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

Ankylosis of temporomandibular joint - fibrous or bone fusion of articular surfaces, causing partial or complete disappearance of the joint gap.

In the presence of the patient along with the intra-articular (ankylosing) adhesions, and also the extraarticular (contracture) bone formations, one should speak about the combination of ankylosis of the temporomandibular joint with the contracture of the lower jaw. Such a diagnosis requires an appropriate surgical intervention plan.

Based on the classification of bone and joint diseases in children (MV Volkov), N. N. Kasparova refers to the state of fibrous adhesion of articular surfaces (ie fibrous ankylosis of the TMJ), combined with a coarse deformity of the condylar process (its shortening and conglomeration overgrowth) , secondary deforming osteoarthritis (ODD). On the basis of this circumstance, we divide fibrotic ankylosis into two subgroups that have the right to self-sustaining nosological forms:

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

[1], [2], [3], [4]

What causes ankylosis of the temporomandibular joint?

The cause of intraarticular battles may be infectious osteoarthritis and trauma, including birth defects; in isolated cases there is stiffness in the joint, which occurs even before the birth of the child. It is accepted to divide ankyloses into acquired and congenital, inflammatory and traumatic.

In children, ankylosis develops most often as a result of purulent otitis caused by an infectious disease (scarlet fever, mumps, etc.).

The development of ankylosis is also possible (both in children and adults) due to arthritis of any other etiology. According to available data, in peacetime, about 30% of ankylosis occurs as a result of damage to the muscular process of the lower jaw and the joint fossa of the temporal bone during falls, shocks to the chin and injuries during childbirth; 22% - due to secondary septic joint damage with purulent otitis; 13% - due to osteomyelitis of the head of the lower jaw; gonorrheal, rheumatic, deforming arthritis are the cause of ankylosis in 13% of patients. According to our clinic, in 13% of patients the cause of ankylosing is birth trauma, 25% have a domestic trauma (strokes, falls), 47% have osteomyelitis of condylar processes, haematogenic, otogenous and other etiologies, 7% have polyarthritis; in 7-8% of patients the cause is not established.

Traumatic ankylosis usually develops after closed fractures of the condylar process of the lower jaw. After open, especially gunshot, damage ankylozirovanie occurs not so often.

Sometimes ankylosis develops as a result of unplanned dislocation of the lower jaw. In infants, traumatic ankylosis can occur due to joint damage when applying forceps during childbirth.

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

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

The damage to the growth zones is due to the subsequent underdevelopment of the corresponding branch of the jaw; if it is not damaged, the microgeny develops because the "energy" of the growth zone goes to the formation of the bone conglomerate: the bigger it is, the more massive, the more the branch of the jaw is underdeveloped in its height. Therefore, in order to prevent posttraumatic ankylosis in children, it is recommended to carefully compare and securely fix fragments of the jaw branch.

Pathological anatomy of ankylosis of temporomandibular joint

With ankylosis developing in childhood and young age, most often the bone fusion of articular surfaces occurs, 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 comparatively thin hyaline cartilage, and the articular disk is not made up of cartilage, but of collagenous connective tissue. In addition, the mandibular fossa and articular tubercle are lined only with the periosteum and are devoid of cartilaginous cover. This determines the rapid completion of the destructive process in the articular cartilage, exposure of the articulating bones and the formation of bone adhesions between them.

In adulthood, the periosteum and perichondria of 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 tissue is formed. These anatomo-histological age changes determine more frequent fibrous (and not bone) fusion in the joints of adult patients.

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

The combination of scar or bone contracture of the lower jaw with ankylosis of the joint, which we tend to call "complicated bone ankylosis", or ankylosing contracture, occurs in the literature under the name of widespread ankylosis. In this conglomerate, it is sometimes impossible even to roughly determine the true contours of the head and the mandibular incision, which is sometimes so flat that it is impossible to insert an injection needle or probe between it and the lower edge of the zygomatic arch.

The earlier the patient developed the pathological process in the joint, the stronger the secondary deformity of the entire lower jaw is expressed, especially on the diseased side. This is due to the damage to the growth zones in the jaw branch area and adynamics (lack of chewing function) of the mandible, as well as the pulling action of the muscle group attached to its chin. As a result, one-sided underdevelopment of the mandibular branch is observed, shortening of the body and displacement of its chin; in the region of the angle of the jaw, the 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 bones of the face and their deformation, in particular the deformation of the upper jaw and the upper dentition.

Symptoms of ankylosis of temporomandibular joint

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

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

An indispensable symptom of ankylosis is a persistent full or partial restriction of the opening of the mouth, that is, a restriction of lowering the lower jaw and a complete absence of sliding movements in the affected joint horizontally. According to some authors, complete immobility of the lower jaw with bone bilateral ankylosis is noted in 50% of patients, and in unilateral - in 19%. The possibility of opening the mouth in patients with bone ankylosis is explained by some authors by the elasticity of the lower jaw, and others by the presence of a more or less significant layer of fibrous tissue in the bone conglomerate that immured the joint.

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

The degree of mobility of the head of the lower jaw is determined by its palpation in front of the tragus of the ear and through the front wall of the external auditory canal. In fibrotic 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, the mobility of the head of the lower jaw remains, albeit insignificant, on the healthy side. This is possible due to the elasticity of the entire mandibular bone.

Sometimes, in cases of recurrence of ankylosis, there is a stably fixed open bite. This is usually the result of a relapse after surgery, in which a significant fragment of the jaw branch is resected, or the result of incorrect fixation of the mandible after surgery, as well as improperly conducted mechanotherapy, when the patient pays attention only to opening the mouth.

When examining an adult patient whose ankylosis developed in childhood, they exhibit a marked delay in growth of the affected half of the lower jaw and the entire corresponding half of the face. However, in children with ankylosis, the asymmetry of the face is noticeable due to the displacement of the chin and the tip of the nose to the sore side, reducing all the dimensions of the affected half of the body and the mandibular branch (unilateral microgenia or mandibular retrognathy). In addition, the auricle on the sore side can be located lower than on the healthy one. As a result, the healthy half of the face looks sunken and flattened. The chin is displaced to the sore side, which, due to the placement of the normal volume of soft tissues in the area of the reduced body and mandibular branch, seems more rounded and creates the impression of being healthy. Therefore, there are cases when an inexperienced doctor takes a healthy side for a patient and even undertakes an operation on a healthy joint. In this regard, you need to carefully determine the main dimensions of the lower jaw from both sides.

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

In the case of development of ankylosis in an adult who has already completed the formation of the skeleton, a delay in the development of the lower jaw is negligible or completely absent.

As a result of prolonged ankylosing, the function of nutrition and speech is sharply disrupted, especially with bilateral fibrotic and bone ankylosis. In these cases, due to insufficient opening of the mouth, food intake of a normal consistency is completely or almost completely eliminated. Patients eat liquid or mushy food through a narrow gap between the dentition rows, through a gap in the place of the missing tooth or a posterolar gap; they have to rub their fingers through the crevices between their teeth.

According to the data of masticiography, ankylosis is characterized by a crushing type of chewing, a decrease in the frequency of masticatory movements (up to 0.4-0.6 in 1 s), a loss of chewing efficiency fluctuating within 17-98%.

The bioelectrical activity of the masticatory muscles (BADM) on the diseased and healthy sides is very different and depends on the degree of spread of the cicatricial changes in the joint and surrounding tissues; in cases where bone or fibrous adhesions are localized in the joint itself, BAJM is always higher on the diseased side than on the healthy one, and when the scars have spread to the muscles and surrounding soft tissue, BAJM is lower on the diseased side than on the healthy side. With bilateral ankyloses BAJM is almost the same on both sides.

