We respond to the comments received by the Editor concerning our publication, “New protocol to prevent TMJ reankylosis and potentially life threatening complications in triad patients”.

We appreciate the comments made by the reader and acknowledge the authors for their work on primary mandibular distraction for the management of nocturnal desaturations secondary to temporomandibular joint (TMJ) ankylosis (2008), which was overlooked and remained uncited in our publication. However, we wish to add to this and clarify certain points.

In our article we discussed the incidence of reankylosis in patients treated surgically for TMJ ankylosis and correlated this to their posterior airway space (PAS), apnoea/hypopnoea index (AHI), and the extent of their micrognathia; in that article we introduced the term ‘triad cases’, and this was the first use of the term in the literature.

Moreover, over the years of follow-up and management of such cases, we found that the more severe the AHI and micrognathia, the higher the incidence of reankylosis when such cases were treated using our ‘old’ protocol of TMJ ankylosis management. We were also the first to report the occurrence of bradycardia, a life-threatening complication that we hypothesized occurred through the trigemino-cardiac reflex (TCR), in those patients treated using our ‘old’ protocol and the severe cases returning with reankylosis. The term ‘new protocol’ was related to the use of a protocol different from that previously used for all categories of OSAS (the ‘old’ protocol).

Further, through that publication we were attempting to highlight our observations and the incidence of life-threatening complications witnessed in our cases, as well as the reasons for reankylosis in such triad cases when the old protocol was used.

We had published this protocol previously in the Asian Journal of Oral and Maxillofacial Surgery (2009), highlighting the benefits of the technique. However, over the years of practical experience in TMJ ankylosis, we came to understand that patients failed to undergo active physiotherapy due to the development of bradycardia if their PAS was narrow and not attended to at the outset. The occurrence of this bradycardia and the incidence of reankylosis as a failure of physiotherapy is an important add-on in the recent publication. This was an eye-opener to us and we wished to share our experience with all in the hope of contributing towards the prevention of reankylosis and the life-threatening complications as discussed.