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Gap Vs Interpositional Arthroplasty In TMJ

ORIGINAL ARTICLE

GAP VS INTERPOSITIONAL ARTHROPLASTY IN THE MANAGEMENT OF TEMPOROMANDIBULAR JOINT ANKYLOSIS
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NADIA MANSOOR, BDS (PESH), FCPS (ORAL AND MAXILLOFACIAL SURGERY) MUSLIM KHAN, BDS (LUMHS, SINDH), FCPS (ORAL & MAXILLOFACIAL SURGERY) 3 BUSHRA MEHBOOB, BDS (PESH), 4 QIAMUD DIN, BDS, MSc (London) FCPS
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ABSTRACT The objectives of the study were to evaluate the outcome of Gap arthroplasty and Interpositional arthroplasty in terms of mouth opening for management of TMJ ankylosis. This Quasi experimental study was carried out in Oral & Maxillofacial Surgical unit, Khyber College of Dentistry, Peshawar from May 2006 to August 2007. Sixty patients of TMJ ankylosis seeking treatment for the first time, irrespective of age and gender were included in the study. Thirty patients were treated by gap arthroplasty (group A), while thirty patients by disc interpositional arthroplasty (group B). A postoperative jaw opening exercise regimen was followed and interincisal distance/ mouth opening was measured at each follow up visit. Both groups were evaluated for difference in mouth opening. Descriptive statistics and Independent samples T-test was applied with significance level at P < 0.05. After 6-months postoperative follow up, mean interincisal distance was 30.80 mm (± 3.17 mm) for group A, and 32.20 mm (± 4.14 mm) for group B. Difference between the two groups was not significant (p= 0.147). Postoperative jaw opening exercises are crucial for lasting success. Key Words: TMJ ankylosis, Condylar fracture, Disc repositioning, Gap arthroplasty. INTRODUCTION Ankylosis of the Temporomandibular joint (TMJ) is a disfiguring condition.1 The unfortunate patient experiences problems in food intake, speech and maintaining oral hygiene due to limited mouth opening. The facial deformity resulting from ankylosis also has a psychosocial impact.2 TMJ ankylosis is an intracapsular fibrous or bony fusion of the mandibular condyle, joint disc and the glenoid fossa complex.3 It most likely occurs due to disruption of the meniscus and organisation of haematoma within the joint with or without a related intracapsular fracture of the condyle.4 TMJ ankylosis is relatively common in
For correspondence: Dr. Nadia Mansoor, 1 Demonstrator, Oral and Maxillofacial Surgery, Khyber College of Dentistry, Peshawar, Res: 13-D, Circular Road, University Town, Peshawar. Email: nadomj@hotmail.com Associate Professor, Oral and Maxillofacial Surgery. Resident, Oral and Maxillofacial Surgery. Prof & Head Deptt of Oral Maxillofacial Surgery Received for Publication: Revision Received: Revision Accepted: January 21, 2013 February 2, 2013 February 10, 2013

developing countries especially in the South-Asian population. Previous trauma, especially to the chin area in young age, has been documented as the most common etiological factor.5 The management of TMJ ankylosis is mainly surgical, followed by early physiotherapy and functional rehabilitation but differs according to the age of the patient and the extent and duration of ankylosis.4 During the past 150 years since the first condylectomy for the relief of ankylosis there has been a gradual evolution of the techniques employed for its management.6 However, so far no single method has produced uniformly successful results to avoid the major problems of limited range of motion and recurrence of ankylosis.7 The most frequently used procedures include Gap arthroplasty, interpositional arthroplasty, excision and joint reconstruction with grafts (autogenous and alloplastic), and total TMJ replacement with joint prosthesis.8,9 Recently, distraction osteogenesis has become a popular method for correction of the mandibular deformity and relief of upper airway obstruc8

