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British Journal of Oral and Maxillofacial Surgery 47 (2009) 200204

Gap arthroplasty combined with distraction osteogenesis in the treatment of unilateral ankylosis of the temporomandibular joint and micrognathia
Hongbo Yu, Guofang Shen , Shilei Zhang, Xudong Wang
Department of Oral and Maxillofacial Surgery, Ninth peoples Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China Accepted 10 August 2008 Available online 21 September 2008

Abstract Our aim was to evaluate the efcacy of simultaneous gap arthroplasty and distraction osteogenesis (DO) in the treatment of unilateral ankylosis of the temporomandibular joint (TMJ) in patients with micrognathia. During the period January 2000-December 2006, 11 patients with unilateral ankylosis of the TMJ and micrognathia were treated with simultaneous gap arthroplasty, mandibular osteotomy, and implantation of a distractor. Mouth opening exercises were started on the rst postoperative day and distraction on the fth postoperative day. All patients had satisfactory mouth opening at follow-up, the mean (range) being 32.4 (2837) mm in 13 to 58 months follow-up. Mean length (range) of the mandibular body increased by DO was 12.4 (715) mm. Facial asymmetry was corrected and satisfactory occlusions achieved with the help of postoperative orthodontic treatment. We conclude that DO and gap arthroplasty can be used simultaneously in the treatment of patients with ankylosis of the TMJ and micrognathia. 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Arthroplasty; Temporomandibular joint ankylosis; Distraction osteogenesis; Micrognathia

Introduction Ankylosis of the temporomandibular joint (TMJ) involves fusion of the mandibular condyle to the base of skull, which causes distressing conditions including impaired speech, difculty in chewing, facial disgurememt, compromise of the airway and psychological stress.13 This is particularly true in young children who are completely unable to open their mouths. It is usually caused by trauma and infection.35 For the patients with ankylosis of the TMJ and micrognathia, the treatment is often in two parts: trismus can be managed by gap arthroplasty or by reconstruction of the

Corresponding author. Department of Oral and Maxillofacial Surgery, Ninth peoples Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China. Tel.: +86 21 63138341 5548; fax: +86 21 63136856. E-mail addresses: yuhb@sdu.edu.cn (H. Yu), maxillofacsurg@163.com (G. Shen), othoms9h@online.sh.cn (S. Zhang), xudongwang70@163.com (X. Wang).

TMJ,3,6,7 while the micrognathia can be treated by autoplastic bony transplantation or distraction osteogenesis (DO).8,9 Costochondral grafts, which have the advantages of being autogenous material with a cartilaginous articulating surface and the potential for growth and adaption, are commonly used to reconstruct the mandibular condyle. Their disadvantages are the need for an additional operation, which may cause morbidity at the donor site, and an unpredictable pattern of growth.6 Routinely a gap arthroplasty or reconstruction of the joint is done rst, followed by correction of secondary mandibular and maxillary growth deformities, although simultaneous correction of the facial asymmetry has been reported.10 Recently, DO has been used to treat ankylosis of the TMJ and proved to be ideal.11 Simultaneous gap arthroplasty and DO for the treatment of micrognathia in ankylosis of the TMJ was rst reported in 1999.12,13 However, there is controversy about whether distraction should be done at the time of arthroplasty. Some authors prefer to do the procedures

0266-4356/$ see front matter 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjoms.2008.08.003

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Fig. 1. Frontal view (A), lateral view (B), and cephalometric radiograph (C) of a 5-year-old patient with severe micrognathia and asymmetry secondary to ankylosis of the TMJ (published with the guardians consent).

simultaneously,9,13 while Lpez et al.2 suggested that the mandibular DO should be done after the arthroplasty. Here we describe our experiences and results in 11 cases of ankylosis of the TMJ with micrognathia in children and teenagers, in whom the gap arthroplasty, mandibular osteotomy, and implantation of a distractor were done in a single operation.

