Ankylosis of the temporomandibular joint: causes, symptoms, diagnosis, treatment

Ankylosis of the temporomandibular joint is a fibrous or bony fusion of the articular surfaces, causing partial or complete disappearance of the joint space.

If the patient has extra-articular (contracture) bone formations along with intra-articular (ankylosing) adhesions, we should talk about a combination of ankylosis of the temporomandibular joint with contracture of the lower jaw. Such a diagnosis also requires an appropriate surgical intervention plan.

Based on the classification of bone and joint diseases in children (M. V. Volkov), N. N. Kasparova calls the condition of fibrous adhesion of articular surfaces (i.e. fibrous ankylosis of the TMJ), combined with gross deformation of the condylar process (its shortening and conglomerate growth), secondary deforming osteoarthrosis (SDAO). Based on this circumstance, we divide fibrous ankylosis into two subgroups, which have the right to independent nosological forms:

1. uncomplicated fibrous ankylosis and
2. complicated (by deformation) fibrous ankylosis, which can also be called secondary deforming osteoarthrosis or ankylosing contracture.

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What causes temporomandibular joint ankylosis?

The cause of intra-articular adhesions may be infectious osteoarthritis and trauma, including birth trauma; in isolated cases, joint stiffness is observed, which occurs even before the birth of the child. It is customary to divide ankylosis into acquired and congenital, inflammatory and traumatic.

In children, ankylosis most often develops as a result of purulent otitis media, which occurs in connection with some infectious disease (scarlet fever, mumps, etc.).

Ankylosis may also develop (in both children and adults) in connection with arthritis of any other etiology. According to available data, in peacetime about 30% of ankylosis occurs as a result of damage to the condylar process of the lower jaw and the glenoid fossa of the temporal bone during falls, blows to the chin area and injuries during childbirth; 22% - due to secondary septic damage to the joint in purulent otitis; 13% - due to damage to the head of the lower jaw by osteomyelitis; gonorrheal, rheumatic, deforming arthritis are the cause of ankylosis in 13% of patients. According to our clinic, in 13% of patients the cause of ankylosis is birth trauma, in 25% - household trauma (blows, falls), in 47% - osteomyelitis of the condylar processes, hematogenous, otogenic and other etiology, in 7% - polyarthritis; In 7-8% of patients the cause is not established.

Traumatic ankylosis usually develops after closed fractures of the condylar process of the mandible. After open, especially gunshot, injuries, ankylosis occurs less often.

Sometimes ankylosis develops as a result of an unresolved dislocation of the lower jaw. In infants, traumatic ankylosis may occur due to damage to the joint when forceps are applied during childbirth.

The mechanism of development of ankylosis and secondary deforming osteoarthrosis is presented in the diagram below.

The mechanism of development of bone ankylosis after a fracture of the neck of the lower jaw in children can be imagined as follows: the displaced head of the lower jaw retains epiphyseal growth zones, which continue to function - producing new bone tissue, which gradually fills the mandibular fossa, fuses with it and leads to ankylosis.

Damage to the growth zones explains the subsequent underdevelopment of the corresponding jaw branch; if it is not damaged, then microgenia develops due to the fact that the "energy" of the growth zone is spent on the formation of a bone conglomerate: the larger and more massive it is, the more underdeveloped the jaw branch is in its height. Therefore, to prevent post-traumatic ankylosis in children, it is recommended to carefully compare and securely fix the fragments of the jaw branch.

Pathological anatomy of ankylosis of the temporomandibular joint

In ankylosis developing in childhood and adolescence, most often there is a bone fusion of the articular surfaces, and in more mature age - fibrous. This is due to the fact that in children the head of the lower jaw is covered with a relatively thin hyaline cartilage, and the articular disc does not yet consist of cartilage, but of collagen connective tissue. In addition, the mandibular fossa and articular tubercle in them are lined only with periosteum and are devoid of cartilaginous cover. This determines the rapid completion of the destructive process in the articular cartilages, exposure of the articulating bones and the formation of a bone adhesion between them.

In adulthood, the periosteum and perichondrium of the temporomandibular joints are replaced by fibrous cartilage, and the disc is transformed into dense fibrous cartilage. As a result of their slow destruction, abundant scar fibrous tissue is formed. These anatomical and histological age-related changes determine the more frequent fibrous (rather than bony) fusion in the joints of adult patients.

Often, the acute inflammatory process in the joint spreads to the adjacent bones and soft tissues, which subsequently leads to a violent proliferative process with the development of coarse cicatricial and bone adhesions that extend far beyond the joint capsule. Thus, extensive synostosis of the temporal bone, its zygomatic process and the entire upper section of the lower jaw branch develops.

The combination of cicatricial or bone contracture of the lower jaw with ankylosis of the joint, which we tend to call "complicated bone ankylosis" or ankylosic contracture, is found in the literature under the name of widespread ankylosis. In this conglomerate, it is sometimes impossible to even approximately determine the true contours of the head and notch of the lower jaw, which is sometimes so smoothed that it is impossible to insert an injection needle or probe between it and the lower edge of the zygomatic arch.

The earlier the pathological process in the joint develops in the patient, the more pronounced is the secondary deformation of the entire lower jaw, especially on the affected side. This is due to damage to the growth zones in the area of the jaw branch and adynamia (absence of chewing function) of the lower jaw, as well as the pulling action of the group of muscles attached to its chin section. As a result, there is a unilateral underdevelopment of the lower jaw branch, shortening of the body and displacement of its chin section; in the area of the angle of the jaw, a pathological curvature of its lower edge appears in the form of a spur.

Underdevelopment of the lower jaw entails a delay in the development of the remaining facial bones and their deformation, in particular, deformation of the upper jaw and upper dentition.

Symptoms of temporomandibular joint ankylosis

Congenital ankylosis is extremely rare. According to available data, up to 80% of ankylosis of the temporomandibular joint develop in children under 10-15 years of age. However, many patients are admitted to medical institutions much later.

Ankylosis can be complete and partial, bony and fibrous, unilateral (about 93%) and bilateral (about 7%).

An essential symptom of ankylosis is a persistent, complete or partial limitation of mouth opening, i.e., a limitation of lowering the lower jaw and a complete absence of horizontal sliding movements in the affected joint. According to some authors, complete immobility of the lower jaw with bilateral bone ankylosis is observed in 50% of patients, and with unilateral - in 19%. Some authors explain the ability to open the mouth in patients with bone ankylosis by the elasticity of the lower jaw itself, while others - by the presence of a more or less significant layer of fibrous tissue in the bone conglomerate that has walled up the joint.

In our opinion, the possibility of some abduction of the frontal section of the lower jaw is due, first of all, to the elasticity of its angular sections, as well as to the incomplete filling of the joint cavity with bone adhesions.

The degree of mobility of the head of the lower jaw is determined by palpating it in front of the tragus of the ear and through the anterior wall of the external auditory canal. In fibrous ankylosis, the doctor feels a barely noticeable mobility of the head of the lower jaw, which is not the case with synostosis. However, despite the complete synostosis in the affected joint, there is still some mobility of the head of the lower jaw on the healthy side, although it is insignificant. This is possible due to the elasticity of the entire mandibular bone.

Sometimes, in cases of recurrent ankylosis, a persistently fixed open bite is observed. This is usually a consequence of a relapse after surgery, in which a significant fragment of the jaw branch is resected, or the result of improper fixation of the lower jaw after surgery, as well as improperly performed mechanotherapy, when the patient pays attention only to opening the mouth.

When examining an adult patient who developed ankylosis in childhood, a marked growth retardation of the affected half of the lower jaw and the entire corresponding half of the face is found. However, even in children with ankylosis, facial asymmetry is noticeable due to the displacement of the chin and tip of the nose to the affected side, a decrease in all sizes of the affected half of the body and the branch of the lower jaw (unilateral micrognathia or mandibular retrognathia). In addition, the auricle on the affected side may be located lower than on the healthy side. As a result, the healthy half of the face looks sunken and flattened. The chin is displaced to the affected side, which, due to the placement of the normal volume of soft tissue in the area of the reduced body and branch of the lower jaw, seems more rounded and creates the impression of being healthy. Therefore, there are cases when an inexperienced doctor takes the healthy side for the diseased one and even undertakes an operation on the healthy joint. In this regard, it is necessary to carefully determine the main dimensions of the lower jaw on both sides.

If both joints are affected in childhood, bilateral microgenia develops, characterized by the so-called bird face, i.e. a sharp underdevelopment of the entire lower part of the face.

