Minjie Chen

Intracapsular Condylar Fracture of the Mandible: Our Classification and Open Treatment Experience

PURPOSE We studied the classification of intracapsular condylar fracture (ICF) of the mandible based on coronal computed tomography (CT) scans and present our open treatment experience at the temporomandibular joint (TMJ) division of Shanghais Ninth Peoples Hospital (Shanghai, China). MATERIALS AND METHODS From 1999 to 2008, 229 patients with 312 ICFs were treated in our division. Among them, 195 patients (269 joints) had CT scans for classification. We modified the classification of Neff et al, adding a new fracture type according to our experience: type A, fracture line through lateral third of condylar head with reduction of ramus height; type B, fracture line through middle third of condylar head; type C, fracture line through medial third of condylar head; and type M, comminuted fracture of condylar head. There was no ramus height reduction in fracture types B and C. Our treatment protocol is open reduction for a fracture in which the superolaterally dislocated ramus stump is out of the glenoid fossa or any type of fracture with displaced or dislocated fragments that may cause TMJ dysfunction later. RESULT Among the 269 joints, 116 had type A fractures (43.1%), 81 had type B fractures (30.1%), 11 had type C fractures (4.1%), and 58 had type M fractures (21.6%); 3 joints (1.1%) had fractures that were not displaced. Of the joints, 173 had open reduction-internal fixation; postoperative CT scans showed that 95.6% of these had absolute anatomic or nearly anatomic reduction. In all of them normal mouth opening and occlusion were restored. No or little deviation was found during mouth opening. Complications were pain in the joint (n = 1), crepitations (n = 2), and facial nerve (temporal branch) paralysis (n = 1). Two patients had the plate removed because of these complications. CONCLUSION Our new classification based on CT scans can better guide clinical treatment. Open reduction for ICF can restore the anatomic position for both the condyle and TMJ soft tissues with few complications, which can yield better functional and radiologic results.

Septic Arthritis of the Temporomandibular Joint: A Retrospective Review of 40 Cases

PURPOSE Septic arthritis of the temporomandibular joint is an uncommonly reported entity. The aim of the present study was to review the cases treated at our clinic, analyze the characteristics of this disease and the responses to management, and recommend a protocol for managing suspected cases. PATIENTS AND METHODS A total of 40 consecutive patients were included from 1995 to 2007. Their demographics, predisposing factors, clinical manifestations, radiologic findings, joint fluid analysis results, treatment, and outcomes were reviewed. RESULTS The 40 patients included 26 men and 14 women, with an average age of 36 years. Original infections were found in 15 patients (local spread in 4 and hematogenous dissemination from a distant site in 11). All patients complained of trismus and tenderness in the temporomandibular joint. Sudden malocclusion was found in 33 patients. Joint space widening and limitation of condyle movement were demonstrated by plain film in 33 patients. Increased joint effusion was confirmed by magnetic resonance imaging in 7 patients. Joint fluid was obtained from 35 patients. A high level of neutrophils and fibrin were found under microscopy with hematoxylin-eosin staining. Staphylococcus saprophyticus and S. aureus were cultured from 5 patients. Arthrocentesis under low pressure was applied to 35 patients, and arthroscopy was used in 9 patients. Major sequelae occurred in 11 patients, including fibrosis in 2 and postinfectious osteoarthritis in 9. CONCLUSIONS Septic arthritis of the temporomandibular joint mainly arises from hematogenous spread, but the original infection is often occult. Antibiotic therapy, arthrocentesis under low pressure, and joint immobilization are recommended for patients in the acute stage. The common sequela is osteoarthritis.

Modified Preauricular Approach and Rigid Internal Fixation for Intracapsular Condyle Fracture of the Mandible

