Reconstruction of ankylosed temporomandibular joint: Sternoclavicular grafting as an approach to management

Abstract

A retrospective analysis of 15 cases of ankylosed temporomandibular joint (TMJ) reconstructed, with sternoclavicular joint graft (SCG), during the period 2002–2007 was undertaken. All cases were analyzed for functional adaptation of the graft, considering maximum interincisal opening, and protrusive and laterotrusive movement of the jaw. Significant improvement was noticed in all cases except one, although maximum improvement was seen 3–6 months postoperatively. Radiological evaluation was carried out at regular intervals for 2–3 years to assess the anatomical adaptation of the graft. No major postoperative complications were observed and all the cases showed complete regeneration of the clavicle during follow up. This finding indicates that reconstruction of ankylosed TMJ with sternoclavicular joint graft is a satisfactory method of treatment.

The temporomandibular joint (TMJ) is a complicated anatomical structure that is concerned with mastication, deglution, speech and head posture . Ankylosis of the TMJ occurs when the condyle is fused to fossa by bony or fibrous tissue . It is an incapacitating problem, occurring in children and commonly associated with trauma or infection. It can impair mandibular growth and function which may result in severe facial asymmetry and mandibular retrusion .

The impairment of orofacial function may include restricted mouth opening, limited chewing ability, impairment of speech, compromised oral hygiene, restricted airway problem and psychological stress disrupting family life . Although this condition is uncommon in developed countries, it is common in the developing world . Preservation of this joint or construction of an artificial one that functions properly is of prime importance.

Surgery is the only effective method of correction to restore and maintain normal function. Gap arthroplasty, interpositional arthroplasty and osteotomy across and excision of the ankylotic mass within the TMJ have been described. Good functional results can be obtained with gap arthroplasty if meticulous attention is paid to postoperative physiotherapy , but increased chances of reankylosis and aesthetic problems, in the form of deviation of mouth opening and associated asymmetry, favor interpositional arthoplasty as the preferred choice .

A variety of interposition materials have been used, such as temporalis fascia, muscles, dermis auricular cartilage, fascia lata, fat and costochondral graft as autogenous materials and non-biological material such as methyl methacrylate, silastic, silicone, and various metals . The inherent growth (adaptive) potential within the cartilage favors the use of cartilaginous graft as the first choice for joint reconstruction among surgeons who advocate early surgical correction of growth deficiencies . Traditionally costochondral graft has been used for reconstruction of TMJ ankylosis , but continued and harmonious growth following rib grafting is the exception rather than the rule. This may be due to the differences in the growth characteristics of the costal cartilage and the condyle. The sternoclavicular graft, which has been introduced as a good alternative for reconstruction in ankylosed patients , is similar developmentally and structurally to the TMJ.

The purpose of this retrospective study is to assess the usefulness of sternoclavicular graft as interposition material in the reconstruction of the ankylosed TMJ.

Materials and methods

[15] patients with TMJ ankylosis (8 males, 7 females) underwent release of the ankylosed joint by the senior author, between May 2002 and March 2007. The age of the patients ranged from 10 to 18 years. Limited mouth opening and asymmetry was the main complaint, while one patient reported pain around the pre-auricular region. In most cases traumatic injury (13) in the chin region and ear infection (2) was the main etiology ( Table 1 ). Of 15 patients, 13 (7 on the left and 6 on the right side) required unilateral release and sternoclavicular reconstruction, while in 2 patients with bilateral ankylosis, reconstruction was carried out with sternoclavicular grafts (SCGs) and costochondral grafts (CCGs) simultaneously on each side.

Table 1
Patient data.
Sr. no Age Sex Side Etiology Mouth opening (mm) Protrusive movement (mm) Laterotrusive movement (mm) Follow up (month) Post-op X-ray finding Donorsite morbidity
Preop Post op 1 year 3 years Pre op Post op (6th month) Pre op Post op (6th month)
1 15 M L Trauma 3 34 36 39 0 4 2 9 36 Adaptation to anatomical condyle & glenoid fossa Regeneration
2 15 M L Infection 2 30 31 31 0 4 3 11 36 Adaptation to anatomical condyle & glenoid fossa Regeneration
3 15 M R Trauma 5 28 30 0 3 2 10 15 Interarticular space Regeneration
4 15 M R Trauma 4 32 36 36 0 3 2 11 36 Interarticular space Clavicle #
5 17 F L Trauma 2 34 34 0 4 2 10 18 NA NA
6 18 F R Trauma 0 35 0 3 3 10 12 NA NA
7 14 F R Trauma 2 39 42 41 0 4 4 9 36 Adaptation to condyle Regeneration
8 12 F R Trauma 1 38 05 0 2 2 5 16 Renankyloses NA
9 15 M L Infection 4 37 37 38 0 3 3 10 36 Adaptation to condyle Regeneration
10 15 F L Trauma 3 34 36 37 0 3 0 11 36 Adaptation to condyle Regeneration
11 16 M L Trauma 2 36 38 39 0 4 2 10 36 Adaptation to condyle Clavicle #
12 18 F L Trauma 0 39 38 40 0 4 2 11 36 Interarticular space Regeneration
13 10 M L Trauma 2 32 35 37 0 4 3 11 36 Adaptation to condyle Regeneration
14 11 F R Trauma 4 37 39 0 3 3 10 12 NA NA
15 18 M R Trauma 3 39 39 0 4 0 10 14 NA NA
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Feb 7, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Reconstruction of ankylosed temporomandibular joint: Sternoclavicular grafting as an approach to management
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