In the case of ankylosis development in an adult whose skeletal formation has already ended, the delay in the development of the lower jaw is insignificant or completely absent.

As a result of prolonged ankylosis, the functions of nutrition and speech are severely impaired, especially in bilateral fibrous and bone ankylosis. In these cases, due to insufficient opening of the mouth, the intake of food of normal consistency is completely or almost completely excluded. Patients eat liquid or mushy food through a narrow gap between the dental arches, through a gap in the place of a missing tooth or a retromolar gap; they have to wipe bread with a finger through the gaps between the teeth.

According to mastication studies, ankylosis is characterized by a crushing type of chewing, a decrease in the frequency of chewing movements (up to 0.4-0.6 per 1 sec), and a loss of chewing efficiency that ranges from 17-98%.

Bioelectrical activity of the masticatory muscles (BAM) on the diseased and healthy sides is very different and depends on the extent of cicatricial changes in the joint and surrounding tissues; in cases where bone or fibrous adhesions are localized in the joint itself, BAM on the diseased side is always higher than on the healthy side, and when scars have spread to the muscles and soft tissues surrounding the joint, BAM on the diseased side is lower than on the healthy side. In bilateral ankylosis, BAM is almost the same on both sides.

The inability to normally eat and chew food leads to the development of gingivitis, pathological gum pockets, the deposition of large amounts of tartar, multiple dental caries and fan-shaped displacement of teeth.

Such patients are usually weakened, emaciated and have an unhealthy complexion; most of them have low or zero acidity of gastric juice due to impaired gastric secretion. However, in some cases, patients adapt well to such conditions of food intake and their nutrition is almost not affected. The speech of patients with ankylosis is impaired and difficult.

Treatment and removal of teeth when the jaws are completely closed is either very difficult or completely impossible.

In case of vomiting (due to intoxication, intoxication), such patients are at risk of aspiration and asphyxia.

Underdevelopment of the jaw leads to the tongue sinking during sleep on the back, as a result of which it is completely impossible to sleep in this position or sleep is accompanied by the strongest snoring. Constant lack of sleep leads to exhaustion of the nervous system, the patient becomes irritable, loses weight and loses working capacity.

The structure of the lower jaw is characterized by a chaotic bone pattern and the absence of functional orientation of the bone beams to varying degrees.

Mandatory radiographic signs in patients with bone ankylosis are the complete or partial absence of the joint space, the transition of the structure of one bone to another, and the absence of an image of the contours of those parts of the bones that form the joint.

If ankylosis developed long ago (in early childhood), the radiograph will show a shortening and thickening of the muscular process, a “spur” in the area of the angle of the lower jaw, and the presence of an unerupted lower 7th or 8th tooth in the area of its branch.

The notch of the lower jaw is reduced, merges with the processes of the branch of the lower jaw or has an acute-angled shape.

In fibrous uncomplicated or complicated ankylosis, the joint cavity is narrowed, but over most or even over its entire length it is quite clearly contoured; the head and neck of the lower jaw in uncomplicated fibrous ankylosis may thicken somewhat or retain their normal shape, while in complicated ankylosis (i.e., secondary deforming arthrosis), the head of the lower jaw is either already destroyed or represents a shapeless conglomerate of overgrown bone tissue, separated from the temporal bone by a narrow strip of the joint cavity.

Complications of ankylosis of the temporomandibular joint

Complications are divided into those that arise during the operation, soon after the operation, and at a later date. The most common complication during the operation is damage to the branches of the facial nerve and large vessels. Damage to the branches of the facial nerve is especially common when accessing the temporomandibular joint through a subzygomatic incision (according to A.E. Rauer) and with a typical submandibular access. Therefore, we recommend using the above-described access according to G.P. Ioannidis.

During skeletonization of the mandibular branch, osteotomy and separation of bone fragments, significant bleeding is possible due to injury to veins and arteries. There are known cases of severe arterial bleeding, which required ligation of the external carotid artery or tight tamponade of the wound surface and even suspension of the operation.

The literature describes cases of injury to the cerebral vessels caused by a chisel that slipped (during osteotomy of a branch) and penetrated into the cranial cavity.

In the early postoperative period, the most common complication is inflammation, suppuration in the area of the operation (phlegmon, abscess, osteomyelitis), which is usually associated with a rupture of the oral mucosa and infection of the wound. Paresis or paralysis of the marginal branch of the lower jaw of the facial nerve, etc. are also possible.

After operations involving the reduction and extension of the displaced jaw by means of an extramedullary clamp (according to A. A. Limberg), marginal osteomyelitis of the lower jaw may occur; after an operation involving the interposition of the stalked flap tissue (according to A. A. Limberg), there may be a rupture of the oral mucosa, significant venous bleeding, suppuration of the wound near the extramedullary clamp, and damage to the trunk of the facial nerve; after operations involving the insertion of bioplastic (according to L. M. Medvedev), there may be an allergic reaction to foreign protein; temporary paresis of the marginal branch of the lower jaw of the facial nerve is also possible.

Even targeted postoperative inflammation prevention in patients by using antibiotics is not always successful. Therefore, strict adherence to aseptic and antiseptic requirements during surgery (including and above all - preventing perforation of the oral mucosa) is the key to wound healing by primary intention after the elimination of TMJ ankylosis.

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Differential diagnosis of ankylosis of the temporomandibular joint

Uncomplicated bone ankylosis must be differentiated from bone contracture of the lower jaw (see above), as well as from mechanical obstructions to opening the mouth. Obstructions may be caused by a tumor (osteoma, odontoma, sarcoma, etc.) in the area of the branch of the jaw, the tubercle of the upper jaw, or the zygomatic bone. Therefore, to establish a final diagnosis, a thorough digital examination (with the index finger inserted between the tubercle of the upper jaw and the branch of the lower jaw of the patient, and the lateral wall of the pharynx palpated) and radiography should be performed.

In fibrous, bone or bone-fibrous contracture of the lower jaw, not combined with ankylosis, the limitation of its mobility is caused by extra-articular fibrous or bone contractions or growths.

The diagnosis of ankylosis should be based on anamnesis data (identification of the etiological factor and dynamics of the disease), clinical and radiographic examination, namely:

1. persistent complete or partial limitation of movement in the temporomandibular joint;
2. deformation of the condylar process;
3. changes in the size and shape of the lower jaw on the affected side;
4. presence of radiographic signs of ankylosis.

When examining the joint area, it is necessary to pay attention to the presence of scars on the skin (traces of injury or inflammation), postoperative scars behind the auricle (due to mastoiditis, otitis) and pus discharge from the external auditory canal, as well as the position of the auricles, the chin section of the lower jaw and the level of its lower edge on the diseased and healthy sides. These and other data are analyzed when describing the clinical symptoms of ankylosis.

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Treatment of ankylosis of the temporomandibular joint

Treatment of ankylosis should be started as early as possible, preferably in the phase of fibrous intra-articular adhesions. This prevents the development of severe secondary deformations of the entire facial part of the skull.

The surgeon's task is to restore the mobility of the lower jaw, and in the case of a combination of ankylosis and microgenia (retrognathia), to correct the shape of the face.

Ankylosis is treated only surgically, with additional orthodontic and orthopedic measures prescribed.

Local and general changes in the body of a patient with ankylosis of the temporomandibular joint (changes in the structure of the skeleton, bite, position of the teeth; disorders of the cervical spine; the presence of inflammatory changes in the mucous membrane of the oral cavity, etc.) to one degree or another complicate the conditions for endotracheal intubation, affect the choice of induction anesthesia and determine the characteristics of the course of the immediate postoperative period.

According to the available data, the indices of external respiration function in patients with ankylosis change already in the pre-anesthesia period: the respiratory volume decreases by 18-20%, the minute volume of respiration increases to 180+15.2, the vital capacity of the lungs decreases to 62%, and the oxygen utilization coefficient to 95%. Therefore, anesthetic support for surgery for TMJ ankylosis can only be entrusted to a very well-trained anesthesiologist with sufficient experience in anesthesia in children and adults with disorders of the maxillofacial region. He must also be well trained as a resuscitator in order to take emergency measures in case of respiratory arrest, cardiac arrest, shock and collapse in difficult local conditions (the mouth does not open, the patient's head does not throw back, the nasal passages are obstructed, etc.) and in the presence of pre-operative dysfunctions of vital organs in the patient.

With complete jaw closure, the most acceptable, safe for the patient and convenient for the surgeon is nasotracheal intubation of patients "blindly" with local anesthesia of the mucous membrane of the upper respiratory tract (with spontaneous breathing of the patients). With nasal intubation, there is no need to use tubes of a smaller diameter than with oral intubation, inflate cuffs and tamponade the pharynx.