Patients and methods During the 7-year period (January 2000 to December 2006), 11 patients with unilateral ankylosis of the TMJ and micrognathia were treated in the department of Oral and Maxillofacial Surgery, Ninth Peoples Hospital of Shanghai Jiao Tong University. Radiological examinations included cephalometric radiographs (anteroposterior and lateral), panoramic radiograph, transcranial projection of TMJ and computed tomograms (CT) (Fig. 1). CT data were imported into the Simplant Pro 11.02 software system (Materialise Corporation, Belgium) for three-dimensional morphometry, diagnosis, and planning and simulation of the operation. The osteotomy site

and the range of ankylotic bone to be resected were dened. Under general anaesthesia, all patients had simultaneous gap arthroplasty of the TMJ, osteotomy of the mandibular body, and implantation of the distractor. Firstly, through a standard preauricular approach, the ankylotic mass on the affected side was exposed and removed for at least 1520 mm vertically, and the free end of the mandibular ramus was shaped to form a round surface. The temporal musculofascial ap with its fascia was turned outwards and downwards over the zygomatic arch, and placed into the glenoid fossa to complete the interposition of the temporal musculofascial ap. It was then sutured medially and posteriorly to adjacent tissues. If necessary, we also did a coronoidectomy. Secondly, an intraoral uniaxial double pin distractor (Martin Corporation, Germany) was xed on the proposed osteotomy site with its axis parallel to the occlusal plane. Complete osteotomy was insured by intraoperative distraction. Two patients with mandibular ramus microsomia had extraoral biaxial distractors (Martin Corporation, Germany) to lengthen the mandibular body and ramus. Dynamic mouth opening exercises were started on the rst postoperative day. A wooden exerciser was used to

Fig. 2. Frontal view (A), lateral view (B), and cephalometric radiograph (C) of the patient 3 months postoperatively. (same patient, published with the guardians consent).

202 Table 1 Patients data and aetiology Case no. 1 2 3 4 5 6 7 8 9 10 11 Age (years) 5 11 9 14 10 7 8 15 5 17 12 Sex M F F F M M F M F M F

H. Yu et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 200204

Affected side L L R L L R R L L R L

Aetiology Falls Otitis media Falls Unknown Trafc accident Falls Falls Trafc accident Falls Unknown Otitis media

12-week consolidation period followed, and the distractor was removed after osteogenesis had been conrmed by cephalometric and panoramic radiographs.

Results Eleven patients (5 male and 6 female) whose ages ranged from 517 years (mean (SD) 10 (4)) were treated with simultaneous gap arthroplasty and mandibular DO. Age at the time of treatment, sex, cause of ankylosis, clinical features, radiographic ndings, surgical treatment, complications, results and follow-up were recorded in all cases. The aetiology, clinical details, and results are shown in Tables 1 and 2. The mean (range) mouth opening was 32 (2835) mm, and there were no signs of reankylosis during the 13 to 58 months follow up (Fig. 3). No patient had excessive pain at the distraction site. New bone with sufcient volume and density for satisfactory chewing had been formed after 3 months consolidation.

help passive mouth opening. Parents were trained to help their children to open their mouths with a wooden exerciser if the children could not do it actively. Distraction was activated on the fth postoperative day at a distraction rate of 0.5 mm twice daily. The DO was maintained until the midline of the chin coincided with that of the face, and 23 mm overcorrection was guaranteed (Fig. 2). A
Table 2 Summary of preoperative and postoperative results Case no. Mouth opening (mm) Before 1 2 3 4 5 6 7 8 9 10 11 3 5 2 1 3 4 5 5 2 4 3 After 31 30 28 32 35 31 32 37 34 35 31 32.4 (2.6) Chin midline discrepancy before operation (mm) 8 5 7 7 6 5 7 8 7 6 8 6.7 (1.1)

Length of mandibular body (mm) Before 43 54 56 50 56 51 47 52 45 51 53 50.7 (4.2) After 57 61 67 63 69 62 59 65 59 64 68 63.1 (3.9)

Distraction length (mm) 14 7 11 13 13 11 12 13 14 13 15 12.4 (2.2)

Follow -up (months) 42 36 48 20 13 35 58 43 24 28 35 34.7 (13.0)

Ramus distraction length (mm) 12 14

Mean (SD) 3.4 (1.4)

Fig. 3. Preoperative (A), and postoperative (B) interincisal distance. (same patient, published with the guardians consent).

