Autogenous Dermis-fat Graft in Temporomandibular Joint Ankylosis Surgery.

Temporomandibular joint (TMJ) ankylosis is fusion or a bony union of the head of the condyle and the glenoid fossa by bony or fibrotic tissues. Due to the immobility of the TMJ, all mandibular movements get affected. Treatment goals are to allow nearly normal TMJ movements, restore symmetry of the face and occlusion, and promote growth and correction of deformity in children. The surgical techniques used to treat TMJ ankylosis are a gap or interpositional arthroplasty, joint reconstruction, and distraction osteogenesis. Appropriate interposition materials include autogenous tissues, allogeneic tissues, and alloplastic and xenograft tissues. This report presents the treatment of a patient with a diagnosis of TMJ ankylosis, who had failed surgery. Interpositional autogenous dermis-fat graft was used to manage TMJ ankylosis of the right side. The technique is discussed within the current literature.

INTRODUCTION

Ankylosis is a chronic hypomobility or immobility of a joint. Temporomandibular joint (TMJ) ankylosis is fusion or a bony union of the head of the condyle and the glenoid fossa by bony or fibrotic tissues. TMJ ankylosis is most commonly associated with trauma (13%–100%), local or systemic infection (10%–49%), or systemic disease (10%), such as ankylosing spondylitis, rheumatoid arthritis, and psoriasis congenital and failed surgery.[1] TMJ ankylosis is classified by location (intra- or extra-articular), type of tissue involved (e.g., bone, fibrous, or fibro-osseous), and extent of fusion (complete or incomplete).[2]

TMJ ankylosis is a serious and disabling condition that often leads to facial deformity, inability to open mouth, difficulty chewing and swallowing, impairment of speech, difficulty with mastication, poor oral hygiene, disturbances of facial and mandibular growth, malocclusion and acute compromise of the airway, and aggravating psychological stress.

Diagnosis of TMJ ankylosis should be by clinical examination and imaging studies such as plain films, orthopantomograms, computed tomography (CT) scans, Magnetic resonance imaging, and three-dimensional reconstruction.[3]

Kazanjian classified ankylosis as true and false. Any condition that gives rise to osseous or fibrous adhesion between the surfaces of the TMJ is a true ankylosis.[1] In the present report, a true ankylosis has been demonstrated.

Multiple surgical modalities such as gap arthroplasty, interpositional arthroplasty, and total joint reconstruction (TJR) have been described to manage TMJ ankylosis. Interpositional arthroplasty is the initiation of gap by resecting the osseous aggregation followed by interposition with autogenous or alloplastic material at the osteotomy site. For preventing recurrence, the distance between the osteotomized bone ends of the ramus and cranial base has been increased with interposition materials.[4]

Various materials have been used to reconstruct the mandibular condyle such as skin, dermis, flaps of the temporal muscle/fascia, silicone, and cartilage to prevent fibrosis and heterotopic bone formation. To prevent re-ankylosis postoperatively, physiotherapy is highly recommended to building up muscle bulk, strength and improving motility.[56]

In the present report, the management of the TMJ ankylosis using dermis-fat graft was discussed considering the current literature.

CASE REPORT

An 18-year-old male patient was referred to Department of Oral and Maxillofacial Surgery, Faculty of Dentistry Istanbul University for the investigation and treatment of a unilateral TMJ ankylosis. The chief complaint was a limitation of severe mouth opening [Figure 1]. The patient claimed that he had been operated before from both sides. Radiographic assessment was carried out using CT scan and panoramic radiography. CT scan and panoramic radiograph revealed the massive heterotopic bone development and bony ankylosis surrounding the right TMJ. Panoramic radiograph also demonstrated the area of previous surgery on the left side [Figures 2 and 3]. A preoperative model which was maintained from the CBCT of the patient was also used to observe properly the extension of the ankylotic mass [Figure 4].

Figure 1

Preoperative view of the limited mouth opening

Figure 2

Preoperative panoramic view which shows the heterotopic bone mass on right temporomandibular joint and previous surgery area at the left temporomandibular joint

Figure 3

Blue arrow shows the ankylotic mass at the axial view of the cone beam computerized tomography

Figure 4

Preoperative model which shows the borders of the ankylosis at the right side of the temporomandibular joint

On clinical examination, 11 mm mouth opening with facial asymmetry and bird face-like appearance was observed. On the left side, a scar at preauricular region was seen, but on the right side, there was no sign of a previous operation. Clinical findings demonstrated slight mandibular retrognathia and deviation of the mandible to the affected (right) side.

General anesthesia with nasotracheal intubation and total muscle relaxation was administered. A single intravenous dose of steroid was given at the beginning of the case. The TMJ is approached through a modified preauricular incision with temporal extension to expose the temporalis fascia and muscle, zygomatic arch, ankylotic mass, and sigmoid notch. The ankylosed TMJ was palpable, and an incision was made directly onto the bone, exposing the ankylosed TMJ. After determining the anterior and posterior limits of the ankylosed condyle, the bony segment was resected using a piezoelectric osteotome. The irregular edges of the segments were smoothed by a bur, and the ramus was completely disconnected from the upper bony block. Ipsilateral coronoidectomy was also performed to maintain adequate mouth opening. A manual-guided mouth opening was done to observe condylar movements. The abdomen was prepared from above the umbilicus to the pubic region. A 4–5 cm transverse incision was made in the midline through skin and subcutaneous tissue and then deepened to obtain fat graft. The fat graft was trimmed, and the dermis with fat graft was passively inserted between the segments and secured with 3-0 vicryl [Figures 5 and 6]. Layer-wise closure was performed. Maxillomandibular fixation was maintained to 3 days, and the patient was discharged from hospital 2 days after surgery.