If the mouth opening is possible within 2-2.5 cm, the most rational method is the nasotracheal intubation method using direct laryngoscopy and a flat spatula-shaped blade.

The most common complications during induction of anesthesia and intubation in patients with ankylosis and contracture of the lower jaw are hypoxia, bleeding, trauma to the mucous membrane of the pharynx, a sharp decrease in hemoglobin saturation, and a decrease in blood pressure.

To prevent bleeding and injury during intubation in patients with significant contractures of the sternomental region and ankylosis of the temporomandibular joint, it is necessary to use special techniques and instruments (e.g., spatula-shaped laryngoscope blades, tracheal signalers and indicators, auscultation of the chest, fitting of endotracheal tubes, appropriate positioning of the head, oxygenographic and EEG monitoring). Equipment for determining the depth of anesthesia plays a certain role.

In case of difficult intubation of the trachea through the nose due to limited opening and deformation of the mouth, the method of nasotracheal intubation through a guidewire proposed by P. Yu. Stolyarenko, V. K. Filatov and V. V. Berezhnov (1992) can be used: against the background of induction anesthesia with barbiturates with muscle relaxants and artificial ventilation of the lungs, a puncture of the trachea is made in the area of the cricoid-thyroid membrane with a hemotransfusion needle; in this case, the needle is directed towards the nasopharynx, and a guidewire made of polyamide thread (fishing line) with a diameter of 0.7 mm and a length of 40-50 cm is inserted through its lumen. After passing through the glottis, the fishing line is wound into a ball in the mouth. Then a rubber catheter with a blunt metal hook on the end is inserted through the nasal passage. The fishing line is captured by rotational movements of the catheter and removed through the nose. Then an intubation tube is passed through it into the trachea. The guide line is removed.

Intubation through a tracheostomy is indicated in patients with significant curvature of the nasal septum, cicatricial fusion and atresia of the nasal passages with a sharp displacement of the larynx, upper sections of the trachea, etc.

In patients with ankylosis and contracture of the lower jaw, its position changes after the operation, it moves, as a result of which the upper respiratory tract moves. All this, combined with edema, the inability to open the mouth (therapeutic immobilization), significantly worsens the function of external respiration in the near future after the operation. In such cases, the question of the timing of tracheostomy closure can be decided 36-48 hours after the operation.

The choice of surgical intervention method is a complex task, as it is dictated by a number of circumstances outlined above.

All modern surgical methods used to treat ankylosis can be divided into the following main groups:

1. exarticulation of the head of the mandible, the entire condylar process or the condylar and coronoid processes together with the underlying section of the jaw branch and their subsequent replacement with an auto-, allo- or xenogenic bone or osteochondral transplant, a metal, metal-ceramic or other explant;
2. osteotomy along the line of the former joint cavity or in the area of the upper third of the branch of the lower jaw, followed by modeling the head of the lower jaw and covering it with some kind of cap-gasket;
3. dissection or rupture of scars formed inside the joint capsule, lowering the condylar process downwards.

Treatment of uncomplicated fibrous ankylosis

Redressing of the lower jaw

The rupture of fibrous adhesions formed in the joint (the so-called redressal) is a "bloodless" operation. Surgeons have different opinions about this method of treatment.

Some authors quite rightly believe that attempts to achieve mouth opening and lower jaw mobility by forcibly spreading the jaws with a mouth expander under general anesthesia or subbasal anesthesia are useless and harmful. Having discovered foci of chronic inflammation in the thickness of the affected condylar process, they believe that redressation, causing increased load on the diseased joint, promotes increased bone formation processes in the thickness and on the surface of the head of the lower jaw and thereby promotes the development of bone ankylosis. We share this point of view. However, there are authors who believe that in some cases of fibrous ankylosis such intervention gives a stable good result. Therefore, we present here the redressation technique.

Under general anesthesia or after carefully administered potentiated local anesthesia, a metal spatula or flat osteotome is inserted into the area of the oval opening between the premolars. Gradually, trying to place the instrument on its edge, the gap between the dental arches is widened to the extent necessary for inserting the Geister mouth expander.

Having installed the mouth expander between the incisors, slowly move its cheeks apart, achieving such an opening of the mouth, which makes it possible to fix the second mouth expander next to the first between the upper and lower premolars. In this case, it is necessary to simultaneously insert the mouth expander on both the diseased and healthy sides. However, after the jaws are spread between the antagonist incisors by 2 cm, further opening of the mouth is performed using the mouth expander only on the diseased side, in order to avoid dislocation in the healthy joint.

After the jaws are spread by 3-3.5 cm (between the antagonist incisors), a spacer made of quick-hardening plastic is installed between the molars for 48 hours. The spacer is made directly during the operation (if a mouth gag is present). In the next 1-2 days after redressing, the patient usually complains of pain in both the affected and healthy joints. In this regard, analgesics must be prescribed.

In order to prevent an outbreak of a dormant infection, antibiotic therapy must be administered before and after forced opening of the mouth. Active and passive functional therapy (therapeutic exercises) is prescribed 2-3 days after the operation, which includes the following measures:

1. cancellation of the postoperative gentle diet and appointment of a general diet;
2. 1-1.5 weeks after using the common table - increased chewing load (it is recommended to eat raw carrots, nuts, fresh cucumbers, apples, etc. - in accordance with the possibilities of the season);
3. active, strictly dosed gymnastic exercises under the guidance of a specially trained exercise therapy specialist against the background of the use of functional orthodontic devices, rubber spacers, plastic wedges-spacers on molars, etc. It should be remembered that an overdose of muscle load can cause pain with subsequent reflexive persistent stiffness of the lower jaw, caused by the protective contraction of the masticatory muscles; excessive load on young scar tissue can stimulate the processes of bone tissue formation in the osteotomy zone and, consequently, lead to a relapse of ankylosis.

Dissection of fibrous adhesions inside the joint

Dissection of fibrous adhesions inside the joint and lowering of the head of the lower jaw are indicated in cases of unilateral fibrous ankylosis and after unsuccessful attempts at “bloodless” opening of the mouth.

The operation is performed under general anesthesia or potentiated regional subbasal anesthesia of the branches of the trigeminal nerve that innervate the joint and the soft tissues around it.

Through an incision according to A.E. Rauer or G.P. Ioannidis, the joint capsule is opened with a scalpel, the cicatricial disc and surrounding scars are removed.

If this intervention does not achieve a sufficient degree of mouth opening (2.5-3 cm), the end of a metal spatula or osteotome can be placed into the joint cavity and the operation can be supplemented by breaking the adhesions that have formed on the inner surface of the joint.

After the operation, a spacer is installed between the large molars on the operated side and intermaxillary elastic traction is applied for 5-6 days to move the head of the lower jaw away from the bottom of the mandibular fossa. After 6 days, the traction and spacer are removed, and active and passive functional therapy is prescribed.

Treatment of bone ankylosis and secondary deforming osteoarthrosis

In each operation for bone ankylosis, the following principles must be observed: performing the osteotomy higher, i.e. closer to the level of the natural joint cavity; maintaining the height of the jaw branch, and if it is shortened, bringing its height to normal dimensions.

The level of osteotomy and the nature of arthroplasty are determined by radiographic data, which are checked during surgery by examining the bone in the wound area.

In case of severe asymmetry of the lower jaw (due to unilateral microgenia), it is necessary to set its chin section in a normal median position, and eliminate the resulting submandibular cavity.

In case of bilateral ankylosis, which has caused severe bilateral microgenia, the entire mobilized lower jaw should be pushed forward to eliminate the disfigurement of the facial profile (“bird face”), improve the conditions for biting and chewing food, ensure normal breathing conditions and relieve the patient from tongue retraction during sleep.

Bony adhesions are visible only within the joint capsule, head of the mandible and mandibular fossa. The articular tubercle of the temporal bone is defined. Microgenia is not expressed.

Bony fusions within the joint and posterior part of the mandibular notch. The articular tubercle of the temporal bone is not determined. Microgenia is not expressed.

Bony fusions in the area of the joint and the entire notch of the lower jaw. Microgenia is absent.

Bone fusions in the area of the joint and the entire notch of the lower jaw are supplemented by bone growth in front of the anterior edge of the branch of the jaw. Microgenia is expressed moderately; it is necessary to move the branch of the jaw forward by no more than 10-12 mm. The same, but microgenia is sharply expressed; it is necessary to move the lower jaw by 13-20 mm and fill the resulting postmandibular depression (after moving the jaw forward).

