Induction, Treatment, and Prevention of Temporomandibular Joint Ankylosis-A Systematic Review of Comparative Animal Studies.

PURPOSE: Several animal models of temporomandibular joint ankylosis (TMJA) have been described for more than the past 2 decades. The aim of this study was 2-fold: 1) to compile and summarize the evidence of animal studies that compare different forms to induce, treat (disease already established), or prevent (after trauma) TMJA; and 2) to address the following focused question: what is the quality of reporting in these studies? MATERIALS AND METHODS: A systematic review was conducted. Animal studies conducted up to October 2019 comparing at least 2 procedures to induce, treat (disease already established), or prevent (after trauma) TMJA were considered. Compliance with the Animal Research Reporting In Vivo Experiments guidelines was checked for all studies. Studies evaluating treatment of TMJA or preventive measures also were evaluated using the SYstematic Review Center for Laboratory animal Experimentation's risk of bias tool for animal studies. RESULTS: A total of 24 studies were included. The studies were evaluated for feasibility regarding data synthesis, and a meta-analysis was not suitable because of methodological differences, mainly regarding the animal model chosen and surgical procedures performed to induce TMJA. In 17 articles, authors aimed to investigate different procedures to induce TMJA (fibrous, fibro-osseous, or bony). In 7 articles, different treatment or preventive strategies were compared. The sheep was the most used animal in models of TMJA. Only 25% (6 of 24) of studies reported some step to minimize bias (ie, blinding of investigators, randomization procedures, or allocation concealment). Approximately 54% (13 of 24) of articles clearly commented on study limitations and potential sources of bias. Further animal studies on TMJA should consider improving their reporting standards to increase their validity and improve the reproducibility of animal experiments.

Pediatric Mandibular Condylar Fractures With Concomitant Cervical Spine Injury: A Treatment Protocol for Prevention of Temporomandibular Joint Ankylosis.

In pediatric patients with mandible fractures and concomitant cervical spine injury (CSI), treatment strategies may occasionally compete: condylar fractures require functional therapy with range of motion exercises of the temporomandibular joint (TMJ), while CSI requires neck immobilization. The authors report the case of a child presenting with bilateral condylar head fractures, a right parasymphyseal fracture, and concomitant CSI treated with cervical collar immobilization, who ultimately developed TMJ ankylosis. Here, the authors review mandibular condylar fracture management and suggest an approach for the pediatric patient presenting with condylar fractures and concomitant CSI requiring immobilization. To preserve range of motion at the TMJ, it is critical to prevent external restriction by prolonged cervical collar use. Instead, these patients benefit from a protocol utilizing conventional halo or noninvasive, pinless halo cervical spine stabilization. Without limitation of the TMJ, condylar fracture rehabilitation and healing may proceed unhindered.

Protection of the Temporomandibular Joint During Syndromic Mandibular Distraction With a Novel Condylar Offloading Device.

Mandibular distraction for severe micrognathia in syndromic patients often leads to temporomandibular joint (TMJ) ankylosis, which requires further interventions to regain joint motion. The increased incidence of postdistraction ankylosis is likely related to increased prevalence of preoperative joint pathology in syndromic micrognathic patients. Previous studies have demonstrated that offloading the pressure on the condyle during the distraction process can prevent such TMJ pathology. In this article, the authors describe a successful new method for offloading the condyle to prevent postdistraction ankylosis using an external TMJ offloading device.

Skeletal complications of rheumatoid arthritis.

Rheumatoid arthritis (RA) is associated with local and systemic inflammation that induces many changes in the skeletal health. Locally, periarticular bone loss and juxta-articular bone erosions may occur while joint ankylosis, generalized bone loss, osteoporosis, and fractures may develop secondary to inflammation. The aim of this narrative review is to summarize the clinical evidence for abnormal skeletal health in RA, the effects of disease modifying anti-rheumatic drugs (DMARDS) on bone health, and the effects of drugs for the prevention or treatment of osteoporosis in the RA population.

Surgical treatment of condylar head fractures, the way to minimize the postraumatic TMJ ankylosis.