Impossibility of normal reception and chewing food leads to the appearance of gingivitis, pathological gingival pockets, to the deposition of a large amount of calculus, multiple tooth damage by carious process and fan-shaped dislocation of teeth.

Such patients are usually weakened, depleted and have an unhealthy complexion; most of them have a decreased or zero acidity of gastric juice due to a violation of gastric secretion. However, in some cases, patients are well adapted to such conditions of food intake and their nutrition is almost not disturbed. The speech of patients with ankylosis is disturbed and difficult.

Treatment and removal of teeth with complete reduction of the jaws is very difficult, or completely impossible.

In the case of vomiting (with intoxication, intoxication) such patients are threatened with aspiration and asphyxia.

Underdevelopment of the jaw causes the tongue to fall asleep during sleep on the back, which makes it impossible to sleep in this position, or the sleep is accompanied by the strongest snoring. Constant lack of sleep leads to the exhaustion of the nervous system, the patient becomes irritable, loses weight and loses efficiency.

The structure of the lower jaw is characterized by chaotic bone pattern, the lack of a functional orientation of the bone beams in varying degrees.

Obligatory radiographic signs in patients with bone ankylosis are full or partial absence of the joint gap, the transition of the structure of one bone to another and the absence of images of the contours of those parts of the bones that form the joint.

If ankylosis developed long ago (in early childhood), the x-ray will determine the shortening and thickening of the muscular process, the "spur" in the angle of the lower jaw, the presence of an unsharpened lower 7 or 8 tooth in the region of its branch.

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

With fibrotic uncomplicated or complicated ankylosis, the articular cavity is narrowed, but it is sufficiently clearly contoured at a greater or even throughout its length; the head and neck of the lower jaw with uncomplicated fibrous ankylosis may somewhat thicken or maintain its normal shape, while in the case of complicated (ie, with secondary deforming arthrosis) the head of the lower jaw is either already destroyed, or is a formless conglomerate of enlarged bone tissue, Separated from the temporal bone by a narrow band of the articular cavity.

Complications of ankylosis of temporomandibular joint

Complications are divided into those arising during the operation, shortly after the operation and at a later date. The most common complication during surgery is damage to the branches of the facial nerve and large vessels. Especially often, damage to the branches of the facial nerve is observed when accessing the temporomandibular joint through the subcutaneous incision (according to AE Rauer) and with typical submandibular access. Therefore, we recommend the use of the access described above by GP Ioannidis.

During skeletonization of the mandibular branch, osteotomy and bone fragments, significant bleeding can occur due to injury of veins and arteries. There are cases of severe arterial bleeding, to stop which you had to resort to bandaging the external carotid artery or to a tight tamponade of the wound surface and even to suspend the operation.

In the literature, cases of wounding the cerebral vessels that have slipped (during the osteotomy of the branch), a chisel penetrated into the cavity of the skull, are described.

In the early postoperative period, the most frequent complication is inflammation, festering in the operation area (phlegmon, abscess, osteomyelitis), which is usually associated with 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 is also possible.

After the operations of lowering and extension of the displaced jaw for the bone clamp (according to A. A. Limberg), marginal osteomyelitis of the lower jaw may occur; after surgery with interposition of the fiber of the stalk flap (according to A. A. Limberg), rupture of the mucous membrane of the oral cavity, significant venous bleeding, suppuration of the wound near the occlusal jaw, damage to the trunk of the facial nerve; after operations with a bookmark of bioplastics (according to LM Medvedev) - an allergic reaction to a foreign protein, a temporary paresis of the marginal branch of the lower jaw of the facial nerve is also possible.

Even targeted postoperative prevention of inflammation in patients through the use of antibiotics is not always successful. Therefore, strict compliance with the requirements of aseptic and antiseptic during surgery (including, first of all, prevention of perforation of the oral mucosa) is the key to wound healing by primary tension after the elimination of ankylosis of the TMJ.

[5], [6], [7], [8], [9], [10], [11]

Differential diagnosis of ankylosis of the temporomandibular joint

Uncomplicated bone ankylosis must be differentiated from the bony contracture of the lower jaw (see above), as well as with mechanical obstructions to opening the mouth. Obstacles can be caused by a tumor (osteoma, odontoma, sarcoma, etc.) in the region of the jawbone, the upper jawbone or the malar bone. Therefore, for a final diagnosis, a thorough finger examination should be performed (the index finger is inserted between the upper jawbone and the branch of the lower jaw of the patient, and also palpates the sidewall of the pharynx) and radiography.

In fibrotic, bone, or osteo-fibrous contracture of the lower jaw, which does not combine with ankylosis, the limitation of its mobility is caused by extraarticular fibrous or osseous joints or proliferation.

The diagnosis of ankylosis should be based on history data (elucidation of the etiologic factor and dynamics of the disease), clinical and radiographic examination, namely:

1. persistent full or partial restriction of movements in the temporomandibular joint;
2. deformation of the condylar process;
3. change in the size and shape of the lower jaw on the affected side;
4. presence of radiographic signs of ankylosis.

Examining the area of the joints, it is necessary to pay attention to the presence of scars on the skin (trauma or inflammation), postoperative scars behind the auricle (for mastoiditis, otitis) and pus discharge from the external auditory meatus, as well as the position of the ears, the chin of the lower jaw and to the level of its lower edge on the diseased and healthy sides. These and other data were analyzed in describing the clinical symptoms of ankylosis.

[12], [13], [14]

Treatment of ankylosis of temporomandibular joint

Begin the treatment of ankylosis as early as possible, preferably in the phase of fibrous intraarticular 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 when combining ankylosis with microgenia (retrognathy) - correcting the shape of the face.

Treat ankylosis only surgically, additionally appoint orthodontic and orthopedic measures.

Local and general changes in the body of a patient with ankylosis of the temporomandibular joint (changes in the structure of the skeleton, bite, location of the teeth, disorders of the cervical spine, the presence of inflammatory changes in the mucosa of the oral cavity, etc.) to some extent hamper the conditions for endotracheal intubation, affect the choice of introductory anesthesia and determine the features of the course of the nearest postoperative period.

According to available data, in patients with ankylosis, the parameters of the function of external respiration change even in the pre-narcosis period: the respiratory volume decreases by 18-20%, the minute volume of breathing increases to 180 + 15.2, the vital capacity of the lungs decreases to 62%, and the oxygen utilization factor to 95 %. Therefore, anesthesiologic support for surgery for ankylosis of the TMJ can only be entrusted to a very well- trained anesthesiologist, who has a large enough experience of anesthesia in children and adults with violations of the maxillofacial area. He should be well prepared and as an intensive care specialist in order to take urgent measures when stopping breathing, stopping the activity of the heart, shock and collapse in difficult local conditions (the mouth does not open, the head of the patient does not tilt, the nasal passages are impassable, etc.) and if available the patient has preoperative disorders of vital organs.

With complete reduction of the jaws, nasotracheal intubation of patients blindly with local anesthesia of the mucous membrane of the upper respiratory tract (with independent breathing of the patients) is the most acceptable, safe for the patient and convenient for the surgeon. When intubation through the nose does not need to use a tube of smaller diameter than with intubation through the mouth, inflate the cuffs and do a tamponade of the pharynx.

