Background: The principal transfacial routes described to approach condylar process fractures are... more Background: The principal transfacial routes described to approach condylar process fractures are preauricular, retromandibular, high submandibular, and their various modifications. The selection of a specific surgical approach mainly depends on the level of condylar fracture, displacement/dislocation of the proximal segment and time elapsed from the date of trauma. Not too many studies proclaim a unanimous consensus on “gold standard” approaches for particular levels of fracture. Aim: This study was conducted with the aim to lay down guidelines for determining the ideal surgical approach for treating different condylar fractures based on different clinical situations. Methodology: This prospective study was conducted on 60 patients that underwent open reduction internal fixation of condylar fractures according to preset study design. Inclusion criteria were fracture displacement more than 10 degrees, dislocation, shortening of ramal height more than 2 mm. Patients having maxillofac...
The purpose of this study is to evaluate the survival rate of the basal cortical screw (BCS) impl... more The purpose of this study is to evaluate the survival rate of the basal cortical screw (BCS) implant system inserted in healed edentulous ridges (E) or extraction sockets (ES) with immediate loading functional protocol in varying clinical situations. A total of 125 BCS implants were placed in 14 patients, immediately loaded and observed for 20.07(± 4.23) months. Ninety-four were placed in E sites and 31 were placed in ES sites. They were evaluated for bone loss, soft tissue shrinkage around the prosthesis, improvement in quality of life (QOL), and their survival after 1 year. Total of 121/125(96.8%) implants survived while 4/125(3.2%) failed at the end of follow-up. Average bone loss after 1 year was 0.33 mm (E) and − 1.57 mm (ES), average soft tissue shrinkage was 0.50 mm (E) and 1.42 mm (ES) and average Patient's Global Impression of Change (PGIC) scale score was 6.36(± 0.63) at 1 year. The complications observed were mobility {3(2.4%)}, pain/discomfort {1(0.8%)} and fracture of abutment at the neck {1(0.8%)}, prosthesis loosening {2(9%)} and requirement of relining {3(13%)}. No periimplantitis was observed. This is the only study to report the marginal bone loss and soft tissue changes around BCS implants and an index-based improvement in QOL of such patients. The BCS implant system with immediate functional loading protocol is a versatile modality to rehabilitate a single tooth, a segment or a full arch with healed ridges as well as extraction sites; it gives high success rate and minimal complications.
Oral and Maxillofacial Surgery for the Clinician, 2021
The purpose of this chapter is to inculcate a newer, deeper understanding of TMJ Ankylosis– both ... more The purpose of this chapter is to inculcate a newer, deeper understanding of TMJ Ankylosis– both from the pathological as well as the clinical view point. Newer classifications may now determine surgical procedures. Interpositional materials may not be just soft tissues interposed between the cut ends, but also hard tissues forming the new Ramus Condyle Unit (RCU). Facial deformity may be recognized to be as important as inability to open the mouth; more so, if accompanied by Obstructive sleep apnea (OSA). Multi-staged treatment plans of release first followed by asymmetry correction may be replaced by single staged joint replacement & total facial aesthetic as well as functional rehabilitation. Finally, the importance of unfavorable events in TMJ Ankylosis surgery may be recognized, which would lead to better results in terms of treatment goals, i.e. to restore joint function, improve facial appearance & airway issues, correct malocclusion & re-establish harmony between the TMJ, th...
The purpose of this single-centre prospective clinical study was to evaluate the correction of se... more The purpose of this single-centre prospective clinical study was to evaluate the correction of severe facial deformity and Obstructive sleep apnoea hypopnoea syndrome (OSAHS) in 22 patients aged from 9 to 42 years (mean 20.09) of bilateral Temporomandibular joint ankylosis. Patients underwent multisegment distraction using external bilateral bidirectional distractors. Facial deformity was evaluated clinically in terms of mouth opening and neck chin angle and cephalometrically in terms of corpus length (gonion-pogonion), ramal height (articulare-gonion), chin deficiency (N perpendicular to Pog and SNB). OSAHS was evaluated through Epworth sleepiness scale, Berlin’s questionnaire, pharyngeal airway space, apnoeic hypoapnoeic index, oxygen desaturation index, average arterial oxygen saturation and minimal fall in O2 saturation. Patients were followed up for a period of 13–74 months (mean 28.68). Statistically highly significant results were obtained in all parameters. Complications encountered were pin infection (13.63%), loosening of pins (4.5%), wound dehiscence (9.09%), tooth fracture (4.5%) and parotid fistula (9.09%). Intermediate segment necrosis and vector loss were not observed. This study is a large case series using two corticotomy cuts for external bilateral bidirectional distracters with concomitant neo callous moulding in patients both pre- and post-ankylosis release. It is extremely efficient in correcting mandibular corpal and ramal deficiency as well as improving OSAHS.