Management of condylar head fractures (CHF) of the temporomandibular joint (TMJ) remains a source of controversy. Based on established literature, group of CHFs and conservative treatment connected with period of maxillomandibular fixation (MMF) increases the risk for TMJ ankylosis. This paper presents anatomical and functional results of surgical treatment of condylar head fractures in a group of 24 patients (29 joints). Fractures were diagnosed based on conventional radiographs and computed tomography (CT) scans. Utilising an intraoperative arthroscopy authors evaluated actual intraarticular posttraumatic changes. This study presents acceptable functional and radiological results of surgical treatment of condylar head fractures with more than 3-year follow-up. The authors believe that re-establishing the pretraumatic anatomic position of the TMJ components (fragment and the disc) and early postoperative rehabilitation are inevitable to minimize the risk of postraumatic TMJ ankylosis (Tab. 2, Fig. 8, Ref. 31).

Pre-surgical CT-assessment of neurogenic myositis ossificans of the hip and risk factors of recurrence: a series of 101 consecutive patients.

BACKGROUND: Neurogenic Myositis Ossificans (NMO) is a rare disabling pathology characterized by peri-articular heterotopic ossifications following severe peripheral or central nervous system injuries. It results in ankylosis and vessels or nerves compressions. Our study aimed to describe the pre-operative findings of patients with NMO of the hip using biphasic computerized tomography (CT). METHODS: Between 2006 and 2012, we retrospectively analyzed 101 consecutive patients with hip NMO. We analyzed all CTs and surgical reports following a standardized grid depicting the osteoma and its relations with joint capsule, vessels and nerves and bone mineralization. We studied surgical complications and recurrence during follow-up. Chi2-test and Fischer's test were performed to compare qualitative values with respectively normal and non-normal distribution. Quantitative values were analyzed with a one factor analysis of variance (ANOVA) test. Agreement between pre-surgical CT and surgical observations was evaluated with Cohen's kappa test. RESULTS: Correlation between pre-operative CT and surgical findings was excellent regarding relationships with vessels (0,82) and was good concerning relationships with sciatic nerves (0.62) and with joint capsule (0.68). Close contact or disruption of joint capsule (p = 0.005), joint space narrowing (p = 0.007) and bone demineralization (p < 0.001) were correlated with NMO recurrence. CONCLUSIONS: Biphasic enhanced-CT allows pre-operative assessment of NMO with good correlation to surgical observations and helps prevent surgical complications.

[Superolateral dislocation of the temporomadibular joint: Case report]. / Luxations supéro-externes bilatérales de l'articulation temporo-mandibulaire: à propos d'un cas.

INTRODUCTION: Superolateral disclocations of the temporomandibular joint are rare. They mostly occur after high-energy trauma and are frequently associated with fractures of the mandibular body. CASE REPORT: A 35-year-old man was admitted for the management of a high-energy craniofacial trauma due to a road accident. The initial assessment revealed bilateral superolateral temporomandibular joint disclocations, with bilateral sagittal fractures of the condyle head and a fracture of the right parasymphysis. The treatment consisted in an external reduction of both condyles, followed by open reduction and internal fixation of the parasymphysis. The patient quickly started physiotherapy after the procedure and recovered a normal mouth opening after a month of follow-up. DISCUSSION: For most authors, a quick management of superolateral dislocations is necessary in order to achieve a proper reduction of the temporomandibular joint dislocation and avoid surgical reduction. Temporomandibular joint ankylosis is the main complication of such lesions. Early physiotherapy is indicated in order to prevent ankylosis.

Interleukin-17 is a critical target for the treatment of ankylosing enthesitis and psoriasis-like dermatitis in mice.

Ankylosis is a major pathological manifestation of spondyloarthropathy. The aim of this study was to evaluate the effects of anti-IL-17 therapy on spontaneous ankylosing enthesitis in mice. In this study, we used male DBA/1 mice as a spontaneous ankylosis model. Serum IL-17 concentrations were determined using enzyme-linked immunosorbent assay. Male DBA/1 mice from different litters were mixed and caged together preceding the treatment at 10 weeks (wk) of age (prophylaxis) or 21 wk of age (intervention). Treatment with anti-IL-17 antibodies or saline was initiated after caging in groups of mice and administered weekly. The onset of tarsal ankylosis was assessed by ankle swelling and histopathological examination. Pathological changes and mRNA expression levels were assessed in joints and ears obtained at the experimental end-point. We found that circulating IL-17 increased with the onset of ankylosis in male DBA/1 mice, coinciding with the onset of dermatitis. The symptoms of dermatitis corresponded to the pathological characteristics of psoriasis: acanthosis with mild hyperkeratosis, scaling, epidermal microabscess formation and augmented expression of K16, S100A8 and S100A9. Prophylactic administration of anti-IL-17 antibodies significantly prevented the development of both ankylosis and dermatitis in male DBA/1 mice caged together. On the other hand, administration of anti-IL-17 antibodies after disease onset had a lesser but significant effect on ankylosis progression but did not affect dermatitis progression. In conclusion, IL-17 is a key mediator in the pathogenic process of tarsal ankylosis and psoriasis-like dermatitis in male DBA/1 mice caged together. Thus, IL-17 is a potential therapeutic target in ankylosing enthesitis and psoriasis in humans.

