Effect of Temporomandibular Joint Bony Ankylosis and Surgical Sequelae of Gap Arthroplasty on Middle Ear Volume Mohammad Dehisa, Wahid H
72 Research paper
Effect of temporomandibular joint bony ankylosis and surgical sequelae of gap arthroplasty on middle ear volume Mohammad Dehisa, Wahid H. Tantawyb, Abeer Kamalc, Sayed A. Rashedc and Mamdouh Sayeda
Aim The aim of this study was to evaluate the effect of significant decrease in MEV 3 months postoperatively temporomandibular joint bony ankylosis and surgical when compared with the preoperative volume. sequelae of gap arthroplasty on middle ear volume (MEV). Conclusion Patients with temporomandibular joint Patients and methods Sixteen Egyptian individuals were bony ankylosis showed a decrease in MEV selected and divided into two equal groups. The first group compared with normal individuals; also, gap arthroplasty (group I) included eight patients with 14 bony ankylosed has a decreasing effect on MEV. Egypt J Oral Maxillofac joints; the second group (group II) included eight normal Surg 4:72–77 c 2013 The Egyptian Association of Oral & individuals. The operated patients were chosen from those Maxillofacial Surgeons. attending the outpatient clinic of the Department of Egyptian Journal of Oral & Maxillofacial Surgery 2013, 4:72–77 Oral and Maxillofacial Surgery, Faculty of Oral and Dental Medicine, Cairo University. Gap arthroplasty was utilized Keywords: computed tomography, gap arthroplasty, middle ear volume, temporomandibular joint ankylosis for the management of such patients. Radiographic assessments for MEV for the first group were obtained aDepartment of Oral and Maxillofacial Surgery, Faculty of Oral and Dental Medicine, Cairo University, bDepartment of Radiology, Faculty of Medicine, for all the participants preoperatively and also 3 months Ain Shams University, Cairo and cDepartment of Oral Surgery, Faculty of Oral and postoperatively. Comparison of MEV was carried out with Dental Surgery, Misr University for Science and Technology (MUST), Giza, Egypt normal individuals both preoperatively and 3 months Correspondence to Abeer Kamal, BDS, MSc, PhD, Department of Oral Surgery, postoperatively. Faculty of Oral and Dental Surgery, Misr University for Science and Technology (MUST), 7 Ghernat St., Roxy Heliopolis, 413 Egypt It was observed that there was a significant Tel: + 20 24543572/ + 20 1005168009; fax: + 002 02 24543572; Results e-mail: [email protected] decrease in MEV of ankylosed patients preoperatively when compared with normal individuals and a Received 20 June 2013 accepted 20 July 2013
Introduction and review of the literature height, to minimize the possibility of occurrence of Trauma was reported to be the first etiologic factor in anterior open bite, and to increase the chance of temporomandibular joint (TMJ) bony ankylosis. Hemar- normality of postoperative mandibular function [5–7]. throsis and the anatomical nature of joints in children are believed to be the major cause, whereas condylar The ear and the TMJ are embryologically, physically, and fractures with iatrogenic factors were found to be the anatomically very close to each other and have a strong major etiologic factor in adults. TMJ disruption was influence on proper functioning of each other. Pain of reported to be involved in massive head trauma the TMJ may lead to contraction of the little muscles complicated with the presence of a temporal bone (the tensor tympani and tensor veli palatini) inside the fracture. It was hypothesized that displaced fracture of tympanic cavity. These muscles hold the ear bones the posterior wall of the TMJ may affect the middle ear (malleus, incus, and stapes) in place. All these three ear because of a concomitant perforation, leading to ossicular bones are essential to the function of hearing. The chain discontinuity. High-resolution computed tomogra- contraction and spasm of these muscles cause hearing phy (CT) is an appropriate investigation for the detection impairment by affecting the proper functioning of the ear of middle ear changes with ossicular disruptions showing bones [8,9]. separation of the incudostapedial joint, fracture of the Posterior displacement of the condyle has been reported stapes, and dislocation of the incus [1–3]. to exert pressure on the auriculotemporal nerve and the The treatment of TMJ ankylosis poses a significant chorda tympani, as well as the Eustachian tube. Pressure challenge because of its technical difficulties and a high on these structures might induce erosion of the tympanic incidence of recurrence. Gap arthroplasty has been plate. Eustachian tube dysfunction has been attributed described as a simple and effective surgical technique to reflex disturbances of the tensor tympani and the veli in the management of TMJ ankylosis. It is the technique palatini muscles. Bettega et al. [10] and Ioannides and of resecting a segment of the bone at some point between Hoogland [11] reported that the otomandibular (e.g. the base of the skull and the site of the mandibular diskomalleolar and tympanomandibular) ligaments are foramen. The gap created usually ranges from 0.6 to among the structural causes for aural symptoms. It is 1.5 cm and up to 2 cm as recommended by Topazian [4]. hypothesized that patients with TMJ disorders have The induced gap should be established at the most muscle spasms responsible for regulating the activity of superior part of the ramus to maintain a maximal ramal the Eustachian tube [12–17].
