with immediate or delayed reconstruction with autogenous bone, such as costochondral grafts, grafts using fibula, clavicle, iliac crest, or metatarsal head, or alloplastic material have all been reported. (Zhu et al., 2013, Arakeri et al., 2012, Kaban et al., 2009, Mercuri et al., 2008, Haq et al., 2014).

No single technique has uniformly proved to be successful to reduce the high incidence of ankylosis recurrence (Al-Moraissi et al., 2015)

The pathogenesis and the mechanism of recurrence are not fully understood (Arakeri et al., 2012, Haq et al., 2014, Zhu et al., 2013): many factors have been reported in the literature to affect the recurrence of ankylosis after surgical treatment but, in spite of progress in research, the mechanism of heterotopic bone formation in the TMJ remains unclear.

Concerns still remain about the treatment of choice in severe cases with multiple recurrences of bony ankylosis.

Aim of this study is to retrospectively analyze our 11-year experience in total alloplastic reconstruction of the TMJ in case of multiply recurred total bony ankylosis.

Section snippets

Patients and methods

From January 2002 to April 2013, a total of 36 consecutive patients underwent single stage alloplastic total joint replacement at the Division of Maxillofacial Surgery, “Città della Salute e della Scienza Hospital”, University of Torino (Torino, Italy).

In this retrospective cohort study, the inclusion criteria were as follows: 1) severe ankylosis with mouth opening less than 20 mm, 2) bony ankylosis type IV according to Sawhney classification 3) heterotopic ossification in the TMJ grade 2 or 3

Results

Twelve patients met the inclusion criteria and were enrolled in the study. Patient demographic characteristics and pathological features are listed in Table 2. The average number of previous surgeries was 4. The average follow up is 49 months (range 18–150 months).

Six patients underwent Biomet total joint reconstruction system with stock prosthesis (4 bilateral and 2 monolateral), 6 patients underwent bilateral total joint reconstruction system with custom made (patient matched) prosthesis.

No

Discussion

Management of TMJ bony ankylosis remains a significant clinical challenge. The variety of techniques reported reflects the complexity of the problem.

Gap arthroplasty with or without interpositional material, gap arthroplasty with immediate or delayed reconstruction, with autogenous or alloplastic materials have all been described and no strategy has been universally accepted (Kaban et al., 2009, Zhu et al., 2013, Arakeri et al., 2012)

Reankylosis is a frequently reported complication and no

Conclusion

This series of 12 patients with 22 joints demonstrates that the single stage resection and reconstruction with total alloplastic TMJ reconstruction is an effective and reliable method to reestablish stable long–term mandibular range of motion in ankylotic patients.

Consequently, this specific technique is today our first option for treatment of bony ankylosis in the adult patient.

Authors' Roles

Giovanni Gerbino – Conception and design, analysis and interpretation of data, drafting the article.

Emanuele Zavattero – Data collection, analysis and interpretation of data.

Guglielmo Ramieri and Sid Berrone – Critically revising the article, study supervision.

Financial disclosure and products

None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.

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  • Outcomes of total joint alloplastic reconstruction in TMJ ankylosis

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    Citation Excerpt :

    In addition, the use of TMJR has the ability to reposition the mandible into its proper position, often with significant mandibular advancements to correct malocclusions secondary to TMJ ankylosis. Wolford et al.,21 Chowdhury et al.,22 Gerbino et al.,20 and Roychoudhury et al.23 reported a mean preoperative MIO of 14.5, 2, 7.9, and 5.17 mm and a mean postoperative MIO of 35, 31.8, 27.3, and 35.32 mm, respectively, after treating TMJ ankylosis with TMJR. All studies had a minimum of 12 months’ follow-up and no reported re-ankylosis.

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