Abstract
Background
Temporomandibular joint (TMJ) ankylosis is a challenging clinical entity and management is primarily surgical. Patients with neurological conditions such as epilepsy may be prone to frequent joint dislocations or trauma over their lifetimes. They may also undergo surgeries to prevent recurrent joint dislocation that may increase the risk of TMJ ankylosis. Epileptic patients represent a population in which treatment of TMJ ankylosis, particularly bilateral ankylosis, can be complicated by difficult airway or medical management in the postoperative period. Tracheostomy is not often required for airway management in patients undergoing total joint replacement for bilateral TMJ ankylosis but may be a useful surgical adjunct to increase treatment safety in certain patient populations. A multi-disciplinary approach to anti-epileptic medication management is also beneficial given potential difficulties with oral intake in patients with TMJ ankylosis.
Methods
A systematic review of the literature was undertaken for evaluation of available literature using the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). A representative case example was provided for consideration.
Results
Review of the available literature resulted in no articles addressing the potential utilization of tracheostomy in patients with TMJ ankylosis. A variety of literature is available for patients with craniofacial anomalies who may require tracheostomy and who may develop TMJ ankylosis from a young age, but no literature is available to provide evidenced-based treatment guidelines for adult patients with ankylosis who may be at increased risk for airway compromise. Medical management of patients with refractory seizure activity can be difficult to optimize, and treatment regimens may require alterations during the perioperative period for patients undergoing TMJ total joint replacement.
Conclusions
Patients undergoing surgical treatment for bilateral TMJ ankylosis who also have neurological conditions such as epilepsy may be at increased risk for airway compromise during the postoperative period. Patients with difficult to control seizure activity may also be at increased risk for joint dislocation during the postoperative period of TMJ total joint replacement. Temporary tracheostomy represents a surgical option to improve patient safety in the immediate postoperative period along with appropriate medical management, and its consideration has not previously been reported for this patient population.
1
Introduction
Temporomandibular joint (TMJ) ankylosis can be a challenging clinical entity to treat. For patients who present with ankylosis following trauma, infection, or previous surgical interventions, airway management is an integral part of treatment planning. Trauma is the most common cause of TMJ ankylosis [ ]. While patients with craniofacial anomalies may require tracheostomy at an early age and may present in childhood or young adulthood with TMJ ankylosis, tracheostomies are rarely present or needed during total joint replacement for TMJ ankylosis in patients without craniofacial anomalies who present as adults. However, medical comorbidities may complicate early postoperative management, and certain patients may benefit from consideration of temporary tracheostomy.
TMJ ankylosis is an intra-articular process that can be classified as fibrous, fibro-osseous, or osseous and results in the obliteration of the joint space between the mandibular condyle and glenoid fossa. The process results in decreased mandibular range of motion and often discomfort. In severe cases, patients may experience complete loss of mouth opening. Restricted mouth opening results in a significantly decreased quality of life. Patients experience difficulty eating, speaking, and maintaining appropriate oral hygiene measures [ ]. Certain routine procedures such as endoscopy or endotracheal intubation may be difficult or impossible to complete.
Non-surgical therapies such as anti-inflammatory medications and muscle relaxers are not typically helpful when managing TMJ ankylosis, and surgery is often indicated. Surgical options include Brisement procedures, gap arthroplasty, isolated condylectomy, or total joint replacement [ ]. Some evidence exists that gap arthroplasty may be similarly effective to total joint replacement for surgical management of TMJ ankylosis [ ]. However, several studies have demonstrated improvement in both maximal incisal opening (MIO) as well as quality of life factors such as diet, jaw function, and pain reduction with total joint replacement [ , ]. In patients with bilateral TMJ ankylosis, total joint replacement may be preferred to gap arthroplasty only and staged reconstruction due to the potential loss of a posterior vertical dimension of the mandible and potential airway embarrassment without application of maxillomandibular fixation.
Airway management when treating patients with TMJ ankylosis, particularly those with bilateral TMJ ankylosis, is of the utmost importance before, during, and after surgical management. Tracheostomy is not routinely needed when managing patients with TMJ ankylosis but should be considered for certain patient populations.
1.1
Representative case
Patient consent was obtained. A 24-year-old male patient presented to the Department of Oral and Maxillofacial Surgery at The Dental College of Georgia at Augusta University for evaluation of severely limited mouth opening. Review of the patient’s medical history demonstrated epilepsy that his neurologists noted to be difficult to control due to nausea and emesis that complicated compliance with oral anticonvulsants. It was previously determined that he was not a candidate for neurosurgical intervention. His social history was positive for marijuana use weekly. The patient frequently presented to the medical center emergency department over the previous five years for recurrent open locking due to his seizure activity.
The patient underwent bilateral eminectomies and postoperative physical therapy three years prior but was subsequently lost to follow up. Closer to the time of his presentation to the department, multiple emergency room visits and admissions were documented where emergent nasotracheal intubation was difficult but successfully accomplished by the anesthesia department. Concern for a difficult airway and recurrent admissions for poorly controlled seizures prompted referral to the oral and maxillofacial surgery service, and bilateral TMJ ankylosis was noted on computed tomography. Ankylosis is demonstrated in Fig. 1 . The patient demonstrated very minimal movement of his mandible – approximately 2–3 mm – indicating near but not complete bony ankylosis of the temporomandibular joints.
All treatment options were discussed with the patient including no treatment, and the patient elected to undergo bilateral temporomandibular joint replacement with custom prostheses. The surgical plan was discussed with the Neurology department as well as concerns for postoperative prosthesis management in the setting of frequent seizures, frequent episodes of emesis, and potential for poor oral compliance with the patient’s anticonvulsant regimen.
It was recommended that the patient be transitioned to a new oral anti-epileptic regimen that would allow for ease of intravenous administration preoperatively and postoperatively. The patient’s current regimen of oxcarbazepine and lamotrigine could not be easily transitioned and titrated intravenously. The need for compliance with antiepileptic medications both preoperatively and postoperatively was a concern for the patient. The potential for increased risk of bleeding due to the anti-platelet activity of valproic acid and its derivates was discussed but determined to be of acceptably low risk for surgery.
An oral regimen of scheduled lacosamide, valproate, and levetiracetam with phenytoin available for breakthrough was devised, and the patient was gradually transitioned over several weeks. After transitioning and prior to surgery, the patient still demonstrated episodes of emesis and seizure activity, though less frequent. Given the concern for potential dislocation of the temporomandibular joint and possible airway compromise in the acute postoperative period – as a short period of maxillomandibular fixation was planned postoperatively following bilateral joint replacement – airway management was discussed with the patient in detail.
A joint decision was made to proceed with intravenous administration of anti-epileptic medications and placement of a temporary tracheostomy for postoperative airway management. Custom joints were fabricated. Preoperative and postoperative images of the prostheses are provided in Fig. 2 .
