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)

Gap Vs Interpositional Arthroplasty In TMJ

tion due to ankylosis.10 In interpositiosional arthroplasty, a variety of materials including skin grafts, temporalis muscle, temporalis fascia, homologous cartilage, and silastic, silicone or acrylic implants have been used as interpositioning materials.11 The interpositioning material of choice is the one which is easily available, has the same operative field, causes minimal donor site morbidity and postoperative complications. Both the dislocated native disc if present intact, and the pedunculated temporalis myofascial flap have these properties.7,12,13 Early postoperative jaw mobilization and aggressive physiotherapy are an integral part of a treatment protocol for TMJ ankylosis.13 Amongst the procedures used primarily for the relief of ankylosis, some researchers have advocated in favour of Gap arthroplasty whereas others have concluded that Interpositional arthroplasty is a better option.14 The purpose of this study was to evaluate and find the results of Gap and Interpositional arthroplasty, in order to standardize the management of TMJ ankylosis among patients reporting at Khyber College of Dentistry, Peshawar. METHODOLOGY This Quasi experimental study was carried out at Oral & Maxillofacial Surgical Unit, Khyber College of Dentistry, Peshawar from 20th May 2006 till 20th August 2007. Sixty patients of TMJ ankylosis were included in the study. They were divided into two treatment groups (group A and B). Each group had 30 patients. Patients managed by Gap arthroplasty were assigned group A, while patients who had undergone Interpositional arthroplasty were included in group B. Only Diagnosed patients of TMJ ankylosis, irrespective of age and gender, recommended for surgery were included in the study, while recurrent cases of ankylosis were excluded. A detailed history was taken and thorough clinical examination was carried out with the consent of the patient. 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. Computed Tomography scan was advised for two patients. The patients were recalled on preset appointments after the surgical planning. Before the procedure, the
Pakistan Oral & Dental Journal Vol 33, No. 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. All the 60 patients were operated under general anesthesia with blind nasotracheal intubation. Surgical approach to the TMJ was same in all the patients i.e.,the modified preauricular incision by Al-Kayat and Bramley, with temporal extension shaped like a question mark (Popowichs modification of Al-Kayat & Bramleys incision). The joint capsule was divided by a T-shaped incision. Inter-incisal distance (IID)/mouth opening was noted at the operating table immediately following completion of the surgical procedure. Postoperatively, patients were routinely administered antibiotics for 7-10 days. All patients were advised and demonstrated the same mouth opening exercises. 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. Patients were discharged on the 7th postoperative day after removal of the skin sutures, with instructions of active and passive physiotherapy. The wooden spatula exercise was advised 5 times a day for 15 minutes, a spatula was added per day to the previous count up to insertion of 30-35 spatulas. The exercise was continued at least for 6 months. Each patient was monthly reviewed for a period of 6 months; mouth opening/IID was measured on each visit and at the end of six months follow-up. The data collected from the two groups were entered into SPSS version 10 and analyzed by applying descriptive statistics, and Independent-samples Ttest. For comparison of treatment outcome, Independent-samples T-test was used to compare the means of IID of the two groups at the end of 6 months follow-up. The level of significance was set at p < 0.05. RESULTS The mean age of the patients at the time of presentation in this study was 13.33 ( 4.85) years. In group A, the mean age was 16 ( 3.8) years while in group B it was 10.5 ( 4) years. Maximum number of patients presented in 5-10 years (n=20, 33.3%), followed by 1115 years (n=19, 31.6%). In group A, maximum number of patients presented in 16-20 years (n=14, 46.6%), followed by 11-15 years (n=10, 33.3%). In group B, maximum number of patients presented in 5-10 years 9

Gap Vs Interpositional Arthroplasty In TMJ

(n=17, 56.6%), followed by 11-15 years (n=9, 30%). The detailed age distribution is given in Table No.1.Gender distribution of the study showed that 60% patients were male (n=36), while the remaining 40% were female (n=24), with a male to female ratio of 1.5:1. Group A had 53.3% males while group B had 66.6% males. The mean pre-operative mouth opening/interincisal distance (IID) was 7.45 mm ( 4.26 mm). In group A, the mean mouth opening/ IID was 6.47 mm ( 4.23 mm), while in group B was 8.43 mm ( 4.12 mm), as shown in Tables 2 and 3.60 patients of TMJ ankylosis were treated in this study. Patients in group A were treated by gap arthroplasty (n=30) while patients in group B with interpositional arthroplasty. The mean mouth opening of group A, just after completion of surgery was 25.5 mm ( 3.7 mm), while in group B, it was 27.10 mm ( 3.42 mm), as given in Tables 4 and 5. The difference is not significant statis-