Distraction Osteogenesis is a technique of inducing de novo bone formation by utilising bone’s ab... more Distraction Osteogenesis is a technique of inducing de novo bone formation by utilising bone’s ability to regenerate by controlled and gradual callus traction that forms between surgically osteotomized bone segments. One of its major advantages is simultaneous soft tissue (skin, muscle, and neurovascular structures) formation, which stabilizes skeletal reconstruction. We present the treatment of an adult patient who had severe mandibular deficiency & obstructive sleep apnea secondary to TMJ Ankylosis release. Bilateral Biplanar Distraction was performed with extraoral Distractors which resulted in drastic improvement in patients profile ANB decreased from 22 to 11, Ramal length increased from 25mm to 32mm, Corpus was lengthened from 34mm to 52mm, Overjet was decreased from 14mm to 9mm. Also, the pharyngeal airway space was improved significantly which was attributed to the anterior growth of the mandible. Chin augmentation as a secondary surgery with PTFE chin implant was performed ...
Aim and Purpose: To evaluate the feasibility of the L-shaped osteotomy in reconstructing the Ramu... more Aim and Purpose: To evaluate the feasibility of the L-shaped osteotomy in reconstructing the Ramus Condyle Unit (RCU) after gap arthroplasty in patients with temporomandibular joint (TMJ) ankylosis. Objectives: To evaluate the efficacy of the above procedure by evaluating the increase in mouth opening, by assessing the resorption of the newly reconstructed RCU, by assessing any occlusal disturbances, deviation upon mouth opening and obstructive sleep apnoea, caused by decrease in height of the ramus of the mandible as well as to evaluate complications of the procedure, if any. Materials and Method: 13 patients (22 joints) with TMJ ankylosis along with resection of the ankylosed condyle, underwent L-shaped ramus osteotomy. Patients were followed up for an average of 14.07 months (range 12–17 months). Results: In all patients, increase in mouth opening was noted, from an average of 3.3 mm preoperative to 32.2 mm at maximum follow up. When comparing the height of the newly reconstructe...
Temporomandibular joint subluxation is defined as self-reducing partial dislocation of the TMJ du... more Temporomandibular joint subluxation is defined as self-reducing partial dislocation of the TMJ during which the condyle passes anterior to the articular eminence. The study consisted of 30 patients, 19 females and 11 males with 14 unilateral and 16 bilateral cases of chronic symptomatic subluxation. Treatment consisted of arthrocentesis followed by 2 ml of autologous blood injection into upper joint space and 1 ml into pericapsular tissues using an autoclaved soldered double needle with single puncture technique. Parameters evaluated were pain, maximum mouth opening, excursive jaw movements, deviation on mouth opening and quality of life, hard and soft tissue changes on X-ray TMJ view and MRI. At 12 month follow-up, average reduction in maximum interincisal opening, deviation on mouth opening, range of excursive movements on right and left sides and VAS scores were 20.54%, 32.84%, 29.59%, 27.37% and 74.53%, respectively. Out of 93.3% who responded to therapy, 66.7%, 20% and 6.7% res...
Internal derangement of the temporomandibular joint is defined as an abnormal position of the art... more Internal derangement of the temporomandibular joint is defined as an abnormal position of the articular disc in relation with mandibular condyle and articular eminence presenting as disc displacement with or without reduction. This study was conducted on thirty patients diagnosed with Internal derangement of TMJ consisting of 8 males and 22 females averaging 34.6 years. Two groups Conventional Arthrocentesis (Group A) and Level 1 Arthroscopy (Group B) consisted of 15 cases each divided alternately. Clinical evaluation parameters included VAS for pain, maximal interincisal opening, deviation on mouth opening, range of motion including lateral excursion & protrusion movements recorded at 1 week, 1 month & 6 months postoperatively. Wilke’s Staging according to MRI findings was recorded preoperatively and 6 months postoperatively. At 6 month follow-up, average reduction in VAS for pain & deviation on mouth opening was 72.43% & 24.73% in Group A and 77.66% & 65.41% in Group B, respectively. Average increase in MIO, right & left excursion & protrusion movements was 29.55%, 31.33%, 20.12% & 32.45% in Group A and 34.94%, 41.37%, 39.29% and 36.51% in Group B, respectively. Improved results were obtained clinically for all Wilke’s stages in both groups with more number of patients improving in Group B. On comparing results, improvement was observed in various clinical evaluation parameters of both the groups at 6 months follow-up. However, statistically significant & better results were obtained for the Arthroscopy group.
