Dr. Girish Giraddi

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA. ANNEXURE II PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. NAME OF THE CANDIDATE AND DR.SAIANUSHA.A.J ADDRESS POST GRADUATE STUDENT GOVERNMENT DENTAL COLLEGE AND RESEARCH INSTITUTE, BANGALORE.

2. NAME OF THE INSTITUTE GOVERNMENT DENTAL COLLEGE AND RESEARCH INSTITUTE, BANGALORE.

3. COURSE OF STUDY AND SUBJECT MASTER OF DENTAL SURGERY IN ORAL AND MAXILLOFACIAL SURGERY

4. DATE OF ADMISSION TO COURSE 01.06.2009

5. TITLE OF THE TOPIC: “ Efficacy of Simultaneous gap arthroplasty and Distraction osteogenesis for the treatment of mandibular micrognathia in ankylosis of the TMJ.

6. BRIEF RESUME OF THE INTENDED WORK:

6.1 NEED FOR THE STUDY: - Ankylosis of the temporomandibular joint (TMJ) involves fusion of the mandibular condyle to the base of skull, which causes distressing conditions including impaired speech, difficulty in chewing, facial disfigurememt, compromise of the airway and psychological stress. Temporomandibular joint ankylosis is a common cause of acquired mandibular deformity in children. It can be caused by a variety of causes, trauma and infection being the commonest in the paediatric age group. Long standing temporo-mandibular ankylosis leads to damage of the condyle with deficiency of the mandibular body and ramus. The treatment of TMJ ankylosis requires restoration of proper mandibular form, length and vertical dimension, occlusal stability and satisfactory joint movement. With children, future symmetrical growth must also be considered, the treatment is often in two parts: trismus can be managed by gap arthroplasty or by reconstruction of the TMJ while the micrognathia can be treated by autoplastic bony transplantation or distraction osteogenesis (DO) Costochondral grafts, which have the advantages of being autogenous material with a cartilaginous articulating surface and the potential for growth and adaption, are commonly used to reconstruct the mandibular condyle. Their disadvantages are the need for an additional operation, which may cause morbidity at the donor site, and an unpredictable pattern of growth. DO has become a popular and reliable alternative for the correction of craniomaxillomandibular deformities,secondary to TMJ ankylosis, proving to be a promising method. Many surgeons have of done condylectomy and gap arthroplasty in the first stage and DO in the second stage and others have reversed the order, both techniques had disadvantages reankylosis and difficulty in intubation needing tracheostomy and requirement of second surgery. In the present study we would like to study the outcome of simultaneous gap arthroplasty and distraction osteogenesis.

1 6.2 REVIEW OF LITERATURE:

Distraction osteogenesis was used in the head and neck by Snyder et al. In 1973 after it had been extensively used by orthopaedicians for lengthening of long bones. Presently this technique is often applied for mandibular lengthening in various disorders like hemifacial microsomia, Pierre Robin sequence, etc. (McCarthy, 1994). Simultaneous gap arthroplasty and DO for the treatment of micrognathia in ankylosis of the TMJ was first reported in 1999.

1. Gap arthroplasty can be combined with distraction osteogenesis of the mandibular body. Distraction osteogenesis is a good means of mandibular lengthening in patients with mixed dentition (McCarthy et al., 1992). Dean and Alamillos (1999) used simultaneous gap arthroplasty and distraction osteogenesis for the treatment of mandibular deformity in temporomandibular joint ankylosis. In their study, three patients successfully underwent this kind of combination of treatment for temporo-mandibular joint ankylosis deformity. A maximum mouth opening of 25mm was achieved in their patients.

2. Papageorge and Apostolidis (1999) reported similar results with gap arthroplasty and distraction osteogenesis in patients with TMJ ankylosis and mandibular deformity.

3. Yoon and Kim (2002) successfully used gap arthroplasty with intraoral mandibular distraction osteogenesis in two patients with TMJ ankylosis and mandibular deformity. Both the patients had undergone failed gap arthroplasty and costochondral graft interposition. This study reported a positive result with a total follow-up of 2 years.

4. Douglas et al. (2000) used a pin and tube device for intraoral distraction in an adult patient with micrognathia due to temporomandibular joint ankylosis. The authors achieved a lengthening of 10mm in their patient, which remained stationary after surgery.

6.3 OBJECTIVES OF THE STUDY: To evaluate the efficacy and outcome of the surgical procedure involving simultaneous gap arthroplasty and implantation of a distractor in a single operation.

