e516 CONCLUSIONS REFERENCES Brief Clinical Studies The Journal of Craniofacial Surgery & Volume 23, Number 5, September 2012

Transcription

1 3 weeks to 20 years or more after the external injury. 15 In our patient, as similarly reported by Spinazze et al, 11 laboratory examinations revealed serum calcium, phosphorus, and parathyroid hormone levels were within reference range. It is reported that roentgen rays and CT, including three-dimensional CT, are useful in diagnosis. Although the generating mechanism of MOT is not clear, Carey 16 has posited 4 hypotheses: (1) displacement of bony fragments into the soft tissue and hematoma with subsequent proliferation, (2) detachment of periosteal fragments into the surrounding tissue with proliferation of osteoprogenitor cells, (3) migration of subperiosteal osteoprogenitor cells into surrounding soft tissue through periosteal perforations induced by trauma, and (4) differentiation of extraosseous cells exposed to bone morphogenic protein. Among these, hypothesis 4 has received the most support. 5,17 The typical pathology image of MOT has a 3-layer structure. 14 The outer zone is composed of mature lamellar bone in a less cellular fibrous stroma; the intermediate zone has immature osteoid formation, cartilage, and active osteoblasts, and the central zone is composed hematoma, muscle cell necrosis, and granulation tissue and is cellular with variable mitotic activity. 6,14 Many cases of MOT in the oral area are managed operatively. 12 However, it is difficult to determine suitable timing for the operation. Because many recurrent cases have been reported, 12,13,15 some suggest that surgery should be performed 6 to 12 months after initial symptom onset. 18 However, if the trismus is neglected, it may result in poor nutritional status and temporomandibular joint contracture. Surgeons tend to choose surgical management at an early stage, even though full ossification of MOT may take 6 weeks. 5,6 Consequently, the disease should be observed for at least 6 weeks before surgery is performed, and the operation should be planned after checking that the ossification has stopped. 5 Aoki et al 12 reported that osteotomy of the muscle attachment is desirable in addition to complete muscular excision. These procedures may have prevented recurrence in our case. We also recommend excision of all the ossified muscle and osteotomy and dissection of the ossified muscle attachment from the bone. The hematoma may be the cause of MOT, and therefore caution is also required for operatively induced hematoma. Transplant of abdominal adipose tissue and pedicled buccal fat as the interposition between the bone and muscles has been reported to prevent recurrence. 6,17 Physical therapy should be started early in the postoperative period. In our case, because the lateral pterygoid muscle was involved, the mandibular protrusion arose from postoperative scar formation. Although a chin cap was used to improve occlusion, this was in conflict with the opening exercise. Indeed, it proved difficult to balance both management aspects in this case. Magnesium agents, steroids, nonsteroidal anti-inflammatory drugs, low-dose radiation therapy, warfarin, and bisphosphonates such as etidronate have been used for conservative treatment and postoperative recurrence prevention. 13,19 Long-term administration of etidronate has been linked with osteomalacia but is often administered for MOP. 13,20 Etidronate has been recommended to be given for 2 to 3 months after surgery for the prevention of postsurgical recurrence, 5 although its efficacy, as well as that of other drugs, remains controversial at present. CONCLUSIONS We experienced a case of MOT involving the bilateral masseter muscles, the left temporal muscle, the left lateral pterygoid muscle, and the left frontal muscle. A good outcome was obtained by surgically excising the invaded muscles, osteotomy, and dissection of the ossified muscle attachment. Surgeons treating facial injury should be cognizant of this disease. e516 REFERENCES 1. Kaplan FS, Tabas JA, Zasloff MA. Fibrodysplasia ossificans progressive: a clue from the fly? Calcif Tissue Int 1990;47:117Y Debeney-Bruyerre C, Chikhani L, Lockhart R, et al. Myositis ossificans progressiva: five generations where the disease was exclusively limited to the maxillofacial region. A case report. Int J Oral Maxillofac Surg 1998;27:299Y Cushner FD, Morwessel RM. Myositis ossificans traumatica. Orthop Rev 1992;21:1319Y Ivy RH, Ebr JD. The Medical Department of the United States Army in the World War II, Surgery. Part 2. Washington, DC: Government Printing Office, 1924: Conner GA, Duffy M. Myositis ossificans: a case report of multiple recurrences