Accepted Manuscript Interpositional arthroplasty versus reconstruction arthroplasty for temporomandibular joint ankylosis: a systematic review and meta-analysis Junli Ma, D.D.S, Hua Jiang, D.D.S, Limin Liang, D.D.S PII:
S1010-5182(15)00121-3
DOI:
10.1016/j.jcms.2015.04.017
Reference:
YJCMS 2041
To appear in:
Journal of Cranio-Maxillo-Facial Surgery
Received Date: 12 October 2014 Revised Date:
21 March 2015
Accepted Date: 22 April 2015
Please cite this article as: Ma J, Jiang H, Liang L, Interpositional arthroplasty versus reconstruction arthroplasty for temporomandibular joint ankylosis: a systematic review and meta-analysis, Journal of Cranio-Maxillofacial Surgery (2015), doi: 10.1016/j.jcms.2015.04.017. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Interpositional arthroplasty versus reconstruction arthroplasty for temporomandibular joint ankylosis: a systematic review and meta-analysis
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Junli Maa, D.D.S, Hua Jiangb, D.D.S, Limin Liangb* D.D.S
Department of Stomatology, the General Hospital of Guangzhou Military Command
of PLA, Guangzhou, CHINA Department of Stomatology, the General Hospital of the People's Liberation Army, Beijing, CHINA
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*Corresponding author: Limin Liang Tel:86-010-66938217 Fax: 86-010-66938217 Email: [email protected] Department of Stomatology The General Hospital of the People's Liberation Army
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Fuxing road 28#，Beijing, CHINA, 100853
ACCEPTED MANUSCRIPT INTRODUCTION
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Temporomandibular joint ankylosis (TMJA) is the functional disability of the
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mandible, caused by the fibrous or bony adhesion among the condyle, disc, glenoid
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fossa, and eminence (Long et al., 2005). Trauma is the most common etiologic factor,
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documented in 13% to 100% cases of TMJA. Local or systemic infection is the
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second most common etiology. In rare circumstances, systemic diseases, such as
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ankylosing spondylitis, rheumatoid arthritis, and psoriasis, may also lead to TMJ
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ankylosis (Chidzonga, 1999; Vasconcelos et al., 2009).
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TMJA causes functional impairment in mastication and speech; in addition, it poses a
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severe threat to facial development in children. In unilateral cases, TMJA can cause
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hypoplasia of the mandible and deviation to the affected side. In bilateral cases, a
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typical bird-face appearance with retrognathia, mandibular alveolar protrusion, and
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open bite may appear (Güven, 2009).
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Currently, the following three techniques are most often ussed: gap arthroplasty (GA);
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interpositional arthroplasty (IA); and reconstruction arthroplasty (RA). However,
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none of these three techniques has been accepted as a universally successful method
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for various type of TMJA. Reankylosis is the most common and troubling
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postoperative complications encountered in clinical practice.
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ACCEPTED MANUSCRIPT GA is the oldest type of surgery for treating TMJA; however, due to the high
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incidence of recurrence and malocclusion caused by shortened mandibular ramus, its
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application is becoming limited, and some authors have even suggested abandoning
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GA (Kaban et al., 1990; Matsuura et al., 2001). Currently, IA and RA are more
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popular, especially for children with TMJA. Although successful application of IA
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and RA have been widely reported, direct comparison between RA and IA is rare and
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results are controversial, which leads to a dilemma for surgeons when choosing
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certain treatment modalities (Sahoo et al., 2012).
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Therefore we conducted this systematic review and meta-analysis to compare the
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outcomes of IA and RA to provide some evidence-based suggestions for clinicians.
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MATERIAL AND METHODS
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Literature search
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The PubMed, EMBASE, OVID EBM Reviews, and Web of Science were searched up
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to October 11, 2014, using the following key words with combinations:
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temporomandibular joint, TMJ, ankylosis, interpositional arthroplasty, interposition
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arthroplasty; joint reconstruction, articulation reconstruction, joint replacement,
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autogenous graft, alloplastic graft, costochondral graft. The references lists of
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included studies were also manually searched.
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ACCEPTED MANUSCRIPT Inclusion criteria and quality assessment
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The inclusion criteria were as follows: randomized controlled trial (RCT) or
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observational cohort study with a follow-up of at least 12 months; and comparison of
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clinical outcomes between the patients who received IA and those who received RA,
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including reankylosis or maximal incisal opening (MIO). Potentially eligible studies
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were assessed by two authors (J.M., H.J.) independently. Any uncertainty regarding
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eligibility was discussed in consultation with a third reviewer (L.L.) to make a
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decision. The methodological quality of the included studies was evaluated at this
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stage using the Newcastle-Ottawa Scale (NOS); scores are listed in Table 1.
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Data extraction
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An Excel sheet was designed to record the following data: the name of the first author,
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year of publication, materials used in IA and RA, mean age at operation, sample size,
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outcomes, size of cartilage, size of gap created, and length of follow-up. Two
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reviewers (J.M., H.J.) performed data extraction independently. All of the data were
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from those published in the included studies. The recorded data were compared by the
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third reviewer (L.L.) to prevent omissions and errors.
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Assessment of heterogeneity
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The heterogeneity was evaluated by the χ2 and I2 tests. Substantial heterogeneity was
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defined as I2 > 50%.
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ACCEPTED MANUSCRIPT Outcome measures
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Two main outcomes of interest were the incidence of reankylosis and the MIO, other
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postoperative complications (malocclusion and overgrowth of cartilage) were also
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documented.