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

The most frequent complications during the initial anesthesia and intubation in patients with ankylosis and contracture of the lower jaw are hypoxia, bleeding, trauma of the pharyngeal mucosa, a sharp decrease in the saturation of hemoglobin, a decrease in blood pressure.

To prevent bleeding and trauma during intubation, if patients have significant contractures of the sternum-subordinate area and ankylosis of the temporomandibular joint, special techniques and instruments should be used (for example, spatula blades of the laryngoscope, tracheal signals and indicators, auscultation of the thorax, fit endotracheal tubes, the corresponding position of the head, oxygen and EEG control). A certain role is played by the apparatus for determining the degree of anesthesia depth.

If the trachea is difficult to intubate through the nose from the connection with the restriction of opening and deformity of the mouth, the method of nasotracheal intubation along the conductor suggested by P. Yu. Stolyarenko, V. K. Filatov and V. V. Berezhnov (1992) can be used : anesthesia with barbiturates with muscle relaxants and artificial ventilation of the lungs is a puncture of the trachea in the region of the cricoid-thyroid membrane with a hemotransfusion needle; the needle is directed towards the nasopharynx and a conductor made of polyamide filament (fishing line) 0.7 mm in diameter and 40-50 cm in length is inserted through its lumen. Passing through the voice gap, the line is wound in the mouth in a tangle. Then, through the nasal passage, a rubber catheter with an obtuse metal hook at the end is inserted. The rotating line of the catheter captures the line and is extracted through the nose. Next, an endotracheal tube is inserted into the trachea. The conductor is removed.

Intubation through the tracheostomy is indicated in patients with a significant curvature of the septum of the nose, Rubtsov infection and atresia of the nasal passages with a sharp mixing of the larynx, upper trachea, etc.

In patients with ankylosis and contracture of the lower jaw, its postoperative position changes, it mixes, as a result of which the upper respiratory tract moves. All this in combination with edema, 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 resolved 36-48 hours after the operation.

The choice of the method of surgical intervention is a complex task, as dictated by a number of circumstances described 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 coronary processes along with the lower portion of the jaw branch and subsequent replacement with an auto-, allo- or xenogeneic bone or bone-cartilage graft, metal, cermet or other explant;
2. osteotomy along the line of the former joint cavity or in the zone of the upper third of the mandibular branch with subsequent modeling of the head of the lower jaw and covering it with some kind of cap-lining;
3. dissection or rupture of scars formed inside the articular capsule, bringing down the condylar process downward.

Treatment of uncomplicated fibrotic ankylosis

Reduction of the lower jaw

The rupture of fibrous adhesions formed in the joint (so-called redress) is a "bloodless" operation. With regard to this method of treatment, the opinions of surgeons differ.

Some authors quite rightly believe that attempts to achieve the opening of the mouth and mobility of the mandible by forcibly diluting the jaws with the expander under anesthesia or sub-basal anesthesia are useless and harmful. Having discovered the foci of chronic inflammation in the thick of the affected condylar process, they believe that redression, causing an increased strain on the affected joint, increases the formation of bone tissue in the body and on the surface of the head of the lower jaw, and thus contributes to the development of bone ankylosis. We share this view. However, there are authors who believe that in some cases with fibrotic ankylosis such interference gives a persistent good result. Therefore, we give here the technique of redress.

Under anesthesia or after carefully conducted potentiated local anesthesia, a metal spatula or a flat osteotome is introduced in the area of the oval opening between the premolars. Gradually, trying to put the instrument on the edge, widen the gap between the dentitions to the extent necessary for the introduction of the geyser expander.

Having installed the rotor widener between the incisors, slowly move its cheeks, achieving such opening of the mouth, at which it becomes possible to fix next to the first second expander between the upper and lower premolars. At the same time, it is necessary to simultaneously introduce the expander on both the patient and the healthy side. However, after the expansion of the jaws between the antagonist incisors by 2 cm, further opening of the mouth is performed, using the expander only on the diseased side in order to avoid dislocation in the healthy joint.

After the jaws are cleaved to 3-3.5 cm (between incisors) between the molars, a brace made of bovine-treaded plastic is fixed for 48 hours, which is made directly during the operation (if there is a rotor-expander in the mouth). In the next 1-2 days after the treatment, the patient usually complains of pain both in the affected and in the healthy joints. In this regard, it is necessary to prescribe analgesics.

To prevent the outbreak of dormant infection before and after the forcible opening of the mouth, antibiotic therapy should be performed. 2-3 days after the operation, active and passive functional therapy (therapeutic gymnastics) is prescribed, which includes the following activities:

1. the cancellation of a postoperative, sparing diet and the appointment of a general table;
2. after 1-1.5 weeks after using the general table - strengthening the masticatory load (recommend eating raw carrots, nuts, fresh cucumbers, apples, etc. - in accordance with the opportunities of the season);
3. active strictly dosage gymnastic exercises under the guidance of a specially trained LFK methodologist using functional orthodontic devices, rubber struts, plastic wedges on the molars, etc. It should be remembered that an overdose of muscular load can cause pain sensations with a subsequent reflex stand stiffness of the lower jaw caused by a protective contraction of the chewing muscles; excessive load of young scar tissue can stimulate the processes of formation of bone tissue in the zone of osteotomy and, consequently, lead to recurrence of ankylosis. 

Dissection of fibrous adhesions within the joint

The dissection of fibrous adhesions within the joint and the lowering of the head of the lower jaw are shown in unilateral fibrous ankylosis and after unsuccessful attempts to "bloodless" open the mouth.

The operation is performed under anesthesia or a potentiated regional subbasal anesthetic of the branches of the trigeminal nerve, innervating the joint and soft tissues around it.

Through a cut according to AE Rauer or GP Ioanidis with a scalpel, the joint capsule is opened, the scar-modified disk and surrounding scars are removed.

If, with this intervention, a sufficient degree of opening of the mouth (2.5-3 cm) is not achieved, the end of the metal spatula or osteotomy can be placed in the joint cavity and the operation can be completed by rupturing the adhesions formed on the inner surface of the joint.

After the operation between the large molars on the operated side, a spacer is placed and for 5-6 days an intermaxillary elastic extension is applied to withdraw the head of the lower jaw from the bottom of the mandibular fossa. After 6 days, the traction and striation are removed, assigning active and passive functional therapy.

Treatment of bone ankylosis and secondary deforming osteoarthritis

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

The level of osteotomy and the character of arthroplasty are determined from the radiography data, which is checked during the operation by examining the bone in the wound area.

If the asymmetry of the lower jaw is sharp (due to the one-sided microgenia), it is necessary to establish its chin part in the normal middle position, and eliminate the formed maxillary cavity.

In bilateral ankylosis, which caused a sharp bilateral microgenesis, the entire mobilized lower jaw should be pushed forward to eliminate the disfigurement of the face profile ("bird face"), improve the conditions for biting and chewing food, ensure normal breathing and relieve the patient from slipping the tongue during sleep .

Bony fissures are visible only within the joint capsule, the head of the lower jaw and the mandibular fossa. The articular tubercle of the temporal bone is determined. Microgenia is not expressed

Bony fissures within the joint and posterior section of the mandible scrap. The articular tubercle of the temporal bone is not determined. Microgenia is not expressed

Bony fusion in the region of the joint and the entire incision of the lower jaw. Microgenia is absent

Bony fusion in the region of the joint and the whole incision of the lower jaw is supplemented by the growth of the bone in front of the anterior edge of the jaw branch. Microgenia is moderately expressed; The extension of the jaw branch forward is required no more than 10-12 mm. The same, but the microgenia is sharply expressed; It is required to move the lower jaw by 13-20 mm and fill the resulting paniculent zapadeniya (after moving the jaw forward).