PURPOSE This article reports a modified preauricular approach for intracapsular condyle fracture (ICF) of the mandible and evaluates the stability of various internal fixation methods in the temporomandibular joint (TMJ) division of the Shanghai Ninth Peoples Hospital. MATERIALS AND METHODS One hundred fifty-one patients with 208 ICFs diagnosed by panoramic radiograph and computed tomographic (CT) scan received open treatment in the TMJ division from 1999 to 2008. Their charts were reviewed. Classification of the fracture was based on coronal CT scan. Forty-three patients also underwent magnetic resonance imaging before the operation to check displacement of the disc. A modified preauricular approach was used for all patients. Various internal fixation methods from wire, to screw, to plate were evaluated for stability. RESULTS There were 110 ICFs of type A fracture, 60 of type B fracture, 9 of type C fracture, 25 of type M fracture, and 4 fractures without displacement. A modified preauricular approach was used for open treatment, which can better expose and protect the TMJ and superficial temporal vessels. Wire and plate is the commonly used stable fixation method for type A, B, and M fractures, which accounted for 56.7% (101/178). Small fracture fragments were removed with disc repositioning for all type C fractures (n = 9) and some type B (n = 9) and M fractures (n = 5). Three type M fracture and 3 nondisplaced ICFs were treated closed. Eighty-nine patients with 115 ICFs had postoperative CT scan, which showed anatomic and nearly anatomic fracture reduction rates of 95.6%. Thirty-five patients with 44 ICFs had long-term follow-ups from 3 months to 5 years. Among them, 63.2% (n = 12/19) pediatric ICFs had continuous condyle growth after open reduction and rigid fixation; 92% adults had ICFs that healed well (n = 23/25). Postoperative complications were facial nerve injury (n = 3), TMJ clicking (n = 1), and condyle resorption that required plate removal (n = 4). CONCLUSION A modified preauricular approach provides better exposure and protection of the TMJ and superficial temporal vessels. Wire and plate provides stable fixation for type A and some type B and M fractures. Open reduction and rigid fixation produce good results for adult patients.

Application of Rapid Prototyping for Temporomandibular Joint Reconstruction

PURPOSE To introduce the preliminary application of rapid prototyping (RP) for temporomandibular joint (TMJ) surgery. MATERIALS AND METHODS This study included 11 consecutive patients (13 joints) seeking TMJ replacement. All patients had previously undergone 3-dimensional computed tomography (CT) scanning (0.625-mm slice thickness) of the craniofacial skeleton. The data from CT scanning in DICOM (Digital Imaging and Communications in Medicine) format were input into the interactive Simplant CMF software program (Materialise Medical, Leuven, Belgium). Preoperative planning included segmentation and osteotomies. The movements of the jaw bones were simulated by use of Simplant CMF. The affected mandible was reconstructed based on the contralateral side. Then, the titanium plate was shaped on the reconstructed model before surgery. The bone graft was transplanted by the shaped titanium plate during the operation to reconstruct the TMJ. Twenty-four patients who underwent traditional surgery were used as the control group. The operative time of the 2 groups was analyzed with the SPSS software package, version 13.0 (SPSS, Chicago, IL), with the Student t test. The data from CT scanning in the experimental group before and after surgery were compared by paired t test. RESULTS All the incisions healed primarily without any complications. All patients were satisfied with the operation, because of their symmetric faces and good occlusion. Postoperative magnetic resonance imaging confirmed the position of the transplanted costochondral cartilage in the glenoid fossa. A group t test showed that the operative time was longer in the control group (mean, 7.09 hours) than that in the RP group (mean, 5.67 hours). Three parameters (condyle-incisor, condyle-mental foramen, and condyle-angle) from the postoperative CT scan were analyzed by paired t test, and there was no significant difference between the 2 sides. CONCLUSION RP technology provides an advanced method for TMJ reconstruction that can make the TMJ reconstruction more accurate and symmetric, improve the mandibles function, and consequently, enhance the reconstructive effect.

New arthroscopic disc repositioning and suturing technique for treating internal derangement of the temporomandibular joint: part II--magnetic resonance imaging evaluation.