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Statistical analysis
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RevMan 5.3 software (Cochrane Collaboration, Software Update, Oxford, UK) and
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Stat 12 (StataCorp, College Station, TX) were used in this meta-analysis. Risk
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difference (RD) with a 95% confidence interval (95% CI) was calculated for binary
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outcomes, and mean differences (MDs) with 95% confidence intervals (CIs) for
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continuous outcomes. A fixed-effects model (Mantel-Haenszel method) was used if
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there was no heterogeneity; otherwise a random-effects model (Der Simonian-Laird
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method) was used. Pooled RDs and MDs were calculated, and a two-sided P < 0.05
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was considered statistically significant. Publication bias was evaluated using a funnel
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plot and Egger test. A symmetric funnel-shaped distribution and P > 0.10 in the Egger
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test indicated the absence of publication bias.
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RESULTS
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Study characteristics
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The selection process is shown in Figure 1. Eight studies with a total of 234 patients
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were included in this meta-analysis (Balaji, 2003; Manganello-Souza and Mariani,
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2010; Loveless et al., 2010; Sahho et al., 2012). All of these were retrospective cohort
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studies; no RCT was found. The clinical characteristics and the methodological
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qualities of these studies are listed in Table 1.
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Temporalis myofascial flap (TMF) was the main interposional material used in 7 of 8
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studies. Other materials included silicone, dermis/fat, and cartilage. Costochondral
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graft (CCG) was chosen in 7 studies to reconstruct condyle (Balaji, 2003;
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Manganello-Souza and Mariani, 2003; Qudah et al., 2005; Tanrikulu et al., 2005; Erol
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et al., 2006; Elgazzar et al., 2010; Sahho et al., 2012). Nearly all of the patients who
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received CCG were children, although adult bilateral cases also received this
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technique (Erol et al., 2006). Prosthetic total joint replacement was used only in adults
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in the study by Loveless et al. (Loveless et al, 2010). In the RA group, TMF or other
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materials were also used to fill the space between graft and articulation fossa in 3
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studies (Balaji, 2003; Manganello-Souza and Mariani, 2003; Elgazzar et al., 2010).
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Specific information on mean age at operation and length of follow-up for each
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technique was partially missing.
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Primary outcome: incidence of reankylosis
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The data from 7 studies with a total of 198 patients were collected to compare the
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incidence of reankylosis between IA and RA (Balaji, 2003; Manganello-Souza and
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Mariani, 2003; Qudah et al., 2005; Tanrikulu et al., 2005; Erol et al., 2006; Elgazzar et
ACCEPTED MANUSCRIPT al., 2010; Sahho et al., 2012). Both the χ2 and the I2 tests did not show significant
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heterogeneity (Q = 0.72, df = 4, P = 0.95; I2 = 0%); a fixed-effect model was used.
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There were 6 cases of reankylosis among 106 patients who received RA, compared
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with 4 cases among 92 patients in the IA group. Pooled analysis revealed no
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significant differences in the incidence of reankylosis between IA and RA groups for
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(RD = −0.00; 95% CI = −0.08–0.07; Z = 0.06, P = 0.95). Because TMF and CCG
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were the most commonly used materials in IA and RA, respectively, we further
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performed a subgroup analysis to compare the incidence of ankylosis in the IA and
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RA groups when only these two materials were used (Qudah et al., 2005; Tanrikulu et
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al., 2005; Erol et al., 2006; Elgazzar et al., 2010; Sahho et al., 2012). The result was
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similar; no significant difference in reankylosis between IA (TMF) and RA (CCG)
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was demonstrated (RD = −0.01, 95% CI = –0.10 to 0.07, Z = 0.30, P = 0.77) (Fig. 2).
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Secondary outcome: MIO
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Seven studies with a total 209 patients were included to compare the MIO between
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the IA and RA groups (Balaji, 2003; Manganello-Souza and Mariani, 2003; Qudah et
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al., 2005; Tanrikulu et al., 2005; Elgazzar et al., 2010; Loveless et al., 2010; Sahho et
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al., 2012). Substantial heterogeneity was found (Q = 22.96, df = 6, P = 0.0008; I2 =
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74%). A random-effects model was used; no significant difference in MIO between
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the IA and RA groups was found (MD = 0.99; 95% CI = –1.43 to 3.4, Z = 0.8; P =
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0.42) (Fig. 3). A subgroup analysis was performed in an attempt to eliminate
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substantial heterogeneity; 4 studies that chose TMF and CCG alone in IA and RA,
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ACCEPTED MANUSCRIPT respectively, were included (Qudah et al., 2005; Tanrikulu et al., 2005; Elgazzar et al.,
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2010; Sahho et al., 2012). The subgroup also showed substantial heterogeneity (I2 =
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77%); the combined MD based on the random-effects model reveled no significant
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difference in MIO (MD = 0.22, 95% CI = –2.95 to 3.40; Z = 0.14, P = 0.89).
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The results of sensitivity analysis by removing 1 study in turn are summarized in
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Table 2. Exclusion of the study by Elgazzar et al. reduced the I2 value from 74% to
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14% in the comparison between IA and RA. A fixed-effects model showed that IA had
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a significant larger MIO than RA (MD = 2.1; 95% CI = 0.90–3.30; P = 0.0006; Z =
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3.43) if the Elgazzar et al. study was removed.
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In subgroup analysis, removing the Elgazzar et al. study resulted in moderate
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hetergenity (I2 = 49%), but the MD in MIO between IA (TMF) and RA (CCG) did not
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reach significance (MD = 1.21; 95% CI = –0.65 to 3.07, P = 0.2; Z = 1.28).
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Other postoperative complications
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Four studies reported the information about overgrowth of CCG with 3 occurrences
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among 114 patients (2.6%) (Manganello-Souza and Mariani., 2003; Qudah et al.,
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2005; Elgazzar et al., 2010; Sahho et al., 2012). Three studies reported the
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postoperative malocclusion, mainly open bite, which was found in both the IA and RA
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groups (Manganello-Souza and Mariani, 2003; Erol et al., 2006; Elgazzar et al.,
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2010).
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Publication bias
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A symmetric funnel-shaped distribution and results of the Egger test (P = 0.81) did
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not reveal significant publication bias while reporting reankylosis (Fig. 4).