The use of temporalis muscle graft, fresh and cryopreserved amniotic membrane in preventing temporomandibular joint ankylosis after discectomy in rabbits.

PURPOSE: The aim of the study was to evaluate the efficacy of temporalis muscle-fascia graft, fresh and cryopreserved human amniotic membrane as an interpositional material in preventing temporomandibular joint ankylosis in a rabbit model. MATERIALS AND METHODS: In this experimental study, 21 New Zealand white rabbits were used. The condyle and the joint disc were removed to induce ankylosis in left TMJs. Reconstruction was immediately performed with temporalis muscle-fascia graft (tMFG) in group I (n = 7), fresh human amniotic membrane (fHAM) in group II (n = 7) and cryopreserved human amniotic membrane (cHAM) in group III (n = 7). All rabbits were sacrificed at 3 months after the operation. The comparison was made among three groups by means of vertical mouth opening and weight measurements, radiologic and histologic findings obtained before and after surgery. RESULTS: In all rabbits, there was no statistically significant difference in the jaw movements and weight among groups at commencement and 3 months after surgery. The condylar surfaces were more irregular in HAM groups. There were mild osteophyte formations, sclerosis, fibrosis and calcification around the condyle in all groups however the joint gap was more preserved in group I. All interpositional materials were also seen to be partially present in the joint gap at 3 months. Ankylosis was not seen in the joint gap in any group. CONCLUSION: With the results of this study it was concluded that interpositional arthroplasty with HAM and tMFG have an almost similar effect in preventing TMJ ankylosis after discectomy in the rabbit model.

Surgical disaster in temporomandibular joint: case report / Catástrofe quirúrgica en la articulación temporomandibular: informe de caso

Fundamento. La anquilosis temporomandibular se asocia a importantes limitaciones de la calidad de vida del paciente. Con frecuencia, es necesario un tratamiento quirúrgico asociado a una rehabilitación continua. Para evitar las lesiones yatrogénicas, se requieren conocimientos exhaustivos de la anatomía de esta región y de las complicaciones potenciales de la cirugía. Presentación del caso. Un paciente joven se sometió a tratamiento quirúrgico de una anquilosis bilateral congénita con consecuencias catastróficas, como parálisis facial, sordera y extravasación de líquido cefalorraquídeo en el lado derecho relacionada con el traumatismo intraoperatorio, que afectó a las estructuras del oído externo, medio e interno. Conclusión. Puesto que no se dispone de un tratamiento corrector para este tipo de lesiones, tanto el cirujano experto en cabeza y cuello como otros profesionales que efectúan intervenciones de esta naturaleza necesitan unos conocimientos óptimos sobre la anatomía del hueso temporal y la base del cráneo, y deben tener en cuenta el riesgo de una catástrofe quirúrgica como la descrita en este paciente (AU)

Background. Temporomandibular-ankylosis brings extensive limitations on the patient quality of life. Surgical treatment is frequently necessary associated with a continuous rehabilitation. The anatomy of this region and potential complications of this surgery must be thoroughly known to avoid iatrogenic injuries. Case presentation. A young patient underwent surgical treatment of congenital bilateral ankylosis with disastrous consequences such as facial palsy, deafness and cerebrospinal leaks on the right side related to intraoperative trauma involving structures of the external, middle and inner ear. Conclusion. Since there is no corrective treatment for this type of injuries, the craniomaxillofacial surgeon and other professionals who carry out interventions of this nature need perfect knowledge of the anatomy of the temporal bone and lateral skull base, taking into account the risk of surgical disasters like the one here reported (AU)

Teste da linguinha e a anquiloglossia: as controvérsias do assunto / Litle tongue test and ankyloglossia: the controversies of the subject

Resumo / No Congresso Nacional tramita um projeto de lei que institui o “teste da linguinha” para tornar obrigatória a avaliação bucal criteriosa de recém-nascidos, especialmente quanto à mobilidade lingual, a partir da análise do frênulo lingual. Essa iniciativa da Sociedade Brasileira de Fonoaudiologia sofre restrição por parte da Sociedade Brasileira de Pediatria, que a considera desnecessária e onerosa. O objetivo é o diagnóstico e tratamento precoce da anquiloglossia resultante da inserção curta e/ou anteriorizada do frênulo lingual. A plena mobilidade da língua favorece o desempenho das suas várias funções desde quando bebê até a fase adulta da vida. A avaliação bucal em todos os recém-nascidos pode levar, ainda, a diagnósticos mais precoces de fissuras, dentes natais, cistos e tumores. Os vários aspectos da anquiloglossia são discutidos no presente trabalho.