2090-097X c 2013 The Egyptian Association of Oral & Maxillofacial Surgeons DOI: 10.1097/01.OMX.0000434297.76601.e3 TMJ bony ankylosis and middle ear volume Dehis et al.73
It has been reported that the average middle ear volumes those attending the outpatient clinic of the Department (MEVs) in the normal ears, as measured using CT, were of Oral and Maxillofacial Surgery, Faculty of Oral and 5.6–7.9 ml [18–20]. Ahn et al. [21] reported that the Dental Medicine, Cairo University, Egypt. The second MEVs were 1.1 ± 0.8 ml in 44 ears with chronic otitis group (group II) included normal individuals of the same media, which were smaller than the normal values. age (range, mean) and sex distribution. They were Acquired cholesteatoma is the main complication of recruited from among patients with other medical chronic otitis, resulting from ingrowth of the keratinizing conditions of the temporal bone in whom no abnormal- squamous epithelium from the external acoustic meatus ities of the middle ear were detected; consequently, CT to the middle ear through the tympanic membrane. It was not performed specifically for the middle ear to avoid was represented on the CT scan in the form of a soft- extra radiation hazard. The condition was explained and tissue mass-like opacity in the middle ear cavity and their consents were obtained. Every patient of group I mastoid antrum associated with smooth bony erosion of was subjected to laboratory routine investigations for the ossicles and expansion of adjacent structures [22]. general anesthesia. Surgically, the preauricular approach CT examination of patients with osteopetrosis showed was used in all patients to gain access to the TMJ area. conductive hearing loss, and this was attributed to Gap arthroplasty was applied to release the TMJ exostosis projection into the middle ear cavity, calcified ankylosis. MEVs were measured preoperatively and 3 and sclerotic ossicles, recurrent otitis media, and poor months postoperatively. aeration of the mastoid air cells, with no evidence of Radiographic assessment for ankylosis and for the middle internal auditory canal narrowing [23–25]. A CT scan of ear was performed using multislice CT scan. Volumetric Paget’s disease of the skull showed thickening of the measurement of middle ear was estimated semidigitally. auditory ossicles and stapes suprastructure was not MEV was calculated starting from the tympanic mem- visible; these findings explain the hearing impairment brane to the bony part of the Eustachian tube. in patients with Paget’s disease [26]. Comparison of the MEV in TMJ ankylosis patients with High-resolution CT of the temporal bone is the method normal individuals was carried out. Also, comparison of choice for the evaluation of ossicular chain integrity between MEV preoperatively and postoperatively for and tympanic cavity walls. Axial high-resolution CT scans detection of the effect of gap arthroplasty on the MEV can ordinarily show the exact nature and placement of was carried out. The data were tabulated and analyzed the ossicular fractures and dislocations. High-resolution statistically (Fig. 1). CTof the middle ear is a useful noninvasive technique; it can detect the extent of the disease, exact location, Radiological assessment of the middle ear structures involved, and possible bone erosion. It can be All the CT examinations were performed using a slice addressed in cases of traumatic and nontraumatic multidetector CT scanner (Aquillion 64; Toshiba, Tokyo, opacified middle ear, acute coalescent otomastoiditis, Japan). Scanning was performed on the standard axial and chronic otitis media. Recently, virtual endoscopy and plane using the helical technique (a field of view of three-dimensional reconstructions of the middle ear as 18 cm, a pitch of 0.562, a rotation time of 0.35 s, a section well as the tympanic cavity were used to assess middle thickness of 0.5 mm, and a matrix of 512 Â 512). The ear pathologies and ossicular injuries