following third molar extractions and review of the literature. J Oral Maxillofac Surg 2009;67:920Y Thangavelu A, Vaidhyanathan A, Narendar R. Myositis ossificans traumatica of the medial pterygoid. Int J Oral Maxillofac Surg 2011;40:545Y Trautmann F, Moura P, Fernandes TL, et al. Myositis ossificans traumatica of the medial pterygoid muscle: a case report. J Oral Sci 2010;52:485Y Ramieri V, Bianca C, Arangio P, et al. Myositis ossificans of the medial pterygoid muscle. J Craniofac Surg 2010;21:1202Y Abdin HA, Prabhu SR. Traumatic myositis ossificans of lateral pterygoid muscle. J Oral Med 1984;39:54Y Lello GE, Makek M. Traumatic myositis ossificans in masticatory muscles. J Maxillofac Surg 1986;14:231Y Spinazze RP, Heffez LB, Bays RA. Chronic, progressive limitation of mouth opening. J Oral Maxillofac Surg 1998;56:1178Y Aoki T, Naito H, Ota Y, et al. Myositis ossificans traumatica of the masticatory muscles: review of the literature and report of a case. J Oral Maxillofac Surg 2002;60:1083Y Kim DD, Lazow SK, Har-El G, et al. Myositis ossificans traumatica of masticatory musculature: a case report and literature review. Oral Maxillofac Surg 2002;60:1072Y Ackerman LV. Extra-osseous localized non-neoplastic bone and cartilage formation (so-called myositis ossificans): clinical and pathological confusion with malignant neoplasms. J Bone Joint Surg Am 1958;40:279Y Arima R, Shiba R, Hayashi T. Traumatic myositis ossificans in the masseter muscle. J Oral Maxillofac Surg 1984;42:521Y Carey EJ. Multiple bilateral periosteal bone and callus formations of the femur and left innominate bone. Arch Surg 1924;8: Rattan V, Rai S, Vaiphei K. Use of buccal pad of fat to prevent heterotopic bone formation after excision of myositis ossificans of medial pterygoid muscle. J Oral Maxillofac Surg 2008;66:1518Y Ferlito A, Barion U, Nicolai P. Myositis ossificans of the head and neck. Review of the literature and report of a case. Arch Otorhinolaryngol 1983;237:103Y Steidl L, Ditmar R. Treatment of soft tissue calcifications with magnesium. Acta Univ Palacki Olomuc Fac Med 1991;130:273Y Bar Oz B, Boneh A. Myositis ossificans progressiva: a 10-year follow-up on a patient treated with etidronate disodium. Acta Paediatr 1994;83:1332Y1334 Recurrent Mandibular Dislocation Treated by Eminectomy Gabriela Mayrink, DDS, PhD,* Sergio Olate, DDS, PhD,Þ Adriano Assis, DDS, PhD,* Alex Sverzut, DDS, PhD,* Márcio de Moraes, DDS, PhD* Abstract: Mandibular dislocations present with frequency; when they are recurrent and sustained over time, surgical treatment is

2 The Journal of Craniofacial Surgery & Volume 23, Number 5, September 2012 Brief Clinical Studies indicated. Although different therapeutic techniques exist, the eminectomy is one of the most often applied. In this investigation, 3 cases are described where the bilateral eminectomy was performed for recurrent mandibular dislocation with 5 years of duration. No dislocation recurrence, postoperative pain, or functional alterations were observed in any of the patients. The bilateral eminectomy is a wellknown procedure described in the literature, with good scientific support and constant modifications to optimize its indications and results. Compared with the results from other investigations, it is concluded that treatment with a bilateral eminectomy can be applied safely in cases of recurrent mandibular dislocations. Key Words: Eminectomy, recurrent mandibular dislocation, TMJ surgery Temporomandibular joint (TMJ) dislocation is defined as the displacement of the condyle beyond the glenoid fossa without the ability to reduce itself. It appears mainly in young adults and presents clinically as the inability to close the mouth. This occurs most frequently in people who have a weakness in the ligament and the joint capsule and in people with condylar erosion or flattening of the articular eminence 1 ; other possible factors include trauma, abnormal masticatory movements, and masticatory muscle disorders. 2 In acute cases, manual reduction generally solves the problem, whereas in other cases this situation is repetitive, with monthly and even daily episodes becoming recurrent and chronic pathologies. Different techniques have been applied to treat recurrent mandibular dislocations (Table 1), with the aim of enabling the free movement of the condyle or limiting condylar movement exclusively to the glenoid cavity. 