Slanting osteotomy at the level of the neck of the lower jaw with an interposition of deepidermis skin or a white coat 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 an interposition of the sclerocorneal membrane.

Arthroplasty with the use of an outgrowth or arthroplasty of autosuscus from the foot by the method of VA Malanchuk, the endoprosthesis of Yu. E. Bragin, or M. And E. Sonnburgh, I. Hertel or the porous implant FT Temerhanov

1. Arthroplasty with the use of auto-, allo- or xenoplastic rigid elongation of the branch and the body of the lower jaw.
2. Suspended "arthroplasty" according to the method of VS Yovchev.
3. Explantation of a metal or metal-ceramic prosthesis of the temporomandibular joint or arthroplasty by the autostimulation method according to the method of VA Malanchuk, the endoprosthesis of Yu. E. Bragin, or M. And E. Sonnenburg, I. Hertel or the porous implant FT Temerkhanov.

Arthroplasty according to the method of PP Lvov

The incision for access to the ankylosed joint begins 1.5-2 cm below the earlobe, bordering the angle of the jaw, parallel to the edge of the lower jaw (stepping downward by 2 cm) and ending approximately at the midpoint of the jawbone. Through this incision, the places of attachment of the masticatory and medial pterygoids 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 cut off to the zygomatic arch, first from the outside, and then from the inside.

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

For osteotomy, circular saws, spear-shaped and fissure burs are used, fixed in the straight end of the drill or in the clamp of the apparatus for treating bone tissue. With an excessively massive thickening of the bone, it is difficult or impossible to perform osteotomy with the aid of only a circular saw or spear and fissure burs; in such cases, use an osteotome.

To avoid injury to the circular saw of an exfoliated masticatory muscle, the assistant, using, for example, the Farabef crochet or Buyalsky's shoulder blade, pushes the muscle outward along with the parotid salivary gland. To prevent the rupture of the soft tissue saw from the inside of the jaw branch, the second assistant holds the Bujalsky spatula between the bone and soft tissues.

The next task is to lower the underdeveloped branch of the lower jaw downward and to interpolate into the bone gap material that mimics the articular cartilage and the meniscus (disc). To do this, the angle of the jaw is grasped by the bone support and pulled downwards or a wide spatula is introduced into the bone gap or a wide spatula is introduced into the bone gap and the bone edges of the wound are diluted by the necessary distance (1.5-2.5 cm).

The more the degree of underdevelopment of the jaw branch on the affected side was before the operation, the more it is necessary to widen the gap in the area of the bone wound. Only with this condition can you achieve good cosmetic and functional results. In addition, an increase in the dilution of bone fragments reduces the risk of recurrence of ankylosis.

When the jaw is lowered and moved forward (if there is microgenia), there is sometimes a risk of rupture of the oral mucosa and infection of the wound. To prevent this, follow the curved descender carefully to separate the soft tissues from the front edge of the jaw branch and the retro-molar triangle up to the lower wisdom tooth.

If there is a very pronounced microgenerosis, if a significant movement of the lower jaw is necessary in advance, it is necessary to resect the bone from the anterior section of the jaw branch, and in some cases even remove the upper 8th tooth on the side of the ankylosis. This eliminates the risk of rupture of the mucosa in the area of the wing-jaw fold or the appearance after the operation of a decubitus between this tooth and the anterior edge of the mandibular branch.

If, despite all the measures taken, rupture of the mucosa occurred, the place of rupture is sutured with at least a two-row catgut suture.

With a significant shortening of the mandibular branch and forced large dilution of bone fragments in the area of osteotomy, and if there is a need for a significant movement of the chin forward (in order to restore its normal position), sometimes it is impossible to completely eliminate the perforation of the external wound with the oral cavity. In such cases it is necessary to tamponize the wound of the mucosa from the oral cavity with iodine gauze, which is gradually removed on the 8th-10th day after the operation.

With bilateral bone ankylosis, arthroplasty is performed on both sides.

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

Measures to prevent the recurrence of ankylosis during surgery by the method of PP Lvov

The bone spines and protrusions that remain in the neck, especially in the back and inner parts of the wound, contribute to the formation of bone tissue and the recurrence of ankylosis. Therefore, after completing the lowering of the jaw, the surgeon, using straight cutters driven into the rotation by the bone processing machine, should smooth the edges of the bone wound on the lower (lower) and upper fragments of the jaw branch and model its head. After this, the wound should be thoroughly rinsed to remove bone chips from it, which can stimulate the formation of bone tissue.

Recurrence of ankylosis is also promoted by the periosteum of the lower jaw covering the bone at the site of the osteotomy. Therefore, in order to suppress the ability to osteoarthritis, it is desirable in this area to excise or coagulate it.

Prevention of recurrence of ankylosis is also promoted to a great extent by careful hemostasis, which is very difficult to perform in a slit-like wound. Nevertheless, it is necessary to achieve the cessation of bleeding from both large and small vessels. To do this, for example, resort to a temporary tamponade wound gauze soaked in a solution of hydrogen peroxide or in hot isotonic sodium chloride solution. You can also use a hemostatic sponge, a powder or an aminocaproic acid solution (on a tampon), which have a well-defined hemostatic effect with capillary hemorrhages.

The joint surfaces of the normal temporomandibular joint are covered with cartilage and are 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 interpolated between bone fragments to mimic missing tissue and prevent fusion of the sawn bone. As early as 1860, Vernenil, and in 1894 Helferich and other authors suggested making an artificial interposition of soft tissues. So, Helferich used a flap (on the leg) from the temporal muscle.

As an interponated material, we suggested using flaps of chewing, gluteus muscles, a fascial or fascial fat flap from the temporalis muscle region, a flap from the broad fascia and an adjacent subcutaneous tissue of the thigh, a freely transplanted subcutaneous tissue or skin itself, a skin 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 used.

Arthroplasty according to A. A. Limberg

The author uses an interosseous bookmark from the connective tissue base of VP Filatov's stem flap, which has the above qualities and, in addition, eliminates the soft tissue waning behind the jaw branch (after it is moved forward).

To do this, use a filate stalk of sufficient length (not less than 25-30 cm). One end of it after a proper training is transplanted to the wrist, and the second to the angle of the lower jaw with time. After 3-4 weeks, cut the peduncle of the stem from the brush and transfer it to a symmetrical site in the region of the other corner of the lower jaw. As a result, the stem hangs in the form of a shallow arc under the lower jaw.

After a strong engraftment of both legs of the stem (about 3-4 weeks), bilateral osteotomy of the mandibular branches is made, the bone surfaces are smoothed at the site of the osteotomy and the wound is cleaned (washed) of the bone from sawdust.

The stem is dissected by a transverse median incision into 2 equal parts, de-epidermalized and inserted into each end of the corresponding slot at the site of the osteotomy.

Each half of the stem is completely immersed under the skin, so de-epidermisation must be performed throughout the stem.

Between the molar teeth, antagonists from both sides are placed rubber spacers (gaskets); with the help of the intermaxillary elastic traction or the chin sling, contact between the antagonist incisors is achieved.

Arthroplasty according to Yu. I. Vernadsky

As an interponable material, a freely transplantable de-epidermal skin flap is used, completely devoid of subcutaneous tissue (as it soon dissolves).