New protocol to prevent TMJ reankylosis and potentially life threatening complications in triad patients.

The management of patients with the triad of temporomandibular joint (TMJ) ankylosis, micrognathia and obstructive sleep apnea syndrome is challenging for the oral and maxillofacial surgeon because it involves achieving the desired oral opening, correction of micrognathia, and correction of the obstructed airway. Seven of the authors' triad patients, in whom only the release of ankylosis was performed, developed bradycardia and respiratory distress during postoperative jaw physiotherapy, leading to their non-compliance for active jaw physiotherapy and subsequent reankylosis. This paper suggests a new surgical protocol for the management of patients with the triad, to achieve correction of the obstructed airway, relief of the respiratory distress symptoms, correction of micrognathia and restricted mouth opening. It also provides a logical reason for the occurrence of bradycardia following ankylosis release and its potential role in TMJ reankylosis. It emphasizes that the occurrence of bradycardia in triad patients during jaw exercises is dictated by the severity of their apnea-hypopnea index and the degree of narrowing of their posterior airway space. The recognition and prevention of this by the new protocol is discussed in 7 patients.

Improvement of mouth opening for a patient with fibrodysplasia ossificans progressiva: a case report.

The aim of this article is to describe the care of a patient with fibrodysplasia ossificans progressiva (FOP) and to provide dentists with a guide for how to safely care for patients with FOP. Treatment improved the patient's limited mouth opening. FOP is a rare autosomal dominant disorder characterized by congenital malformation of the fingers and toes by heterotopic ossification progressiva of the connective tissue. This ossification causes a limitation in osteoradicular mobility, mainly affecting the spine, shoulders, hips, and peripheral joints. The disease can manifest from pregnancy until adulthood, with no greater prevalence associated with race or gender. Although rare, the disease can be easily identified by its clinical features, and diagnosis can be confirmed by a radiographic examination. There is no known effective treatment for this disease. All therapeutic treatment must be conservative to avoid any condition that may cause heterotopic ossification. Guidelines to prevent new ossifications are important for patients with FOP. Dental professionals should be cautious in planning treatment, avoiding anesthesia, especially in the mandible, to prevent ankylosis of the temporo-mandibular joints. The prevention of dental caries is essential to avoid the need for more invasive treatment.

Tuberculous sacroiliitis: a study of the diagnosis, therapy and medium-term results of 15 cases.

This report reviews the diagnosis, treatment and follow-up of 15 Chinese patients with tuberculous sacroiliitis (TBS) from 1997 to 2007. Buttock pain and lower back pain were the main complaints. All patients received antituberculosis chemotherapy treatment for at least 18 months; 10 also underwent surgery, with seven undergoing modified Smith-Petersen arthrodesis (evaluated using a visual analogue scale [VAS] for pain and the Oswestry Disability Index [ODI]). No simplex tuberculous synovitis existed at diagnosis. Bone-marrow oedema, cold abscess and soft-tissue oedema responded to antituberculosis treatment. Thirteen patients (86.7%) had satisfactory outcomes. There were also significant improvements in VAS and ODI scores post-operatively. In the chemotherapy plus surgery group, eight patients had solid bony fusions at 24 months post-operatively, while the five on chemotherapy alone presented with fibrous ankylosis at 24 months. Chemotherapy is the main treatment for TBS and modified arthrodesis is a feasible and effective method for treating severe joint destruction.

Histological fate of abdominal dermis-fat grafts implanted in the temporomandibular joint of the rabbit following condylectomy.