5 The modified LeClerc procedure (oblique osteotomy of the zygomatic arch) was applied by Undt et al, 6 demonstrating that in 3 of the 9 patients there were recurrence and new postoperative dislocations; in addition, in long-term evaluations, noises (clicking) and pain were observed that were not present before the surgery. Srivastava et al 7 operated on 12 patients using Dautrey procedure, and in a 5-year follow-up, recurrence was observed in only 1 patient. A recent investigation by Gadre et al 5 treated 20 patients with Dautrey procedure (in this case stabilized with plate osteosynthesis) with an 18-month follow-up, with a success rate of 100%; however, they reported a zygomatic arch fracture as a complication in a 60-year-old patient, who was treated immediately with osteosynthesis. In all the patients, there was an approximately 6-mm decrease in the mouth opening with no signs of pain or postoperative alterations. Another surgical alternative for recurrent mandibular dislocation is the placement of plates in the articular eminence, which impede the condylar passage in its transitional movement. 8 The aim of this technique is essentially the same as the LeClerc procedure or the From the *Division of Oral and Maxillofacial Surgery, Piracicaba Dental School, State University of Campinas, São Paulo, Brazil; and Division of Oral and Maxillofacial Surgery, School of Medicine, Universidad de La Frontera, Temuco, Chile. Received February 21, Accepted for publication April 13, Address correspondence and reprint requests to Prof. Dr. Sergio Olate, DDS, PhD, Facultad de Medicina, Universidad de La Frontera, Claro Solar 115, 4to Piso, Oficina 20, Temuco, Chile; solate@ufro.cl The authors report no conflicts of interest. Copyright * 2012 by Mutaz B. Habal, MD ISSN: DOI: /SCS.0b013e31825ab523 TABLE 1. Surgeries to Treat Recurrent Mandibular Dislocations (According to Mizuno et al 3 and Weinberg et al 4 ) Surgeries Indicated to Treat Recurrent Mandibular Dislocations Condylectomy and condylotomy Kostecka s osteotomy Subcondylar osteotomy with coronoidectomy Coronoidectomy Mandibular ramus L-inverted osteotomy Modified subsigmoid vertical osteotomy Temporal myotomy Fink s method Traction with wires of the mandibular angle (surgical approach) Meniscectomy Dautrey procedure (also called the modified LeClerc procedure): to prevent the movement of the condyle beyond the glenoid cavity. Cardoso et al 9 published the results of 11 patients treated with osteosynthesis plates installed in the articular eminence, comparing them with eminectomy procedures, and indicating that there were no differences in the results of the 2 procedures. Nevertheless, Vasconcelos and Porto 10 (from the same group as Cardoso et al 9 ) conducted the same study with a larger sample, indicating that in the patients treated with eminectomy, there was no recurrence of the pathology, whereas in patients treated with plates, 2 patients (11%) had a recurrence due to the plate fracturing; they therefore concluded that although plates are used, there is always the possibility that they will fracture. In these cases, an eminectomy would pose less of a potential for recurrence. The eminectomy technique proposed by Myrhaug 11 in 1951 is designed to remove the articular eminence and allow free movement of the condyle. In his article, Myrhaug describes the surgical procedure to remove the articular eminence in cases of recurrent mandibular dislocations. Helman et al 12 presented 8 patients treated by unilateral or bilateral eminectomy, demonstrating success in 7 patients; the failure occurred in 1 patient because the initial pathology stemmed from neuromuscular alterations with spasms that induced mandibular dislocation in such a way that surgical treatment was not correctly indicated. In one of the largest series of patients treated with eminectomy, published in 1984, Oatis and Baker 13 treated 44 patients diagnosed with painful chronic subdislocation and painful chronic dislocation with a bilateral eminectomy. They reported that 82% were pain-free and with no alterations in mandibular function in the postoperative stage, 11% had tolerable discomfort, and in 7% the procedure failed because of diagnostic errors or postoperative behavior. The eminectomy has been used in other joint pathologies, such as those associated with a reduction in the mouth opening (closed lock), resulting in a decrease in pain and an improvement in the mouth opening. 14 In fact, Weinberg 4 established some surgical parameters for achieving success in managing the pain associated with TMJ, with the eminectomy being considered a method for improving recurrent FIGURE 1. Computed tomography, sagittal image, demonstrating the presence of a pronounced articular eminence. e517

