WESTERMARK,
SINDET-PEDERSEN,
primary fibrinolysis. This theory gained further acceptance after the demonstration of high levels of plasminogen activator in prostatic tissue.6 It is believed that this excess plasminogen activator is produced as a result of surgical trauma to prostatic tissue, resulting in a hypocoagulability of the blood.7 More recent clinical studies have suggested that thromboplastins released from prostatic tumor cells initiate a disseminated intravascular coagulation (DIC) syndrome, with fibrinolysis occurring secondarily. It is estimated that 25% of cases of chronic DIC have an underlying carcinoma of the prostate.8 DIC was ruled out in this case. Systemic use of l-aminocaproic acid, a drug that can effectively prevent clot dissolution by inhibiting the activation of plasminogen by plasminogen activators, was considered in the treatment of the patient. However, it was not used because of the consulting physician’s fears that it could contribute to systemic thrombosis and because the patient’s condition appeared to be improving. However, the local
J Oral Maxillofac 48:881-865,
861
AND BOYNE
or systemic use of an antifibrinolytic cases warrants further investigation.
agent for such
References 1. Bhaskas SN: Synopsis of Oral Pathology. St Louis. MO, Mosby, 1973, p 304 2. Mejer I, Shklar G: Malignant tumors metastatic to the mouth and jaws. Oral Surg 20:350, 1965 3. Thatcher SL. Dve CG: Carcinoma of the orostate metastatic to the mandibular condyle mimicking -a parotid tumor. J Oral Maxillofac Surg 44:394, 1986 4. Wosnitzer M: Aid to decrease postoperative bleeding in transurethral resection of prostate gland. Urology 23: 187, 1983 5. Tagnon HJ, Whitmore WF, Shulman NR: Fibrinolysis in metastatic cancer of the prostate. Cancer 5:9, 1952 6. Ladehoff AA, Rasmussen J: Fibrinolysis and thromboplastic activity in relation to hemorrhage in transvesical prostatectomy. Stand J Clin Lab Invest 13:231, 1961 7. Smith RB, Raich P: Epsilon aminocaproic acid and the control of post-prostatectomy bleeding: A prospective double-blind study. J Ural 131:1093, 1984 8. Goldenberg SL, Fenster HN: Disseminated intravascular coagulation in carcinoma of prostate: Role of estrogen therapy. Urology 22: 130, 1983
Surg
1940
Bony Ankylosis of the Temporomandibular Joint: Case Report of a Child Treated With Delrin Condylar Implants ANDERS H. WESTERMARK, DDS,* STEEN SINDET-PEDERSEN, AND PHILIP J. BOYNE, DMD, MST Bony ankylosis of the temporomandibular joint (TMJ) results in immobilization of the mandible, and when occurring in children it impairs mandibular growth and results in mandibular retrognathism. The ankylosis thus induces functional and esthetic
* Staff, Department of Oral and Maxillofacial Surgery, Aarhus University Hospital, Norrebrogade, Aarhus, Denmark. t Professor and Chairman, Department of Surgery, School of Medicine, Loma Linda Universitv Medical Center. Loma Linda. CA. Address correspondence and reprint requests to Dr Westermark: Department of Oral and Maxillofacial Surgery, Aarhus University Hospital, Norrebrogade DK 8000 Aarhus, Denmark. 0 1990 American Association geons 0278-2391/90/4808-0016$3.00/O
of Oral and Maxillofacial Sur-
DDS,*
disturbances as well as difficulties with nutrition and oral hygiene. I-6 Trauma in early childhood is the most common cause of the TMJ ankylosis.7-‘0 Therefore, to prevent growth disturbances, early surgical intervention has been advocated,233.5*‘1~‘2 and a variety of surgical approaches have been recommended 3.6.9,13,14 Osteotomy of the ankylosed area combined with the interposition of various materials has been advocated by numerous authors.4-6,9914-22The type of interpositional material recommended has included a skin flap (dermis?),” metatarsal bone,** a muscle flap,6 an iliac crest graft,23 rib grafts,576Y18*21 clavicular osteochondral grafts,24 acrylic cylinders,’ silicone elastomer,‘2*‘5~16~‘9720~25 a silicone tube,4 Proplast (Vitek Inc, Houston, TX),” and Teflon-
862
BONY ANKYLOSIS OF THE TM3: CASE REPORT
Proplast (Vitek Inc, Houston, TX) combined with a TMJ prosthesis.‘3P’4 Dehin (Timesh, Inc., Calabasas, CA) a polyacetyl homopolymer polyoxymetylene, has been successfully used in orthopedic joint replacement, and Boyne et al have published results of an experimental study using a Delrin prosthesis for condylar replacement.26 In growing baboons, condyles were removed unilaterally and replaced with Delrin condyles fixed to the ramus of the mandible with a titanium mesh.26 On the Delrin-treated side, they observed increase in bone formation in the roof of the glenoid fossa, in the floor of the middle cranial fossa, and in the marrow space between. A new condylar head was formed on the Delrin condyle by apposition of bone on the superior and posterior surfaces of the implants.26 Based on these favorable biologic reactions to Delrin condylar implants Boyne et al questioned whether costochondral grafts are necessary in the surgical treatment of growing patients with TMJ ankylosis. 26The following report describes a case in which Delrin condylar prostheses were used to treat a child with bilateral bony ankylosis of the TMJ. Report of a Case An &year-old Vietnamese girl was referred for treatment of TMJ ankylosis. Five years previously, she had