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DISCUSSION
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In this meta-analysis of 8 studies, we compared the outcomes of IA and RA. Pooling
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the data did not reveal any significant differences in the incidence of reankylosis and
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MIO between IA and RA. Based on this result, and after taking technique difficulty
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and donor site morbidity into consideration, we believe that IA seems to be superior
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over RA in treating TMJA. However, this conclusion should be drawn cautiously,
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especially for children, because the differences in facial development after IA and RA
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have not been statistically compared.
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The goal of surgery in treating TMJA is to reestablish the joint movements, prevent
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relapse, restore normal occlusion, and achieve normal facial growth in children (Rowe,
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1982; el-Sheikh, 1999). Although it has been almost 200 years since 1854, when the
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first condylectomy was performed (Danda et al., 2009), and although many reports
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have described successful application of GA, IA, and RA in treating TMJA, widely
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accepted and definitive indications for each techniques have not been established, and
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controversies surrounding the selection of techniques still exist ( Roychoudhury et al.,
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1999; Topazian, 2001; Sahoo, 2006).
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GA is the oldest technique used to treat TMJA and is also the foundation of IA and
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RA. Simplicity and short operating time are the advantages of GA. However, because
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of a high relapse rate and malocclusion, the sole use of GA in treating TMJA is
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becoming less popular (Kaban et al., 1990; Roychoudhury et al., 1999; Elgazzar et al.,
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2010). IA was first introduced by Verneuil in 1860; it improves upon GA by inserting
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interposition materials into the gap and minimizing reduction in the vertical height of
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ramus to reduce the risk of relapse and malocclusion (Tideman and Doddridge, 1987;
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Jain et al., 2008; Babu et al., 2013). Numerous autogenous and alloplastic materials
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have been used; the temporalis myofascial flap is the most common material because
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of easy use, rich blood supply, minimal donor site morbidity, and close proximity to
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the TMJ (Feinberg and Larsen, 1989; Kaban et al., 1990, Karamese et al., 2013).
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RA was introduced later to restore a condyle after extensive resection by using
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various materials (Khadka and Hu, 2012). A costochondral graft (CCG) is the most
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commonly selected autogenous graft, first used in 1920 (Crawley et al., 1993).
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Traditionally it has been believed that CCG has growth potential and adaptability
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similar to that of to condylar cartilage, and that transferring CCG to mandible ramus
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can restore the normal growth of the mandible in children. Thus RA with CCG is
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almost a standard treatment modality for children with TMJA ( Kaban et al., 1990;
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Jain et al., 2008).
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According to the included studies, IA was used mainly in adults, although children
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with type 3 TMJA also received IA (Qudah et al., 2005); TMF was chosen as the
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interpositional material in 7 of 8 included studies. RA was used mostly in children and
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in adults with bilateral TMJA. CCG was the most common material used in RA. The
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recurrences of ankylosis in both groups were rare (4.3% in IA and 5.7% in RA),
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mostly because of poor patient compliance with postoperative physiotherapy. The
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mean postoperative MIO of IA and RA were also similar, with an MD of 0.99 mm.
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Although CCG has been widely used with satisfying results, overgrowth of CCG is
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still an unavoidable and unpredictable complication, which often requires further
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orthognathic surgery to correct facial deformity and functional disturbances.
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Incidence of overgrowth of CCG as high as 50% to 75% have been reported (Guyuron
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and Lasa, 1992; Ko et al., 1999; López and Dogliotti, 2004). In contrast, the incidence
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in the present study was very low, with only 3 cases of overgrowth of CCG among
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119 patients (2.5%). However, this low incidence might be misleading. First, only 4
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studies provided information about overgrowth of CCG (Elgazzar et al., 2010;
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Khadka and Hu., 2012; Sahoo et al., 2012). Second, overgrowth could occur
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throughout growing period, usually 2 to years after grafting; but not all of the young
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patients were followed up to the completion of growth, according to the reported
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length of follow-up. The possibility that some occurrences of overgrowth might be
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documented cannot be excluded.
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The overgrowth of CCG has been associated with the amount of cartilage transplanted,
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and cartilage of less than 5 mm is believed to have minimal chance of overgrowth.
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Indeed, high incidences of overgrowth of CCG (75% and 70% respectively) have
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been observed after 1.5 cm of cartilage was retained in the graft; however, overgrowth
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was still observed in 2 patients who received transplantation of only 2 to 3 mm of
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cartilage, so the amount of cartilage may be not the only factor that could decide the
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fate of CCG (Peltomäki and Rönning, 1991; Perrott et al., 1994; Qudah et al., 2005).
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Uncertain growth has raised the question as to the validity of using CCG, and some
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authors have even suggested replacing RA with CCG by other techniques with a
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two-stage strategy in children (Ellis et al., 2002; Güven, 2004; Sayan et al., 2007). So
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far, however, the comparison of growth status of mandibles between the children who
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underwent CCG and those who underwent other techniques is lacking. RA with CCG
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is still a technique for treating children with TMJA that is recommended by most
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authors.
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Occlusion is also an important factor influencing mastication besides opening ability.
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In the practice of IA and RA, complete resection of ankylosis often results in a gap of
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1 to 2 cm, leading to malocclusion. In the present review, only 3 studies reported the
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postoperative occlusion status, with open bite observed mostly, which made a
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statistical comparison between IA and RA impossible.
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Lacking RCTs to perform our meta-analysis is 1 major limitation of our work. TMJA
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is a relatively rare disease, and it is difficult to perform an RCT with large sample size
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in clinical settings with the consent of patients. This reality is common in evaluating
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various interventions in treating different diseases and pathologic conditions.