3 FIGURE 2. Biomodel used for surgical planning, indicating the osteotomy line to be used during the procedure. mandibular dislocation and also for achieving intra-articular decompression, thereby reducing regional pain. The aim of this investigation was to present 3 new cases of recurrent mandibular dislocations treated by eminectomy using Myrhaug s procedure 11 and to discuss the indication and the particularities of these cases. Patient 1 CLINICAL REPORT A male patient, 23 years old, white, arrived at our practice complaining of pain in both TMJ. He also referred to recurrent episodes of mandibular dislocations of 5 years duration. During the physical examination, stable occlusion and limitation of the mouth opening were observed. Computed tomography revealed the presence of a prominent articular eminence and deep articular fossa on both the right and left sides. The attempt was made at a conservative treatment using face support bandages and intraoral devices with no satisfactory results. This being the case, surgical treatment by bilateral eminectomy was indicated (Fig. 1). The surgery was planned using the TMJ biomodel obtained from the computed tomography, in which the necessary measurements were taken to determine the amount of bone structure that had to be removed (Fig. 2). The surgery was performed under general anesthesia, using Myrhaug s procedure, by means of a bilateral preauricular access and osteotomy of the articular eminence with an oscillating saw (Fig. 3). The osteotomy was concluded in the medial region with a chisel. Next, the region was flattened with erosion drilling, taking special care not to invade the infratemporal fossa. The surgical procedure was evaluated postoperatively with computed tomography, and during the postoperative 12-month followup, there were no new episodes of mandibular dislocation. The mouth opening at that point was 36 mm, with no painful alterations of the TMJ in either the static or functional dynamic state. Patient 2 A male patient, 48 years old, black, presented in our practice with an episode of mandibular dislocation (Fig. 4). The examination revealed tooth destruction as a result of decay, in addition to a significant sagittal mandibular deficiency. The patient had these events repeatedly, daily, of 5 years duration, being treated with manual reduction and stabilization with bandages. Dental management was performed by a specialist and was rehabilitated with a dental prosthesis, stabilizing the occlusion; nevertheless, the mandibular dislocations continued with the same frequency. FIGURE 4. Patient during one of the TMJ dislocation episodes at the initial consultation. The patient indicated that in some days there were 3 or more dislocations episodes. An eminectomy was indicated using Myrhaug s procedure; the x-ray and computed tomography showed a prominent articular eminence (Fig. 5). The surgery was performed similarly to the previous case, and after 12 months follow-up, no dislocation recurrence was observed, and the patient did not experience any pain or postoperative sensory or motor deficiencies. Patient 3 A male patient, 20 years old, white, arrived at our practice with recurrent episodes of TMJ dislocation. The examination showed the absence of some bilateral molars. The patient was treated by specialists for oral rehabilitation, yet despite the occlusal stabilization and the improvements in the clinical picture, the dislocations were still frequent, occurring several times per month. In the tomography, it was possible to observe a pronounced articular eminence and a deep articular fossa. A surgical procedure with eminectomy using Myrhaug s procedure bilaterally was indicated. After 2 years follow-up, there was no dislocation recurrence, and no pain or functional impotence was observed. DISCUSSION Temporomandibular joint dysfunctions appear in different forms and with different symptoms. 15 In some cases, conservative management is an ineffective and inefficient option, with surgery being necessary. In all the cases presented, the dislocations evolved over more than 5 years, with episodes of multiple dislocations in the same month and even in the same day. Eminectomy has proven to be a versatile technique in the management of different types of patients, with different complexities and with no age limit. Mizuno et al 3 presented 2 cases of permanent dislocation, these being a 62-year-old woman with mandibular dislocation with some weeks of duration due to repeated vomiting and a 74-year-old patient with a mandibular dislocation of 57 days of duration; Klüppel et al 16 also presented the case of a woman with chronic dislocation with 3 months of duration that was treated FIGURE 3. Osteotomy of the articular eminence using a sagittal saw and constant irrigation with 0.9% saline solution. e518 FIGURE 5. Computedtomography demonstrating large articular eminence. In this case, the articular eminence is an obstacle to the manual resolution of the pathology.

