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Modified coronoid process grafts combined with sagittal split osteotomy for treatment of bilateral tmj ankylosis /certified fixed orthodontic courses by Indian dental academy
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Modified coronoid process grafts combined with sagittal split osteotomy for treatment of bilateral tmj ankylosis /certified fixed orthodontic courses by Indian dental academy


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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit ,or call

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  • 1. INDIAN DENTAL ACADEMY Leader in continuing dental education
  • 3. INTRODUCTION • Tmj ankylosis leads to restriction of oral opening ranging from partial reductioon to complete immobility of the jaw. • The most common cause is the macrotrauma associated with a condylar process # during the active growth period in childhood. • Commonly used tech’s such as gap arhroplasty at different levels, interpositional cartilage grafts, and arthroplasty. • Recently to improve both function and profile, an arthroplasty combined with orthognathic surgery has been recomended
  • 4. PATIENTS AND METHODS • Six pts with bilateral tmj ankylosis and severe retrognathia were treated during the period june 1996 to march 1999. • 4 male, 2 female. Youngest being 6 years and the oldest being 17 years. • Ethilogy for 4 pts being trauma during 1st decade and other two suffered from otitis media. • All pts were not treated previously and had complete bony ankylosis. • Obstructive sleep apnea was the principal complaint in 5 pts. In which 3 of them were unable to sleep except in the sitting position and had frequent hypoapnoeic episodes each night. • The pts were treated with sagittal split ramus osteotomy and immediate coronoid process grafts. A fibular graft was used to stabilize mand segment in 4 pts.
  • 5. SURGICAL PROCEDURE • GA via nasotracheal intubation in 2 pts and via tracheostomy in 4 pts. • Mandible approached through combined retromandibular and extended pre auricular incisions. • The retromandibular incision was made 5 cm below the lobe of the ear and 2.5cm behind the angle of the mandible on the anterior border of the sternocleidomastoid muscle. • The scm muscle was retracted posteriorly, the parotid gland upward, and the skin fascia flap forward. • Through this incision the angle of the mandible and post border of the ramus were exposed. Then the pterygomassetric sling was striped completely from its attachments .
  • 6. • An extended pre auricular incision was made next. After retracting the flap, the superficial temporalis fascia was incised at 45o angle statrting at the root of the zygomatic arch and extending upward to a point 2cm above the arch deep to temporal fat pad. • The reflected flap included the superficial temporalis fascia, periosteum, temporal fat pad, and the zygomatic and temporal branches of the facial nerve. • Then the ankylosed condyle was resected and removed takin care not to injure the internal max artery behind and deep to the osseous mass. • A space atleast 1.5 to 2cm between zygomatic arch and superior margin of the ramus was created.
  • 7. • Then the coronoid process was detached with a reciprocatig saw and was used to replace the resected ankylosed condyle. • The glenoid fossae was created by trimming with rose-head burs, a small flap of temporalis fascia or muscle was inserted in the gap to prevent bony reunion. • Now the horizontal cortical osteotomy of the sagittal split was made. This cut was continued down the external oblique ridge to the second molar region. • The lateral vertical cortical osteotomy was started just distal to the second molar and was extended to the inferior border of the mandible. • Then to initiate the actual plane for the split, a thin, straight osteotome and a bone splitter were alternately malleted into the area parallel to and just beneath the lateral cortex.
  • 8. • After condylectomy and bsso, the mandible was pulled forward and rotated into a reasonable position for restoring the occlusion. • The coronoid process graft was rotated 180o and the former anterior border of the segment was alligned with the post border of the ramus. • The tip of the coronoid process graft was also alligned in the newly fashioned glenoid fossa and fixed to the ramus with a microplate and screws. • If both the buccal and lingual cortices were not strong enough or if their overlap was inadequete, a fibular bone graft was used to stabilize the segments. • A maxillo-mandibular fixator was used for six weeks.
  • 9.
  • 10. RESULTS • All patients mouth opening and aesthetic appearances were found to be satisfactory. • Both mentolabial and mentocervical angles had returned to normal shape in late examinations. • The alignment between middle 3rd and lower 3rd of the face had become normal after 1 or 2 years. • In 5 cases, the OSAS disappeared completely immediately after surgery. • One pt only had a interincisal opening of 10mm after 1 year that was related to his poor compliance with mouth opening exercises.
  • 11. DISCUSSION • Bilateral tmj ankylois developing during the active growth period is often complicated by development of secondary changes such as the body and ascending rami fail to develop, the chin recedes, and the coronoid process is markedly elongated and thickened. • The temporalis muscle is stronger and hypertrophic, and the suprahyoid muscle group is shorter and hypertrophic. • Respiration can be severly jeopardized, causing snoring and OSAS. • The method chosen for the reconstruction of the ramus and condyle in a pt with tmj ankylosis not only should provide a functional joint but also help restore the facial profile.
  • 12. • Autogenous costochondral rib grafts have been used as a substitute for mandibular ramus and condyle, • Several studies have shown that in children costochondral grafts have the potential to grow. However, this factor alone doesnot mean that growth will always proceed normally . • Growth of these grafts is unpredictable, ranging from resorption to overgrowth and sometimes necessating secondary surgical procedure. • The coronoid process of patients with long standing tmj ankylosis is longer and thicker so it could be used to take the place of the condyle and lengthen the mandibular ramus, thus avoiding a second surgical site.
  • 13.