The histological fate of abdominal dermis-fat grafts implanted into the temporomandibular joint (TMJ) following condylectomy was studied. 21 rabbits underwent left TMJ discectomies and condylectomies; 6 were controls (Group A; no graft used); 15 (Group B) had autogenous abdominal grafts transplanted into the left TMJ. Animals were killed after 4, 12 and 20 weeks. Specimens of the TMJ were histologically and histomorphometrically evaluated. At 4 weeks, fat necrosis was clear in all specimens. The dermis component survived and formed cysts with no necrosis. By 12 weeks, viable fat deposits appeared with no evidence of necrotic fat. At 20 weeks, large amounts of viable fat were present in Group B specimens. Group A had no fat, although the missing condyles regenerated. In the presence of viable fat, Group B showed little condyle regeneration 20 weeks after condylectomy. Non-vascularised fat grafts do not survive transplantation, but stimulate neoadipogenesis. The fate of the dermis component of the graft is independent of the fat component. Fat in the joint space disrupts the regeneration of a new condylar head. Neoadipogensis inhibits growth of new bone and cartilage. This has clinical implications for TMJ ankylosis management and preventing heterotopic bone formation around prosthetic joints.

Can we stop progression of ankylosing spondylitis?

Ankylosing spondylitis is characterised by inflammation of the spine and the entheses followed by bone formation. Excessive bone formation in ankylosing spondylitis leads to the formation of bone spurs, such as syndesmophytes and enthesiophytes, which contribute to ankylosis of joints and poor physical function. This process is based on increased differentiation of osteoblasts from their mesenchymal precursors, which allows to rapidly build up new bone. Prostaglandins, bone morphogenic proteins and Wnt proteins play an essential role in this process. By contrast, tumour necrosis factor (TNF) does not appear to be the direct trigger for osteophyte formation in ankylosing spondylitis. The article reviews the current knowledge regarding the mechanisms and clinical role of ankylosis and explains strategies on how to prevent it in patients with ankylosing spondylitis.

Lo que el clínico debe saber sobre los mecanismos de conexión entre la inflamación y la formación de hueso. ¿Es suficiente el bloqueo de la inflamación para prevenir la osificación? / What the clinician needs to know about the relationship between inflammation and bone formation. Is blocking inflammation enough to prevent ossification?

En las espondiloartropatías, la marca distintiva del daño esquelético es la neoformación ósea en forma de entesopatía calcificante, axial o periférica, y de anquilosis ósea. Las terapias biológicas que neutralizan el factor de necrosis tumoral se han mostrado eficaces para controlar la actividad inflamatoria de estas enfermedades. Sin embargo, datos procedentes de modelos animales, estudios clínicos de imagen y datos ecográficos parecen indicar que la inflamación y la formación ósea podrían ser procesos independientes y que el control de la inflamación puede no ser suficiente para impedir el desarrollo de anquilosis en estos pacientes. En la diferenciación y la activación del osteoblasto para inducir la formación ósea, la vía Wnt (wingless) y las proteínas morfogenéticas óseas adquieren un especial protagonismo y pueden ser determinantes en el comienzo y la progresión de la osificación entesítica, y convertirse en posibles dianas terapéuticas. Por otro lado, otros hallazgos clínicos, estudios de imagen y de marcadores óseos respaldarían la hipótesis de que la osificación se relaciona con la inflamación como un proceso inicialmente reparador. Se revisan estos hechos y se exponen las últimas teorías que intentan establecer el nexo entre inflamación y formación ósea (AU)

In spondyloarthropathies, the distinctive evidence of skeletal damage is de novo bone formation in the form of an ossifying enthesopathy, be it axial or peripheral, and bony ankylosis. Biologic therapy that neutralize the tumor necrosis factor have shown to be effective controlling the inflammatory activity of these diseases. However, data from animal models, clinical imaging studies and ecographic data seem to indicate that inflammation and bone formation could be independent processes and that control of inflammation might not be enough to impede the development of ankylosis in these patients. In the osteoblasts’ differentiation and activation that leads to bone formation, the Wnt (wingless) pathway and the bone morphogenic proteins acquire a special role and might be determinant in the onset and progression of enthesopathic ossification, as well as become therapeutic targets. On the other hand, clinical and imaging findings as well as the determination of bone markers support the hypothesis that that ossification is initially related to inflammation as a repair process. These facts are reviewed and the latest theories are exposed, in an attempt to establish a link between inflammation and bone formation (AU)

Cervical arthroplasty with the PRESTIGE LP cervical disc.

The technique for anterior cervical arthroplasty using the PRESTIGE LP (Medtronic Sofamor Danek, Memphis, TN) cervical disc is illustrated. Surgical positioning and the operative approach are demonstrated. Our methods of retractor placement and surgical exposure are discussed. The technique used for decompression and endplate preparation is presented in detail. Optimal arthroplasty device positioning is demonstrated. The surgical pearls and pitfalls of anterior cervical arthroplasty are highlighted.