using the standard patients were scanned in a supine position to obtain high-resolution CT temporal bone as a template [27,28]. the image plane parallel to the orbitomeatal line. All the image data sets were transferred from the CT scanner Patients and methods to the PC workstation and the data sets were analyzed This study included 16 Egyptian individuals. They were using the three-dimensional medical imaging software divided equally into two groups. The first group (group I) (Medicor imaging Charlotte, North Carolina, USA) (on had 14 bony ankylosed TMJ. They were selected from vitra workstation). MEVs were measured using the digital
Fig. 1
Axial, coronal, and three-dimensional reconstruction images of computed tomography showing an ankylosis bony mass. 74 Egyptian Journal of Oral & Maxillofacial Surgery 2013, Vol 4 No 3 image processing CT program. The area of the air- (3) Equality test of the right and left MEV. containing cavity was measured semiautomatically. A (4) Comparison of the preoperative results of MEV of volume of interest was applied manually on each slice. TMJ ankylosed joints (group I) versus control joints The volume of the air-containing cavity at each slice was (group II). computed by clicking on the air cavity within the volume (5) Comparison between preoperative and postoperative of interest. The total volume of the air-containing cavity results of MEV of ankylosed joints (group I). was calculated as the sum of the volumes of the air- containing cavities of each slice (Figs 2 and 3). Analysis of patients data Radiological measurements of middle ear volume Group I included 14 bony ankylosed joints in eight patients (two men and six women, age range 18–45 years and mean (1) MEV of the right and left ears of the patient group age 29.5 years). The etiology of ankylosis was trauma in 75% (group I). of cases and congenital cause in the remaining 25%. The (2) MEV of the right and left ears of the control group preoperative interincisal opening ranged from 0 to 6 mm, (group II). mean 3.2 mm. Seventy-five percent of cases had bilateral and
Fig. 2
Outline tracing of preoperative middle ear volume (group I).
Fig. 3
Outline tracing of middle ear volume (group II). TMJ bony ankylosis and middle ear volume Dehis et al.75
25% had unilateral involvement with fibrous ankylosis in the charged from the hospital at the second postoperative contralateral sides. Previous surgical intervention for the day. Follow-up was performed at the outpatient clinic. correction of TMJ ankylosis was reported in six patients: The maximum interincisal opening achieved at the end one of them was operated three times, three patients were of 3 months postoperatively ranged from 24 to 50 mm, operated two times, and two were operated only once. mean 35.3 mm.
Surgical procedure Results of middle ear volume Gap arthroplasty was performed to release TMJ ankylosis Middle ear volume of right and left ears of the through a modified preauricular incision under fiberoptic patient group (group I) nasoendotracheal intubation. Patients were admitted for On studying the MEV of right ears of the patient group, general anesthesia in the Dental Educational Hospital, it was found that the preoperative values obtained ranged Faculty of Oral and Dental Medicine, Cairo University. from 0.036 to 0.528 ml, with a mean of 0.26 ml. The The operation was followed by physiotherapy for 6 3-month postoperative volumes obtained ranged from months to prevent recurrence (Fig. 4). 0.039 to 0.216 ml, with a mean of 0.09 ml (Table 1). On studying the MEV of left ears of the patient group, it Results was found that the recorded preoperative values ranged The postoperative course passed without incidence and from 0.043 to 0.676 ml, with a mean of 0.26 ml. The all patients resumed their normal activities early; they recorded 3-month postoperative volumes ranged from were encouraged for early ambulation and were dis- 0.021 to 0.184 ml, with a mean of 0.07 ml (Table 1).