PURPOSE To evaluate the efficiency of an arthroscopic suturing technique for stabilizing anteriorly displaced discs in patients with internal derangement of the temporomandibular joint (TMJ) by magnetic resonance (MR) imaging. PATIENTS AND METHODS Six hundred thirty-nine patients (764 joints) diagnosed as having stages II to V of internal derangement were treated with arthroscopic disc repositioning and suturing from August 2004 to March 2007. Consecutive MR images were used to evaluate internal derangement before and approximately 1 to 7 days after the operation for all 639 patients. The disc position of the TMJ was judged according to the success criteria, which included 3 different sagittal planes (lateral, central, and medial). Operative efficiency in those patients, whose discs of the TMJ were affirmed to be in a normal position in all 3 planes, was evaluated to be excellent. Those patients whose discs were in a normal position in 2 planes were evaluated to be good. The others were evaluated to be poor. Cases evaluated as excellent and good were considered success cases (if the disc is displaced only in 1 or 2 planes before operation, the efficiency of the operation would be evaluated as a success only if the whole disc was in normal position). RESULTS Postoperative consecutive MR images for all 764 joints confirmed that 95.42% (729/764) of the joints were excellent, 3.14% (24/764) were good, and only 1.44% (11/764) were poor. Repeated arthroscopic surgery or open surgery was carried out for the joints that were evaluated as poor. CONCLUSION This study indicates that the TMJ arthroscopic suturing technique is effective in repositioning the TMJ disc as confirmed by an MR imaging examination, but long-term follow-up is necessary.

Soft Tissue Reduction During Open Treatment of Intracapsular Condylar Fracture of the Temporomandibular Joint: Our Institution's Experience

PURPOSE To evaluate the effect of soft tissue reduction during open surgery of intracapsular condylar fracture (ICF) of the temporomandibular joint (TMJ). MATERIALS AND METHODS A total of 129 patients (164 TMJs) with ICF were treated from June 2004 to May 2009. Osteosynthesis was performed by different methods without stripping the lateral pterygoid muscle (LPM). The disc was reduced with or without transecting adhesions, release of the epimysium of the LPM, and anchorage to the condyle. Retrodiscal tissue tear was repaired. The patients were evaluated by computed tomography, magnetic resonance imaging, and clinical signs pre- and postoperatively. RESULTS Inferomedial displacement of the condylar segment and disc occurred in 97.6% of cases. Adhesion of the superior joint space was found in 37 of 160 TMJs (23.1%). Retrodiscal tissue tear combined with disc displacement was found in 119 of 160 TMJs (74.4%). The condylar stump was found to be superolaterally displaced in 30.6% (49/160) and laterally dislocated out of the fossa in 41.9% (69/160). A lateral capsular tear was observed in 87 of 160 TMJs (54.4%). The condylar fragments and the discs were reduced and fixed completely with preservation of the attachment of the LPM. Coronal CT revealed that 95.6% (130/160 cases) of ICFs were correctly reduced and fixed. Postoperative magnetic resonance imaging showed that the disc was reduced to its normal position in 40 of 42 TMJs. Long-term complications of 45 patients included fibrous ankylosis in 1 case (0.8%), mouth opening limitation (<2.5 cm) in 5 cases, (3.9%), condyle resorption in 3 cases (2.3%) that needed plate removal, facial nerve injury in 3 cases (2.3%), TMJ click in 2 cases (1.6%), mouth open with deviation in 7 cases (5.4%), and malocclusion in 1 case (0.8%). CONCLUSION Anatomic reduction of soft tissue was of benefit for biomechanical function of the TMJ and decreased the complications of open surgery.

Temporomandibular joint disc repositioning using bone anchors: an immediate post surgical evaluation by magnetic resonance imaging.

BackgroundOpen joint procedures using bone anchors have shown clinical and radiograph good success, but post surgical disc position has not been documented with MRI imaging. We have designed a modified technique of using two bone anchors and 2 sutures to reposition the articular discs. This MRI study evaluates the post surgical success of this technique to reposition and stabilize the TMJ articular discs.MethodsConsecutive 81 patients with unilateral TMJ internal derangement (ID) (81 TMJs) were treated between December 1, 2003, and December 1, 2006, at the Department of Oral and Maxillofacial Surgery, Ninth Peoples Hospital, Shanghai, Jiao Tong University School of Medicine. All patients were subjected to magnetic resonance imaging before and one to seven days post surgery to determine disc position using the modified bone anchor technique.ResultsPostoperative MRIs (one to seven days) confirm that 77 of 81 joints were identified as excellent results and one joint was considered good for an overall effective rate of 96.3% (78 of 81 joints). Only 3.7% (3 of 81) of the joints were designated as poor results requiring a second open surgery.ConclusionsThis procedure has provided successful repositioning of the articular discs in unilateral TMJ ID at one to seven days post surgery.

Synovial chondromatosis in the inferior compartment of the temporomandibular joint: different stages with different treatments.