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The only complication was one postoperative haematoma. Periostial bleeding from the medial mandibular ramus was found, and dealt with. We had no damage to the inferior alveolar nerve or the permanent tooth bud, and no complaints of numbness or discomfort in the lower lip, toothache, or tooth impaction. Some patients who had an anterior open bite or cross bite had postoperative orthodontic treatment and satisfactory occlusions were achieved. Two patients with serious facial deformities and malocclusions had orthognathic surgery: one a Le Fort 1 osteotomy to decant the occlusal plane, and the other had a genioplasty to correct mental deviation. Facial symmetry and satisfactory occlusion were achieved in all 11 patients.

Discussion Ankylosis of the TMJ is a common disease,14 one reason for which may be the susceptibility of the articular cartilage to injury.5 Chandra and Dave15 reported that trauma was the main cause. For children, progressive trismus, micrognathia, and deviation of the chin are the main symptoms. The loss of mandibular function and major dentofacial consequences cause various psychosocial problems. Failure to alleviate ankylosis can result in speech impairment, difculty with chewing, poor oral hygiene, rampant caries, disturbance of facial and mandibular growth, and compromise of the airway.1 Traditionally ankylosis of the TMJ and micrognathia have been treated separately, and reconstructing mandibular movement and function, preventing reankylosis, and promoting mandibular growth have always been the main objects of treatment. Now the treatments for ankylosis of the TMJ include interpositional arthroplasty, gap arthroplasty, and reconstruction of the joint using autogenous or articial materials.1618 Erol et al.19 evaluated before, during, and after the procedure, 78 operations on the TMJs in 59 patients who were treated by gap and interpositional arthroplasty for ankylosis of the TMJ, and found no difference between the operations in regaining normal mouth opening. Radical resection of the ankylosed bone, early postoperative exercise, appropriate physiotherapy, and close follow-up play important parts in the prevention of postoperative adhesions and reankylosis. Interposition of a costochondral graft that has the potential for subsequent growth, may be used to reconstruct the condyle and promote mandibular growth.10,14 However, the growth pattern of costochondral graft is extremely unpredictable. Mandibular overgrowth on the grafted side can actually be more trouble than the lack of growth.2,20 DO has become a popular and reliable alternative for the correction of craniomaxillomandibular deformities, and in recent years, it has been used to treat ankylosis of the TMJ, proving to be a promising method.11 Gabbay et al.21 compared the therapeutic effect of transport DO and a Matthews device arthroplasty, and found satisfactory results in both