Figure 5

The view of the dermis fat graft

Figure 6

(a) Intraoperative view of the ankylotic mass. (b) The view of the sutured fat graft

Postoperative medication including antibiotics and nonsteroid anti-inflammatory drugs was prescribed for approximately 2 weeks after the operation. The patient was started on a soft diet. Jaw-opening exercises, active chewing movements, and intensive physiotherapy were started within 7 days of the operation. In first 3 weeks of the physiotherapy, daily active and passive range of motion (ROM) exercises were made in hospital setting with the aid of physiotherapist, and a home exercise program was given to the patient. Before ROM exercises, 10 min hot-pack and 25 min transcutaneous electrical nerve stimulation in burst mode and 4 min therapeutic ultrasound (0.5 watt/cm2, pulsed) were applied to the TMJ region in every session. The patient continued home exercise program after 3-week hospital setting physiotherapy program. Thirty-five millimeters of mouth opening was maintained at the end of the physiotherapy [Figure 7]. The follow-up of the patient was made also by the physiotherapist during 1 year after the operation.

Figure 7

Postoperative mouth opening 1 year after surgery

DISCUSSION

The causative factors of TMJ ankylosis are trauma, systemic and local inflammatory conditions, and neoplasm in TMJ area.[7] In the present case, the history revealed that the patient had a fall from the stairwell and got injury on the face. In addition, he informed that he has undergone a previous bilateral TMJ ankylosis surgery in another department.

One of the main causes of the failed TMJ surgery is inadequate heterotopic bone removal. To prevent possible re-ankylosis, ankylotic bone was aggressively removed during operation. According to the management protocol for TMJ ankylosis reported by Kaban et al., an ipsilateral coronoidectomy was performed to maintain optimum mouth opening.[1] Contralateral coronoidectomy was not found as necessary in the present case. Other factors that can lead to re-ankylosis include wound infection, and a foreign body reaction caused by interpositional materials.[4] In the present case, no wound infection or foreign body reaction associated with the autogenous dermis-fat graft was observed.

The treatment protocol entails surgical approach by releasing and correction of ankylosis. Three main surgical techniques are gap arthroplasty, interpositional arthroplasty, and TJR.[8] The interpositional materials such as skin, dermis, and flaps of the temporal muscle/fascia, silicone, and cartilage for arthroplasty in TMJ ankylosis treatment have been widely discussed. At the present time, there is no gold standard for interpositional graft.[6] Chossegros et al. compared different interpositional materials such as skin, temporal muscle, and homologous cartilage and achieved good results, respectively with full-thickness skin graft and temporal muscle flap. A total of 25 patients (32 joints) with at least 3 years of follow-up were included in their study. Good results were reported in 92% of cases using total full-thickness skin graft and 83% of cases using temporal muscle flap. Homologous cartilage gave poor results.[9]

Alloplasts have their advantages such as avoiding donor site morbidity, reducing operation time, reducing the chance of recurrent ankylosis, and allowing a closer reproduction of the normal anatomy of the joint. They also have some disadvantages such as displacement, failure and fracture of the prosthesis, infection, and extrusion.[10] Heterotopic calcification is also reported commonly after the use of alloplastic materials in the TMJ.[11] Therefore, any alloplastic material was not chosen in the present case.

Posnick and Kaban both used costochondral grafting but different incision and rigid fixation methods. Both have reported good results. Anatomic similarity to the mandibular condyle and growth potential in juveniles makes costochondral graft the most frequently recommended autogenous bone for the reconstruction.[112] On the other hand, costochondral graft was not an option in our case because the patient was an adult.

Reconstruction with custom-made prosthesis for the management of ankylosis has a lot of advantages. These are no requirement for the second surgical field, reduced operative time, no need for vascularization around prosthesis, and rapid recovery period for mastication.[13] On the other hand, the high cost of custom-made prosthesis for TMJ joint replacement was not an option in our case because of the poor socioeconomic situation of the patient. Therefore, dermis-fat graft was advised as an interpositional material after the removal of the ankylotic bone.

Movahed and Mercuri declared that, using fat graft, a physical barrier is produced, which prevents the formation of fibrosis and heterotopic calcification.[13] The use of dermis-fat graft was reported also by Dimitroulis. He presented the clinical experience of using dermis-fat interpositional grafts in the surgical management of TMJ ankylosis in adult patients. Eleven patients with TMJ ankylosis were managed by autogenous dermis-fat interpositional graft. This study demonstrated that the use of the autogenous dermis-fat interpositional graft was an effective procedure for the prevention of re-ankylosis up to 6 years following the surgical release of TMJ ankylosis.[6] Dermal fat graft was performed as an interpositional graft to prevent re-ankylosis as reported by Dimitroulis. In the present study, no sign of re-ankylosis was observed 1 year after the surgery.

Possible complications of abdominal fat graft harvesting include hematoma, seroma, infection, ileus, and inadvertent peritoneal perforation. Wolford suggested to insert a suction drain and leave it in position for approximately 3 days to prevent hematoma or seroma formation. In the present case, no complications were observed at the abdominal site, and we did not prefer to use any drain at surgery because hemostasis was achieved during operation.[11]

CONCLUSION

In the present case, approximately 35 mm of mouth opening was maintained. No postoperative complication was observed regarding the use of the graft. A minimal donor site morbidity was observed, and the manipulation of the graft to the gap was not a complex procedure during operation. In this report, the importance of the multidisciplinary approach including surgical management and physiotherapy was also emphasized.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that their name and initial will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.