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Pakistan Oral & Dental Journal Vol 33, No. 1 (April 2013)

while patients who had undergone Interpositional arthroplasty were included in group B. The exercise was continued at least for 6 months. Peshawar. Sixty patients of TMJ ankylosis were included in the study. Both the dislocated native disc if present intact.8) years while in group B it was 10. patients were routinely administered antibiotics for 7-10 days. In group B.7. Patients were discharged on the 7th postoperative day after removal of the skin sutures. On the 2nd post-operative day only active mouth opening was started and on the 5th post-operative day passive jaw movement exercise with wooden spatulas was started. Khyber College of Dentistry. maximum number of patients presented in 16-20 years (n=14. 1 (April 2013) risks and benefits associated with the treatment were explained and a written informed consent of all the patients or parents (for child patients) was taken. and the pedunculated temporalis myofascial flap have these properties. Only Diagnosed patients of TMJ ankylosis. Computed Tomography scan was advised for two patients. For comparison of treatment outcome. a spatula was added per day to the previous count up to insertion of 30-35 spatulas. and silastic.6%). the mean age was 16 (± 3. some researchers have advocated in favour of Gap arthroplasty whereas others have concluded that Interpositional arthroplasty is a better option. with instructions of active and passive physiotherapy. No. maximum number of patients presented in 5-10 years 9 . with temporal extension shaped like a question mark (Popowich’s modification of Al-Kayat & Bramley’s incision). RESULTS The mean age of the patients at the time of presentation in this study was 13. The wooden spatula exercise was advised 5 times a day for 15 minutes.. mouth opening/IID was measured on each visit and at the end of six months follow-up.the modified preauricular incision by Al-Kayat and Bramley. Before the procedure. The level of significance was set at p < 0. Surgical approach to the TMJ was same in all the patients i. METHODOLOGY This Quasi experimental study was carried out at Oral & Maxillofacial Surgical Unit. The joint capsule was divided by a T-shaped incision. and Independent-samples Ttest.11 The interpositioning material of choice is the one which is easily available. The patients were recalled on preset appointments after the surgical planning. while recurrent cases of ankylosis were excluded. All patients were advised and demonstrated the same mouth opening exercises.33 (± 4. homologous cartilage. In group A.14 The purpose of this study was to evaluate and find the results of Gap and Interpositional arthroplasty. A detailed history was taken and thorough clinical examination was carried out with the consent of the patient. a variety of materials including skin grafts.e.12. irrespective of age and gender.3%). In group A. Postoperatively. temporalis fascia. recommended for surgery were included in the study. Each patient was monthly reviewed for a period of 6 months.5 (± 4) years. silicone or acrylic implants have been used as interpositioning materials.10 In interpositiosional arthroplasty.3%). Peshawar from 20th May 2006 till 20th August 2007. 46. Inter-incisal distance (IID)/mouth opening was noted at the operating table immediately following completion of the surgical procedure. followed by 1115 years (n=19.13 Amongst the procedures used primarily for the relief of ankylosis. causes minimal donor site morbidity and postoperative complications.6%). Maximum number of patients presented in 5-10 years (n=20. 31. The data collected from the two groups were entered into SPSS version 10 and analyzed by applying descriptive statistics. Each group had 30 patients. temporalis muscle. has the same operative field.85) years.13 Early postoperative jaw mobilization and aggressive physiotherapy are an integral part of a treatment protocol for TMJ ankylosis. Orthopantomogram (OPG) was the standard radiograph and when required was supplemented by postero-anterior (PA face) view and lateral oblique view of the mandible for confirmation of diagnosis. followed by 11-15 years (n=10. in order to standardize the management of TMJ ankylosis among patients reporting at Khyber College of Dentistry. 33. They were divided into two treatment groups (group A and B). the Pakistan Oral & Dental Journal Vol 33. 33.05. Independent-samples T-test was used to compare the means of IID of the two groups at the end of 6 months follow-up.Gap Vs Interpositional Arthroplasty In TMJ tion due to ankylosis. Patients managed by Gap arthroplasty were assigned group A. All the 60 patients were operated under general anesthesia with blind nasotracheal intubation.