been involved in a traffic accident and most probably had acquired bilateral condylar fractures with medial displacement on that occasion. The fractures had been left untreated, and eventually the jaw became totally immobilized. The clinical examination revealed that the patient had a marked mandibular retrognathism, a totally immobile mandible, severely decayed posterior teeth, and several retained decidious teeth (Fig 1). Radiographs showed total bony ankylosis of both TMJs (Figs 2 and 3). To treat the patient it was decided to resect the area of ankylosis and install Delrin condylar implants fixed with titanium mesh to the mandible.
SURGICALPROCEDUREAND POSTOPERATIVE MANAGEMENT Endotracheal intubation was achieved via tracheostomy. A submandibularincision was made and with a nerve stimulator was used to identify the marginal branches of the facial nerve. Then the entire mandibular ramus was exposed up to the sigmoid notch, including the coronoid process and the ankylosed region. A wide ostectomy was done in the ankylosed area, and the coronoid process was resected. Sufficient bone was removed to allow the Delrin implant to be installed in the gap between the surgically created glenoid fossa and the resection line in the ramus of the mandible. Care was taken not to interfere with the mandibular nerve or the vessels medial to the surgical site. An identical procedure was done bilaterally. After resection of the ankyloses, it was possible to open the jaw, and a number of decayed teeth were extracted. The surgically created glenoid fossa was lined with ly-
FIGURE1. The patient at the time of admission. A, Frontal view. B, Lateral view showing the retruded mandible. C, The totally immobile jaw, severely decayed posterior teeth and several retained decidious teeth.
WESTERMARK,
SINDET-PEDERSEN,
AND BOYNE
863
FIGURE 2. Panoramic radiograph showing widely ankylosed TMJ areas. Also note the high coronoid processes and enlarged gonial protuberances.
ophilized
dura, sutured
to the bone. The
Delrin condyles
fixed in titanium mesh were then installed after the mandible had been positioned in a reasonable occlusion (Fig 4). The incisions were closed in layers. Penicillin and Decadron were administered during surgery and continued postoperatively. Postoperatively, a tendency toward anterior luxation of the condylar prostheses out of the glenoid fossae was noted; this problem was treated with maxillomandibular fixation using training elastics for 1 week. Five days postoperatively, in spite of the elastics, the patient was able to open her mouth to an interincisal distance of 30 mm without luxation. An intensive jaw exercise program was instituted. In spite of this, the jaw opening was reduced over the first month to a minimal level of 22 mm. Thereafter, it slowly increased to 30 mm 4 months postoperatively. The patient was recalled at regular intervals for 2 years. The jaw opening has remained stable at 30 mm (Fig 5), but the patient cannot perform any laterotrusions. Radiographs show good adaptation of the titanium mesh; however, it has not been possible to identify any bone apposition on the Dehin implants. As indicated in Fig 6, there has been forward and
FIGURE 3. PA radiograph showing what appears to resemble the radiological findings in a patient with medially displaced condylar fractures.
downward growth of the maxilla, and also the morphology of the mandible has changed. The patient has also developed a slight open bite (Fig 7).
Discussion When a child has chin trauma there is a potential risk that condylar fractures with medial displacement of the fragments will occur. lo A condylar fracture with medial displacement results in rupture of the articular capsule, hemarthrosis, intra- and extracapsular hematoma, and possible rupture of the articular disc. It has been proposed” that rupture of the articular disc might predispose to the development of TMJ ankylosis. However, we think that the role of a ruptured disc is minor compared with the fact that the lateral surface of a medially displaced condyle usually will be positioned in close contact with the bone of the skull base and surrounded by a hematoma. Because of the high osteogenic activity
FIGURE 4. Delrin condylar implant fixed to the ramus of the mandible (thin arrows) and articulating in the surgically created glenoid fossa which is lined with lyophilized dura sutured to the bone (thick arrows).