4 The Journal of Craniofacial Surgery & Volume 23, Number 5, September 2012 Brief Clinical Studies with an eminectomy with no painful sequelae or recurrences of dislocation. These 3 cases showed a decrease in the mouth opening, consistent with the results of Vasconcelos et al, 17 who presented the followup of 10 patients treated with bilateral eminectomy for an average of 37 months; in all the patients, the maximum mouth opening decreased (from 48 to 41 mm), and there were no new episodes of mandibular dislocation. Before this, Williamson et al 18 had performed the eminectomy to treat TMJ dysfunction that was unresponsive to conservative treatments; in the 20 patients treated, an improvement was observed in the degree of pain, increasing the maximum mouth opening on average 9 mm after the surgery. The difference in the results obtained in the maximum mouth opening of the patient between the groups of Vasconcelos et al 17 and Williamson et al 18 maybeinthedifferencesindiagnosisofthe 2groups. Although condylar hypermobility might be expected because there is no articular eminence capable of containing it, the study by Undt et al 6 did not show any changes in the joint movements preoperatively or postoperatively; the extreme translocation that might be expected from not presenting the eminence was not observed in these patients, indicating as a probable cause the presence of a fibrous scar in the anterior sector of the capsule that would prevent excessive movement. This situation is also demonstrated in the 3 cases presented here. A particularity of cases 2 and 3 is in the absence of posterior teeth. The study by Tallents et al 19 indicated that modification of the occlusion, optimizing it with prosthesis use, would not necessarily improve the pain or the functional deficiency of the TMJ. Cases 2 and 3 were ultimately solved by bilateral eminectomy, supporting the fact that, in the presence of recurrent dislocations, deficient occlusal stability may only be 1 factor contributing to the joint pathology. In terms of complications, the series of 14 patients by Undt et al 20 showed that the complications were observed in 3 cases, these being fracture of the condylar head, persistence of the mandibular dislocation, and osteoarthrosis of the TMJ. Surgical access is not observed as a complication in the postoperative aesthetics or possible damage to the facial nerve; in fact, nowadays preauricular or endaural access is considered routine procedure. Horizontal access, on the zygomatic arch, investigated initially so as not to damage the facial nerve, did not present any differences when compared with preauricular access. 21 The neurovascular complications have also been referred to on the basis of regional anatomical conditioners, 15 including reports of sinus bradycardia associated with the proximity of the carotid artery. 22 In our cases, motor complications of the facial nerve, functional alterations, and recurrent dislocation were not observed. Considering the potential complications that the procedure poses, an extra aid lies in the use of biomodels, which make it possible to define and plan the surgical procedures not only in the image but also in volume. In addition, it allows the surgery to be performed on the biomodel, identifying distances and points of insertion for the saws or drills, as well as the obstacles that may be found during the osteotomy. 23 In the first case dealt with, the use of the biomodel optimized the treatment by visualizing the surgery before performing it. Variations and modifications of the initial procedure have also been proposed by some authors. Gay Escoda 24 presented a series of 12 patients with eminectomy and repositioning of the temporal muscle instead of the articular eminence; he reported success in terms of the absence of dislocation recurrence and an almost 4-mm reduction in the maximum mouth opening after a year of follow-up. Güven 1 presented 12 cases of patients with recurrent dislocations who underwent eminoplasty, where a wedge osteotomy was performed from the posterior toward the anterior in the articular eminence, and a bone graft was installed to increase the eminence vertically; the author indicated good results with a reduction in the mouth opening to approximately 38 mm and with no dislocation recurrence. Sato et al 25 conducted a comparative study of patients treated with eminectomy by means of Myrhaug s procedure 11 and with eminoplasty by means of the arthroscopic technique. 