Figure 1: Post-procedure film demonstrating successful embolization on the internal Maxillary artery medial to the ankylotic mass.Surgeons with the Department of Oral and Maxillofacial Surgery at Penn Medicine are using a protocol with Penn Interventional Neuroradiologists to prevent massive blood loss during total replacement of the temporomandibular (TMJ) joint in advanced ankylosis.
TMJ ankylosis is a functional disorder of the mandible that presents as varying degrees of limited jaw opening. In this condition, the lower jaw fuses with the skull base. The degree of bone fusion can range from moderate condylar impairment with fibrous attachments, or massive bony fusion between the condyle and fossa at the skull base with near absent mobility.1
If untreated, ankylosis of the TMJ can lead to progressive debility, limitation of mouth opening, mandible deformity, malocclusion and persistent lockjaw. Ankylosis can also interfere with intubation during surgery.
Correction of advanced TMJ ankylosis involves surgery with the objective of removing the ankylotic bony mass and restoring function to the joint. Of particular concern is the surgeon's inability to access the internal maxillary artery beneath the ankylotic mass. Compromise of the vessel at surgery presents the possibility of unmanageable hemorrhage. Postoperative heterotopic bone formation and reankylosis at the original site of surgery can also be troublesome.
Penn Oral and Maxillofacial Surgery has assumed a leading role in addressing these concerns, not only as a major contributor to the development of the Biomet® Microfixation Total Mandibular Joint (TMJ) Replacement System, but as a proponent of a multi-specialty team approach to optimize patient outcomes.
To prevent potentially massive hemorrhage, Penn Interventional Neuroradiology selectively embolizes arteries around the TMJ ankylotic mass prior to surgery, permitting the surgical team to remove bone as needed to obtain their objectives.
Case Study
Mr. W, a 51-year-old man, was referred to Penn Oral and Maxillofacial Surgery for an evaluation of longstanding inability to move his jaw. He had previously had a gap arthroplasty of his right TMJ which had subsequently re-fused. At Penn, Mr. W had an initial maximal mouth opening of 2mm, along with difficulties with speaking.
Following a CT angiogram, massive ankyloses was evident along with intimate involvement of the internal maxillary artery. Virtual surgical – planning was performed in order to design the bone cuts to ensure adequate bone removal along with avoidance of the middle cranial fossa, external auditory canal, and inferior alveolar nerve. Custom printed cutting guides were manufactured to ensure recapitulation of the surgical plan in the operating room.
Figure 2: A. Preoperative coronal CT showing massive TMJ ankylosis and fusion of the mandible to the skull base. B. Postoperative coronal CT following ankylosis resection and immediate temporomandibular joint replacement. Note arrow showing the embolized internal maxillary artery.
The day before surgery, Mr. W had a percutaneous embolization procedure on his left internal maxillary artery under continuous fluoroscopic guidance, with post-embolization angiography demonstrating exclusion of the artery at a segment medial and deep to the ramus of the mandible (Figure 1).
At his scheduled surgery, the bone resection occurred as planned and a stock TMJ Biomet prosthesis was placed (Figure 2B). Mr. W started immediate function using the TMJ enhanced recovery after surgery (ERAS) protocol and was discharged the following day.
At his one year follow-up, Mr. W had a functional opening of 30mm and was maintaining a normal diet.
Access
Penn Oral and Maxillofacial Surgery
Perelman Center for Advanced Medicine
South Pavilion, 4th Floor
3400 Civic Center Boulevard
Philadelphia, PA
Penn Interventional Neuroradiology
Hospital of the University of Pennsylvania
Ground Founders
3400 Spruce Street
Philadelphia, PA
Published on: February 25, 2020
References
1. Hossameldina RH, McCain JP, Dabuse G. Prophylactic embolisation of the internal maxillary artery inpatients with ankylosis of the temporomandibular joint. Br J Oral Maxillofac Surg 2017;55:584–588.
About Penn Oral and Maxillofacial Surgery
The faculty at Penn Oral and Maxillofacial Surgery includes internationally known surgeons and pioneers in TMJ surgery. Penn surgeons have extensive experience in treating conditions involving the temporomandibular joint, including complex joint and combined jaw surgeries, and see one of the highest volumes of joint surgery in the country.
The mission of the Penn Center for Temporomandibular Joint Disease at the Department of Oral & Maxillofacial Surgery is to advance the understanding and treatment of temporomandibular joint disease. Finding the source of the pain to define the etiology of TMJ is one of the Center's key services.
In addition to practical evaluations, diagnostic tools include Panorex, MRI and CT imaging. Treatment at the Center is directed at the origin of pain. The first-line therapy for TMJ disorders is short-term conservative management. Patients who continue to have symptoms of TMJ disease or progression despite optimal conservative management may benefit from interventional therapy.
Penn Faculty Team
Director, Center for Temporomandibular Joint Disease
Professor of Radiology at the Hospital of the University of Pennsylvania
Professor of Radiology in Neurosurgery
Associate Professor of Radiology at the Hospital of the University of Pennsylvania
Associate Professor of Radiology in Neurosurgery