10 3. and Africa16 is much more than in the developed ones. No. the frequency of TMJ ankylosis in developing countries including Pakistan 15 India.77 3.1. The most common age group came out to be 11-20 years. while of group B.3%) 30 (100%) Group B 17 (56.3%) 0 0 30 (100%) Total 20 (33.85) years.73 IID 6 months Post-op (mm) 30 30. just after completion of surgery was 25. as given in Tables 4 and 5.20 mm (± 4.18 Involvement of the lesser age group is due to the fact that fractures of condyles are more common in children as compared to other sites of the mandible.47 3. DISCUSSION TMJ ankylosis is a relatively common condition of the younger age.6%) 9 (30%) 4(13. it was 27.Gender distribution of the study showed that 60% patients were male (n=36).12 mm). while the remaining 40% were female (n=24). China7.147).60 patients of TMJ ankylosis were treated in this study.23 Period of Ankylosis (years) 30 7.3%) 1 (1. the mean age of the patients was 13. the mean IID/mouth opening of group A was 30. Deviation Valid 30 16. 30%). followed by 11-15 years (n=9.39 IID after Completion of surcal procedure (mm) 30 27.80 3.6%) 18 (30%) 2 (3.47 mm (± 4. while in group B was 8.23 mm). with a male to female ratio of 1.08 Pakistan Oral & Dental Journal Vol 33. The result is similar to studies conducted by Sawhney17 and Li.17 mm).10 mm (± 3. The difference is not significant statistically (p= 0.17 N Mean Std.5 mm (± 3.12 Period of Ankylosis (years) 30 3. the mean mouth opening/ IID was 6.88 TABLE 3: STATISTICS OF GROUP B (n=30) Age Pre-op Interincisal distance 30 8.Gap Vs Interpositional Arthroplasty In TMJ (n=17. but facial trauma remains the major factor in TMJ ankylosis in this part of the world.14 10 N Mean Std. The difference is not significant statis- tically (p= 0. while in group B.80 mm (± 3.26 mm). as shown in Tables 2 and 3.42 mm).43 mm (± 4.5:1.43 4.53 4. Patients in group A were treated by gap arthroplasty (n=30) while patients in group B with interpositional arthroplasty.7 mm). Regarding gender distri- TABLE 1: AGE DISTRIBUTION OF PATIENTS (n=60) Group A Age in Groups 5-10 years 11-15 years 16-20 years 21-25 years Above 25 years Total 3 (10%) 10 (33.47 4. Group A had 53.At the end of 6 months post-operative follow up. 56.6%) 2 (6. The detailed age distribution is given in Table No. The mean pre-operative mouth opening/interincisal distance (IID) was 7.43 4.3% males while group B had 66.20 4.13 3. it was 32.6%) 1 (3.6% males. Deviation Valid 30 10.42 IID 6 months Post-op (mm) 30 32. In this study.082).6%). 1 (April 2013) . Not often seen in the west.14 mm). The mean mouth opening of group A. In group A.45 mm (± 4.6%) 60 (100%) TABLE 2: STATISTICS OF GROUP A (n=30) Age Pre-op Interincisal distance 30 6.3%) 19 (31.58 IID after Completion of surcal procedure (mm) 30 25.33 (± 4.3%) 14 (46.