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Nonrandomized cohort studies, although suboptimal, may be the only feasible
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approach, and meta-analyses using these studies is gaining increasing popularity
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(Berlin, 1995; Rajasekhar et al., 2011). Another limitation is the quality of included
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studies. Most studies did not provide clear criteria for the selection of a certain
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technique based on TMJA type, age, or other factors, which influenced the
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comparability between these studies to some extent; also, a subgroup analysis based
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on these factors is impossible. In the present analysis, including or excluding the
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study by Elgazzar et al. produced different results regarding MIO, but the MD was so
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small that its impact on selecting IA or RA might be neglected.
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CONCLUSION
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No significant differences between IA and RA regarding reankylosis and MIO were
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detected by the present meta-analysis; reankylosis occurred in both groups. Wide
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surgical exposure, complete resection, early mobilization, aggressive physiotherapy,
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and good patient compliance are all indispensible to guarantee the success of surgery.
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Other clinical outcomes, including postoperative occlusion, growth of CCG, and
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growth of the mandible, need more thorough evaluation.
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Funding
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None.
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Financial disclosure
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None.
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Conflict of interest
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None.
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prophylaxis with inferior vena cava filters in trauma patients: a systematic review
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using the Meta-analysis of Observational Studies in Epidemiology (MOOSE)
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guidelines. J Thromb Thrombolysis 32:40-46, 2011.
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Sahoo NK, Tomar K, Kumar A, Roy ID. Selecting reconstruction option for TMJ
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ankylosis: a surgeon's dilemma. J Craniofac Surg 23:1796-1801, 2012.
13
Sayan NB, Karasu HA, Uyanik LO, Aytaç D. Two-stage treatment of TMJ ankylosis
14
by early surgical approach and distraction osteogenesis. J Craniofac Surg 18:212-217,
15
2007.
16
Tanrikulu R, Erol B, Görgün B, Söker M. The contribution to success of various
17
methods of treatment of temporomandibular joint ankylosis (a statistical study
18
containing 24 cases). Turk J Pediatr 47:261-265, 2005.
19
Tideman H, Doddridge M. Temporomandibular joint ankylosis. Aust Dent J
20
32:171-177, 1987.
21
Topazian RG. Comparison of gap and interposition arthroplasty in the treatment of
22
temporomandibular joint ankylosis. J Oral Surg 24:405-409, 1966
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ACCEPTED MANUSCRIPT Topazian RG. Gap versus interposition arthroplasty for ankylosis of the
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temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
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91:388-389, 2001.
4
Vasconcelos BC, Porto GG, Bessa-Nogueira RV, Nascimento MM. Surgical treatment
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of temporomandibular joint ankylosis: follow-up of 15 cases and literature review.
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Med Oral Patol Oral Cir Bucal 14:E34-38, 2009.
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Figure 1. Flow diagram for study selection.
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Figure 2. Forest plot of meta-analysis for reankylosis in interpositional arthroplasty
4
(IA) and reconstruction arthroplasty (RA) groups.
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Figure 3. Forest plot of meta-analysis for maximal incisal opening (MIO) in
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interpositional arthroplasty (IA) and reconstruction arthroplasty (RA) groups.
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Figure 4. Funnel plot of studies reporting reankylosis.
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Table 1. Clinical characteristics of the included studies IA
RA
Mean
Sample
Follow-up
Study
OG of
Malocclusion
(year)
material
material
age at
size
IA/RA
quality
CCG
(gap size)
operation
IA/RA
(max =
(cartilage
IA/RA Erol
12–144 TMF
CCG
18 y
15/10
(2006)
mo 36.6/45.6 TMF*
TJR
CCG+TMF y
(2003) Manganello
Silicone CCG+TMF 32/12.8 y (2003) Tanrikulu
12.7/10.9 TMF
CCG
Elgazzar TMF (2010)
CCG △
Qudah (2005) Sahoo (2012)
CCG
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TMF
CCG
9/8 y
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TMF
NA
13.2 y
(NA) NA (NA)
9/22
6y
7
NA (NA)
NA (NA)
NO (1.5
Mandibular
5/9
28.2 mo
7 cm)
deviation (NA)
NA(NA)
NA (NA)
1 (3–6
Open bite
mm)
(1.5–2 cm)
18.9/20.1
7
mo
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Open bite
NA (NA)
9/7
(2005)
NA (NA)
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27.6/9.6 TMF
7
12 mo
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size)
14/22 y
（2010）
9)
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First author
14/20
14–96 mo
6
22.8/24.3
8/14
2 (2–3 7
mo
NA (1.5–2 cm) mm) NO (6–8
19/37
4.7 y
6
NA (1.5 cm) mm)
IA: Interpositional arthroplasty; RA: Reconstruction arthroplasty; Max = maximum; TMF: Temporalis myofascial flap; TJR: Total joint replacement; OG: Overgrowth; CCG: Costochondral graft. * TMF+ dermis/fat, silicone, cartilage graft, meniscal placation. △: 1.CCG +/– TMF/buccal pad fat/ original disc. 2. Surgibone. 3. Coronoid process graft and TMF. 4. IA with TMF + distraction osteogenesis
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I2
MD (95% CI)
P-value
Z-value
65%
0.48 (–2.17 to
0.72
0.36
Balaji
3.14) Elgazzar*
14%
2.10 (0.90 to
0.0006
3.43
0.55
0.59
78%
0.79 (–1.82 to 3.40)
78%
1.05 (–1.52 to
0.42
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IA vs. RA
0.8
3.62)
Sahoo
77%
1.33 (–1.43 to
0.35
0.94
0.51
0.66
0.76
0.31
0.20
1.28
0.75
0.75
0.98
0.03
0.50
0.68
4.10)
Quadah
78%
1.05 (–2.05 to
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74%
0.40 (–2.09 to 2.88)
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IA (TMF) vs. RA (CCG)
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Elgazzar*
Sahoo
Qudah
Tanrikulu
49%
84%
1.21 (–0.65 to 3.07) 0.69 (–3.56 to 4.94)
79%
0.07 (–4.44 to 4.57)
70%
–0.98 (–3.80 to 1.84)
IA: interpositional arthroplasty; RA: reconstruction arthroplasty. MD: mean difference; TMF: temporalis myofascial flap; CCG: costochondral graft.