864
BONY ANKYLOSIS
FIGURE 7.
FIGURE 5. Cephalogram 2 years postoperatively shows adequate jaw opening. The interincisal distance is 30 mm.
of an organizing hematoma in a young person, combined with the restricted jaw mobility in the posttraumatic period due to pain, there is a risk that the area between the lateral surface of the medially dis\
FIGURE 6. Schematic drawing showing the maxillary and mandibular growth during the 2-year postoperative follow-up period. Thin line = postoperatively.
OF THE TMJ: CASE REPORT
View of slight anterior open bite.
placed condyle and the skull base will be tilled with bone. This explanation corresponds very well with the radiologic appearance of such patients, including the present one. A variety of surgical procedures have been described for the treatment of bony ankylosis of the TMJ and several reviews on the subject have been published.3*9~12-14The theory of mandibular growth as a result of the functional matrix is today widely accepted. l-6,12,27-29 According to this theory, the condylar cartilage is not regarded as a primary growth center responsible for mandibular growth, but rather as a site of secondary and compensatory growth of the condylar process responding to forces caused by muscular function. This compensatory growth keeps the condyle in contact with the glenoid fossa as the mandible is carried downward and forward by forces exerted by the surrounding soft tissues 5.27,29,30 Those who favor the functional matrix theory also support early surgical treatment to normalize mandibular function and thus facilitate mandibular growth. Ohno et al ” have shown how patients treated for TMJ ankylosis before the age of 4 develop a growth pattern almost identical to that of unaffected controls during a postoperative followup period of 8 years. In the literature the recommendations seem to be divided between reconstructing the TMJ with an alloplastic material or an osteochondral graft. The alloplastic materials used for reconstruction of TMJ ankylosis include acrylic cylinders,’ silicone silicone tube,4 Proplast, and elastomer, 12~15T16,19,20 Teflon-Proplast combined with TMJ prosthesis.‘3*14 Various osteochondral grafts have been described, including the sternoclavicular joint,24 metatarsal grafts,22 an iliac crest osteochondral graft,23 and There is considerable costeochondral grafts. 5*6218*21 evidence in favor of the use of costeochondral grafts for replacement of ankylosed mandibular However, there may be condyles. 2~3~5~6~12~‘8~21~28 some drawbacks to the use of costeochondral grafts for treatment of TMJ ankylosis. The growth of the
WESTERMARK,
SINDET-PEDERSEN,
AND BOYNE
graft is unpredictable and Tasanen and Leikomaa’* have reported a case with unilateral bony TMJ ankylosis in a child in whom the rib-grafted side grew more than the nongrafted side. In our own experience we have seen reankylosis after use of costeochondral grafts for treatment of ankylosed TMJs. Moreover, reports on jaw opening ability after surgical correction of ankylosed TMJs show that cases treated with costeochondral grafts reach a maximal jaw opening of 20 mm,556,1872’whereas patients treated with alloplastic materials usually reach an opening of 30 mm or more.4~9S35-37S39q20 No evidence has yet been presented showing the effect on maxillary growth of osteochondral reconstructions. It has, however, been shown that the hypoplastic mandible in hemifacial microsomia interferes with the normal downward growth of the maxilla. By lengthening the mandible on the affected side, it is possible to achieve an almostnormal downward growth of the maxilla.30 It is therefore probable that the degree of jaw mobility achieved after surgical treatment of TMJ ankylosis may influence the maxillary growth of such patients. In children with TMJ ankylosis, it is therefore reasonable to use a surgical approach that allows for the highest degree of mobility of the mandible. The present patient so far has demonstrated a normal forward-downward growth of the maxilla, whereas a posterior rotation of the mandible has been observed. From the previous experimental studies,26 there was reason to expect apposition of bone on the Delrin condyles; however, this has not been observed so far. The absence of condylar remodeling, combined with normal maxillary growth, has resulted in persistent mandibular retrognathism which will be surgically treated when the girl has finished her growth. References 1. Moss ML, Rankow RM: The role of the functional matrix in mandibular growth. Angle Orthod 38:95, 1968 2. Poswillo D: Experimental reconstruction of the mandibular joint. Int J Oral Surg 3:400, 1974 3. Irby WB: Current Advances in Oral Surgery, ~013. St Louis, MO, Mosby. 1980 pp 240-248, 320-328 4. Moorthy AP, Finch LD: Interpositional arthroplasty for ankylosis of the temporomandibular joint. Oral Surg Oral Med Oral Path01 55545, 1983 5. Politis C, Fossion E, Bossuyt M: The use of costochondral grafts in arthroplasty of the temporomandibular joint. J Craniomaxillofac Surg 15:345, 1987 6. Tideman H, Doddridge M: Temporomandibular joint ankylosis. Aust Dent J 32:171, 1987
