Interdisciplinary management of severe vertical deficiency following ankylosis in childhood

AimS: Temporomandibular joint (TMJ) ankylosis in early childhood results in a typical pattern of mandibular and midfacial growth deficiencies. In adult patients the interdisciplinary team approach includes an operative release of the ankylosis, orthodontic alignment of the dental arches, reconstruction ot the TMJ and adjustment of the occlusal plane by complementary maxillary and/or mandibular osteotomies. MaterialS AND Methods: due to late onset of initial treatment in four patients with severe deformities as a consequence of long lasting joint malfunction, surgical reconstruction had to be delayed until adulthood. In three of them unilateral TMJ ankylosis occurred following condylar fractures in the second or third year of life. After release of the ankylosis by resection of the osseous bridge and temporary interpositioning of a silastic sheet, reconstruction of the TMJ with a costochondral graft was performed in a two-stage operation, together with complementary osteomtomies to reposition the tilted occlusal plane. Intermaxillary wire fixation was employed for approximately 2 weeks. Results: The en face aspects, as well as profiles, were markedly improved in all patients. Stable occlusion and acceptable facial symmetry was achieved in 3 out of 4 patients. All patients suffered temporary palsy of the facial nerve that recovered within 3 to 4 month. Pre-operative alignment of dental arches could not be achieved in one patient with considerable myofunctional habits, resulting in an increase of funtional loading of the reconstructed TMJ. In this particular case resorption, secondary infection and finally loss of the costochondral graft was witnessed. Conclusion: TMJ reconstruction, with predictable results, can be achieved in adult patients by costochondral grafting and simultaneous surgical correction of the concomitant dentofacial deformities. A careful dental alignment pre-operatively is mandatory, not only for long-term occlusal stability but also to prevent functional overloading of the graft post-operatively. Keywords: Rahmenlose Stereotaxie, computergestützte Chirurgie, Zygomaticus Fixture, Tumorchirurgie