If necessary, in a significant dilution of fragments of the jaw from the flap, you can make a thick enough (two-, three-layer gasket) and lay it between them; The posterior end of this napkin is used to fill the resulting occlusion behind the branch of the lower jaw.

The de-epidermis flap is strengthened by fixing it with thick catgut sutures to the remnants (edges) of the chewing and medial pterygoids left for this purpose at the edge of the angle of the jaw. This method favorably differs from the method described by A. A. Limberg, since it does not require multistage surgical intervention associated with harvesting, migration, and engraftment of the stem.

The disadvantage of Yu. I. Vernadsky's method is the traumatic nature and duration of the operation, although this pays for itself at one stage.

To shorten the duration of the operation, it is recommended to perform it by two groups of surgeons: at the time when the first group produces the osteotomy of the jaw branch and the formation of a new joint, the second deepidermizes the area of the skin to be excised, cuts it and sutures the wound on donor soil (usually on the front surface of the abdomen).

Operation on this method is carried out against a background of gradual (drop) compensatory blood transfusion.

As the data of experimental researches of our employee V.F. Kuzmenko (1967) showed, the interfaced auto-skin reliably protects the ends of the bone fragments of the jaw from the fusion.

Already a month after the operation, a dense bone plate (by the type of a closure) is visible at the ends of the bone (along the cutting line), the formation of which ends at the end of the third month.

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

The de epidermis flap fuses with the bone and surrounding muscles by the end of week 1, but between the two skin layers the first small areas of adhesion appear only one month after the operation.

Further, the layers of the skin do not fully fuse; there are small slit-like spaces, devoid of lining or lined with a flat epithelium, apparently fulfilling the role of the articular cavity.

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

Cysts were not formed in the interponated skin.

Clinical experience and data from histological studies confirm the possibility of using the autoderm as a packing material and for leveling the maxillary cavity that occurs after the lower jaw is moved forward.

Arthroplasty according to the I method of GP Vernadskaya and Yu. I. Vernadsky

According to available data on arthroplasty of large joints with the use of a white shell of the testicle (bulls) and our observations, it can be concluded that this kind of interposition material is quite applicable for arthroplasty of the temporomandibular joint.

Due to the fact that the use of the Filatov stalk is associated with the repeated infliction of additional trauma to the patient, and the size of the testis of the bull considerably exceeds the dimensions of the modeled lower jaw head (and therefore they must be reduced in size and sutured during surgery), we proposed the use of xenogeneic arthroplasty sclerocorneal envelope, which has a number of advantages, namely: it has smaller dimensions than the testicle of the testis, and a cartilaginous consistency; if it is necessary to create a wider gasket, 2-3 scleras can be worn on the head of the lower jaw.

After extraoral exposure, the mandibular branches produce mobilization of the mandibular head or horizontal osteotomy at the border of the upper and lower sections of the jaw branch. Then, the head of the lower jaw (from the lower fragment of the osteotomized jaw branch) is modeled and covered with a cap from the sclerocorneal membrane of the bull.

In order for the cap from the sclerocorneal shell not to move during the movement of the head of the lower jaw, it is fixed with sutures (from the chromed catgut) to the edge of the masticatory muscle left in the region of the angle of the lower jaw during its intersection. Next, the wound is sewn layer by layer; in the corner it is left for a graduate for 1-2 days.

If some displacement of the chin is necessary in a more symmetrical position, the extension of the jaw is usually carried out through a block on a special beam or fixed to a rod embedded in a gypsum or foam head (according to VF Kuzmenko) head cap.

After the operation, insert a gasket between the molars of the operated side, and after the removal of the sutures, an active and passive functional joint therapy is immediately prescribed.

This method of treatment, shown with uncomplicated fibrous and bone ankylosis, which does not combine with microgeny, is advantageous in that the non-autologous material used as a cushion material is a transplant that is associated with additional trauma to the patient (for example, a wide fascia of the thigh, de-epidermis skin, the middle part of Filatov's stem), and the xenogeneic tissue is the sclerocorneal membrane. Unlike the belly shell of the bull testis, this material can be taken from any cattle. Preservation of the xenogeneic sclerocorneal envelope is carried out in the usual way, for example with the help of solution No. 31-e AD 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 gasket is the chemical or thermal treatment of bone sections. Some authors recommend burning the ends of fragments of bone with fuming nitric acid (for 1-2 minutes before rusting), followed by neutralization with saturated sodium bicarbonate solution. For this purpose use an ordinary wooden stick or metal probe, the end of which is wrapped with cotton wool, reinforced with a thread. At the same time, protective gauze tissues should be protected with gauze tampons.

You can also use a piocid, which is applied with small cotton balls on the surface of bone sections. The piocide causes a slight burn of bone substance, suppresses osteo-poetry and thus prevents the recurrence of ankylosis. In the absence of a piocid, bone can be treated with a diathermocoagulant or a red-hot stucco, 96% alcohol, a concentrated solution of potassium permanganate (1:10), etc.

After the ends of the bone fragments are chemically or thermally treated, and the interleaved material is inserted and fixed in the osteotomy slit, all the stripped tissues are laid back and the upper end of the excised chewing muscle is hemmed slightly above its previous position.

Eliminating ankylosis and often accompanying microgeny (retrognathy), it should be borne in mind that all soft-tissue pads of biological origin dissolve over time and replaced by a connective tissue, the volume of which is much less than the volume of the surgeon placed by the surgeon. In connection with this, the branch of the lower jaw, gradually "shortening", returns almost or completely to its former position, and this entails a relapse of microgenia (retrognathy) and the associated asymmetry of the chin.

Prolonged traction of the mandible, as well as the lowering of its head in children, or osteotomy of the jaw branch and wide dilution of the fragments according to A. A. Limberg (1955) only provide a medial position of the chin for a short time, supporting the illusion of cosmetic wellbeing of the doctor and patient. Over time, the relapsed asymmetry of the face begins to bother the patient or his parents and sometimes there is a need for additional surgeries (contour plasty, osteoplastic lengthening of the jaw body) to make the face symmetrical.

In this connection, in recent years surgeons have been trying to use (in the presence of a combination of ankylosis and microgenia) pads made of more resistant biological material (bone, cartilaginous auto-, allo- or xenografts) or metal, metal-ceramic prosthetic explants, or a stair-like the protuberance of the branch of the lower jaw (for lengthening its height), etc.

Arthroplasty according to the method of VS Yovchev

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

After exposure of the mandibular branch through the submandibular access, a step-like osteotomy is produced 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 joined by a suture (polyamide thread). To remove the resulting absent-minded westernization, a piece of allogeneic cartilage along the posterior edge of the mandibular branch is hemmed.

Although the operation is called arthroplastic, but, in fact, no joint is ever reconstructed.

Arthroplasty according to the method of VI Znamensky

The operation consists in the fact that after excision from the scars and osteotomy, the branch of the jaw is moved to the correct position and then fixed by a transplant from the allogenic cartilage, which is hemmed along the posterior edge of the branch.

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

Arthroplasty according to the method of GP Ioannidis

The operation is as follows. Make a cut of the skin 6-7 cm long behind the angle of the lower jaw by 0.5-1.0 cm below the earlobe and extend it into the chin area, receding from the lower edge of the jaw by 2.5 cm.

The submaxillary incision is made below the usual with such a calculation that after the lower branch of the mandible is lowered the scar was not on the cheek, as with the usual submaxillary incision, but under the lower edge of the jaw.