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*Results were based on fixed-effects model.
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ACCEPTED MANUSCRIPT Highlights 1.
First systematic review and meta-analysis in evaluating interpositional arthroplasty and reconstruction arthroplasty in treating temporomandibular joint ankylosis;
2.
Thorough systematic review was performed after searching Pubmed, EMBASE, OVID EBM
3.
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Reviews, and Web of science; Study quality evaluation, sensitivity analysis and detection of publication bias were all performed to make the results of meta-analysis as reasonable as possible;
Subgroup analysis was also made trying to eliminate substantial heterogeneity;
5.
The pooled results did not review the differences in reankylosis and maximum incisal
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opening between Interpositional arthroplasty and reconstruction arthroplasty in treating
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temporomandibular joint ankylosis.
S1010-5182(15)00121-3
DOI:
10.1016/j.jcms.2015.04.017
Reference:
YJCMS 2041
To appear in:
Journal of Cranio-Maxillo-Facial Surgery
Received Date: 12 October 2014 Revised Date:
21 March 2015
Accepted Date: 22 April 2015
Please cite this article as: Ma J, Jiang H, Liang L, Interpositional arthroplasty versus reconstruction arthroplasty for temporomandibular joint ankylosis: a systematic review and meta-analysis, Journal of Cranio-Maxillofacial Surgery (2015), doi: 10.1016/j.jcms.2015.04.017. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Interpositional arthroplasty versus reconstruction arthroplasty for temporomandibular joint ankylosis: a systematic review and meta-analysis
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Junli Maa, D.D.S, Hua Jiangb, D.D.S, Limin Liangb* D.D.S
Department of Stomatology, the General Hospital of Guangzhou Military Command
of PLA, Guangzhou, CHINA Department of Stomatology, the General Hospital of the People's Liberation Army, Beijing, CHINA
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*Corresponding author: Limin Liang Tel:86-010-66938217 Fax: 86-010-66938217 Email: [email protected] Department of Stomatology The General Hospital of the People's Liberation Army
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Fuxing road 28#，Beijing, CHINA, 100853
ACCEPTED MANUSCRIPT INTRODUCTION
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Temporomandibular joint ankylosis (TMJA) is the functional disability of the
4
mandible, caused by the fibrous or bony adhesion among the condyle, disc, glenoid
5
fossa, and eminence (Long et al., 2005). Trauma is the most common etiologic factor,
6
documented in 13% to 100% cases of TMJA. Local or systemic infection is the
7
second most common etiology. In rare circumstances, systemic diseases, such as
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ankylosing spondylitis, rheumatoid arthritis, and psoriasis, may also lead to TMJ
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ankylosis (Chidzonga, 1999; Vasconcelos et al., 2009).
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TMJA causes functional impairment in mastication and speech; in addition, it poses a
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severe threat to facial development in children. In unilateral cases, TMJA can cause
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hypoplasia of the mandible and deviation to the affected side. In bilateral cases, a
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typical bird-face appearance with retrognathia, mandibular alveolar protrusion, and
15
open bite may appear (Güven, 2009).
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Currently, the following three techniques are most often ussed: gap arthroplasty (GA);
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interpositional arthroplasty (IA); and reconstruction arthroplasty (RA). However,
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none of these three techniques has been accepted as a universally successful method
20
for various type of TMJA. Reankylosis is the most common and troubling
21
postoperative complications encountered in clinical practice.
22
ACCEPTED MANUSCRIPT GA is the oldest type of surgery for treating TMJA; however, due to the high
2
incidence of recurrence and malocclusion caused by shortened mandibular ramus, its
3
application is becoming limited, and some authors have even suggested abandoning
4
GA (Kaban et al., 1990; Matsuura et al., 2001). Currently, IA and RA are more
5
popular, especially for children with TMJA. Although successful application of IA
6
and RA have been widely reported, direct comparison between RA and IA is rare and
7
results are controversial, which leads to a dilemma for surgeons when choosing
8
certain treatment modalities (Sahoo et al., 2012).
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Therefore we conducted this systematic review and meta-analysis to compare the
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outcomes of IA and RA to provide some evidence-based suggestions for clinicians.
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MATERIAL AND METHODS
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Literature search
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The PubMed, EMBASE, OVID EBM Reviews, and Web of Science were searched up
17
to October 11, 2014, using the following key words with combinations:
18
temporomandibular joint, TMJ, ankylosis, interpositional arthroplasty, interposition
19
arthroplasty; joint reconstruction, articulation reconstruction, joint replacement,
20
autogenous graft, alloplastic graft, costochondral graft. The references lists of
21
included studies were also manually searched.
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ACCEPTED MANUSCRIPT Inclusion criteria and quality assessment
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The inclusion criteria were as follows: randomized controlled trial (RCT) or
3
observational cohort study with a follow-up of at least 12 months; and comparison of
4
clinical outcomes between the patients who received IA and those who received RA,
5
including reankylosis or maximal incisal opening (MIO). Potentially eligible studies
6
were assessed by two authors (J.M., H.J.) independently. Any uncertainty regarding
7
eligibility was discussed in consultation with a third reviewer (L.L.) to make a
8
decision. The methodological quality of the included studies was evaluated at this
9
stage using the Newcastle-Ottawa Scale (NOS); scores are listed in Table 1.
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Data extraction
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An Excel sheet was designed to record the following data: the name of the first author,
13
year of publication, materials used in IA and RA, mean age at operation, sample size,
14
outcomes, size of cartilage, size of gap created, and length of follow-up. Two
15
reviewers (J.M., H.J.) performed data extraction independently. All of the data were
16
from those published in the included studies. The recorded data were compared by the
17
third reviewer (L.L.) to prevent omissions and errors.
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Assessment of heterogeneity
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The heterogeneity was evaluated by the χ2 and I2 tests. Substantial heterogeneity was
21
defined as I2 > 50%.