865
7. Topazian RG: Etiology of ankylosis of temporomandibular joint: Analysis of 44 cases. J Oral Surg Anesth Hosp Dent Serv 221227, 1964 8. Chandra P, Dave PK: Temporomandibular joint ankylosis. Prog Clin Biol Res 187:449, 1985 9. Sawhney CP: Bony ankylosis of the temporomandibular joint: Follow-up of 70 patients treated with arthroplasty and acrylic spacer interposition. Plast Reconstr Surg 77129, 1986 10. Laskin DM: Role of the meniscus in the etiology of posttraumatic temporomandibular joint ankylosis. lnt 1 Oral Surg 7:340, 1978 11. Ohno K, Michi KI, Ueno T: Mandibular growth following ankylosis operation in childhood. Int J Oral Surg l&324, 1981 12. Rowe NL: Ankylosis of the temporomandibular joint. J R Co11Surg Edinb 27:67, 167, 209, 1982 13. Kent JN, Block MS, Homsy CA, et al: Experience with a polymer glenoid fossa prosthesis for partial or total temporomandibular joint reconstruction. J Oral Maxillofac Surg 44:520, 1986 14. Moriconi ES, Popowich LD, Guernsey LH: Alloplastic reconstruction of the temporomandibular joint. Dent Clin North Am 30:307, 1986 15. Foo GC: A case report on the surgical management of true ankylosis of the temporomandibularjoint. Singapore Dent J 8:15, 1983 16. Foo GC: Interpositional arthroplasty for true ankylosis of the temporomandibular joint-A report of two cases. Singapore Med J 27:432, 1986 17. DeLuke DM: High-gap arthroplasty for treatment of bony ankylosis of the temporomandibularjoint: Report of case. J Am Dent Assoc 115:281, 1987 18. Tasanen A, Leikomaa H: Ankylosis of the temporomandibular joint of a child. Report of case. Int J Oral Surg 6:95, 1977 19. Given JW, Sanders B: Surgical management of longstanding temporomandibular joint ankylosis and resultant skeletal deformity. J Craniomandib Disord 1: 127. 1987 20. DeChamplain RW, Gallagher CS, Marshall ET Jr: Autopolymerizing Silastic for interpositional arthroplasty. J Oral Maxillofac Surg 46:522, 1988 21. Schneider PE, Zide MF: Rib implant for mandibular ankylosis in five-year-old child: Clinical report. Pediatr Dent 6:259, 1984 22. Dattilo DJ, Granick MS, Soteranos GS: Free vascularized whole joint transplant for reconstruction of the temporomandibular joint: A preliminary case report. J Oral Maxillofac Surg 44:227, 1986 23. Kummoona R: Chondro-osseous iliac crest graft for one stage reconstruction of the ankylosed TMJ in children. J Maxillofac Surg 14:215, 1986 24. Siemssen SO: Temporomandibular joint arthroplasty by transfer of the Sterno-clavicular joint. Br J Plast Surg 351225, 1982 25. DeBurgh Norman JE: Post-traumatic disorders of the jaw joint. Ann R Cob Surg Engl 64:27, 1982 26. Boyne PJ, Matthews FR. Stringer DE: TMJ bone remodeling after polyoxymethylene condylar replacement. Int J Oral Maxillofac Implants 2:29, 1987 27. Durkin JF, Heeley JD, It-wing JT: The cartilage of the mandibular condyle. Oral Sci Rev 2:22, 1973 28. MacIntosch RB, Henny FA: A spectrum of application of autogenous costochondral grafts. J Maxillofac Surg 5:257, 1977 29. Harvold EP: Treatment of Hemifacial Microsomia. New York, NY, Liss, 1983 30. Kaban LB, Moses MH, Mulliken JB: Surgical correction of hemifacial microsomia in the growing child. Plast Reconstr Surg 82:9, 1988
SINDET-PEDERSEN,
primary fibrinolysis. This theory gained further acceptance after the demonstration of high levels of plasminogen activator in prostatic tissue.6 It is believed that this excess plasminogen activator is produced as a result of surgical trauma to prostatic tissue, resulting in a hypocoagulability of the blood.7 More recent clinical studies have suggested that thromboplastins released from prostatic tumor cells initiate a disseminated intravascular coagulation (DIC) syndrome, with fibrinolysis occurring secondarily. It is estimated that 25% of cases of chronic DIC have an underlying carcinoma of the prostate.8 DIC was ruled out in this case. Systemic use of l-aminocaproic acid, a drug that can effectively prevent clot dissolution by inhibiting the activation of plasminogen by plasminogen activators, was considered in the treatment of the patient. However, it was not used because of the consulting physician’s fears that it could contribute to systemic thrombosis and because the patient’s condition appeared to be improving. However, the local
J Oral Maxillofac 48:881-865,
861
AND BOYNE
or systemic use of an antifibrinolytic cases warrants further investigation.