22 However. Though a definite reason could not be ascertained. 2003: 683-84. REFERENCES 1 Roychoudhury A. Missouri: Mosby. Perciaccante VJ.7. Krishnan DG. Among patients treated by Gap arthroplasty (group A) at the end of 6 months post-operative follow up. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 1999. St.Gap Vs Interpositional Arthroplasty In TMJ bution. the mean IID was measured. which is a major factor for noncompliance of patients to postoperative physiotherapy. Topazian compared gap and interpositional arthroplasties. 87: 166-69. Parkash H. when only gap and interpositional arthroplasty are considered. 2007: 1522-37.22 Surgery is not the end point of treatment of TMJ ankylosis. Early postoperative jaw-opening exercises are essential and should be supplemented by analgesic and anti-inflammatory medications to reduce the pain. as the disc was unable to be repositioned because it was severely damaged or missing. 4th ed. in the present study 60% patients were male (n=36) and 40% were female (n=24) with male to female ratio was 1. 2 3 4 11 . In a study on disc repositioning by Zhang and He 21 recurrence occurred in a patient 6 months postoperatively. Recurrence was observed in only one case in whom bilateral interpositional soft tissue arthroplasty was done. reported 53% recurrence in patients treated by gap arthroplasty but no recurrence was observed when autogenous tissue was interposed.13 In a comparative statistical study by Tanrikulu. Recurrence is of major concern in all methods of treatment of TMJ ankylosis.24 This may be due to complete removal of the medial ankylotic mass and having carried out postoperative physiotherapy strictly. Management of Temporomandibular Disorders. Postoperative rehabilitation is equally important and neglect here is often a reason for failure. recent studies on disc repositioning arthroplasty provide more direct evidence that disc interpositioning is an ideal approach for the treatment of TMJ ankylosis as it restores normal structure of TMJ and prevents recurrence. Missouri: Churchill Livingstone. In a study by Vasconcelos patients were equally distributed in both sexes. In: Maxillofacial Surgery. 1 (April 2013) leads to unstable occlusion and anterior open bite thus interpositioning of an autograft or allograft is a good means of limiting resection and preventing recurrence. Moreover. good results were obtained with full thickness skin graft and disc repositioning. Tucker MR. Functional restoration by gap arthroplasty in temporomandibular joint ankylosis. The IID after gap arthroplasty in the present study is almost the same as in this study. Louis. Temporal fascia as interpositioning material in cases of temporomandibular ankylosis. 15(2): 89-91. the relatively high number of male to female patients in our study may be due to the fact that male children are more active and involved more in outdoor activities. Nayak P. risks of graft harvesting and immunologic risk. Thirty patients of group B were treated by Interpositional arthroplasty of whom. The effort to increase the gap Pakistan Oral & Dental Journal Vol 33. In: Contemporary Oral and Maxillofacial surgery. in studies by Cheema2 and Tanrikulu20 the number of female patients was more than the male. Cheema SA.19 However. Ochs MW. J Coll Physicians Surg Pak 2005. Recurrence was observed in only one case.23.11 Though little has been reported about the status of use of the dislocated disc. Statistical evaluation otherwise showed that postoperative mouth opening achieved was the greatest with interpositional arthroplasty. other studies on gap arthroplasty and the present study show better results of gap arthroplasty. displacement of the repositioned disc may be the reason but a definite cause could not be ascertained due to the time limitation of the study. nine by interpositional soft tissue arthroplasty and seven by joint reconstruction with costochondral graft. No. A variety of materials have been used but the most widely used and reported interpositioning material is temporalis myofascial flap. Anterior open bite was encountered in 4 cases after bilateral gap arthroplasty. it will not present problems such as cost. The results of that study are consistent to that of the present study. St Louis. while homologous cartilage gave poor results.25 In a study by Chossegros.K. Roychoudhury1 emphasized that gap arthroplasty supplemented with vigorous jaw opening exercises have good long term functional results. Gap arthroplasty is widely reported to be associated with re-ankylosis if a sufficient gap is not produced. 26 patients had the natural disc repositioning while in the remaining 4 patients pedunculated temporalis myofascial flap was used for interpositioning. Ankylosis of the Temporomandibular Joint. eight cases were treated by gap arthroplasty. In the single reankylosis case in this study too. Trikha A.5:1.12. Statistical evaluation of the difference in IID between the two groups was insignificant. Nair SC. 2nd ed.

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