Distraction Osteogenesis ,A New Hope For Tmj Ankylosis · TMJ ankylosis treatment using distraction...

TMJ ankylosis treatment using distraction osteogenesis

Volume 2 Issue 1

February 2011

108 Journal of Dental Sciences and Research

Case Report

Distraction Osteogenesis ,A New Hope For Tmj Ankylosis

Dr. Amarnath.B.C , M.D.S* , Dr. Dharma R.M.,M.D.S**,

Dr. Prashanth C.S.,M.D.S*** Dr. Rajkumar G.C.,M.D.S#

* Professor, ** Professor , *** Professor, D.A.P.M.R.V. Dental College, Bangalore. #Professor, Oral and Maxillofacial Surgery ,V.S. Dental College

ABSTRACT

This case report presents the results of extraoral mandibular distraction

osteogenesis and gap arthroplasty in a patient with biilateral

temporomandibular joint bony ankylosis. Distraction osteogenesis with gap arthroplasty proved successful in this patient with follow-up of longer than 2

years.

Keywords : Distraction Osteogenesis, TMJ ankylosis, Gap Arthroplasty Journal of Dental Sciences & Research 2:1: Pages 108-115

INTRODUCTION

Ankylosis of the TMJ is a common

pathology affecting the facial

skeleton, which often gets

overlooked during younger

age,thereby creating a more

complex situation making it difficult

to manage during the later years of

life. The treatment of the sequelae

of bilateral temporomandibular

ankylosis is difficult, because these

patients present with significant

micrognathia, and it is impossible

to use the conventional techniques

for mandibular augmentation.

The latest technique for combating

the same is “Distraction

Osteogenesis”. Distraction


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February 2011


techniques have been used in the

facial bone area for the past 10

years.1,2

Distraction osteogenesis (DO) is a

biologic process of new bone

formation by gradual traction of a

fracture callus formed between

osteotomised bone segments.3-5

Bone lengthening by osteotomy

and distraction osteogenesis of

long bones was first described by

Codivilla6 and later popularized by

Ilizarov.7 DO has been applied to

the craniofacial region since

McCarthy et al reported the first

clinical application of the technique

in the treatment of four children

with either unilateral or bilateral

mandibular hypoplasia.8

This case report describes a 16 yr

old male patient with bilateral TMJ

ankylosis and severe bilateral

mandibular hypoplasia. Orthodontic

treatment in combination with gap

arthroplasty and distraction

osteogenesis was carried out.

CASE REPORT

The patient,a 16 yr old

boy,reported to the Department of

Orthodontics and Dentofacial

Orthopaedics with the chief

complaint of an inability to open

the mouth.Thorough clinical

examination revealed the cause as

bilateral TMJ ankylosis.The patient

had a convex profile,recessive chin

and high clinical FMA.(Fig 1)

On intraoral examination, Cl I

molar relation was noted bilaterally

with posterior open bite.The upper

incisors were retroclined and the

lower incisors were proclined.15

mm of overjet and 3 mm of

overbite was present.Mouth

opening was restricted to 8 mm.


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February 2011


Fig 1 : Pretreatment extraoral photographs showing bird beak face, with a mouth opening of 8mm and overjet of 15mm

The treatment was carried out in

three phases :

PHASE I : Bilateral gap

arthroplasty with Temporalis graft

interposition was carried out , to

relieve the TMJ ankylosis.(Fig

2).9The patient was also instructed

to carry out certain mouth opening

exercises using spring loaded

acrylic plates to improve the

function. Mandibular distraction

osteogenesis was then carried out

using Bilateral Extraoral

unidirectional distractors (Fig 4).10


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February 2011


FIG. 2: CONDYLECTOMY PROCEDURE

FIG 3: POST SURGICAL MOUTH OPENING OF 26 MM

FIG 4 : PLACEMENT OF EXTRAORAL DISTRACTORS


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February 2011


Fig 5 : post distraction extra oral and intraoral photographs


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February 2011


PHASE II: It consisted of the

functional appliance phase in which

the Frankel 2 appliance was used

to allow functional modulation of

the orofacial capsular matrix to

prevent relapse , reankylosis and

also aid in mouth opening.(Fig 6).

FIG 6 :Tthe Frankel 2 appliance to prevent relapse due to abnormal pressure from orofacial

musculature during the retention phase.

PHASE III : Fixed

mechanotherapy was initiated after

1 year of Frankel 2 appliance

wear(Fig 7), for aligning and

establishment of occlusion using

022 MBT appliance.

Fig 7 : intraoral photographs showing intiation of fixed mechanotherapy


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February 2011


Fig 8 : 1 year post retention extraoral and intraoral photographs, showing stable results.

DISCUSSION

There was significant improvement

obtained by employing Distraction

Osteogenesis for this case,none of

the other Orthodontic or combined

Orthognathic approaches would

have given the same results.

Probably the use of a multi-

directional distractor would have

given better results in terms of

reduced open bite to be managed

post distraction.

CONCLUSION

The patient described here showed

favourable results in terms of

function and aesthetics(Fig 8).

Without the osteogenic distraction process, the results we achieved

would not have been the same,

since success with other


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February 2011


mandibular augmentation

techniques are limited . Although it represents a new kind of technique

with several questions still

unanswered, osteogenic distraction

is the best indicated treatment in such patients.

References

1. Drew SJ, Schwartz MH, Sachs

SA. Distraction osteogenesis. N Y

State Dent J.1999;65:26-29

State Dent J. 1999;65:26–29.

2. Carls FR, Sailer HF. Seven years

clinical experience with mandibular

distraction in children J Craniomaxillofac Surg.

1998;26:197-208

3. Cope JB, Samchukov ML.

Mineralization dynamics of regenerate bone during mandibular

bone during mandibular

osteodistraction. J Oral Maxillofac

Surg. 2001;30:234–242.

4. McCarthy JC, Schreiber J, Karp

N, Thorne CH, Grayson BH.

Lengthening of the human mandible by gradual distraction.

Plast Reconstr Surg. 1992;89:1–8.

5. Hopper RA et al Cephalometric

analysis of the consolidation phase following bilateral pediatric

mandibular distraction. Cleft Palate

Craniofac J. 2003;40:233–240.

6. Codivilla A. On the means of

lengthening, in the lower limbs,the

muscles and tissues which are shortened through deformity.1904.

Clin Orthop Relat Res 1994;301:4–

9

7. Ilizarov GA. The principles of the Ilizarov method. Bull Hosp Jt Dis

Orthop Inst 1988;48:1–11

8.McCarthy JG, Schreiber J, Karp N, et al.: Lengthening of the

human mandible by gradual

distraction. Plast Reconstr Surg

1992, 89:1–8.

9.Rao K et al The role of

simultaneous gap arthroplasty and

distraction osteogenesis in the

management of temporomandibular joint ankylosis

in children.Journal of Cranio-

Maxillofacial Surgery 2004,vol

32,issue 1,38-42.

10. Seung-Hak Baek, Sukwha

Kim.The Determinants of

Successful Distraction Osteogenesis of the Mandible in

Hemifacial Microsomia From

Longitudinal Results.The Journal of

Craniofacial Surgery 2005,Vol 16,no 4.

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