agent for such
References 1. Bhaskas SN: Synopsis of Oral Pathology. St Louis. MO, Mosby, 1973, p 304 2. Mejer I, Shklar G: Malignant tumors metastatic to the mouth and jaws. Oral Surg 20:350, 1965 3. Thatcher SL. Dve CG: Carcinoma of the orostate metastatic to the mandibular condyle mimicking -a parotid tumor. J Oral Maxillofac Surg 44:394, 1986 4. Wosnitzer M: Aid to decrease postoperative bleeding in transurethral resection of prostate gland. Urology 23: 187, 1983 5. Tagnon HJ, Whitmore WF, Shulman NR: Fibrinolysis in metastatic cancer of the prostate. Cancer 5:9, 1952 6. Ladehoff AA, Rasmussen J: Fibrinolysis and thromboplastic activity in relation to hemorrhage in transvesical prostatectomy. Stand J Clin Lab Invest 13:231, 1961 7. Smith RB, Raich P: Epsilon aminocaproic acid and the control of post-prostatectomy bleeding: A prospective double-blind study. J Ural 131:1093, 1984 8. Goldenberg SL, Fenster HN: Disseminated intravascular coagulation in carcinoma of prostate: Role of estrogen therapy. Urology 22: 130, 1983
Surg
1940
Bony Ankylosis of the Temporomandibular Joint: Case Report of a Child Treated With Delrin Condylar Implants ANDERS H. WESTERMARK, DDS,* STEEN SINDET-PEDERSEN, AND PHILIP J. BOYNE, DMD, MST Bony ankylosis of the temporomandibular joint (TMJ) results in immobilization of the mandible, and when occurring in children it impairs mandibular growth and results in mandibular retrognathism. The ankylosis thus induces functional and esthetic
* Staff, Department of Oral and Maxillofacial Surgery, Aarhus University Hospital, Norrebrogade, Aarhus, Denmark. t Professor and Chairman, Department of Surgery, School of Medicine, Loma Linda Universitv Medical Center. Loma Linda. CA. Address correspondence and reprint requests to Dr Westermark: Department of Oral and Maxillofacial Surgery, Aarhus University Hospital, Norrebrogade DK 8000 Aarhus, Denmark. 0 1990 American Association geons 0278-2391/90/4808-0016$3.00/O
of Oral and Maxillofacial Sur-
DDS,*
disturbances as well as difficulties with nutrition and oral hygiene. I-6 Trauma in early childhood is the most common cause of the TMJ ankylosis.7-‘0 Therefore, to prevent growth disturbances, early surgical intervention has been advocated,233.5*‘1~‘2 and a variety of surgical approaches have been recommended 3.6.9,13,14 Osteotomy of the ankylosed area combined with the interposition of various materials has been advocated by numerous authors.4-6,9914-22The type of interpositional material recommended has included a skin flap (dermis?),” metatarsal bone,** a muscle flap,6 an iliac crest graft,23 rib grafts,576Y18*21 clavicular osteochondral grafts,24 acrylic cylinders,’ silicone elastomer,‘2*‘5~16~‘9720~25 a silicone tube,4 Proplast (Vitek Inc, Houston, TX),” and Teflon-
862
BONY ANKYLOSIS OF THE TM3: CASE REPORT
Proplast (Vitek Inc, Houston, TX) combined with a TMJ prosthesis.‘3P’4 Dehin (Timesh, Inc., Calabasas, CA) a polyacetyl homopolymer polyoxymetylene, has been successfully used in orthopedic joint replacement, and Boyne et al have published results of an experimental study using a Delrin prosthesis for condylar replacement.26 In growing baboons, condyles were removed unilaterally and replaced with Delrin condyles fixed to the ramus of the mandible with a titanium mesh.26 On the Delrin-treated side, they observed increase in bone formation in the roof of the glenoid fossa, in the floor of the middle cranial fossa, and in the marrow space between. A new condylar head was formed on the Delrin condyle by apposition of bone on the superior and posterior surfaces of the implants.26 Based on these favorable biologic reactions to Delrin condylar implants Boyne et al questioned whether costochondral grafts are necessary in the surgical treatment of growing patients with TMJ ankylosis. 26The following report describes a case in which Delrin condylar prostheses were used to treat a child with bilateral bony ankylosis of the TMJ. Report of a Case An &year-old Vietnamese girl was referred for treatment of TMJ ankylosis. Five years previously, she had
