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MODIFIED CORONOID
PROCESS GRAFTS COMBINED
WITH SAGITTAL SPLIT
OSTEOTOMY FOR
TREATMENT OF BILATERAL
TMJ ANKYLOSIS
BY
HONG YONGLONG et al.,XIAN,
CHINA
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INTRODUCTION
Tmj ankylosis leads to restriction of oral opening
ranging from partial reductioon to complete
immobility of the jaw.

The most common cause is the macrotrauma
associated with a condylar process # during the
active growth period in childhood.

Commonly used techs such as gap arhroplasty at
different levels, interpositional cartilage grafts, and
arthroplasty.

Recently to improve both function and profile, an
arthroplasty combined with orthognathic surgery
has been recomended
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PATIENTS AND METHODS
Six pts with bilateral tmj ankylosis and severe retrognathia
were treated during the period june 1996 to march 1999.

4 male, 2 female. Youngest being 6 years and the oldest being
17 years.

Ethilogy for 4 pts being trauma during 1
st
decade and other two
suffered from otitis media.

All pts were not treated previously and had complete bony
ankylosis.

Obstructive sleep apnea was the principal complaint in 5 pts. In
which 3 of them were unable to sleep except in the sitting
position and had frequent hypoapnoeic episodes each night.

The pts were treated with sagittal split ramus osteotomy and
immediate coronoid process grafts. A fibular graft was used to
stabilize mand segment in 4 pts.
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SURGICAL PROCEDURE
GA via nasotracheal intubation in 2 pts and via tracheostomy in
4 pts.
Mandible approached through combined retromandibular and
extended pre auricular incisions.

The retromandibular incision was made 5 cm below the lobe of
the ear and 2.5cm behind the angle of the mandible on the
anterior border of the sternocleidomastoid muscle.

The scm muscle was retracted posteriorly, the parotid gland
upward, and the skin fascia flap forward.

Through this incision the angle of the mandible and post
border of the ramus were exposed. Then the pterygomassetric
sling was striped completely from its attachments .
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An extended pre auricular incision was made next.
After retracting the flap, the superficial temporalis
fascia was incised at 45
o
angle stat\rting at the root
of the zygomatic arch and extending upward to a
point 2cm above the arch deep to temporal fat pad.

The reflected flap included the superficial temporalis
fascia, periosteum, temporal fat pad, and the
zygomatic and temporal branches of the facial nerve.

Then the ankylosed condyle was resected and
removed takin care not to injure the internal max
artery behind and deep to the osseous mass.

A space atleast 1.5 to 2cm between zygomatic arch
and superior margin of the ramus was created.


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Then the coronoid process was detached with a
reciprocatig saw and was used to replace the
resected ankylosed condyle.

The glenoid fossae was created by trimming with
rose-head burs, a small flap of temporalis fascia or
muscle was inserted in the gap to prevent bony
reunion.

Now the horizontal cortical osteotomy of the sagittal
split was made. This cut was continued down the
external oblique ridge to the second molar region.

The lateral vertical cortical osteotomy was started
just distal to the second molar and was extended to
the inferior border of the mandible.

Then to initiate the actual plane for the split, a thin,
straight osteotome and a bone splitter were
alternately malleted into the area parallel to and just
beneath the lateral cortex.
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After condylectomy and bsso, the mandible was
pulled forward and rotated into a reasonable position
for restoring the occlusion.

The coronoid process graft was rotated 180
o
and the
former anterior border of the segment was alligned
with the post border of the ramus.

The tip of the coronoid process graft was also
alligned in the newly fashioned glenoid fossa and
fixed to the ramus with a microplate and screws.

If both the buccal and lingual cortices were not
strong enough or if their overlap was inadequete, a
fibular bone graft was used to stabilize the
segments.

A maxillo-mandibular fixator was used for six weeks.


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RESULTS
All patients mouth opening and aesthetic
appearances were found to be satisfactory.

Both mentolabial and mentocervical angles had
returned to normal shape in late examinations.

The alignment between middle 3
rd
and lower 3
rd
of
the face had become normal after 1 or 2 years.

In 5 cases, the OSAS disappeared completely
immediately after surgery.

One pt only had a interincisal opening of 10mm after
1 year that was related to his poor compliance with
mouth opening exercises.
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DISCUSSION
Bilateral tmj ankylois developing during the active
growth period is often complicated by development
of secondary changes such as the body and
ascending rami fail to develop, the chin recedes, and
the coronoid process is markedly elongated and
thickened.

The temporalis muscle is stronger and hypertrophic,
and the suprahyoid muscle group is shorter and
hypertrophic.

Respiration can be severly jeopardized, causing
snoring and OSAS.

The method chosen for the reconstruction of the
ramus and condyle in a pt with tmj ankylosis not
only should provide a functional joint but also help
restore the facial profile.
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Autogenous costochondral rib grafts have been
used as a substitute for mandibular ramus and
condyle,

Several studies have shown that in children
costochondral grafts have the potential to grow.
However, this factor alone doesnot mean that growth
will always proceed normally .

Growth of these grafts is unpredictable, ranging
from resorption to overgrowth and sometimes
necessating secondary surgical procedure.

The coronoid process of patients with long standing
tmj ankylosis is longer and thicker so it could be
used to take the place of the condyle and lengthen
the mandibular ramus, thus avoiding a second
surgical site.
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