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ACCEPTED MANUSCRIPT Outcome measures
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Two main outcomes of interest were the incidence of reankylosis and the MIO, other
3
postoperative complications (malocclusion and overgrowth of cartilage) were also
4
documented.
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Statistical analysis
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RevMan 5.3 software (Cochrane Collaboration, Software Update, Oxford, UK) and
8
Stat 12 (StataCorp, College Station, TX) were used in this meta-analysis. Risk
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difference (RD) with a 95% confidence interval (95% CI) was calculated for binary
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outcomes, and mean differences (MDs) with 95% confidence intervals (CIs) for
11
continuous outcomes. A fixed-effects model (Mantel-Haenszel method) was used if
12
there was no heterogeneity; otherwise a random-effects model (Der Simonian-Laird
13
method) was used. Pooled RDs and MDs were calculated, and a two-sided P < 0.05
14
was considered statistically significant. Publication bias was evaluated using a funnel
15
plot and Egger test. A symmetric funnel-shaped distribution and P > 0.10 in the Egger
16
test indicated the absence of publication bias.
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RESULTS
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Study characteristics
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The selection process is shown in Figure 1. Eight studies with a total of 234 patients
22
were included in this meta-analysis (Balaji, 2003; Manganello-Souza and Mariani,
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2010; Loveless et al., 2010; Sahho et al., 2012). All of these were retrospective cohort
3
studies; no RCT was found. The clinical characteristics and the methodological
4
qualities of these studies are listed in Table 1.
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Temporalis myofascial flap (TMF) was the main interposional material used in 7 of 8
7
studies. Other materials included silicone, dermis/fat, and cartilage. Costochondral
8
graft (CCG) was chosen in 7 studies to reconstruct condyle (Balaji, 2003;
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Manganello-Souza and Mariani, 2003; Qudah et al., 2005; Tanrikulu et al., 2005; Erol
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et al., 2006; Elgazzar et al., 2010; Sahho et al., 2012). Nearly all of the patients who
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received CCG were children, although adult bilateral cases also received this
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technique (Erol et al., 2006). Prosthetic total joint replacement was used only in adults
13
in the study by Loveless et al. (Loveless et al, 2010). In the RA group, TMF or other
14
materials were also used to fill the space between graft and articulation fossa in 3
15
studies (Balaji, 2003; Manganello-Souza and Mariani, 2003; Elgazzar et al., 2010).
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Specific information on mean age at operation and length of follow-up for each
17
technique was partially missing.
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Primary outcome: incidence of reankylosis
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The data from 7 studies with a total of 198 patients were collected to compare the
21
incidence of reankylosis between IA and RA (Balaji, 2003; Manganello-Souza and
22
Mariani, 2003; Qudah et al., 2005; Tanrikulu et al., 2005; Erol et al., 2006; Elgazzar et
ACCEPTED MANUSCRIPT al., 2010; Sahho et al., 2012). Both the χ2 and the I2 tests did not show significant
2
heterogeneity (Q = 0.72, df = 4, P = 0.95; I2 = 0%); a fixed-effect model was used.
3
There were 6 cases of reankylosis among 106 patients who received RA, compared
4
with 4 cases among 92 patients in the IA group. Pooled analysis revealed no
5
significant differences in the incidence of reankylosis between IA and RA groups for
6
(RD = −0.00; 95% CI = −0.08–0.07; Z = 0.06, P = 0.95). Because TMF and CCG
7
were the most commonly used materials in IA and RA, respectively, we further
8
performed a subgroup analysis to compare the incidence of ankylosis in the IA and
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RA groups when only these two materials were used (Qudah et al., 2005; Tanrikulu et
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al., 2005; Erol et al., 2006; Elgazzar et al., 2010; Sahho et al., 2012). The result was
11
similar; no significant difference in reankylosis between IA (TMF) and RA (CCG)
12
was demonstrated (RD = −0.01, 95% CI = –0.10 to 0.07, Z = 0.30, P = 0.77) (Fig. 2).
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Secondary outcome: MIO
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Seven studies with a total 209 patients were included to compare the MIO between
16
the IA and RA groups (Balaji, 2003; Manganello-Souza and Mariani, 2003; Qudah et
17
al., 2005; Tanrikulu et al., 2005; Elgazzar et al., 2010; Loveless et al., 2010; Sahho et
18
al., 2012). Substantial heterogeneity was found (Q = 22.96, df = 6, P = 0.0008; I2 =
19
74%). A random-effects model was used; no significant difference in MIO between
20
the IA and RA groups was found (MD = 0.99; 95% CI = –1.43 to 3.4, Z = 0.8; P =
21
0.42) (Fig. 3). A subgroup analysis was performed in an attempt to eliminate
22
substantial heterogeneity; 4 studies that chose TMF and CCG alone in IA and RA,
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2010; Sahho et al., 2012). The subgroup also showed substantial heterogeneity (I2 =
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77%); the combined MD based on the random-effects model reveled no significant
4
difference in MIO (MD = 0.22, 95% CI = –2.95 to 3.40; Z = 0.14, P = 0.89).
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The results of sensitivity analysis by removing 1 study in turn are summarized in
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Table 2. Exclusion of the study by Elgazzar et al. reduced the I2 value from 74% to
8
14% in the comparison between IA and RA. A fixed-effects model showed that IA had
9
a significant larger MIO than RA (MD = 2.1; 95% CI = 0.90–3.30; P = 0.0006; Z =
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3.43) if the Elgazzar et al. study was removed.
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In subgroup analysis, removing the Elgazzar et al. study resulted in moderate
13
hetergenity (I2 = 49%), but the MD in MIO between IA (TMF) and RA (CCG) did not
14
reach significance (MD = 1.21; 95% CI = –0.65 to 3.07, P = 0.2; Z = 1.28).