been involved in a traffic accident and most probably had acquired bilateral condylar fractures with medial displacement on that occasion. The fractures had been left untreated, and eventually the jaw became totally immobilized. The clinical examination revealed that the patient had a marked mandibular retrognathism, a totally immobile mandible, severely decayed posterior teeth, and several retained decidious teeth (Fig 1). Radiographs showed total bony ankylosis of both TMJs (Figs 2 and 3). To treat the patient it was decided to resect the area of ankylosis and install Delrin condylar implants fixed with titanium mesh to the mandible.
SURGICALPROCEDUREAND POSTOPERATIVE MANAGEMENT Endotracheal intubation was achieved via tracheostomy. A submandibularincision was made and with a nerve stimulator was used to identify the marginal branches of the facial nerve. Then the entire mandibular ramus was exposed up to the sigmoid notch, including the coronoid process and the ankylosed region. A wide ostectomy was done in the ankylosed area, and the coronoid process was resected. Sufficient bone was removed to allow the Delrin implant to be installed in the gap between the surgically created glenoid fossa and the resection line in the ramus of the mandible. Care was taken not to interfere with the mandibular nerve or the vessels medial to the surgical site. An identical procedure was done bilaterally. After resection of the ankyloses, it was possible to open the jaw, and a number of decayed teeth were extracted. The surgically created glenoid fossa was lined with ly-
FIGURE1. The patient at the time of admission. A, Frontal view. B, Lateral view showing the retruded mandible. C, The totally immobile jaw, severely decayed posterior teeth and several retained decidious teeth.
WESTERMARK,
SINDET-PEDERSEN,
AND BOYNE
863
FIGURE 2. Panoramic radiograph showing widely ankylosed TMJ areas. Also note the high coronoid processes and enlarged gonial protuberances.
ophilized
dura, sutured
to the bone. The
Delrin condyles
fixed in titanium mesh were then installed after the mandible had been positioned in a reasonable occlusion (Fig 4). The incisions were closed in layers. Penicillin and Decadron were administered during surgery and continued postoperatively. Postoperatively, a tendency toward anterior luxation of the condylar prostheses out of the glenoid fossae was noted; this problem was treated with maxillomandibular fixation using training elastics for 1 week. Five days postoperatively, in spite of the elastics, the patient was able to open her mouth to an interincisal distance of 30 mm without luxation. An intensive jaw exercise program was instituted. In spite of this, the jaw opening was reduced over the first month to a minimal level of 22 mm. Thereafter, it slowly increased to 30 mm 4 months postoperatively. The patient was recalled at regular intervals for 2 years. The jaw opening has remained stable at 30 mm (Fig 5), but the patient cannot perform any laterotrusions. Radiographs show good adaptation of the titanium mesh; however, it has not been possible to identify any bone apposition on the Dehin implants. As indicated in Fig 6, there has been forward and
FIGURE 3. PA radiograph showing what appears to resemble the radiological findings in a patient with medially displaced condylar fractures.
downward growth of the maxilla, and also the morphology of the mandible has changed. The patient has also developed a slight open bite (Fig 7).
Discussion When a child has chin trauma there is a potential risk that condylar fractures with medial displacement of the fragments will occur. lo A condylar fracture with medial displacement results in rupture of the articular capsule, hemarthrosis, intra- and extracapsular hematoma, and possible rupture of the articular disc. It has been proposed” that rupture of the articular disc might predispose to the development of TMJ ankylosis. However, we think that the role of a ruptured disc is minor compared with the fact that the lateral surface of a medially displaced condyle usually will be positioned in close contact with the bone of the skull base and surrounded by a hematoma. Because of the high osteogenic activity
FIGURE 4. Delrin condylar implant fixed to the ramus of the mandible (thin arrows) and articulating in the surgically created glenoid fossa which is lined with lyophilized dura sutured to the bone (thick arrows).