tically (p= 0.082).At the end of 6 months post-operative follow up, the mean IID/mouth opening of group A was 30.80 mm ( 3.17 mm), while of group B, it was 32.20 mm ( 4.14 mm). The difference is not significant statistically (p= 0.147). DISCUSSION TMJ ankylosis is a relatively common condition of the younger age, the frequency of TMJ ankylosis in developing countries including Pakistan 15 India, China7, and Africa16 is much more than in the developed ones. Not often seen in the west, but facial trauma remains the major factor in TMJ ankylosis in this part of the world. In this study, the mean age of the patients was 13.33 ( 4.85) years. The most common age group came out to be 11-20 years. The result is similar to studies conducted by Sawhney17 and Li.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. 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 (33.3%) 14 (46.6%) 2 (6.6%) 1 (3.3%) 30 (100%) Group B 17 (56.6%) 9 (30%) 4(13.3%) 0 0 30 (100%) Total 20 (33.3%) 19 (31.6%) 18 (30%) 2 (3.3%) 1 (1.6%) 60 (100%)

TABLE 2: STATISTICS OF GROUP A (n=30) Age Pre-op Interincisal distance 30 6.47 4.23 Period of Ankylosis (years) 30 7.43 4.58 IID after Completion of surcal procedure (mm) 30 25.47 3.73 IID 6 months Post-op (mm) 30 30.80 3.17

N Mean Std. Deviation

Valid

30 16.13 3.88

TABLE 3: STATISTICS OF GROUP B (n=30) Age Pre-op Interincisal distance 30 8.43 4.12 Period of Ankylosis (years) 30 3.77 3.39 IID after Completion of surcal procedure (mm) 30 27.10 3.42 IID 6 months Post-op (mm) 30 32.20 4.14 10

N Mean Std. Deviation

Valid

30 10.53 4.08

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

Gap Vs Interpositional Arthroplasty In TMJ

bution, in the present study 60% patients were male (n=36) and 40% were female (n=24) with male to female ratio was 1.5:1. In a study by Vasconcelos patients were equally distributed in both sexes.19 However, in studies by Cheema2 and Tanrikulu20 the number of female patients was more than the male. Though a definite reason could not be ascertained, 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. Among patients treated by Gap arthroplasty (group A) at the end of 6 months post-operative follow up, the mean IID was measured. Anterior open bite was encountered in 4 cases after bilateral gap arthroplasty. Thirty patients of group B were treated by Interpositional arthroplasty of whom, 26 patients had the natural disc repositioning while in the remaining 4 patients pedunculated temporalis myofascial flap was used for interpositioning, as the disc was unable to be repositioned because it was severely damaged or missing. Recurrence was observed in only one case. Statistical evaluation of the difference in IID between the two groups was insignificant. In a study on disc repositioning by Zhang and He 21 recurrence occurred in a patient 6 months postoperatively. In the single reankylosis case in this study too, 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. Roychoudhury1 emphasized that gap arthroplasty supplemented with vigorous jaw opening exercises have good long term functional results. The IID after gap arthroplasty in the present study is almost the same as in this study. Topazian compared gap and interpositional arthroplasties, reported 53% recurrence in patients treated by gap arthroplasty but no recurrence was observed when autogenous tissue was interposed.22 However, other studies on gap arthroplasty and the present study show better results of gap arthroplasty.23,24 This may be due to complete removal of the medial ankylotic mass and having carried out postoperative physiotherapy strictly. Recurrence is of major concern in all methods of treatment of TMJ ankylosis. Gap arthroplasty is widely reported to be associated with re-ankylosis if a sufficient gap is not produced. The effort to increase the gap
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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. A variety of materials have been used but the most widely used and reported interpositioning material is temporalis myofascial flap.12,25 In a study by Chossegros, good results were obtained with full thickness skin graft and disc repositioning, while homologous cartilage gave poor results.11 Though little has been reported about the status of use of the dislocated disc, 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. Moreover, it will not present problems such as cost, risks of graft harvesting and immunologic risk.7,13 In a comparative statistical study by Tanrikulu, eight cases were treated by gap arthroplasty, nine by interpositional soft tissue arthroplasty and seven by joint reconstruction with costochondral graft. Recurrence was observed in only one case in whom bilateral interpositional soft tissue arthroplasty was done. Statistical evaluation otherwise showed that postoperative mouth opening achieved was the greatest with interpositional arthroplasty. The results of that study are consistent to that of the present study, when only gap and interpositional arthroplasty are considered.22 Surgery is not the end point of treatment of TMJ ankylosis. Postoperative rehabilitation is equally important and neglect here is often a reason for failure. Early postoperative jaw-opening exercises are essential and should be supplemented by analgesic and anti-inflammatory medications to reduce the pain, which is a major factor for noncompliance of patients to postoperative physiotherapy. REFERENCES
1 Roychoudhury A, Parkash H, Trikha A. Functional restoration by gap arthroplasty in temporomandibular joint ankylosis. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 1999; 87: 166-69. Cheema SA. Temporal fascia as interpositioning material in cases of temporomandibular ankylosis. J Coll Physicians Surg Pak 2005; 15(2): 89-91. Tucker MR, Ochs MW. Management of Temporomandibular Disorders. In: Contemporary Oral and Maxillofacial surgery. 4th ed. St Louis, Missouri: Mosby; 2003: 683-84. Nayak P.K, Nair SC, Krishnan DG, Perciaccante VJ. Ankylosis of the Temporomandibular Joint. In: Maxillofacial Surgery. 2nd ed. St. Louis, Missouri: Churchill Livingstone; 2007: 1522-37.