Due to the low incision, it is possible to avoid and injure the marginal branch of the facial nerve of the lower jaw.

After dissection of soft tissues, the chewing and inner pterygoid muscles are separated from the attachment points at the edge of the lower jaw with scissors so that the periosteum does not exfoliate from the bone.

The osteotomy of the mandibular branch is performed with a Jigley saw or an ordinary wire saw. To do this, enter a Kerger needle 1 cm anterior to the tragus of the auricle near the lower edge of the zygomatic arch. The sharp end of the needle slides first along the posterior edge of the branch of the lower jaw, and then along its inner surface. Bypassing the front edge of the branch in this way, the end of the needle is removed to the cheek below the malar bone. To the needle with a thick silk thread bind Jigli saw. After that, the needle of Kerger is removed, and in its place the Jigli saw is stretched.

Sawing branches are produced as high as possible - in the region of the upper third of the branch of the lower jaw - about 35 mm below the incision of the lower jaw.

During osteotomy, a soft spatula is displaced by a metal spatula behind and below the lower jaw branch, which protects them from injury and prevents bleeding.

Kerger's needles are selected during surgery for the thickness and width of the mandible.

This method of osteotomy is easy and quick to perform (30-60 s).

The lower fragment of the branch is maximally taken down by a single-tooth crochet. On the remaining upper fragment, a thin bone jumper is cut, which was formed between the coronoid process and the upper bone mass (for their separation).

The upper bone mass is removed using boron and a chisel. In this case, the chisel is installed parallel to the base of the skull or even with a slight inclination from the bottom up, which can always be done through the submaxillary incision.

Depending on the degree of spread of the bone adhesions, the coronary process is left or removed. If removal of the upper bone mass is technically impossible, in the center it is formed by a deep bed and a piece of allochondria is placed in it, creating an artificial cavity.

In some patients, after the deep cutting of boron, the upper bone mass is removed by cutting pliers, if possible.

Such intervention allows to completely destroy the growth zones preserved in the region of the upper bone mass, and excludes the possibility of the formation of a new bone from its remains (i.e., recurrence of ankylosis).

Therefore, the author considers the removal of the upper bone massif mandatory in young patients (aged up to 20-25 years), especially with ankylosis of traumatic etiology and recurrence of ankylosis of any etiology. In patients of older age, you can limit yourself to osteotomy alone.

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

If there is a sufficiently large bed, the bone part of the transplant, 1-1.5 cm in length, is placed in it completely; if the bed is narrow, the bone part of the transplant is split longitudinally, with one half of the graft placed in the bed, and the other half on the outer surface of the lower jaw.

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

When determining the size of the osseous cartilaginous allografts of the mandibular branch, the size of the removed bone massif and the degree of shortening of the affected jaw branch should be taken into account.

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

Elongated after transplantation, the branch and the entire jaw are shifted to the healthy side and forward; while the chin moves to the middle and significantly reduces its sinking backward.

Due to the movement of the lower jaw forward in the paranasal space, a noticeable deepening of the soft tissues on the diseased side occurs, for the elimination of which a piece of allochondrion length equal to the length of the mandible branch and a width of about 1.5-2 cm is transplanted; The transplant is attached to the periosteum of the jaw branch and soft tissues at the posterior edge of the mandible branch.

After the termination of the operation between the molars, rubber or plastic liners are inserted, and the jaws are connected by means of tooth-wire wires with hooked loops in the state of hypercorrection for 30-40 days.

As a result of the operation, the places of attachment of the chewing muscles move relative to the extended mandible, and its prolonged fixation contributes to a strong increase in these muscles in new places, which is a prerequisite for persistent retention of the jaw in the new position.

A similar technique is used in the treatment of bilateral ankylosis of the temporomandibular joint with the only difference that the operation is performed from two sides (one day).

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

Arthroplasty by the method of AM 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 germ zone between them is introduced into the formed defect.

From the cartilage part form the resemblance of the head of the lower jaw (indicated by an arrow), introduced into the mandibular fossa.

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

Fix the graft with a bone suture.

Immobilization of the lower jaw (for 25-30 days) is carried out with tooth wire strands; after they are removed, active mechanotherapy is used.

According to available data, the growth of the graft is possible while maintaining its growth zones, as well as the growth of the autograft in children. This circumstance is of great importance for the preservation of the symmetry of the person in the long term after operations in children, when in the case of application of allo- or xenocardia it is necessary to give the chin the position of hypercorrection.

Arthroplasty by the method of NA Plotnikov

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

Fabrics are cut layer by layer to the bone. The tendons of the masticatory muscle are not cut off from the bone, but are separated together with the outer plate of the compact substance of the lower jaw. To do this, make a linear cut along the lower-inner edge of the angle of the jaw, ie, at the border of the attachment of the chewing and medial pterygoids, dissect the tendon-muscle fibers and cut them from the lower edge of the bone.

In the region of the lower edge of the angle of the lower jaw and the anterior edge of the masticatory muscle, a sawmill is cut by a circular saw or ultrasound by cutting the outer plate of a compact substance of the lower jaw, which is separated together with the attached muscle by means of a thin wide sharp chisel.

On the rest of the jaw branch (along the outer and inner surface of the jaw), soft tissue is subperiosteally separated from the zygomatic arch along the entire length of the zygomatic arch.

To create a transplant receiving the bed from the outer surface of the jaw branch, remove the remaining layer of a compact substance with a cutter evenly until bleeding points appear.

The level of intersection of the mandibular branch is determined by the nature and prevalence of pathological changes in the bone. So, with fibrous or bone fusion, only the heads of the lower jaw with the articular surface of the temporal bone produce a resection of the condylar process (condylectomy); The bone is cut with a wire saw in an oblique direction through the incision of the lower jaw back and forth.

If, after excision of the condylar process, the thrust of the temporal muscle prevents the branch of the jaw from being lowered, then an osteotomy is performed at the base of the coronoid process.

With massive bony growths, when the condylar and coronary processes form a single bone conglomerate, transverse osteotomy is produced in the upper third of the lower jaw, as close as possible to the joint. For this purpose, use a special sharp long trepan. With the help of a drill make a series of through holes, which connect a trihedral surgical milling cutter. After crossing the jaw branch, it is moved downwards and the cut surface of the bone is leveled by the cutter.

The removed portion of the lower jaw (above the osteotomy) should be as large as possible to approach the site of joint localization under normal conditions.

In some cases, you can completely remove the altered head of the lower jaw. If the bone conglomerate spreads to the base of the skull, the upper jaw and the mandibular fossa, it is not necessary to remove it completely: in these cases, the bone tissue is removed by lapping with various cutting tools to about a level somewhat below the articular tubercle of the temporal bone.

At the level of the natural joint surface, a new articular area of the semi-oval form is formed with the help of a ball-shaped cutter. The surface of it must be thoroughly "polished".

In front of the articular area to prevent dislocation, a bone bump is created, which prevents the head of the lower jaw from moving forward. (The author believes that due to this the head of the lower jaw can perform not only hinged, but to some extent, progressive movements).

If necessary, reduce the branch of the jaw, and the jaw itself is moved to the healthy side, so that the chin is located in the correct position along the middle line.

Considering the subsequent growth of a healthy half of the jaw in children and adolescents, bite is established with some hypercorrection. In this position, the jaw is fixed with a tire.