IntroductionTreatment for TMJ Ankylosis aims at restoring joint function, improving the patient’s... more IntroductionTreatment for TMJ Ankylosis aims at restoring joint function, improving the patient’s aesthetic appearance and quality of life and preventing re-ankylosis. Mouth opening is achieved by gap arthroplasty with various options of interpositional materials. Ramus–condyle unit (RCU) reconstruction maintains the height of the ramus and prevents secondary occlusal problems. Advancement genioplasty corrects chin deformities as well as increases the posterior airway space (N-PAS) by the forward pull exerted on geniohyoid and genioglossus.Materials and MethodsThis prospective single-centre study on 43 joints in 25 adult patients with TMJ Ankylosis aimed at providing a single-staged management plan of ankylosis release, RCU reconstruction and extended advancement centering genioplasty. Interpositional arthroplasty was done using temporalis myofascial flap, abdominal dermis fat or buccal fat pad. RCU reconstruction was done either by vertical ramus osteotomy or L osteotomy.Observations and ResultsFollow-up ranged from 12 to 20 months (mean 14.4). Average mouth opening at maximum follow-up was 34.36 mm with re-ankylosis in no case. Cephalometric parameters showed increase in point P to Pog, decrease in N perpendicular to Pog, angle N–A–Pog, Cg-ANS to Cg-Menton, neck–chin angle and labiomental angle. N-PAS increased, and average 50% improvement in AHI was seen in all patients with OSA. Most common complications involved transient paraesthesia of temporal and zygomatic branches of facial nerve.ConclusionBased on the findings of the above study, we propose treatment guidelines for treatment of TMJ ankylosis in adult patients with AHI < 20.
Background: The principal transfacial routes described to approach condylar process fractures are... more Background: The principal transfacial routes described to approach condylar process fractures are preauricular, retromandibular, high submandibular, and their various modifications. The selection of a specific surgical approach mainly depends on the level of condylar fracture, displacement/dislocation of the proximal segment and time elapsed from the date of trauma. Not too many studies proclaim a unanimous consensus on “gold standard” approaches for particular levels of fracture. Aim: This study was conducted with the aim to lay down guidelines for determining the ideal surgical approach for treating different condylar fractures based on different clinical situations. Methodology: This prospective study was conducted on 60 patients that underwent open reduction internal fixation of condylar fractures according to preset study design. Inclusion criteria were fracture displacement more than 10 degrees, dislocation, shortening of ramal height more than 2 mm. Patients having maxillofac...
The purpose of this study is to evaluate the survival rate of the basal cortical screw (BCS) impl... more The purpose of this study is to evaluate the survival rate of the basal cortical screw (BCS) implant system inserted in healed edentulous ridges (E) or extraction sockets (ES) with immediate loading functional protocol in varying clinical situations. A total of 125 BCS implants were placed in 14 patients, immediately loaded and observed for 20.07(± 4.23) months. Ninety-four were placed in E sites and 31 were placed in ES sites. They were evaluated for bone loss, soft tissue shrinkage around the prosthesis, improvement in quality of life (QOL), and their survival after 1 year. Total of 121/125(96.8%) implants survived while 4/125(3.2%) failed at the end of follow-up. Average bone loss after 1 year was 0.33 mm (E) and − 1.57 mm (ES), average soft tissue shrinkage was 0.50 mm (E) and 1.42 mm (ES) and average Patient's Global Impression of Change (PGIC) scale score was 6.36(± 0.63) at 1 year. The complications observed were mobility {3(2.4%)}, pain/discomfort {1(0.8%)} and fracture of abutment at the neck {1(0.8%)}, prosthesis loosening {2(9%)} and requirement of relining {3(13%)}. No periimplantitis was observed. This is the only study to report the marginal bone loss and soft tissue changes around BCS implants and an index-based improvement in QOL of such patients. The BCS implant system with immediate functional loading protocol is a versatile modality to rehabilitate a single tooth, a segment or a full arch with healed ridges as well as extraction sites; it gives high success rate and minimal complications.