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Gap Vs Interpositional Arthroplasty In TMJ 5 Ansari SR, Iqbal S, Aslam S. Surgical correction of TMJ ankylosis- A study on the incidence & evaluation of success rates of various surgical procedures. Pak Oral Dent J 2003; 23(2): 10512. Humphrey GM. Excision of the condyle of the lower jaw. Assoc Med J 1856; 160: 60-62. Long X, Li X, Cheng Y, Yang X, Qin L, Qiao Y, et al. Preservation of disc for treatment of traumatic temporomandibular joint ankylosis. J Oral Maxillofac Surg 2005; 63(7): 897-902. Karaca C, Barutcu A, Menderes A. Inverted, T-shaped silicone implant for the treatment of temporomandibular joint ankylosis. J Craniofac Surg 1998; 9: 539-542. Wolford LM, Pitta MC, Fischel OR, Franco PF. TMJ Concepts/ Techmedica custom-made TMJ total joint prosthesis: 5-year follow-up study. Int J Oral Maxillofac Surg 2003; 32: 268-274. Rao K, Kumar S, Kumar V, Singh AK, Bhatnagar SK. The role of simultaneous gap arthroplasty and distraction osteogenesis in the management of temporomandibular joint ankylosis with mandibular deformity in children. J Craniomaxillofac Surg 2004; 32: 38-42. Chossegros C, Guyot L, Cheynet F, Blanc JL, Gola R, Bourezak Z, et al. Comparison of different materials for interposition arthroplasty in treatment of temporomandibular joint ankylosis surgery: long-term follow-up in 25 cases. Br J Oral MaxfacSurg 1997; 35: 157-60. Bulgannawar BA, Rai BD, Nair MA, Kalola R. Use of temporalis fascia as an Interpositional arthroplasty in temporomandibular joint ankylosis: analysis of 8 cases. J Oral Maxillofac Surg 2011; 69(4): 1031-35. Kaban LB, Bouchard C, Troulis MJ. A Protocol for Management of Temporomandibular joint Ankylosis in children. J Oral Maxillofac Surg 2009; 1966-78. Devgan A, Siwach RC, Sangwan SS. Functional restoration by excision arthroplasty in temporomandibular joint ankylosis- a report of 35 cases. Indian J Med Sci 2002; 56(2): 61-4. Warraich RA, Cheema SA. Temporomandibular joint ankylosis- A preventable entity? Ann KE Med Coll 2001; 7: 168-9. 25 18 16 Ferretti C, Bryant R, Becker P, Lawrence C. Temporomandibular joint morphology following post-traumatic ankylosis in 26 patients. Int J Oral Maxillofac Surg 2005; 34: 376-381. Sawhney CP. Bony ankylosis of the temporomandibular joint: Follow-up of 70 patients treated with arthroplasty and acrylic spacer interposition. Plast Reconst Surg 1986; 77: 29-38. Li ZB, Li Z, Shang ZJ, Zhao JH, Dong YJ. Potential role of disc repositioning in preventing postsurgical recurrence of traumatogenic temporomandibular joint ankylosis: a retrospective review of 17 consecutive cases. Int J Oral Maxillofac Surg 2006; 35: 219-223. Vasconcelos BCE, Bessa-Nogueira RV, Cypriano RV. Treatment of temporomandibular joint ankylosis by gap arthroplasty. Med Oral Pathol Oral Cir Bucal 2006; 11: 66-69. Tanrikulu R, Erol B, Gorgun B, Soker M. The contribution to success of various methods of treatment of temporomandibular joint ankylosis (a statistical study containing 24 cases). Turk J pediatr 2005; 47: 261-265. Zhang Y, He DM. Clinical investigation of early post-traumatic temporomandibular joint ankylosis and the role of repositioning discs in treatment. Int J Oral Maxillofac Surg 2006; 35: 10961101. Topazian RG. Comparison of gap and interposition arthroplasty in the treatment of temporomandibular joint ankylosis. J Oral Surg 1966; 24: 405-409. Rajgopal A, Banerji PK, Batura V, Sural A. Temporomandibular joint ankylosis. A report of 15 cases. J Oral Maxillofac Surg 1983; 11: 37-41. Tanrikulu R, Erol B, Gorgun B, Soker M. The contribution to success of various methods of treatment of temporomandibular joint ankylosis (a statistical study containing 24 cases). Turk J pediatr 2005; 47: 261-265. Martins WD. Report of ankylosis of the temporomandibular joint: Treatment with a temporalis muscle flap and augmentation genioplasty. J Contemp Dent Pract 2006; 7: 125-133.

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