864
BONY ANKYLOSIS
FIGURE 7.
FIGURE 5. Cephalogram 2 years postoperatively shows adequate jaw opening. The interincisal distance is 30 mm.
of an organizing hematoma in a young person, combined with the restricted jaw mobility in the posttraumatic period due to pain, there is a risk that the area between the lateral surface of the medially dis\
FIGURE 6. Schematic drawing showing the maxillary and mandibular growth during the 2-year postoperative follow-up period. Thin line = postoperatively.
OF THE TMJ: CASE REPORT
View of slight anterior open bite.
placed condyle and the skull base will be tilled with bone. This explanation corresponds very well with the radiologic appearance of such patients, including the present one. A variety of surgical procedures have been described for the treatment of bony ankylosis of the TMJ and several reviews on the subject have been published.3*9~12-14The theory of mandibular growth as a result of the functional matrix is today widely accepted. l-6,12,27-29 According to this theory, the condylar cartilage is not regarded as a primary growth center responsible for mandibular growth, but rather as a site of secondary and compensatory growth of the condylar process responding to forces caused by muscular function. This compensatory growth keeps the condyle in contact with the glenoid fossa as the mandible is carried downward and forward by forces exerted by the surrounding soft tissues 5.27,29,30 Those who favor the functional matrix theory also support early surgical treatment to normalize mandibular function and thus facilitate mandibular growth. Ohno et al ” have shown how patients treated for TMJ ankylosis before the age of 4 develop a growth pattern almost identical to that of unaffected controls during a postoperative followup period of 8 years. In the literature the recommendations seem to be divided between reconstructing the TMJ with an alloplastic material or an osteochondral graft. The alloplastic materials used for reconstruction of TMJ ankylosis include acrylic cylinders,’ silicone silicone tube,4 Proplast, and elastomer, 12~15T16,19,20 Teflon-Proplast combined with TMJ prosthesis.‘3*14 Various osteochondral grafts have been described, including the sternoclavicular joint,24 metatarsal grafts,22 an iliac crest osteochondral graft,23 and There is considerable costeochondral grafts. 5*6218*21 evidence in favor of the use of costeochondral grafts for replacement of ankylosed mandibular However, there may be condyles. 2~3~5~6~12~‘8~21~28 some drawbacks to the use of costeochondral grafts for treatment of TMJ ankylosis. The growth of the
WESTERMARK,
SINDET-PEDERSEN,
AND BOYNE
graft is unpredictable and Tasanen and Leikomaa’* have reported a case with unilateral bony TMJ ankylosis in a child in whom the rib-grafted side grew more than the nongrafted side. In our own experience we have seen reankylosis after use of costeochondral grafts for treatment of ankylosed TMJs. Moreover, reports on jaw opening ability after surgical correction of ankylosed TMJs show that cases treated with costeochondral grafts reach a maximal jaw opening of 20 mm,556,1872’whereas patients treated with alloplastic materials usually reach an opening of 30 mm or more.4~9S35-37S39q20 No evidence has yet been presented showing the effect on maxillary growth of osteochondral reconstructions. It has, however, been shown that the hypoplastic mandible in hemifacial microsomia interferes with the normal downward growth of the maxilla. By lengthening the mandible on the affected side, it is possible to achieve an almostnormal downward growth of the maxilla.30 It is therefore probable that the degree of jaw mobility achieved after surgical treatment of TMJ ankylosis may influence the maxillary growth of such patients. In children with TMJ ankylosis, it is therefore reasonable to use a surgical approach that allows for the highest degree of mobility of the mandible. The present patient so far has demonstrated a normal forward-downward growth of the maxilla, whereas a posterior rotation of the mandible has been observed. From the previous experimental studies,26 there was reason to expect apposition of bone on the Delrin condyles; however, this has not been observed so far. The absence of condylar remodeling, combined with normal maxillary growth, has resulted in persistent mandibular retrognathism which will be surgically treated when the girl has finished her growth. References 1. Moss ML, Rankow RM: The role of the functional matrix in mandibular growth. Angle Orthod 38:95, 1968 2. Poswillo D: Experimental reconstruction of the mandibular joint. Int J Oral Surg 3:400, 1974 3. Irby WB: Current Advances in Oral Surgery, ~013. St Louis, MO, Mosby. 