Oblique osteotomy at the level of the neck of the mandible with interposition of de-epidermized skin or tunica albuginea or sclerocorneal membrane.

The same at the level of the base of the condylar process.

Horizontal osteotomy and formation of the head of the lower jaw with interposition of the sclerocorneal membrane.

Arthroplasty using an autocoronoid process or arthroplasty with an autojoint from the foot using the method of V. A. Malanchuk, the endoprosthesis of Yu. E. Bragin, or M. and E. Sonnenburg, I. Hertel or the porous implant of F. T. Temerkhanov

1. Arthroplasty using auto-, allo- or xenoplastic rigid lengthening of the branch and body of the mandible.
2. Suspension "arthroplasty" according to the method of V.S. Yovchev.
3. Explantation of a metal or metal-ceramic prosthesis of the temporomandibular joint or arthroplasty with an autojoint according to the method of V. A. Malanchuk, with an endoprosthesis by Yu. E. Bragin, or M. and E. Sonnenburg, I. Hertel or a porous implant by F. T. Temerkhanov.

Arthroplasty using the method of P. P. Lvov

The incision for access to the ankylosed joint begins 1.5-2 cm below the earlobe, bordering the angle of the jaw, runs parallel to the edge of the lower jaw (stepping down from it by 2 cm) and ends approximately at the level of the middle of the body of the jaw. Through this incision, the attachment sites of the masseter and medial pterygoid muscles are exposed.

Stepping back 0.5 cm from the angle of the lower jaw, the tendons of these muscles are crossed with a scalpel. Together with the periosteum, the muscles are separated to the zygomatic arch, first from the outside, and then from the inside.

In this case, the inferior alveolar artery is damaged at the entrance to the foramen mandibulae. The resulting bleeding quickly stops after tight tamponade for 3-5 minutes or after applying a catgut ligature. Thus, the outer and inner surfaces of the mandibular branch are exposed.

Circular saws, spear-shaped and fissure burs are used for osteotomy, fixed in the straight tip of the drill or in the clamp of the device for processing bone tissue. In case of excessively massive thickening of the bone, it is difficult or impossible to perform osteotomy using only a circular saw or spear-shaped and fissure burs; in such cases, an osteotome is used.

To avoid injury to the separated masseter muscle with a circular saw, the assistant, using, for example, a Farabeuf hook or a Buyalsky scapula, pushes the muscle outward together with the parotid salivary gland. To prevent the saw from tearing the soft tissues on the inner side of the jaw branch, the second assistant holds the Buyalsky scapula between the bone and the soft tissues.

The next task is to lower the underdeveloped branch of the lower jaw down and interpose a material into the bone gap that would imitate articular cartilage and meniscus (disk). To do this, the angle of the jaw is grasped with a bone holder and pulled down, or a Heister mouth expander or a wide spatula is inserted into the bone gap and the bone edges of the wound are spread apart to the required distance (1.5-2.5 cm).

The greater the degree of underdevelopment of the jaw branch on the diseased side before the operation, the more the gap in the area of the bone wound needs to be widened. Only under this condition can good cosmetic and functional results be achieved. In addition, increasing the separation of bone fragments reduces the risk of recurrence of ankylosis.

When lowering the jaw and moving it forward (if there is microgenia), there is sometimes a risk of rupture of the oral mucosa and infection of the wound. To prevent this, use a curved raspater to carefully separate the soft tissues from the anterior edge of the jaw branch and the retromolar triangle down to the lower wisdom tooth.

In very pronounced microgenia, if it is necessary to significantly move the lower jaw forward, it is necessary to resect a section of bone from the area of the anterior section of the branch of the jaw, and in some cases even remove the upper 8th tooth on the side of the ankylosis. This eliminates the risk of rupture of the mucous membrane in the area of the pterygomaxillary fold or the appearance of a pressure sore between this tooth and the anterior edge of the branch of the lower jaw after surgery.

If, despite all measures taken, a rupture of the mucous membrane occurs, the rupture site is sutured with at least a two-row catgut suture.

In case of significant shortening of the lower jaw branch and forced large spreading of bone fragments in the osteotomy area, as well as in case of necessity of significant forward movement of the chin (in order to restore its normal position), it is sometimes impossible to completely eliminate the perforation communication of the external wound with the oral cavity. In such cases, it is necessary to tamponade the wound of the mucous membrane from the oral cavity side with iodoform gauze, which is gradually removed on the 8-10th day after the operation.

In case of bilateral bone ankylosis, arthroplasty is performed on both sides.

If there is bone ankylosis in one joint and fibrous ankylosis in the other, arthroplasty is performed on the bone side, and on the second side, a rupture or dissection of the fibrous adhesions is performed.

Measures for preventing relapse of ankylosis during surgery using the method of P. P. Lvov

Bone spurs and protrusions remaining in the cut gap, especially in the posterior and internal parts of the wound, promote the formation of bone tissue and relapse of ankylosis. Therefore, having completed the lowering of the jaw, the surgeon must smooth the edges of the bone wound on the lower (lowered) and upper fragments of the jaw branch and model its head using straight cutters driven by a bone processing device. After this, the wound must be thoroughly washed to remove bone chips from it, which can stimulate the formation of bone tissue.

The periosteum of the lower jaw, covering the bone at the site of osteotomy, also contributes to the recurrence of ankylosis. Therefore, to suppress the ability to osteopoiesis, it is desirable to excise or coagulate it in this area.

Careful hemostasis, which is very difficult to achieve in a slit-like wound, also greatly helps to prevent recurrence of ankylosis. Nevertheless, it is necessary to stop bleeding from both large and small vessels. For this purpose, temporary tamponade of the wound with gauze soaked in a solution of hydrogen peroxide or in a hot isotonic solution of sodium chloride is used. It is also possible to use a hemostatic sponge, powder or solution of aminocaproic acid (on a tampon), which have a well-defined hemostatic effect in capillary hemorrhages.

The articular surfaces of the normal temporomandibular joint are covered with cartilage and separated by an articular cartilaginous disc. In the area where the osteotomy was performed, these structures are absent. Therefore, surgeons have long been looking for a material that could be interposed between bone fragments to imitate the missing tissues and prevent the fusion of the sawn bone. As early as 1860, Vernenil, and in 1894, Helferich and other authors proposed artificial interposition of soft tissues. Thus, Helferich used a flap (on a pedicle) from the temporal muscle.

As interposed material, it was proposed to use flaps from the masseter and gluteal muscles, a fascial or fascial-fat flap from the temporalis muscle area, a flap from the broad fascia and adjacent subcutaneous tissue of the thigh, freely transplanted subcutaneous tissue or the skin itself, a skin-fat flap, a piece of costal cartilage, acrylic and other plastics, in particular silicone silastic (Rast, Waldrep, Irby, 1969), etc. We present some of the methods currently in use.

Arthroplasty according to A. A. Limberg

The author uses an interosseous graft made from the connective tissue base of V. P. Filatov's stalk flap, which has the above-mentioned qualities and, in addition, eliminates the recession of soft tissues behind the jaw branch (after its forward movement).

For this purpose, a Filatov stem of sufficient length (at least 25-30 cm) is used. After appropriate training, one end is transplanted to the hand, and the other, over time, to the area of the angle of the lower jaw. After 3-4 weeks, the stem leg is cut off from the hand and transferred to a symmetrical area in the area of the other angle of the lower jaw. As a result, the stem hangs in the form of a gentle arc under the lower jaw.

After both legs of the stem have firmly taken root (about 3-4 weeks), a bilateral osteotomy of the branches of the lower jaw is performed, the bone surfaces at the site of the osteotomy are smoothed with a cutter and the wound is cleaned (washed) of bone shavings.

The stem is cut with a transverse median incision into 2 equal parts, they are de-epidermized and each end is inserted into the corresponding gap at the site of the osteotomy.

Each half of the stem is completely immersed under the skin, so de-epidermization must be carried out along the entire length of the stem.

Rubber spacers (pads) are placed between the opposing molars on both sides; contact between the opposing incisors is achieved using intermaxillary elastic traction or a chin sling.

Arthroplasty according to Yu. I. Vernadsky

The interposed material is a freely transplanted de-epidermized skin flap, completely devoid of subcutaneous tissue (since it is soon absorbed).

If it is necessary to significantly separate the jaw fragments, a sufficiently thick (two- or three-layer) pad can be made from the flap and placed between them; the posterior end of this pad is used to fill the resulting depression behind the branch of the lower jaw.

