In reply: Thank you very much for your contribution to our article. We agree with Dr. Rattan et al. that trigemino-cardiac reflex (TRC) could have been one of many other causes of death for our first case patient. This patient underwent several other surgical procedures at different medical facilities, which were followed every time with physical therapy, without any records of a TRC episode. Other factors could also have been involved, including the chronic malnutrition that the patient was suffering from due to the inability to chew food for many years. However, there is no available means, right now, to determine the exact cause of death, especially as it happened in a different medical facility to ours and we do not have a detailed autopsy report for that case.
We, on the other hand, do not agree with our colleagues on drawing conclusions and recommending a surgical protocol based on a very small number of patients, as in the case of their own experience. They tried the buccal fat pad on one syngnathia patient. As for our article, we reported the only three cases that we have encountered, and due to the rarity of this disorder, it is very difficult to charter a reliable protocol for managing such patients.
Lastly, we disagree with Dr. Rattan et al. on drawing parallels between temporomandibular joint ankylosis, which is an acquired disorder that is caused mainly by a traumatic event, and syngnathia, which is a congenital one. We believe that patients with syngnathia have a different pathophysiology than those with ankylosis, which further complicates their management. Moreover, they tried the buccal fat pad on 18 patients with TMJ ankylosis with 1 year of follow-up, which is not enough time to conclude on a final protocol for managing such cases. It is not reasonable to expect the results from a surgical approach that was not fully investigated to be the same if utilized for a different disorder.