1980 pp 240-248, 320-328 4. Moorthy AP, Finch LD: Interpositional arthroplasty for ankylosis of the temporomandibular joint. Oral Surg Oral Med Oral Path01 55545, 1983 5. Politis C, Fossion E, Bossuyt M: The use of costochondral grafts in arthroplasty of the temporomandibular joint. J Craniomaxillofac Surg 15:345, 1987 6. Tideman H, Doddridge M: Temporomandibular joint ankylosis. Aust Dent J 32:171, 1987
865
7. Topazian RG: Etiology of ankylosis of temporomandibular joint: Analysis of 44 cases. J Oral Surg Anesth Hosp Dent Serv 221227, 1964 8. Chandra P, Dave PK: Temporomandibular joint ankylosis. Prog Clin Biol Res 187:449, 1985 9. Sawhney CP: Bony ankylosis of the temporomandibular joint: Follow-up of 70 patients treated with arthroplasty and acrylic spacer interposition. Plast Reconstr Surg 77129, 1986 10. Laskin DM: Role of the meniscus in the etiology of posttraumatic temporomandibular joint ankylosis. lnt 1 Oral Surg 7:340, 1978 11. Ohno K, Michi KI, Ueno T: Mandibular growth following ankylosis operation in childhood. Int J Oral Surg l&324, 1981 12. Rowe NL: Ankylosis of the temporomandibular joint. J R Co11Surg Edinb 27:67, 167, 209, 1982 13. Kent JN, Block MS, Homsy CA, et al: Experience with a polymer glenoid fossa prosthesis for partial or total temporomandibular joint reconstruction. J Oral Maxillofac Surg 44:520, 1986 14. Moriconi ES, Popowich LD, Guernsey LH: Alloplastic reconstruction of the temporomandibular joint. Dent Clin North Am 30:307, 1986 15. Foo GC: A case report on the surgical management of true ankylosis of the temporomandibularjoint. Singapore Dent J 8:15, 1983 16. Foo GC: Interpositional arthroplasty for true ankylosis of the temporomandibular joint-A report of two cases. Singapore Med J 27:432, 1986 17. DeLuke DM: High-gap arthroplasty for treatment of bony ankylosis of the temporomandibularjoint: Report of case. J Am Dent Assoc 115:281, 1987 18. Tasanen A, Leikomaa H: Ankylosis of the temporomandibular joint of a child. Report of case. Int J Oral Surg 6:95, 1977 19. Given JW, Sanders B: Surgical management of longstanding temporomandibular joint ankylosis and resultant skeletal deformity. J Craniomandib Disord 1: 127. 1987 20. DeChamplain RW, Gallagher CS, Marshall ET Jr: Autopolymerizing Silastic for interpositional arthroplasty. J Oral Maxillofac Surg 46:522, 1988 21. Schneider PE, Zide MF: Rib implant for mandibular ankylosis in five-year-old child: Clinical report. Pediatr Dent 6:259, 1984 22. Dattilo DJ, Granick MS, Soteranos GS: Free vascularized whole joint transplant for reconstruction of the temporomandibular joint: A preliminary case report. J Oral Maxillofac Surg 44:227, 1986 23. Kummoona R: Chondro-osseous iliac crest graft for one stage reconstruction of the ankylosed TMJ in children. J Maxillofac Surg 14:215, 1986 24. Siemssen SO: Temporomandibular joint arthroplasty by transfer of the Sterno-clavicular joint. Br J Plast Surg 351225, 1982 25. DeBurgh Norman JE: Post-traumatic disorders of the jaw joint. Ann R Cob Surg Engl 64:27, 1982 26. Boyne PJ, Matthews FR. Stringer DE: TMJ bone remodeling after polyoxymethylene condylar replacement. Int J Oral Maxillofac Implants 2:29, 1987 27. Durkin JF, Heeley JD, It-wing JT: The cartilage of the mandibular condyle. Oral Sci Rev 2:22, 1973 28. MacIntosch RB, Henny FA: A spectrum of application of autogenous costochondral grafts. J Maxillofac Surg 5:257, 1977 29. Harvold EP: Treatment of Hemifacial Microsomia. New York, NY, Liss, 1983 30. Kaban LB, Moses MH, Mulliken JB: Surgical correction of hemifacial microsomia in the growing child. Plast Reconstr Surg 82:9, 1988