The de-epidermized flap is strengthened by fixing it with thick catgut sutures to the remains (edges) of the masseter and medial pterygoid muscles, left specifically for this purpose at the edge of the angle of the jaw. This method compares favorably with the above-described method of A. A. Limberg, since it does not require multi-stage surgical intervention associated with the procurement, migration and engraftment of the stem.

The disadvantage of the method of Yu. I. Vernadsky is the traumatic nature and duration of the operation, although this is compensated by its one-time nature.

To reduce the duration of the operation, it is recommended to perform it by two groups of surgeons: while the first group performs osteotomy of the jaw branch and formation of a new joint, the second de-epidermizes the area of skin to be excised, excises it and sutures the wound on the donor site (usually on the anterior surface of the abdomen).

The operation using this method is carried out against the background of gradual (drip) compensatory blood transfusion.

As shown by the experimental research data of our employee V. F. Kuzmenko (1967), interposed autogenous skin reliably protects the ends of the jaw bone fragments from fusion.

Already one month after the operation, a dense bone plate (like a closing one) is visible at the ends of the bone (along the cut line), the formation of which ends by the end of the 3rd month.

Histologically, the fibrous structures of the dermis, freely transplanted and placed between bone fragments in the experiment, change little during the first 3 months after the operation. Then, under the influence of the load, they become sclerotic, coarsened and transformed into dense fibrous tissue. Along with this, by the end of the first week, the remains of the subcutaneous tissue become necrotic; constant atrophy and death of the cellular elements of their appendages are also observed.

The de-epidermized flap fuses with the bone and surrounding muscles by the end of the first week, but the first small areas of fusion between the two layers of skin appear only a month after the operation.

Subsequently, the layers of skin do not grow together completely; small slit-like spaces remain, devoid of lining or lined with flat epithelium, which apparently serve as a joint cavity.

The above changes in the interposed skin depend significantly on the load on it. This is confirmed by the fact that the changes occurring in the skin outside the interposition (in the retromaxillary region) are of a somewhat different nature: the fibrous structures of the skin here remain little changed for a longer period of time, and the cellular elements also retain their viability for a much longer period of time. In addition, it was in the skin located outside the osteotomy gap that small cysts were observed on individual preparations prepared after the animal was killed, 3 months after the operation.

No cysts formed in the interposed skin.

Clinical experience and histological data confirm the possibility of using autoderm as a lining material and for leveling the submandibular depression that occurs after the forward movement of the lower jaw.

Arthroplasty according to the first method of G. P. Vernadskaya and Yu. I. Vernadsky

Based on the available data on arthroplasty of large joints using the protein coat of the testicle (of bulls) and our observations, we can conclude that this type of interposition material is also quite applicable in arthroplasty of the temporomandibular joint.

Since the use of Filatov's stem is associated with repeated additional trauma to the patient, and the size of the bull's testicle significantly exceeds the size of the modeled head of the lower jaw (and therefore they have to be reduced in size and sutured during the operation), we have proposed the use of xenogenic sclerocorneal membrane for arthroplasty, which has a number of advantages, namely: it is smaller in size than the protein membrane of the testicle and has a cartilaginous consistency; if it is necessary to create a wider gasket, 2-3 scleras can be placed on the head of the lower jaw.

After extraoral exposure of the mandibular branch, the mandibular head is mobilized or a horizontal osteotomy is performed at the border of the upper and lower sections of the mandibular branch. The mandibular head is then modeled (from the lower fragment of the osteotomized mandibular branch) and covered with a cap made of bovine sclerocorneal membrane.

To prevent the sclerocorneal cap from shifting during the movement of the lower jaw head, it is fixed with sutures (from chromic catgut) to the edge of the masseter muscle, left in the area of the angle of the lower jaw during its intersection. Then, the wound is sutured layer by layer; a graduate is left in the corner for 1-2 days.

If some displacement of the chin to a more symmetrical position is required, jaw traction is usually carried out through a block on a special beam or it is fixed to a rod mounted in a plaster or foam rubber (according to V. F. Kuzmenko) head cap.

After the operation, a spacer is inserted between the molars of the operated side, and after the stitches are removed, active and passive functional joint therapy is immediately prescribed.

This method of treatment, indicated for uncomplicated fibrous and bone ankylosis not associated with microgenia, is advantageously distinguished by the fact that the lining material used is not autogenous material, the transplantation of which is associated with causing additional trauma to the patient (for example, broad fascia of the thigh, de-epidermized skin, the middle part of the Filatov stem), but xenogenic tissue - the sclerocorneal membrane. Unlike the protein membrane of the bull's testicles, this material can be taken from any cattle. Preservation of the xenogenic sclerocorneal membrane is carried out in the usual way, for example, with the help of solution No. 31-e of A.D. Belyakov, which includes: sodium citrate (1.0), glucose (3.0), furacilin (0.01), ethyl alcohol 95% (15.0), sodium bromide (0.2) and distilled water (85.0).

A good addition to osteotomy and the use of a particular pad is chemical or thermal treatment of bone sections. Some authors recommend burning the ends of bone fragments with fuming nitric acid (for 1-2 minutes until browning) followed by neutralization with a saturated solution of sodium bicarbonate. For this purpose, use a regular wooden stick or a metal probe, the end of which is wrapped in cotton wool reinforced with thread. Border soft tissues should be protected with gauze swabs.

You can also use pyocid, which is applied with small cotton balls to the surface of bone cuts. Pyocid causes a slight burn of the bone substance, suppresses osteopoiesis and thus prevents relapse of ankylosis. If you do not have pyocid, you can treat the bone with a diathermocoagulator or a plugger heated in an alcohol lamp, 96% alcohol, a concentrated solution (1:10) of potassium permanganate, etc.

After the ends of the bone fragments have been chemically or thermally treated, and one or another interposing material has been introduced and secured into the osteotomy gap, all separated tissues are placed back in their original place and the upper end of the separated masticatory muscle is sutured slightly above its previous position.

When eliminating ankylosis and the often accompanying microgenia (retrognathia), it should be taken into account that all soft tissue pads of biological origin are eventually absorbed and replaced by connective tissue, the volume of which is significantly less than the volume of the pad placed by the surgeon. In this regard, the branch of the lower jaw, gradually "shortening", returns almost or completely to its previous position, and this entails a relapse of microgenia (retrognathia) and the associated asymmetry of the chin.

Long-term extension of the lower jaw, as well as lowering of its head in children, or osteotomy of the jaw branch and wide separation of fragments according to A. A. Limberg (1955) only for a short time provide a median position of the chin, maintaining the illusion of cosmetic well-being for the doctor and the patient. Over time, recurrent facial asymmetry begins to bother the patient or his parents, and sometimes there is a need for additional operations (contour plastic surgery, osteoplastic lengthening of the jaw body) to give symmetry to the face.

In this regard, in recent years surgeons have been trying to use (in the presence of a combination of ankylosis and microgenia) spacers made of more durable biological material (bone, bone-cartilage auto-, allo- or xenografts) or metal, metal-ceramic prosthetic explants, or to use a step-shaped protrusion of the branch of the lower jaw (to lengthen its height), etc.

Arthroplasty using the method of V. S. Yovchev

The operation is a so-called "suspension" arthroplasty of the temporomandibular joint, which is used to eliminate ankylosis and microgenia in adults.

After exposing the branch of the lower jaw through the submandibular approach, a step-like osteotomy is performed in the upper third.

The jaw is moved forward and to the healthy side, the stump of the coronoid process and the stepped protrusion of the branch are connected with a suture (polyamide thread). To eliminate the resulting retromandibular depression, a piece of allogenic cartilage is sutured along the posterior edge of the branch of the lower jaw.

Although the operation is called arthroplastic, in fact, no joint is recreated.

Arthroplasty according to the method of V. I. Znamensky

The operation consists of the fact that after separation from the scars and osteotomy, the jaw branch is moved to the correct position and then secured with an allogeneic cartilage graft, which is sutured along the posterior edge of the branch.

The proximal end of the transplant is formed in the form of a head and placed with an emphasis on the mandibular fossa.

Arthroplasty using the method of G. P. Ioannidis

The operation is performed as follows. A 6-7 cm long skin incision is made behind the angle of the lower jaw, 0.5-1.0 cm below the earlobe, and extended into the chin area, 2.5 cm from the lower edge of the jaw.

The submandibular incision is made lower than usual, so that after the lowering of the branch of the lower jaw, the scar is not on the cheek, as when using a conventional submandibular incision, but under the lower edge of the jaw.