To replace the formed defect of the head of the lower jaw after removing its upper fragment, use a preserved lyophilized allograft from the mandible branch together with the head (c), and in some cases also with the coronoid process. From the inner surface of the transplant, correspondingly receiving the bed of the recipient's bone, a plate of compact substance is removed.

From the side of its outer surface (in the area of attachment of the outer plate of a compact substance with the masticatory muscle), also create a sensory bed.

The transplant taken from the corpse should include the angle of the mandible in its entire width so that they can simultaneously not only lengthen the branch, but also create a corner of the jaw, and also compensate for the missing part of the bone in the region of the posterior edge of its branch due to the jaw forward movement.

The defect of the jaw is replaced with a graft so that its head coincides with the articular site created during the operation.

The remaining coronoid process of the lower jaw is connected with the coronary process of the transplant.

The second end of the transplant is connected to the end of the recipient's jaw and is tightly reinforced with two wire seams. The venous processes are fixed with a line or chrome catgut.

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

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

In those cases where ankylosis is combined not only with retrognathy, but also with an open bite, simultaneous intervention is shown on both joints. 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 the toothbrushes, proceed to the bone plastic first on one, and then on the other side. For this period, fix the lower jaw to the upper.

After the operation on the side of removal condylar sprouts for 5-7 days put a spacer in the area of the last teeth. After its removal, the patient proceeds to the gradual development of active jaw movements on the background of functional therapy.

This method is very effective, but it has one significant drawback - it 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 the bone bank, which supplies all the clinics with the necessary plastic material, this method can be considered the most acceptable.

Arthroplasty according to NN Kasparova's method

After exposure of the angle and branch of the jaw (through the submaxillary incision), osteotomy of the branch is made, surgical sanation of the oral cavity is made, denticles are made and the jaw is fixed in the correct position.

For osteoplastic replacement of the defect of the mandibular branch arising in connection with its downward descent and forward movement in order to normalize the contours of the lower face, an allotransplant is used from the outer plate of the compact substance of the tibia. Its dimensions should allow the lower jaw to be moved to the correct position relative to the upper jaw and to ensure reliable support of the lower jaw in the newly created joint. The guideline is the position of the chin and the state of the bite.

The superposition of the graft on the outer surface of the lowered branch of the lower jaw provides a sufficient area of contact between the bone fragments and the elimination of the flattenedness of the mandible. The upper edge of the transplant is hemispherical and fixed with a stainless steel wire seam ensuring static compression and immobility of the adjacent bone surfaces.

The new joint surface should be shaped and sized to prevent dislocation of the joint when opening the mouth.

The wound is layer-by-layer, but a rubber graduate is left for a day; impose an aseptic bandage.

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

The lower jaw is fixed (a day after the operation, conducted under anesthesia) for a month. After removal of the fixation, therapeutic sanation of the oral cavity, functional therapy, orthodontic correction of the occlusion are shown.

Arthroplasty according to the II method of GP and Yu. I. Vernadskikh

Arthroplasty with the use of auto-, allo- or xenograft has several disadvantages, namely: additional injury to the patient due to taking a rib fragment from him or searching for a corpse of a human or animal suitable for taking the transplant; preservation, storage and transportation of allo- and xenografts; the possibility of an allergic reaction of the patient to a foreign donor tissue.

In children, surgical intervention associated with borrowing an autograft (most often from the rib) may be more difficult than the main operation and in all cases lengthens 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 injuring the pleura or peritoneum (if the rib or the iliac crest is resected), suppuration of an additional wound resulting from the borrowing process in a patient of an autograft from the bone, a decrease in the resistance of the child's body , an increase in the length of hospital stay, staff time, medicines and bandages for additional ne evyazki in graft borrowing and t. D.

However, the autograft is the most suitable material for lengthening the lower jaw.

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

As our subsequent studies showed, the amplitude of the biopotentials of the actual chewing muscle was sharply reduced on the affected side and the bioelectric activity of the temporal muscle was increased. Perhaps this explains the excessive development of ankylosis of the coronoid process of the lower jaw on the affected side.

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

Procedure of the operation

The procedure for the operation is as follows. The outline of the lower jaw is exposed in an extraoral way; in the usual way or by the steppers that are proposed by us, a stepped osteotomy of the mandibular branch is performed , during which the coronary process is resected, and temporarily placed in a solution of antibiotics.

After the stepwise osteotomy of the condylar process (at the level of its base), move the branch of the jaw forward until the chin is in the middle position (in the adult patient) or with some hyper correction (in the child) and fix the jaw in this position by the tooth bushes or other orthopedic method.

The truncated coronoid process is used as a graft to create a condylar process. For this purpose, a groove (trough) forms in the coronoid process, and the upper-posterior portion of the edge of the jaw branch is decorticated by means of a milling cutter. The groove of the coronoid process and the decorticated portion of the jaw branch are combined, perforated in two sections by spear-boron and joined by a double seam made of synthetic filament or tantalum wire.

Thus, due to the use of the usually hypertrophic coronoid process, the height of the underdeveloped branch of the lower jaw is increased and increased, and since the coronary process connects with the mandible branch from behind, simultaneously its forward movement along the horizontal line occurs, and the face acquires symmetry.

If there is no need for a stepped osteotomy of the articular process, but only the reduction of the condylar process (with uncomplicated fibrous ankylosis), it is "honed" (supplemented) and thus lengthened due to the connection with the transplanted coronary process. For this, the coronoid process is resected with forceps that horizontally bite its base, i.e. With forceps that do not have a stupa, but straight snapping edges.

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 it is possible to connect the coronoid process with the branch not from the back of the plate, but from the top to the back.

The free plane of the jaw branch in the area of osteotomy can be burned with an electric cautery, phenol, piocid, or covered with a xenogenic sclerocorneal membrane, which is fixed with catgut.

After the operation, the following rehabilitation measures are needed:

1. retention of the spacer between the molars on the side of the operation for 25-30 days to ensure peace of the operated branch of the jaw for 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. the appointment of a general diet at home after discharge from the clinic;
4. if necessary, after 4-5 months, orthodontic correction of the occlusion according to known methods.

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

One of the advantages of this method is a sharp decrease in the threat of recurrence of ankylosis and deformity of the mandible for two reasons: firstly, because the transplanted coronary process covered with a powerful bone plate provides the possibility of early functional therapy and creates conditions for long retention of the middle part of the lower jaw in the correct position (until the complete or partial self-regulation of the occlusion is completed); secondly, because the branches are made with the help of a snapping (rather than drilling or sawing) tool, that is, without the formation of a lot of bone chips and small fragments with 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 are suggested to use not only the coronoid process, but also its extension at the bottom - the outer cortical plate of the branch (within its upper 2/3).

With simultaneous elimination of ankylosis and microgenia (retrognathy), the method proposed by Yu. D. Gershuni can be used, which consists in the following: after osteotomy of the mandibular branch near the ankylosed joint, mobilization, traction and fixation of the mandible in the postoperative period is carried out with the help of its devices for treatment fractures of the lower jaw. Compared with existing, this method has the following advantages: it ensures reliable fixation of the lower jaw after it has moved to the correct position and makes it possible to begin functional treatment in the early postoperative period; allows to create a reliable separation between the bone ends in the region of the forming false bone joint during the entire period of traction; eliminates the need for using an interponent material, the use of internal tires or cumbersome (for sick children) head caps.