Fig. 4
(a) Preauricular incision. (b) Exposure of the ankylotic bony mass. (c) Initiation of cutting the ankylotic bony mass. (d) The gap obtained. (e) Intraoperative interincisal opening. 76 Egyptian Journal of Oral & Maxillofacial Surgery 2013, Vol 4 No 3
Table 1 MEVs (ml) of the right and left ears in patients and controls both preoperatively and 3 months postoperatively
Patients and controls Preoperative MEV (Rt) Preoperative MEV (Lt) Postoperative MEV (Rt) Postoperative MEV (Lt) MEV control (Rt) MEV control (Lt)
1 0.181 0.067 0.039 0.042 1.113 1.289 2 0.036 0.043 0.216 0.184 0.976 1.043 3 0.528 0.676 0.058 0.048 0.800 0.991 4 0.229 0.384 0.051 0.054 1.131 1.319 5 0.071 0.045 0.049 0.021 1.878 1.854 6 0.511 0.324 0.078 0.052 0.742 0.864 7 0.365 0.383 0.075 0.085 2.193 1.811 8 0.156 0.122 0.156 0.093 1.041 1.160 Mean 0.25963 0.2555 0.09025 0.07238 1.23425 1.29138
Lt, left; MEV, middle ear volume; Rt, right.
Middle ear volume of the right and left ears of the Table 2 Paired sample t-test for comparison of MEV of preopera- control group (group II) tive MEV of group I with the control group (group II) and for comparison of preoperative with postoperative MEV (group I) The MEV of the right ears of the control group ranged from 0.742 to 2.193 ml, with a mean of 1.23 ml, whereas Mean t-test d.f. P-value that of the left ears ranged from 0.864 to 1.854 ml, with MEV preoperatively (group I) 0.255 –7.849 28 0.000 a mean of 1.29 ml (Table 1). MEV control (group II) 1.262 MEV preoperatively (group I) 0.255 2.623 13 0.021 MEV postoperatively (group I) 0.086 Equality test of right and left middle ear volumes On comparing the results of right and left MEVs of the MEV, middle ear volume. operated and the control individuals, it was found that there was no statistical difference. Hence, the results of the right and left ears of eight patients with ankylosis and Fig. 5 control individuals were summed up into 14 ankylosed mean of MEV joints and 16 normal joints. 1.4 1.2 Comparison of preoperative results of middle ear 1 volume of ankylosed temporomandibular joints (Preop (group I (group I) versus control joints (group II) 0.8 On taking the mean MEV of the control group as a 0.6 (Postop (group I reference point of comparison with the preoperative 0.4 (control (group II mean MEV of ankylosed joints, it was found that there 0.2 was a significant deficiency in the MEV of ankylosed 0 joints preoperatively at a P-value of 0.000 (Table 2). (Preop (group I (Postop (group I (control (group II
Comparison between preoperative and postoperative Mean middle ear volume in group I (preoperative and postoperative) results of middle ear volume of ankylosed joints (group I) and group II. On comparing the MEV in ankylosed patients preopera- tively and 3 months postoperatively, it was found that there was a significant decrease in the volume post- structures of the middle ear; for this reason, it is the operatively at a P-value of 0.021 (Table 2; Fig. 5). modality of choice in the study of conductive hearing loss. Most middle ear lesions cause impairment of one or more Discussion elements of the mechanical chain that transmits sounds There is a close embryological, anatomical, and clinical from the eardrum to the oval window [33,34]. association between TMJ and the middle ear; for this, the The current research showed a marked statistically hypothesis of the present investigation was raised. It was significant deficiency of the preoperative MEV in aimed to clarify the changes in MEV in response to TMJ the TMJ bony ankylosis sample when compared with the bony ankylosis. Gap arthroplasty is a standard technique control group. The same findings were observed when used widely in Egypt to release TMJ bony ankylosis. It compared with the international published results [35–37]. was utilized in this study as it is simple, atraumatic, and led Skeletal changes associated with TMJ bony ankylosis to fewer complications when compared with other extended to include facial skeleton; the detected decrease techniques. It has a low cost and can be used in low in MEV of the current study seems to be responsive to socioeconomic communities. The effect of gap arthroplasty these changes. These findings could be attributed to the on some aspects of the orofacial area was studied [29–32]. lack of functional stimuli transmitted from the jaw to This research aimed to elucidate the changes that were the temporal bone by direct articulation with TMJ and induced by gap arthroplasty on the MEV. indirectly through the temporalis muscle and its related High-resolution CT was utilized in the current study as fascia as well as the styloid process. This consequently it is an excellent technique for determination of interferes with the growth and development of the small abnormalities of the thin and complex bony temporal bone as a whole and its contents, including TMJ bony ankylosis and middle ear volume Dehis et al.77
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