Thanks to the low incision, it is possible to avoid injury to the marginal branch of the facial nerve of the lower jaw.

After dissecting the soft tissues, the masseter and internal pterygoid muscles are separated from their attachment sites at the edge of the lower jaw with scissors in such a way that the periosteum does not separate from the bone.

The osteotomy of the mandibular ramus is performed with a Gigli saw or a regular wire saw. To do this, a Kerger needle is inserted 1 cm in front of the tragus of the auricle at the lower edge of the zygomatic arch. The sharp end of the needle slides first along the posterior edge of the mandibular ramus, and then along its inner surface. Bypassing the anterior edge of the ramus in this way, the end of the needle is brought out onto the cheek below the zygomatic bone. A Gigli saw is tied to the needle with a thick silk thread. After this, the Kerger needle is removed and a Gigli saw is pulled in its place.

The branch is cut as high as possible - in the area of the upper third of the branch of the lower jaw - approximately 35 mm below the notch of the lower jaw.

During osteotomy, a metal spatula is used to displace the soft tissues behind and below the branch of the lower jaw, which protects them from injury and prevents bleeding.

Kerger needles are selected during surgery according to the thickness and width of the lower jaw branch.

This osteotomy method is characterized by its ease and speed of execution (30-60 sec).

The lower fragment of the branch is pulled down as much as possible with a single-tooth hook. On the remaining upper fragment, the thin bone bridge that formed between the coronoid process and the upper bone mass is sawn (to separate them).

The upper bone mass is removed using a bur and a chisel. The chisel is positioned parallel to the base of the skull or even at a slight angle from bottom to top, which can always be done through a submandibular incision.

Depending on the extent of bone adhesions, the coronoid process is left or removed. If removal of the upper bone mass is technically impossible, a deep cavity is formed in its center and a piece of allochondria is placed in it, creating a kind of artificial cavity.

In some patients, after deep cutting with a bur, the upper bone mass is removed with nippers, if possible.

This intervention allows for the complete destruction of growth zones remaining in the area of the upper bone mass, and eliminates the possibility of new bone formation from its remains (i.e. relapse of ankylosis).

Therefore, the author considers removal of the upper bone mass mandatory in young patients (under 20-25 years of age), especially in cases of traumatic ankylosis and relapses of ankylosis of any etiology. In older patients, osteotomy alone may be sufficient.

After this, a depression is created - a bed in the area of the lower bone mass of the jaw (by removing the spongy bone to a depth of 1-1.5 cm) and a modeled bone-cartilage allograft from the rib is placed into it (d, e; indicated by the arrow).

If the bed is wide enough, the bone portion of the graft, 1-1.5 cm long, is placed in it completely; if the bed is narrow, the bone portion of the graft is split longitudinally, with one half of the graft placed in the bed and the other on the outer surface of the lower jaw.

Both methods provide good fixation of the transplant and do not require additional osteosynthesis. During modeling, the cartilaginous part of the transplant is rounded.

When determining the size of the osteochondral allograft of the mandibular branch, it is necessary to take into account the size of the removed bone mass and the degree of shortening of the affected jaw branch.

Thus, as a result of the operation, the length of the branch of the lower jaw on the affected side corresponds to the length of the branch on the healthy side, and the pseudoarthrosis is located almost at the level of the natural one.

The branch lengthened after transplantation and the entire jaw are shifted to the healthy side and forward; in this case, the chin is moved to the middle and its recession to the back is significantly reduced.

As a result of the forward displacement of the lower jaw, a noticeable depression of soft tissues occurs in the retromaxillary space on the diseased side, to eliminate which a piece of allochondria is transplanted, equal in length to the length of the branch of the lower jaw and approximately 1.5-2 cm wide; the transplant is attached to the periosteum of the branch of the jaw and the soft tissues at the posterior edge of the branch of the lower jaw.

After the operation is completed, rubber or plastic spacers are inserted between the molars, and the jaws are connected using dental wire splints with hook loops in a state of hypercorrection for 30-40 days.

As a result of the operation, the attachment points of the masticatory muscles move in relation to the advanced lower jaw, and its prolonged fixation promotes the strong growth of these muscles in new places, which is a necessary condition for the stable retention of the jaw in a new position.

A similar technique is used in the treatment of bilateral ankylosis of the temporomandibular joint, with the only difference being that the operation is performed on both sides (on the same day).

Before and after surgery, general and local exercise therapy and physiotherapy are used.

Arthroplasty according to the method of A. M. Nikandrov

After resection of the entire bone conglomerate in the area of the altered joint, a rib autograft consisting of a part of the rib and 2 cm of cartilage with a growth zone between them is introduced into the resulting defect.

From the cartilaginous part, a semblance of the head of the lower jaw is formed (indicated by the arrow), which is inserted into the mandibular fossa.

The graft should be of such length and width that it is possible to lengthen the underdeveloped branch of the jaw and move it forward to give the chin a symmetrical (median) position.

The transplant is fixed with a bone suture.

Immobilization of the lower jaw (for 25-30 days) is carried out using dental wire splints; after their removal, active mechanotherapy is used.

According to the available data, transplant growth is possible while preserving its growth zones, as well as autotransplant growth in children. This circumstance is of great importance for maintaining facial symmetry in the long term after operations in children, when in the case of using allo- or xenobone it is necessary to give the chin a hypercorrection position.

Arthroplasty according to the method of N. A. Plotnikov

Access to the joint is obtained through a semi-oval skin incision, starting 1.5-2 cm below the earlobe, going around the angle and continuing into the chin area, where it is led 2-3 cm below the edge of the lower jaw, taking into account the shortening and lowering of its branch.

The tissues are dissected layer by layer down to the bone. The tendons of the masseter muscle are not cut off from the bone, but separated together with the outer plate of the compact substance of the lower jaw. For this purpose, a linear incision is made along the lower-inner edge of the angle of the jaw, i.e., at the border of the attachment of the masseter and medial pterygoid muscles, the tendon-muscle fibers are dissected and cut off from the lower edge of the bone.

In the area of the lower edge of the angle of the lower jaw and the anterior edge of the masseter muscle, using a drill, a circular saw or ultrasound, a cut is made in the outer plate of the compact substance of the lower jaw, which is separated together with the muscle attached to it using a thin, wide, sharp chisel.

On the remaining section of the jaw branch (along its outer and inner surfaces) along its entire length to the zygomatic arch, the soft tissues are separated subperiosteally with a raspatory.

To create a receptive bed for the transplant, the remaining plate of compact substance is removed from the outer surface of the jaw branch in an even layer using a milling cutter until bleeding points appear.

The level of intersection of the mandibular branch is determined by the nature and extent of pathological changes in the bone. Thus, in case of fibrous or bony fusion of only the head of the mandible with the articular surface of the temporal bone, resection of the condylar process (condylectomy) is performed; the bone is dissected with a wire saw in an oblique direction through the notch of the mandible backwards and downwards.

If, after excision of the condylar process, the traction of the temporal muscle prevents the lowering of the branch of the jaw, then osteotomy is also performed at the base of the coronoid process.

In case of massive bone growths, when the condylar and coronoid processes form a single bone conglomerate, a transverse osteotomy is performed in the upper third of the lower jaw, as close as possible to the joint. A special sharp long trephine is used for this purpose. A series of through holes are made with a drill, which are connected with a triangular surgical cutter. After the jaw branch is crossed, it is shifted downwards and the cut surface of the bone is leveled with a cutter.

The removed portion of the lower jaw (above the osteotomy) should be as large as possible to get closer to the location of the joint under normal conditions.

In some cases, it is possible to completely remove the altered head of the lower jaw. If the bone conglomerate extends to the base of the skull, the upper jaw and the mandibular fossa, there is no need to remove it completely: in these cases, the bone tissue is removed by cutting with various cutting instruments to a level located slightly below the articular tubercle of the temporal bone.

At the level of the natural articular surface, a new semi-oval-shaped articular surface is formed using a spherical cutter. Its surface must be carefully "polished".

In front of the articular surface, to prevent dislocation, a bony tubercle is created, preventing the forward displacement of the head of the lower jaw. (The author believes that due to this, the head of the lower jaw can perform not only hinge movements, but also, to some extent, translational movements).

If necessary, the jaw branch is lowered, and the jaw itself is shifted to the healthy side so that the chin is located in the correct position along the midline.

Taking into account the subsequent growth of the healthy half of the jaw in children and adolescents, their bite is set with some hypercorrection. In this position, the jaw is fixed with a splint.