groups. They indicated that a combination of these two treatment strategies might increase the benets. Simultaneous gap arthroplasty and DO for the treatment of micrognathia in ankylosis of the TMJ was rst reported in 1999.12,13 In those studies, mouth opening was ameliorated and facial deformity was corrected. Yoon et al.8 used gap arthroplasty and mandibular DO in two patients in whom gap arthroplasty had failed, and interposition of a costochondral graft proved to be successful with follow-up of longer than 2 years. Rao et al.5 achieved satisfactory mouth opening and cosmetic results after correction of mandibular deformities in six young patients with ankylosis of the TMJ and mandibular deformity by simultaneous gap arthroplasty and DO. However, up to now there has been no agreement on whether distraction should be done at the time of arthroplasty. Some authors prefer to do the procedures simultaneously,9,13 but Lpez et al.2 suggested that the mandibular DO should be done after the arthroplasty as the growth potential of the mandible would be known only when the ankylosis had been relieved. Bartlett et al.22 reported that DO is a valuable aid in the treatment of the problematic child with congenital proliferative ankylosis of the TMJ. Interim DO, before denitive arthroplasty, can provide a static open bite that prevents progressive deformity and its associated functional disturbances. The mandibular lengthening obtained by gradual distraction can result not only in expansion of the mandibular bony tissue but in proportional and harmonic modication of the muscles and the surrounding soft tissues. The forces produced by the distractor on the mandible are similar to physiological forces during mandibular development. McCormick et al.23 noticed that the distraction spur operates on the affected condyles, and causes an increase in volume and optimisation of the space orientation. Distraction seems to have benecial effects, therefore, not only on the harmony of the craniofacial complex but also on temporomandibular articulation. By reestablishing correct function of the soft and skeletal tissues, it is possible to regain the normal potential growth of the mandible. In this study, morphometry, diagnosis, surgical planning, and simulation were done on the Simplant system, and the direction and length of distraction were calculated precisely. For 13 to 58 months follow-up, 8 patients had postoperative orthodontic treatment and 2 patients with serious facial deformities and malocclusions had orthognathic surgery. Facial symmetry and satisfactory occlusions were achieved in all 11 patients. Though good results were obtained, there might be a dilemma in that the follow-up period is not longer enough to evaluate mandibular growth and facial symmetry. With adolescence, the maxillofacial bones start to grow quickly, mandibular growth and facial symmetry should be traced and analysed further. The results of this treatment protocol will be the subject of a future paper because there has not been enough follow-up time to evaluate mandibular growth and the necessity of mandibular distraction as a second procedure in patients treated by simultaneous arthroplasty of the TMJ and DO.

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H. Yu et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 200204 13. Papageorge MB, Apostolidis C. Simultaneous mandibular distraction and arthroplasty in a patient with temporomandibular joint ankylosis and mandibular hypoplasia. J Oral Maxillofac Surg 1999;57: 32833. 14. Kaban LB, Perrott DH, Fisher K. A protocol for management of temporomandibular joint ankylosis. J Oral Maxillofac Surg 1990;48:114552. 15. Chandra P, Dave PK. Temporomandibular joint ankylosis. Prog Clin Biol Res 1985;11:44958. 16. Matsuura H, Miyamoto H, Ogi N, Kurita K, Goss AN. The effect of gap arthroplasty on temporomandibular joint ankylosis: an experimental study. Int J Oral Maxillofac Surg 2001;30:4317. 17. Su-Gwan K. Treatment of temporomandibular joint ankylosis with temporalis muscle and fascia ap. Int J Oral Maxillofac Surg 2001;30:18993. 18. Karaca C, Barutcu A, Baytekin C, Yilmaz M, Menderes A, Tan O. Modications of the inverted T-shaped silicone implant for treatment of temporomandibular joint ankylosis. J Craniomaxillofac Surg 2004;32:2436. 19. Erol B, Tanrikulu R, Grgn B. A clinical study on ankylosis of the temporomandibular joint. J Craniomaxillofac Surg 2006;34: 1006. 20. Guyuron B, Lasa Jr CI. Unpredictable growth pattern of costochondral graft. Plast Reconstr Surg 1992;90:8809. 21. Gabbay JS, Heller JB, Song YY, Wasson KL, Harrington H, Bradley JP. Temporomandibular joint bony ankylosis: Comparison of treatment with transport distraction osteogenesis or the matthews device arthroplasty. J Craniofac Surg 2006;17:51622. 22. Bartlett SP, Reid RR, Losee JE, Quinn PD. Severe proliferative congenital temporomandibular joint ankylosis: a proposed treatment protocol utilizing distraction osteogenesis. J Craniofac Surg 2006;17:60510. Erratum: J Craniofac Surg 2006; 17:1265. 23. McCormick SU, Grayson BH, McCarthy JG, Staffenberg D. Effect of mandibular distraction on the temporomandibular joint: Part 2- Clinical study. J Craniofac Surg 1995;6:3647.

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