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Other postoperative complications
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Four studies reported the information about overgrowth of CCG with 3 occurrences
18
among 114 patients (2.6%) (Manganello-Souza and Mariani., 2003; Qudah et al.,
19
2005; Elgazzar et al., 2010; Sahho et al., 2012). Three studies reported the
20
postoperative malocclusion, mainly open bite, which was found in both the IA and RA
21
groups (Manganello-Souza and Mariani, 2003; Erol et al., 2006; Elgazzar et al.,
22
2010).
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Publication bias
3
A symmetric funnel-shaped distribution and results of the Egger test (P = 0.81) did
4
not reveal significant publication bias while reporting reankylosis (Fig. 4).
5
DISCUSSION
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In this meta-analysis of 8 studies, we compared the outcomes of IA and RA. Pooling
9
the data did not reveal any significant differences in the incidence of reankylosis and
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MIO between IA and RA. Based on this result, and after taking technique difficulty
11
and donor site morbidity into consideration, we believe that IA seems to be superior
12
over RA in treating TMJA. However, this conclusion should be drawn cautiously,
13
especially for children, because the differences in facial development after IA and RA
14
have not been statistically compared.
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The goal of surgery in treating TMJA is to reestablish the joint movements, prevent
17
relapse, restore normal occlusion, and achieve normal facial growth in children (Rowe,
18
1982; el-Sheikh, 1999). Although it has been almost 200 years since 1854, when the
19
first condylectomy was performed (Danda et al., 2009), and although many reports
20
have described successful application of GA, IA, and RA in treating TMJA, widely
21
accepted and definitive indications for each techniques have not been established, and
22
controversies surrounding the selection of techniques still exist ( Roychoudhury et al.,
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1999; Topazian, 2001; Sahoo, 2006).
2
GA is the oldest technique used to treat TMJA and is also the foundation of IA and
4
RA. Simplicity and short operating time are the advantages of GA. However, because
5
of a high relapse rate and malocclusion, the sole use of GA in treating TMJA is
6
becoming less popular (Kaban et al., 1990; Roychoudhury et al., 1999; Elgazzar et al.,
7
2010). IA was first introduced by Verneuil in 1860; it improves upon GA by inserting
8
interposition materials into the gap and minimizing reduction in the vertical height of
9
ramus to reduce the risk of relapse and malocclusion (Tideman and Doddridge, 1987;
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Jain et al., 2008; Babu et al., 2013). Numerous autogenous and alloplastic materials
11
have been used; the temporalis myofascial flap is the most common material because
12
of easy use, rich blood supply, minimal donor site morbidity, and close proximity to
13
the TMJ (Feinberg and Larsen, 1989; Kaban et al., 1990, Karamese et al., 2013).
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RA was introduced later to restore a condyle after extensive resection by using
16
various materials (Khadka and Hu, 2012). A costochondral graft (CCG) is the most
17
commonly selected autogenous graft, first used in 1920 (Crawley et al., 1993).
18
Traditionally it has been believed that CCG has growth potential and adaptability
19
similar to that of to condylar cartilage, and that transferring CCG to mandible ramus
20
can restore the normal growth of the mandible in children. Thus RA with CCG is
21
almost a standard treatment modality for children with TMJA ( Kaban et al., 1990;
22
Jain et al., 2008).
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According to the included studies, IA was used mainly in adults, although children
3
with type 3 TMJA also received IA (Qudah et al., 2005); TMF was chosen as the
4
interpositional material in 7 of 8 included studies. RA was used mostly in children and
5
in adults with bilateral TMJA. CCG was the most common material used in RA. The
6
recurrences of ankylosis in both groups were rare (4.3% in IA and 5.7% in RA),
7
mostly because of poor patient compliance with postoperative physiotherapy. The
8
mean postoperative MIO of IA and RA were also similar, with an MD of 0.99 mm.
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Although CCG has been widely used with satisfying results, overgrowth of CCG is
11
still an unavoidable and unpredictable complication, which often requires further
12
orthognathic surgery to correct facial deformity and functional disturbances.
13
Incidence of overgrowth of CCG as high as 50% to 75% have been reported (Guyuron
14
and Lasa, 1992; Ko et al., 1999; López and Dogliotti, 2004). In contrast, the incidence
15
in the present study was very low, with only 3 cases of overgrowth of CCG among
16
119 patients (2.5%). However, this low incidence might be misleading. First, only 4
17
studies provided information about overgrowth of CCG (Elgazzar et al., 2010;
18
Khadka and Hu., 2012; Sahoo et al., 2012). Second, overgrowth could occur
19
throughout growing period, usually 2 to years after grafting; but not all of the young
20
patients were followed up to the completion of growth, according to the reported
21
length of follow-up. The possibility that some occurrences of overgrowth might be
22
documented cannot be excluded.
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The overgrowth of CCG has been associated with the amount of cartilage transplanted,
3
and cartilage of less than 5 mm is believed to have minimal chance of overgrowth.
4
Indeed, high incidences of overgrowth of CCG (75% and 70% respectively) have
5
been observed after 1.5 cm of cartilage was retained in the graft; however, overgrowth
6
was still observed in 2 patients who received transplantation of only 2 to 3 mm of
7
cartilage, so the amount of cartilage may be not the only factor that could decide the
8
fate of CCG (Peltomäki and Rönning, 1991; Perrott et al., 1994; Qudah et al., 2005).
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Uncertain growth has raised the question as to the validity of using CCG, and some
11
authors have even suggested replacing RA with CCG by other techniques with a
12
two-stage strategy in children (Ellis et al., 2002; Güven, 2004; Sayan et al., 2007). So
13
far, however, the comparison of growth status of mandibles between the children who
14
underwent CCG and those who underwent other techniques is lacking. RA with CCG
15
is still a technique for treating children with TMJA that is recommended by most
16
authors.
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Occlusion is also an important factor influencing mastication besides opening ability.