To replace the resulting defect of the head of the lower jaw after removal of its upper fragment, a preserved lyophilized allograft from the branch of the lower jaw is used together with the head (c), and in some cases with the coronoid process. A plate of compact substance is removed from the inner surface of the transplant, corresponding to the recipient's bone bed.

A receptive bed is also created on the side of its outer surface (in the area of attachment of the outer plate of the compact substance with the chewing muscle).

The graft taken from a cadaver must include the angle of the mandible in its entire width so that it can simultaneously not only lengthen the branch, but also create an angle of the jaw, and also compensate for the missing part of the bone in the area of the posterior edge of its branch due to the forward movement of the jaw.

The jaw defect is replaced with a transplant so that its head coincides with the joint surface created during the operation.

The preserved coronoid process of the lower jaw is connected to the coronoid process of the transplant.

The second end of the transplant is connected to the end of the recipient's jaw in an overlapping manner and is firmly secured with two wire sutures. The coronary processes are fixed with fishing line or chromic catgut.

The tendons of the medial pterygoid muscle and the masseter muscle with the bone plate are attached not to the angle of the jaw, but behind it to the posterior edge of the branch of the jaw, i.e. without changing the length of the muscles, in order to reproduce their physiological tension. Preserving the integrity and physiological tension of these muscles undoubtedly has a positive effect on the chewing function. Antibiotics are injected into the wound and it is sutured layer by layer.

In case of bilateral ankylosis of the TMJ, a similar operation is performed simultaneously on the other side.

In cases where ankylosis is combined not only with retrognathia, but also with an open bite, simultaneous intervention on both joints is indicated. In this case, after osteotomy of the branches, the lower jaw can be moved in any direction to give the bite the correct position. After fixing the jaw with dental splints, bone grafting is performed first on one side and then on the other. During this period, the lower jaw is fixed to the upper jaw.

After the operation, a spacer is placed in the area of the last teeth on the side where the condylar process was removed for 5-7 days. After its removal, the patient begins to gradually develop active jaw movements against the background of functional therapy.

This method is very effective, but has one significant drawback - its use requires the presence of a lyophilized cadaveric branch of the lower jaw (one or two), which makes the method practically inaccessible to most modern clinics. After the creation of a bone bank supplying all clinics with the necessary plastic material, this method can be considered the most acceptable.

Arthroplasty according to the method of N. N. Kasparova

After exposing the angle and branch of the jaw (through a submandibular incision), an osteotomy of the branch is performed, surgical sanitation of the oral cavity is performed, dental splints are made and the jaw is fixed in the correct position.

For osteoplastic replacement of the mandibular branch defect, which occurs due to its lowering and forward movement in order to normalize the contours of the lower part of the face, an allograft from the outer plate of the compact substance of the tibia is used. Its size should allow the lower jaw to be moved to the correct position in relation to the upper jaw and provide reliable support for the lower jaw in the newly created joint. The position of the chin and the state of the bite serve as a reference point.

The application of the graft to the outer surface of the lowered branch of the lower jaw provides a sufficient area of contact between the bone fragments and eliminates the flattening of the body of the lower jaw. The upper edge of the graft is given a hemispherical shape and fixed with a stainless steel wire suture, providing static compression and immobility of the adjacent bone surfaces.

The new articular surface must have such a shape and size as to prevent dislocation of the joint when opening the mouth.

The wound is sutured layer by layer, but a rubber drain is left for 24 hours; an aseptic bandage is applied.

After surgery, prophylactic antibacterial (anti-inflammatory), dehydration and desensitizing therapy is prescribed.

The lower jaw is fixed (one day after the operation, performed under anesthesia) for a month. After the fixation is removed, therapeutic sanitation of the oral cavity, functional therapy, orthodontic correction of the bite are indicated.

Arthroplasty according to the II method of G.P. and Yu.I. Vernadsky

Arthroplasty using auto-, allo- or xenograft has a number of disadvantages, namely: additional trauma to the patient due to the removal of a rib fragment or the search for a suitable human or animal corpse for taking a transplant; preservation, storage and transportation of allo- and xenografts; the possibility of an allergic reaction of the patient to foreign donor tissue.

In children, surgical intervention involving the taking of an autograft (usually from a rib) may be more difficult than the main operation and in all cases prolongs the patient's stay on the operating table. To this should be added such additional negative factors of autotransplantation as additional blood loss, the possibility of injury to the pleura or peritoneum (if a rib or iliac crest is resected), suppuration of an additional wound resulting from the operation of taking an autograft from the patient's bone, a decrease in the child's body resistance, an increase in the patient's stay in the hospital, the expenditure of staff time, medications and dressings for additional dressings in the area of the transplant, etc.

At the same time, autograft is the most suitable material for lengthening the lower jaw.

To avoid additional trauma to the patient during autotransplantation (rib fragment or other bone), we recommend using the coronoid process on the affected side, which is usually significantly hypertrophied (2-2.5 times).

As our subsequent studies showed, on the affected side the amplitude of biopotentials of the masticatory muscle itself is sharply reduced and the bioelectrical activity of the temporal muscle is increased. This may explain the excessive development of the coronoid process of the lower jaw on the affected side in ankylosis.

Previously, this process was cut off from the branch of the jaw and from the temporal muscle and thrown away, but, as it turned out, it can be utilized as an autograft.

Operation technique

The surgical technique is as follows. The mandibular branch is exposed extraorally; a step osteotomy of the mandibular branch is performed in the usual way or with the step-shaped nippers we have proposed, during which the coronoid process is resected and temporarily placed in an antibiotic solution.

After a step osteotomy of the condylar process (at the level of its base), the branch of the jaw is moved forward until the chin is set in the middle position (in an adult patient) or with some hypercorrection (in a child) and the jaw is fixed in this position with dental splints or another orthopedic method.

The severed coronoid process is used as a graft to create a condylar process. For this purpose, a groove (gutter) is formed in the coronoid process, and the upper-posterior section of the edge of the jaw branch is decorticated using a burr. The groove of the coronoid process and the decorticated section of the jaw branch are aligned, perforated in two sections with a spear-shaped bur, and connected with a double suture of synthetic thread or tantalum wire.

Thus, by using the usually hypertrophied coronoid process, the height of the underdeveloped branch of the lower jaw is extended and increased, and since the coronoid process connects to the branch of the lower jaw from behind, it simultaneously moves forward horizontally, and the face acquires symmetry.

If there is no need for a step osteotomy of the articular process, and only the condylar process is lowered (in case of uncomplicated fibrous ankylosis), then it is “finished off” (supplemented) and thus lengthened by connecting with the transplanted coronoid process. For this, the coronoid process is resected with forceps that horizontally cut its base, i.e. with forceps that have straight cutting edges rather than step-shaped ones.

If the microgenia in an adult is not very pronounced, and the branch of the lower jaw is underdeveloped only in the vertical direction, then to increase its height, the coronoid process can be connected to the branch not overlapping at the back, but end-to-end at the top.

The free plane of the jaw branch in the area of the osteotomy can be cauterized with electrocautery, phenol, pyocide, or covered with a xenogenic sclerocorneal membrane, which is secured with catgut.

After surgery, the following rehabilitation measures are necessary:

1. maintaining a spacer between the molars on the side of the operation for 25-30 days to ensure rest of the operated branch of the jaw for the fusion of the coronoid process with the branch of the lower jaw;
2. active functional exercises of the lower jaw (starting from the 25th-30th day) to create normal myostatic reflexes;
3. prescribing a general diet at home after discharge from the clinic;
4. implementation, if necessary, after 4-5 months of orthodontic correction of the bite using known methods.

The described technique of step osteotomy and autoplasty for the combination of ankylosis of the temporomandibular joints and microgenia can be used in both adults and children.

One of the advantages of this method is a sharp decrease in the risk of recurrence of ankylosis and deformation of the lower jaw for two reasons: firstly, because the transplanted coronoid process, covered with a powerful bone plate, provides the possibility of early functional therapy and creates conditions for long-term retention of the middle section of the lower jaw in the correct position (until the completion of complete or partial self-regulation of the bite); secondly, because the osteotomy of the branch is performed using a biting (not drilling or sawing) instrument, i.e. without the formation of many bone chips and small fragments that have the ability of osteogenetic growth and stimulation of the development of a new bone conglomerate.

If it is necessary to significantly increase the height of the underdeveloped branch of the lower jaw, we propose using not only the coronoid process, but also its continuation below - the external cortical plate of the branch (within its upper 2/3).