PURPOSE To discuss a new classification and the treatment principles of synovial chondromatosis (SC) in the inferior compartment of the temporomandibular joint (TMJ). PATIENTS AND METHODS Five cases of SC in the inferior compartment were treated in an open manner between January 2008 and May 2011. Each case had different clinical and radiologic aspects and was treated with different surgical therapies. SC in the inferior compartment of the TMJ is classified into 3 stages. All patients were evaluated by computed tomography, magnetic resonance imaging, and clinical manifestations preoperatively and postoperatively. RESULTS There were 3 kinds of manifestation modes from radiologic findings. Case 1 was in stage 1, in which multiple loose bodies are noted without bony erosion. This patient was treated by removal of loose bodies and affected synovium. Case 2 was in stage 2, in which multiple calcified nodules were conglutinated to the condyle; the condyle was enlarged with pressure erosions. This patient was treated by condylectomy and reconstruction with costochondral graft. Case 3, case 4, and case 5 were all in stage 3, in which the condyle was destroyed as a result of pressure erosions or by direct bony invasion of the mass and the inferior surface of the disc was involved. These patients were treated by condylectomy together with discectomy, as well as reconstruction with costochondral graft and pedicled deep temporal fascial fat flap. No recurrence occurred. The height of the ramus and the occlusion were maintained in the same condition as preoperatively. CONCLUSIONS Our new classification of SC in the inferior compartment of the TMJ can better guide clinical treatment.

Surgical Treatment of Traumatic Temporomandibular Joint Ankylosis With Medially Displaced Residual Condyle: Surgical Methods and Long-Term Results

PURPOSE We report a surgical method for the treatment of traumatic temporomandibular joint (TMJ) ankylosis with a medially displaced residual condyle and compare the long-term results with those obtained using different interpositional materials. PATIENTS AND METHODS From 2001 to 2009, 60 patients and 82 joints diagnosed with traumatic TMJ ankylosis with a medially displaced residual condyle were included in the present study. Lateral arthroplasty (LAP) was performed, and either the masseter muscle flap (MMF) or the temporalis myofascial flap (TMF) was used as interpositional material to fill the lateral space. The long-term results of these treatments were compared by performing postoperative computed tomography scans and clinical follow-up examinations. RESULTS Of the 82 joints, 22 were treated with LAP, 28 with LAP and MMF, and 32 with LAP and TMF. Of the 60 patients, 38 (48 joints) participated in long-term follow-up (from 1 to 4 yr). Of the 11 joints treated with LAP, 4 (36.4%) developed reankylosis. Of the 17 joints treated with LAP and MMF, 3 (17.6%) developed reankylosis, and none of the 20 joints treated with LAP and TMF developed reankylosis. Compared with LAP alone, LAP with TMF significantly improved the maximal incisal opening during long-term follow-up. CONCLUSION LAP can preserve the residual TMJ structure. The TMF is a reliable interpositional material in LAP for the prevention of reankylosis.

Metastatic spread to the mandibular condyle as initial clinical presentation: radiographic diagnosis and surgical experience.

PURPOSE Metastatic spread to the mandibular condyle is uncommon. The authors retrospectively evaluated a series of consecutive cases of condylar metastases presenting as the initial clinical event to increase awareness and provide a better understanding of this occurrence. PATIENTS AND METHODS This study consisted of 6 cases of metastatic tumor of the mandibular condyle presenting as the initial clinical event from July 2004 to May 2011. Primary sites included the bladder, prostate, lung, penis, colon, and breast. In 3 cases, positron emission tomographic/computed tomographic scans were performed to detect the primary lesions, which stayed occult at presentation. Surgical removal of the metastatic condylar lesions was performed in 3 patients, and palliative therapy was provided to all patients except a patient with a solitary metastasis. RESULTS Five patients developed disseminated systemic metastases and died within 12 months. Only the patient with a solitary metastasis stayed alive, without any sign or symptom of tumor recurrence or metastasis at the most recent follow-up visit. CONCLUSIONS For adult patients without a history of cancer, metastasis should be taken into consideration when the mandibular condyle is irregularly disrupted. Positron emission tomography/computed tomography is effective for detecting occult malignant lesions, whereas surgery might be indicated only for a solitary condylar metastasis.