7. MATERIALS AND METHODS: This is a prospective study of patients who are diagnosed with tmj ankylosis with mandibular micrognathia

7.1 SOURCES OF THE DATA: Those subjects to be studied will be selected from patients visiting the outpatient section, Department of oral and maxillofacial surgery, Government Dental College and Research Institute, Bangalore, with the diagnosis of mandibular micrognathia secondary to TMJ ankylosis.

2 7.2 METHODS OF COLLECTION OF DATA: Patients are selected based on the following criteria, sample size 20.

INCLUSION CRITERIA: 1. Patients with the diagnosis of tmj ankylosis and micrognathia

EXCLUSION CRITERIA: 1.Medically compromised patients 2. Patients already treated surgically for mandibular micrognathia due to tmj ankylosis. 3. Patients with any other syndromes.

PROCEDURE: Each of the 20 patients who have met the above said criteria will be treated under general anesthesia after obtaining consent. Surgical procedure of simultaneous gap athroplasty with distraction osteogenesis is done. The modified preauricular approach is used to reach the ankylotic mass and removed as per the standard protocol of gap athroplasty. After this temporal myofacial flap is interposioned and secured with resorbable sutures into the gap created. An intraoral distractor will be fixed on the proposed osteotomy site with its axis parallel to the occlusal plane.the surgical insicions are closed in layers. Dynamic mouth opening exercises will be started on the first postoperative day. Distraction will be activated on the fifth postoperative day at a distraction rate of 0.5mm twice daily upto a period of planned desired results are achieved. Consolidation period of 6weeks will be mandatory before the removal of the distractor.patients are followed up and evaluated regularly upto 12weeks. Patient are evaluated for change in profile 1. Lateral cephalometric analysis showing the advancement of the chin at the following intervals: A. preoperatively B. postoperatively on the 5th day. C.12th week postoperatively.

2. Mouth opening will be evaluated at the following intervals: A. Preoperatively B.intraoperatively C.postoperatively on the 5th day,2nd week,4th week,6th week,8th week,12th week.

3. Extraoral measurement from the mid point of tragus to the gonial angle to measure the vertical lengthening of the ramus: a.preoperatively b.intraoperatively c.postoperatively on the 5th day,2nd week,4th week,6th week,8th week,12th week.

3 7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? Surgical procedure will be done on human subjects.

7.4 Has ethical clearance been obtained from your institution in case of 7.3? yes

8. LIST OF REFERENCES:

1.Hongbo Yu, Guofang Shen ∗, Shilei Zhang, Xudong Wang,gap athroplasty combined with distraction osteogenesis in the treatment of the temporomandibular joint and micrognathia.

2. Rao K, Kumar S, Kumar V, Singh AK, Bhatnagar SK. The role of simultaneous gap arthroplasty and distraction osteogenesis in the management of temporo-mandibular joint ankylosis with mandibular deformity in children. J Craniomaxillofac Surg 2004; 32:38–42.

3. Yoon HJ, Kim HG. Intraoral mandibular distraction osteogenesis in facial asymmetry patients with unilateral temporomandibular joint bony ankylosis. Int J Oral Maxillofac Surg 2002; 31:544–8.

4. Su-Gwan K. Treatment of temporomandibular joint ankylosis with temporalis muscle and fascia flap. Int J Oral Maxillofac Surg 2001; 30:189–93.

5. McCarthy JG: The role of distraction osteogenesis in the reconstruction of the mandible in unilateral craniofacial microsomia. Clin Plast Surg 21: 625–631, 1994.

6. Papageorge MB, Apostolidis C: Simultaneous mandibular distraction and arthroplasty in a patient with temporomandibular joint ankylosis and mandibular hypoplasia. J Oral Maxillofac Surg 57: 328–333, 1999

4 9. SIGNATURE OF THE CANDIDATE

10. REMARKS OF THE GUIDE

11. NAME AND DESIGNATION OF

11.1 GUIDE DR. GIRISH GIRADDI PROFESSOR AND HEAD, DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY, GOVERNMENT DENTAL COLLEGE AND RESEARCH INSTITUTE, BANGALORE. 11.2 SIGNATURE

11.3 CO-GUIDE

11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT DR. GIRISH GIRADDI PROFESSOR AND HEAD, DEPARTMENT OF ORAL AND 11.6 SIGNATURE MAXILLOFACIAL SURGERY SGOVERNMENT DENTAL COLLEGE AND RESEARCH INSTITUTE, BANGALORE

12. 12.1 REMARK OF THE CHAIRMAN AND DEAN CUM DIRECTOR

12.2 SIGNATURE