In the case of simultaneous elimination of ankylosis and microgenia (retrognathia), it is possible to use the method proposed by Yu. D. Gershuni, which consists in the fact that after osteotomy of the branch of the lower jaw near the ankylosed joint, mobilization, traction and fixation of the lower jaw in the postoperative period are carried out using his devices for the treatment of fractures of the lower jaw. Compared with existing ones, this method has the following advantages: it ensures reliable fixation of the lower jaw after its movement to the correct position and makes it possible to begin functional treatment in the early postoperative period; allows for the creation of a reliable separation between the bone ends in the area of the forming pseudoarthrosis during the entire period of traction; eliminates the need for the use of interposed material, the use of intraoral splints or bulky (for sick children) head caps.

Arthroplasty according to the method of V. A. Malanchuk and co-authors

It is performed in cases of bone and fibrous ankylosis, combined or not combined with microgenia. In the order of further development of experimental studies by O. N. Stutevelle and P. P. Lanfranchi (1955), V. A. Malanchuk has been successfully using the II, III or IV metatarsal bone with the metatarsophalangeal joint as an autotransplant in our clinic since 1986. In 11 patients (out of 28), additional lengthening of the jaw body was required (second stage).

In case of fibrous ankylosis, the first stage of treatment was lengthening the body of the jaw.

Postoperative care of the patient

The patient must be provided with a varied, energy-rich and vitamin-rich diet; during the first 2 weeks after the operation, the patient is fed liquid food through a tube placed on the spout of a drinking cup.

After each meal, the oral cavity should be irrigated with a potassium permanganate solution (1:1000) from an Esmarch mug or syringe. At the same time, care should be taken to ensure that the bandage does not get wet or contaminated with food residue. Therefore, before irrigation, the patient is given a special light plastic apron, which should fit tightly to the base of the lower lip. If the bandage gets wet, it is immediately removed, and the suture line is lubricated with alcohol and covered with a sterile bandage.

In case of extraoral traction of the lower jaw using a bone clamp or a polyamide thread strand threaded through the chin area of the bone, it is necessary to carefully monitor the sutures at the base of this clamp or the place where the thread exits every day to prevent infection from penetrating the soft tissues and bone. To do this, both the rod (thread) itself and the skin around it are treated with alcohol every day, after which the base of the rod and the sutures around it are covered with a strip of iodoform gauze, secured with adhesive tape.

To prevent osteomyelitis in the area of the osteotomized ends of the lower jaw branch, broad-spectrum antibiotics are prescribed for the first 6-7 days after surgery. The sutures are removed on the 7th day after surgery.

After simple unilateral osteotomy with interposition of a soft pad, active mechanotherapy is performed from the 5th day, after bilateral - from the 10th-12th, and 20 days after the operation, both active and passive (hardware) mechanotherapy are used. It is used to achieve not only maximum mouth opening in patients, but also closure of the teeth and lips. If an open bite is already noted in the first 2-3 weeks after the operation, it is necessary to systematically install an intermaxillary or chin-sling traction at night (according to the A. A. Limberg method), fixed to the head cap, as well as a spacer between the antagonist molars (on the side of the operation) for 30-40 days. As a result of the action of the intermaxillary spacer and the chin sling (or intermaxillary traction), a two-arm lever is created: the angle and branch of the lower jaw are lowered downward, and its chin section is displaced upward.

To ensure constant jaw spreading, one can also successfully use N. N. Yezhkin's method, which consists of the following: a rubber plate folded in half, 5 cm long and 2 cm wide, is placed between the molars. The thickness of the plate should be equal to half the distance between the upper and lower molars with the lower jaw lowered as far as possible. To prevent the plate from slipping off the teeth, it is wrapped in gauze and then inserted between the molars with the curved side facing backwards. Patients wear such a plate around the clock, removing it only during meals and oral hygiene. In some cases, to increase the degree of jaw spreading, plates are inserted on both sides. As the mouth opens more, the plates are replaced with thicker ones.

In cases where active mechanotherapy does not produce a noticeable effect, it should be supplemented with so-called passive exercises. For this, rubber plugs, rubber tubes folded in half or three, rubber or wooden wedges, plastic screws, and special mouth expanders are used.

A. V. Smirnov proposed an apparatus consisting of two splints or orthopedic (impression) trays filled with impression mass. Two arched springs made of steel wire (about 2-3 mm in diameter) are attached to the side surfaces of the splints or trays, thanks to which the apparatus presses evenly on the upper and lower dental arches, moving the jaws apart. The trays of the apparatus are pre-filled with stens to ensure sufficient rigidity of its fixation on the teeth.

The dynamics of the increase in the degree of mouth opening must be documented in millimeters, determined using a special triangular measuring device, which must be installed in front of the same antagonist teeth each time; the data obtained are recorded in the medical history, and at home - in a notebook.

Functional and cosmetic results of ankylosis treatment

The results of treatment should be taken into account only after a sufficiently long period, since about 50% of ankylosis relapses occur during the first year after surgery; the rest develops much later - over 2 and 3 years. In some cases, ankylosis relapses occur 3 years after surgery and even after 5-6 or more years.

According to the available data, relapse of ankylosis is observed in an average of 28-33% of patients. However, the true number of relapses of ankylosis is much higher, since it is necessary to take into account those cases that the authors were unable to record for technical reasons, as well as undetected cases of incomplete reduction of the jaws after surgery (in which the patient is more or less satisfied with the degree of mouth opening).

As clinical studies have shown, the frequency of relapses of ankylosis depends on the surgical technique (the level of osteotomy, the nature of the interposed material, the mobility of the lower jaw achieved during the surgery), complications during and after the surgery (ruptures of the oral mucosa, bedsores on it, bleeding, suppuration, hematomas, etc.), the correct management of the postoperative period with the use of antibiotics, traction, mechanotherapy, etc.

Ankylosis usually recurs in cases where the lower jaw was not sufficiently mobilized during surgery, i.e. the mouth opened only 1-2 cm.

A high percentage of relapses was noted after the use of plastic as an interosseous spacer (73%), all layers of skin or placental membrane preserved according to the method of N. S. Kharchenko (66.6%), as well as in cases where interposition was not performed at all (50%).

After interposition of the de-epidermized skin flap according to the method of Yu. I. Vernadsky, there were no immediate unsatisfactory outcomes. The amount of mouth opening achieved during the operation and soon after (for 5 years) was maintained or, which was observed more often, gradually increased by 0.3-0.5 cm. In cosmetic terms, this method of operation also proved to be more effective. As a rule, after the operation, the patient could open his mouth by 3-4 cm.

A study of even more remote treatment results (after 8-15 years) showed that some patients (5 out of 21) had a relapse of ankylosis, a sign of which, however, was conventionally considered to be opening the mouth less than 1.8 cm. The cause of the relapse in these cases could be errors in the technique of arthroplasty, accidental rupture of the oral mucosa, infection of the wound (during the lowering of the jaw branch) and the associated inflammation, which limited postoperative mechanotherapy, as well as tissue rupture and inevitable hemorrhage during redressing of the stiff joint on the side opposite to the operation.

After using the xenogenic membrane of the bull's testicles as a lining, a relapse of ankylosis in the late postoperative period may be due to the impossibility of establishing a spacer between the jaws due to the pronounced loosening of the milk teeth or the development of a phlegmonous process in the area of inflammation.

After arthroplasty using a sclerocorneal membrane spacer and an autogenous coronoid process spacer, no recurrence of ankylosis was observed in the next 5 years after surgery (patients are being monitored).

The cosmetic effect of the operation is determined by the extent to which it was possible to give the chin the correct (middle) position, as well as to eliminate facial asymmetry in the parotid areas.

As indicated above, the depression behind the lower jaw, which occurs after bringing its branch forward, can be filled with a de-epidermized Filatov stem or a freely transplanted de-epidermized skin flap, completely devoid of subcutaneous tissue; allogeneic or xenogenic cartilage, etc.

Sometimes, to eliminate facial asymmetry, they resort to plastic implantation, free transplantation of subcutaneous tissue or cartilage on the healthy side (to eliminate the flatness of its lower section).

Outcomes of temporomandibular joint arthroplasty

The outcomes of arthroplasty depend on the complications that arise during and shortly after the operation. The use of soft tissue pads does not eliminate facial asymmetry, especially with the mouth open. In this regard, it is necessary to use various types of prostheses and splints (such as Vankevich, Weber, etc.), as well as contour plastic surgery, including that based on the reconstruction of the branches and body of the lower jaw.