We read with interest the queries raised by the authors regarding our article “Gap arthroplasty of temporomandibular joint ankylosis by transoral access: a case series”. Although they refer to “major setbacks of this procedure”, we disagree, as the authors have failed to understand that the intent of the publication was to explore an avenue of access to the ankylosed joint with nil scar and minimal damage to major neurovascular structures. This is relevant in an era of minimal access surgery, where the intent is to minimize morbidity. However, we agree that this approach is not for those with limited experience in this area.
Although the inclusion criteria clearly state Sawhney grade I, II, and III temporomandibular joint (TMJ) ankylosis, this is only to give a guideline for case selection, and the other radiological findings mentioned in the inclusion criteria should also be taken into consideration. It should be noted that our series included grade I and II cases only. We do not suggest the exclusion of all cases involving the arch but for those cases with massive extension onto the arch where computed tomography (CT) images cannot delineate any margins between the exuberant mass and the normal anatomical structures.
The authors were right in pointing out that transoral access is unpredictable owing to the heterogeneous nature of the ankylotic mass. We consider this very heterogeneous nature in milder to moderate cases as an advantage because of the immature bone along the fusion lines, which creates a natural cleavage plane between the mass and the glenoid fossa. The direction of the osteotome is not guided by the articular eminence but by the lower border of the zygomatic arch. It needs to be understood that the superior osteotomy is initiated with the osteotome maintained as parallel to the inferior border of the arch as possible. As it proceeds along the cleavage plane, the osteotome is advanced with a constant prying and forwarding motion until the mass separates out. With a proper sense of the three-dimensional orientation there is no possibility of directing the osteotome obliquely into the centre of the glenoid fossa. In all our cases we could conveniently place a retractor along the posterior border, and the argument regarding a lack of adequate space between the mass and the external auditory meatus is refutable.
Aggressive postoperative physiotherapy plays a crucial role in the prevention of reankylosis and the presence of postoperative pain cannot be considered an excuse not to begin physiotherapy. The argument that the transoral access could cause more postoperative pain compared to the extraoral approach is untenable. In our series, all the patients, starting from 8 years of age, could endure the physiotherapy. It should be noted that it is clearly stated that the patients were not subjected to vigorous, senseless physiotherapy from day 1, but that physiotherapy and mouth opening exercises were started on day 1 and gradually increased in intensity. The idea is to emphasize to the patient the importance of physiotherapy right from the day after surgery and it should not be misinterpreted as patients being subjected to undue pain in the name of therapy. We suggest that the authors also follow a similar regimen in all of their ankylosis cases to minimize recurrence, whether the surgery is performed transorally or extraorally.
It is true that when the release is not successful transorally, the extraoral technique needs to be employed and hence all the patients in our series were consented for the extraoral approach as well.
It should be understood that this novel technique is an addendum in technically experienced hands and should not be conceived as a replacement for the extraoral approach. Patient selection is extremely important and the surgeon and patient should always be prepared for the use of the extraoral approach when this intraoral approach fails to meet the recommended objectives.