26 They identified a dislocation recurrence close to 25% in both groups, concluding that the arthroscopic technique can be just as efficient at reducing mandibular dislocation and is a less invasive procedure, with less bleeding and a shorter surgical time. Another more radical modification was reported by Stassen and O Halloran, 27 who presented a retrospective series of 9 patients who underwent an eminectomy with local anesthesia and conscious sedation, establishing a functional procedure of TMJ surgery. Here, the eminectomy was performed to treat the reduced mouth opening resistant to nonsurgical treatments, indicating a decrease in pain and an improvement in the mouth opening. In conclusion, the bilateral eminectomy applied to cases of recurrent mandibular dislocations is a completely viable option, with few complications; it is currently presented as a well-known procedure that is constantly being modified to optimize the indications and their results. REFERENCES 1. Güven O. Management of chronic recurrent temporomandibular joint dislocations: a retrospective study. J Craniomaxillofac Surg 2009;37:24Y29 2. Cascone P, Ungari C, Paparo F, et al. A new surgical approach for the treatment of chronic recurrent temporomandibular joint dislocation. J Craniofac Surg 2008;19:510Y Mizuno A, Suzuki S, Motegi K. Articular eminectomy for long standing luxation of the mandible. Report of 2 cases. Int J Oral Maxillofac Surg 1988;17:303Y Weinberg S. Eminectomy and meniscorhaphy for internal derangements of the temporomandibular joint. Rationale and operative technique. Oral Surg Oral Med Oral Pathol 1984;57:241Y Gadre KS, Kaul D, Ramanojam S, et al. Dautrey s procedure in treatment of recurrent dislocation of the mandible. J Oral Maxillofac Surg 2010;68:2021Y Undt G, Kermer C, Piehslinger E, et al. Treatment of recurrent mandibular dislocation, part I: LeClerc blocking procedure. Int J Oral Maxillofac Surg 1997;26:92Y97 7. Srivastava D, Rajadnya M, Chaudhary MK, et al. The Dautrey procedure in recurrent dislocation: a review of 12 cases. Int J Oral Maxillofac Surg 1994;23:229Y Bakardjiev A. Treatment of chronic mandibular dislocations by bone plates: two case reports. J Craniomaxillofac Surg 2004;32:90Y92 9. Cardoso A, Vasconcelos BCE, de Oliveira DM. Comparative study of eminectomy and use of bone miniplate in the articular eminence for the treatment of recurrent temporomandibular joint dislocation. Rev Bras Otorrinolaringol 2005;71:32Y Vasconcelos BCE, Porto GG. Treatment of chronic mandibular dislocation: a comparison between eminectomy and miniplates. JOral Maxillofac Surg 2009;67:2599Y Myrhaug H. a new method of operation for habitual dislocation of the mandible. Acta Odontol Scand 1951;9: Helman J, Laufer D, Minkov B, et al. Eminectomy as surgical treatment for chronic mandibular dislocations. Int J Oral Surg 1984;13: 486Y Oatis GW, Baker DA. The bilateral eminectomy as definitive treatment. A review of 44 patients. Int J Oral Surg 1984;13:294Y Stassen LF, Currie WJ. A pilot study of the use of eminectomy in the treatment of closed lock. Br J Oral Maxillofac Surg 1994;32: 138Y Talebzadeh N, Rosenstein TP, Pogrel MA. Anatomy of the structures medial to the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:674Y678. e519

5 16. Klüppel LE, Olate S, Serena-Gomez E, et al. Efficacy of eminectomy in the treatment of prolonged mandibular dislocation. Med Oral Patol Oral Cir Bucal 2010;15:e891Ye Vasconcelos BCE, Porto GG, Neto JP, et al. Treatment of chronic mandibular dislocations by eminectomy: follow-up of 10 cases and literature review. Med Oral Patol Oral Cir Bucal 2009;14:e593Ye Williamson RA, McNamara D, McAuliffe W. True eminectomy for internal derangement of the temporomandibular joint. Br J Oral Maxillofac Surg 2000;38:554Y Tallents RH, Macher DJ, Kyrkanides S, et al. Prevalence of missing posterior teeth and intraarticular temporomandibular disorders. J Prosthet Dent 2002;87:45Y Undt G, Kermer C, Rasse M. Treatment of recurrent mandibular dislocation, part II: eminectomy. Int J Oral Maxillofac Surg 1997;26:98Y Pogrel MA. Articular eminectomy for recurrent dislocation. Br J Oral Maxillofac Surg 1987;25:237Y Chuong R, Piper MA. Sinus bradycardia related to temporomandibular joint surgery. Oral Surg Oral Med Oral Pathol 1991;71:423Y Mayrink G, Asprino L, Moreira RWF, et al. Using biomodels for maxillofacial surgeries: 10 years of experience in a Brazilian public service. Braz J Oral Sci 2011;10:294Y Gay Escoda C. Eminectomy associates with redirectioning of the temporal muscle for treatment of recurrent TMJ dislocation. J Craniomaxillofac Surg 1987;15:355Y Sato J, Segami N, Nishimura M, et al. Clinical evaluation of arthroscopic eminoplasty for habitual dislocation of the temporomandibular joint: comparative study with conventional open eminectomy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:390Y Segami N, Kaneyama K, Tsurusako S, et al. Arthroscopic eminoplasty for habitual dislocation of the temporomandibular joint: preliminary study. J Craniomaxillofac Surg 1999;27:390Y Stassen