Arthroplasty according to the method of VA Malanchuk and co-authors

It is produced with bone and fibrotic ankylosis, combined or not combined with microgenia. In order to further develop the experimental studies of O. N. Stutevelle and PP Lanfranchi (1955), V. A. Malanchuk, since 1986, II, III or IV metatarsal bone with a metatarsal-phalanx joint has been successfully used in our clinic as an autograft . In 11 patients (out of 28), an additional lengthening of the jaw was required (second stage).

In fibrotic ankylosis, the first stage of treatment extended the body of the jaw.

Postoperative management of the patient

The patient needs to provide a diversified, energetically valuable and vitaminized food; during the first 2 weeks after the operation, the patient is fed liquid food through the tube, dressed on the tip of the pointer.

After each meal, the oral cavity should be irrigated from Esmarch's mug or syringe with potassium permanganate solution (1: 1000). In this case, you need to ensure that the dressing does not get wet and not contaminated with food leftovers. Therefore, before irrigation, the patient wears a special light plastic apron, which should fit snugly against the base of the lower lip. If the bandage is soaked, it is immediately removed, and the seam line is smeared with alcohol and covered with a sterile bandage.

In case of extraoral extension of the lower jaw for a caudal clamp or a bone from a polyamide thread passing through the chin bone, it is necessary to carefully monitor the seams at the base of this clamp or the point of exit of the thread every day to prevent the infection from penetrating into soft tissues and bone. To do this, treat both the core itself (thread) and the skin around it with alcohol, after which the base of the stem and the seams near it are covered with a strip of iodine-shaped gauze, strengthened with an adhesive plaster.

For the prevention of osteomyelitis in the area of the osteotomized ends of the mandibular branch during the first 6-7 days after the operation, antibiotics of a wide spectrum of action are prescribed. Sutures are removed on the 7th day after the operation.

After a simple one-sided osteotomy with an interposition of the soft padding, active mechanotherapy is carried out from the 5th day, after bilateral - from 10-12th, and 20 days after the operation, both active and passive (hardware) mechanotherapy are used. It is used to achieve in patients not only the maximum opening of the mouth, but also the closing of teeth and lips. If already in the first 2-3 weeks after the operation, an open bite is planned, it is necessary to establish, over the course of 30-40 days, for the night (according to A. A. Limberg's method) an intermaxillary or chinprayal traction fixed to the head cap, and also a spacer between molar antagonists (on the side of the operation). As a result of the intermaxillary brace and the chin sling (or intermaxillary traction), a two-arm lever is created: the angle and branch of the lower jaw are lowered, and its chin is shifted upward.

To ensure the constant dilution of the jaws, it is also possible to successfully apply NN Yezhkin's method, which consists in the following: between the molars a rubber plate, 5 cm long and 2 cm in width, is folded in two. The thickness of the plate should be equal to half the distance between the upper and lower major molars with the maximum possible lowering of the lower jaw. To avoid slipping of the plate from the teeth, it is wrapped with gauze and then injected between the molars with a curved side to the back. Such a plate is worn by patients 24 hours a day, only when the food is taken and the mouth cavity is removed. In some cases, to increase the degree of dilution of the jaws, the plates are inserted from both sides. As the opening of the mouth increases, the plates are replaced by thicker ones.

In those cases when active mechanotherapy does not give a tangible effect, it should be supplemented with so-called passive exercises. To do this, use rubber plugs, doubled or triple rubber tubes, rubber or wooden wedges, plastic screws, as well as special rotor extensions.

A. V. Smirnov proposed an apparatus consisting of two tires or orthopedic (impression) spoons filled with an impression mass. Two arc-shaped springs of steel wire (diameter about 2-3 mm) are attached to the lateral surfaces of the tires or spoons thanks to which the device evenly presses on the upper and lower dentition, while expanding the jaws. The spoons of the apparatus are pre-filled with a wall to ensure sufficient stiffness of fixation on the teeth.

The dynamics of increasing the degree of opening of the mouth must be documented in millimeters, determined with the help of a special triangular meter, which must always be installed in front of the same antagonist teeth; the findings are recorded in the medical history, and at home - in the notebook.

Functional and cosmetic results of ankylosis treatment

The results of treatment should be considered only after a sufficiently long period, since about 50% of the recurrences of ankylosis occur within the first year after the operation; the rest of them develops much later - for 2 and 3 years. In some cases, relapses of ankylosis occur 3 years after surgery and even after 5-6 or more years.

According to available data, relapse of ankylosis is observed on average in 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 failed to fix for technical reasons, as well as undetected incomplete jaw data after the operation (in which the patient is more or less satisfied with the degree of opening the mouth).

Clinical studies have shown that the incidence of relapses of ankylosis depends on the procedure of operation (the level of osteotomy, the nature of the interposed material achieved during the operations of the lower jaw mobility), complications during and after surgery (ruptures of the oral mucosa, decubitus on it, bleeding, suppuration , hematomas, etc.), the correctness of conducting the postoperative period with the use of antibiotics, traction, mechanotherapy, etc.

Recovers ankylosis, as a rule, in those cases when the lower jaw was insufficiently mobilized during the operation, that is, the mouth was opened only 1-2 cm.

A high percentage of relapses was noted after application of plastic (73%), all layers of the skin or placental coat preserved by the method of NS Kharchenko (66.6%), as well as in those cases, as an interosseous plaque. When no interposition was made at all (50%).

After the interposition of the de-epidermal skin flap according to the method of Yu. I. Vernadsky, the nearest unsatisfactory outcomes were not observed. The size of the opening of the mouth, reached during the operation and shortly after it (for 5 years), was preserved or, which was observed more often, gradually increased by 0.3-0.5 cm. In cosmetic terms, this method of operation was also more effective. As a rule, after the operation the patient could open his mouth 3-4 cm.

A study of even more distant results of treatment (after 8-15 years) showed that in some patients (in 5 of 21) relapsed ankylosis, a symptom of which, however, was conventionally considered opening the mouth by less than 1.8 cm. The reason for the relapse in these cases there 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 associated inflammation that limited postoperative mechanotherapy, as well as rupture of tissues and unavoidable hemorrhage during propagation joint stiffness on the side opposite the operation.

After using as a liner for the xenogeneic shell of the bull testes, the recurrence of ankylosis in the long term after the operation may be due to the inability to establish a spacer between the jaws due to severe loosening of the milk teeth or the development of a phlegmonous process in the inflammation zone.

After arthroplasty with the use of the sclerocorneal liner, as well as the braces from the autogenous coronoid process in the next 5 years after the operation, ankylosis recurrences were not observed (follow-up of the patients continues).

The cosmetic effect of the operation is determined by the extent to which it was possible to give the chin a correct (median) position, and also to eliminate the asymmetry of the face in the parotid areas.

As mentioned above, the occlusion behind the lower jaw, which occurs after the removal of its branch forward, can be filled with a de epidermalized Filatov stalk or a freely transplanted deepidermised skin flap that is completely devoid of subcutaneous tissue; allo- or xenogeneic cartilage, and so on.

Sometimes to eliminate the asymmetry of the face resorted to implantation of plastic, free transplantation of subcutaneous tissue or cartilage on the healthy side (to eliminate the flattening of its lower part).

Outcomes of arthroplasty of the temporomandibular joint

Outcomes of arthroplasty depend on the complications that arose during the operation and shortly afterwards. The use of soft-tissue pads does not eliminate the asymmetry of the face, especially when the mouth is open. In connection with this, we have to use various types of prostheses and tires (such as Vankevich, Weber, etc.), as well as contour plasty, including those based on reconstruction of the branches and the body of the mandible.