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In the practice of IA and RA, complete resection of ankylosis often results in a gap of
20
1 to 2 cm, leading to malocclusion. In the present review, only 3 studies reported the
21
postoperative occlusion status, with open bite observed mostly, which made a
22
statistical comparison between IA and RA impossible.
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Lacking RCTs to perform our meta-analysis is 1 major limitation of our work. TMJA
3
is a relatively rare disease, and it is difficult to perform an RCT with large sample size
4
in clinical settings with the consent of patients. This reality is common in evaluating
5
various interventions in treating different diseases and pathologic conditions.
6
Nonrandomized cohort studies, although suboptimal, may be the only feasible
7
approach, and meta-analyses using these studies is gaining increasing popularity
8
(Berlin, 1995; Rajasekhar et al., 2011). Another limitation is the quality of included
9
studies. Most studies did not provide clear criteria for the selection of a certain
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technique based on TMJA type, age, or other factors, which influenced the
11
comparability between these studies to some extent; also, a subgroup analysis based
12
on these factors is impossible. In the present analysis, including or excluding the
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study by Elgazzar et al. produced different results regarding MIO, but the MD was so
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small that its impact on selecting IA or RA might be neglected.
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CONCLUSION
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No significant differences between IA and RA regarding reankylosis and MIO were
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detected by the present meta-analysis; reankylosis occurred in both groups. Wide
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surgical exposure, complete resection, early mobilization, aggressive physiotherapy,
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and good patient compliance are all indispensible to guarantee the success of surgery.
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Other clinical outcomes, including postoperative occlusion, growth of CCG, and
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growth of the mandible, need more thorough evaluation.
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Funding
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None.
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Financial disclosure
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None.
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Conflict of interest
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None.
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ACCEPTED MANUSCRIPT References
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Figure 1. Flow diagram for study selection.
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Figure 2. Forest plot of meta-analysis for reankylosis in interpositional arthroplasty
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(IA) and reconstruction arthroplasty (RA) groups.
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Figure 3. Forest plot of meta-analysis for maximal incisal opening (MIO) in
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interpositional arthroplasty (IA) and reconstruction arthroplasty (RA) groups.
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Figure 4. Funnel plot of studies reporting reankylosis.
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Table 1. Clinical characteristics of the included studies IA
RA
Mean
Sample
Follow-up
Study
OG of
Malocclusion
(year)
material
material
age at
size
IA/RA
quality
CCG
(gap size)
operation
IA/RA
(max =
(cartilage
IA/RA Erol
12–144 TMF
CCG
18 y
15/10
(2006)
mo 36.6/45.6 TMF*
TJR
CCG+TMF y
(2003) Manganello
Silicone CCG+TMF 32/12.8 y (2003) Tanrikulu
12.7/10.9 TMF
CCG
Elgazzar TMF (2010)
CCG △
Qudah (2005) Sahoo (2012)
CCG
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CCG
9/8 y
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TMF
NA
13.2 y
(NA) NA (NA)
9/22
6y
7
NA (NA)
NA (NA)
NO (1.5
Mandibular
5/9
28.2 mo
7 cm)
deviation (NA)
NA(NA)
NA (NA)
1 (3–6
Open bite
mm)
(1.5–2 cm)
18.9/20.1
7
mo
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Open bite
NA (NA)
9/7
(2005)
NA (NA)
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27.6/9.6 TMF
7
12 mo
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size)
14/22 y
（2010）
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14/20
14–96 mo
6
22.8/24.3
8/14
2 (2–3 7
mo
NA (1.5–2 cm) mm) NO (6–8
19/37
4.7 y
6
NA (1.5 cm) mm)
IA: Interpositional arthroplasty; RA: Reconstruction arthroplasty; Max = maximum; TMF: Temporalis myofascial flap; TJR: Total joint replacement; OG: Overgrowth; CCG: Costochondral graft. * TMF+ dermis/fat, silicone, cartilage graft, meniscal placation. △: 1.CCG +/– TMF/buccal pad fat/ original disc. 2. Surgibone. 3. Coronoid process graft and TMF. 4. IA with TMF + distraction osteogenesis
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I2
MD (95% CI)
P-value
Z-value
65%
0.48 (–2.17 to
0.72
0.36
Balaji
3.14) Elgazzar*
14%
2.10 (0.90 to
0.0006
3.43
0.55
0.59
78%
0.79 (–1.82 to 3.40)
78%
1.05 (–1.52 to
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IA vs. RA
0.8
3.62)
Sahoo
77%
1.33 (–1.43 to
0.35
0.94
0.51
0.66
0.76
0.31
0.20
1.28
0.75
0.75
0.98
0.03
0.50
0.68
4.10)
Quadah
78%
1.05 (–2.05 to
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4.14)
74%
0.40 (–2.09 to 2.88)
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IA (TMF) vs. RA (CCG)
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Sahoo
Qudah
Tanrikulu
49%
84%
1.21 (–0.65 to 3.07) 0.69 (–3.56 to 4.94)
79%
0.07 (–4.44 to 4.57)
70%
–0.98 (–3.80 to 1.84)
IA: interpositional arthroplasty; RA: reconstruction arthroplasty. MD: mean difference; TMF: temporalis myofascial flap; CCG: costochondral graft.
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ACCEPTED MANUSCRIPT Highlights 1.
First systematic review and meta-analysis in evaluating interpositional arthroplasty and reconstruction arthroplasty in treating temporomandibular joint ankylosis;
2.
Thorough systematic review was performed after searching Pubmed, EMBASE, OVID EBM
3.
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Reviews, and Web of science; Study quality evaluation, sensitivity analysis and detection of publication bias were all performed to make the results of meta-analysis as reasonable as possible;
Subgroup analysis was also made trying to eliminate substantial heterogeneity;
5.
The pooled results did not review the differences in reankylosis and maximum incisal
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opening between Interpositional arthroplasty and reconstruction arthroplasty in treating
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temporomandibular joint ankylosis.