LF, O Halloran M. Functional surgery of the temporomandibular joint with conscious sedation for closed lock using eminectomy as a treatment: a case series. J Oral Maxillofac Surg 2011;69:e42Ye49 Two-Stage Total Prosthetic Reconstruction of Temporomandibular Joint in Severe and Recurrent Ankylosis Onur Egemen, MD,* Ozay Ozkaya, MD,* Gaye Taylan Filinte, MD,Þ Ilker Uscetin, MD,* Mithat Akan, MDþ From the *Okmeydani Training and Research Hospital, Plastic and Reconstructive Surgery Clinic; Dr Lutfi KNrdar Kartal Training and Research Hospital, Plastic and Reconstructive Surgery Clinic; and Okmeydani Training and Research Hospital, Plastic and Reconstructive Surgery Clinic, Istanbul, Turkey. Received March 2, Accepted for publication April 18, Address correspondence and reprint requests to Onur Egemen, MD, Atakoy 4, Kisim, TO-80 Blk D:7, 34158, Bakirkoy, Istanbul, Turkey; onuregemen@hotmail.com The authors report no conflicts of interest. Copyright * 2012 by Mutaz B. Habal, MD ISSN: DOI: /SCS.0b013e31825b5afd e520 Abstract: Temporomandibular joint ankylosis is a devastating condition for the patient associated with both functional disability and aesthetic deformities. Various techniques have been described in the literature to overcome this problem; however, there is still a high risk of reankylosis in patients undergoing multiple temporomandibular joint operations, severe heterotopic ossification, and fibrosis of the soft tissues. This study includes 5 patients with severe and recurrent ankylosis. Two-stage reconstruction with excision of the bony mass and placement of a distraction device in the first stage, followed by gradual distraction of soft tissues, and placement of a total joint prosthesis in the second stage were performed in all patients. The 2-step approach helps to overcome the fibrosis and adhesions in the soft tissues and allows placing an implant with a higher ramus component. This approach seems to be a useful and effective technique for the management of such patients with high risk of reankylosis. Key Words: TMJ, ankylosis, prosthesis, joint, distraction Temporomandibular joint (TMJ) ankylosis refers to fibrous and bony adhesion of the joint components and the ensuing loss of their function. 1,2 It may be associated with both functional disability and aesthetic deformity including impaired speech and mastication, poor oral hygiene and caries, and disturbed growth of the middle face and the mandible. 3 The retruded and micrognathic appearance of the mandible with inability to speak adequately and feed freely causes psychiatric issues as well. The etiologies include trauma, arthritis, infection, previous TMJ surgery, congenital, and idiopathic. 4 Regardless of the underlying reason, the chronic process of ossification results with the union of the mandible with the glenoid fossa and the surrounding structures. Temporomandibular joint ankylosis can be classified according to the location of the problem (intra/extra articular), type of tissues involved (osseous/fibrous/ both), and the extent of fusion (complete/incomplete). 5 A variety of techniques for the management of TMJ ankylosis have been described in the literature. Classically, these surgical procedures can be categorized into 3 groups: gap arthroplasty, interpositional arthroplasty, and joint reconstruction with autogenous or alloplastic materials. 6Y10 In gap arthroplasty, the surgeon creates a gap distal to the fused segment that may be used in moderate cases. 7 In interpositional arthroplasty, autogenous or alloplastic materials such as dermis, conchal cartilage, temporalis fascia, and silicone are placed between the bony surfaces to prevent reankylosis. 10Y15 Although Rowe stated that reankylosis is significantly less likely when some substance is placed between the cut surfaces of the bone, there is still a high risk of reankylosis in the patients undergoing multiple TMJ operations, severe heterotopic ossification, and fibrosis of the soft tissues. 16,17 Because remodeling does not occur in ankylosis of the TMJ and the joint is usually surrounded by dense fibrous tissue, the process ultimately results in recurrence in such patients with high risk. When the joint is considered to be anatomically unsalvageable, total joint replacement may provide the only management option. 8 Ankylotic mass is totally excised, and the ramusycondyle unit is reconstructed with autogenous or alloplastic materials in this technique. This study describes a 2-stage reconstruction of the TMJ with total TMJ prosthesis in patients with severe osseous ankylosis of the joint and dense fibrosis of the surrounding soft tissues and in patients with recurrent ankylosis who had undergone multiple previous TMJ operations. The first operation consists of total excision