Oral and Maxillofacial Surgery for the Clinician, 2021
The purpose of this chapter is to inculcate a newer, deeper understanding of TMJ Ankylosis– both ... more The purpose of this chapter is to inculcate a newer, deeper understanding of TMJ Ankylosis– both from the pathological as well as the clinical view point. Newer classifications may now determine surgical procedures. Interpositional materials may not be just soft tissues interposed between the cut ends, but also hard tissues forming the new Ramus Condyle Unit (RCU). Facial deformity may be recognized to be as important as inability to open the mouth; more so, if accompanied by Obstructive sleep apnea (OSA). Multi-staged treatment plans of release first followed by asymmetry correction may be replaced by single staged joint replacement & total facial aesthetic as well as functional rehabilitation. Finally, the importance of unfavorable events in TMJ Ankylosis surgery may be recognized, which would lead to better results in terms of treatment goals, i.e. to restore joint function, improve facial appearance & airway issues, correct malocclusion & re-establish harmony between the TMJ, th...
The purpose of this single-centre prospective clinical study was to evaluate the correction of se... more The purpose of this single-centre prospective clinical study was to evaluate the correction of severe facial deformity and Obstructive sleep apnoea hypopnoea syndrome (OSAHS) in 22 patients aged from 9 to 42 years (mean 20.09) of bilateral Temporomandibular joint ankylosis. Patients underwent multisegment distraction using external bilateral bidirectional distractors. Facial deformity was evaluated clinically in terms of mouth opening and neck chin angle and cephalometrically in terms of corpus length (gonion-pogonion), ramal height (articulare-gonion), chin deficiency (N perpendicular to Pog and SNB). OSAHS was evaluated through Epworth sleepiness scale, Berlin’s questionnaire, pharyngeal airway space, apnoeic hypoapnoeic index, oxygen desaturation index, average arterial oxygen saturation and minimal fall in O2 saturation. Patients were followed up for a period of 13–74 months (mean 28.68). Statistically highly significant results were obtained in all parameters. Complications encountered were pin infection (13.63%), loosening of pins (4.5%), wound dehiscence (9.09%), tooth fracture (4.5%) and parotid fistula (9.09%). Intermediate segment necrosis and vector loss were not observed. This study is a large case series using two corticotomy cuts for external bilateral bidirectional distracters with concomitant neo callous moulding in patients both pre- and post-ankylosis release. It is extremely efficient in correcting mandibular corpal and ramal deficiency as well as improving OSAHS.
Distraction Osteogenesis is a technique of inducing de novo bone formation by utilising bone’s ab... more Distraction Osteogenesis is a technique of inducing de novo bone formation by utilising bone’s ability to regenerate by controlled and gradual callus traction that forms between surgically osteotomized bone segments. One of its major advantages is simultaneous soft tissue (skin, muscle, and neurovascular structures) formation, which stabilizes skeletal reconstruction. We present the treatment of an adult patient who had severe mandibular deficiency & obstructive sleep apnea secondary to TMJ Ankylosis release. Bilateral Biplanar Distraction was performed with extraoral Distractors which resulted in drastic improvement in patients profile ANB decreased from 22 to 11, Ramal length increased from 25mm to 32mm, Corpus was lengthened from 34mm to 52mm, Overjet was decreased from 14mm to 9mm. Also, the pharyngeal airway space was improved significantly which was attributed to the anterior growth of the mandible. Chin augmentation as a secondary surgery with PTFE chin implant was performed ...
Aim and Purpose: To evaluate the feasibility of the L-shaped osteotomy in reconstructing the Ramu... more Aim and Purpose: To evaluate the feasibility of the L-shaped osteotomy in reconstructing the Ramus Condyle Unit (RCU) after gap arthroplasty in patients with temporomandibular joint (TMJ) ankylosis. Objectives: To evaluate the efficacy of the above procedure by evaluating the increase in mouth opening, by assessing the resorption of the newly reconstructed RCU, by assessing any occlusal disturbances, deviation upon mouth opening and obstructive sleep apnoea, caused by decrease in height of the ramus of the mandible as well as to evaluate complications of the procedure, if any. Materials and Method: 13 patients (22 joints) with TMJ ankylosis along with resection of the ankylosed condyle, underwent L-shaped ramus osteotomy. Patients were followed up for an average of 14.07 months (range 12–17 months). Results: In all patients, increase in mouth opening was noted, from an average of 3.3 mm preoperative to 32.2 mm at maximum follow up. When comparing the height of the newly reconstructe...
Temporomandibular joint subluxation is defined as self-reducing partial dislocation of the TMJ du... more Temporomandibular joint subluxation is defined as self-reducing partial dislocation of the TMJ during which the condyle passes anterior to the articular eminence. The study consisted of 30 patients, 19 females and 11 males with 14 unilateral and 16 bilateral cases of chronic symptomatic subluxation. Treatment consisted of arthrocentesis followed by 2 ml of autologous blood injection into upper joint space and 1 ml into pericapsular tissues using an autoclaved soldered double needle with single puncture technique. Parameters evaluated were pain, maximum mouth opening, excursive jaw movements, deviation on mouth opening and quality of life, hard and soft tissue changes on X-ray TMJ view and MRI. At 12 month follow-up, average reduction in maximum interincisal opening, deviation on mouth opening, range of excursive movements on right and left sides and VAS scores were 20.54%, 32.84%, 29.59%, 27.37% and 74.53%, respectively. Out of 93.3% who responded to therapy, 66.7%, 20% and 6.7% res...
Internal derangement of the temporomandibular joint is defined as an abnormal position of the art... more Internal derangement of the temporomandibular joint is defined as an abnormal position of the articular disc in relation with mandibular condyle and articular eminence presenting as disc displacement with or without reduction. This study was conducted on thirty patients diagnosed with Internal derangement of TMJ consisting of 8 males and 22 females averaging 34.6 years. Two groups Conventional Arthrocentesis (Group A) and Level 1 Arthroscopy (Group B) consisted of 15 cases each divided alternately. Clinical evaluation parameters included VAS for pain, maximal interincisal opening, deviation on mouth opening, range of motion including lateral excursion & protrusion movements recorded at 1 week, 1 month & 6 months postoperatively. Wilke’s Staging according to MRI findings was recorded preoperatively and 6 months postoperatively. At 6 month follow-up, average reduction in VAS for pain & deviation on mouth opening was 72.43% & 24.73% in Group A and 77.66% & 65.41% in Group B, respectively. Average increase in MIO, right & left excursion & protrusion movements was 29.55%, 31.33%, 20.12% & 32.45% in Group A and 34.94%, 41.37%, 39.29% and 36.51% in Group B, respectively. Improved results were obtained clinically for all Wilke’s stages in both groups with more number of patients improving in Group B. On comparing results, improvement was observed in various clinical evaluation parameters of both the groups at 6 months follow-up. However, statistically significant & better results were obtained for the Arthroscopy group.
IntroductionTreatment for TMJ Ankylosis aims at restoring joint function, improving the patient’s... more IntroductionTreatment for TMJ Ankylosis aims at restoring joint function, improving the patient’s aesthetic appearance and quality of life and preventing re-ankylosis. Mouth opening is achieved by gap arthroplasty with various options of interpositional materials. Ramus–condyle unit (RCU) reconstruction maintains the height of the ramus and prevents secondary occlusal problems. Advancement genioplasty corrects chin deformities as well as increases the posterior airway space (N-PAS) by the forward pull exerted on geniohyoid and genioglossus.Materials and MethodsThis prospective single-centre study on 43 joints in 25 adult patients with TMJ Ankylosis aimed at providing a single-staged management plan of ankylosis release, RCU reconstruction and extended advancement centering genioplasty. Interpositional arthroplasty was done using temporalis myofascial flap, abdominal dermis fat or buccal fat pad. RCU reconstruction was done either by vertical ramus osteotomy or L osteotomy.Observations and ResultsFollow-up ranged from 12 to 20 months (mean 14.4). Average mouth opening at maximum follow-up was 34.36 mm with re-ankylosis in no case. Cephalometric parameters showed increase in point P to Pog, decrease in N perpendicular to Pog, angle N–A–Pog, Cg-ANS to Cg-Menton, neck–chin angle and labiomental angle. N-PAS increased, and average 50% improvement in AHI was seen in all patients with OSA. Most common complications involved transient paraesthesia of temporal and zygomatic branches of facial nerve.ConclusionBased on the findings of the above study, we propose treatment guidelines for treatment of TMJ ankylosis in adult patients with AHI < 20.
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