Abstract
Background
One of the management modalities of temporomandibular joint ankylosis is interpositional gap arthroplasty. The most commonly used interpositioning material is temporalis myofascial flap owing to its close proximity to operating site. However, sometimes this flap becomes insufficient in terms of length. Hence, we propose a technique of temporalis myofascial flap lengthening.
Technique
The technique described in the manuscript increases the length of the flap by 1½-fold. This increases the reach of the flap till the medial aspect of the created gap avoiding bone-to-bone contact during movement of the jaw.
Conclusion
This technique can be easily and effectively used to ensure proper interpositioning during management of temporomandibular joint ankylosis to avoid recurrence.
Keywords: Temporomandibular joinf ankylosis, Temporali myofacial flap, Jain technique, Extended temporalis flap
Temporomandibular joint ankylosis (TMJa) is a distressing condition characterized by fibrous or bony fusion of mandibular condyle to skull base due to disease process resulting in diminished mouth opening with impaired mandibular movements and functions. TMJa during childhood may cause growth disturbances, facial asymmetry, difficulty in eating and speech, poor oral hygiene and disturbed sleep due to difficulty in breathing. Management of TMJa should be aimed to reestablish movements and functions of the jaw. The treatment should prevent relapse, promote normal growth, achieve normal occlusion and restore appearance. Different treatment modalities have been described in the litearture for this disturbing condition. One of the modalities is interpositional gap arthroplasty which is characterized by interpostioning of different grafts or flaps in the created gap following release of the ankylotic mass.
Murphy in 1914 first used the temporalis muscle for interpositioning in TMJa surgery [1]. The temporalis muscle originates from the superior temporal line and inserts to the head of coronoid process. The cadaveric study conducted by Burggasser et al. [2] highlights that the anterior, middle and posterior part of temporalis muscle is supplied by the anterior deep temporal artery, posterior deep temporal artery and the middle temporal artery, respectively. Temporalis flap, either full or partial thickness, is commonly used for interpositioning after gap arthroplasty as a pedicled flap. However, sometimes, mostly in paediatric patients and in patients with long standing ankylosis leading to atrophy of the temporalis muscle, the length of the flap is found to be insufficient to provide an adequate barrier between the mandible and skull base. An insufficient flap may lead to incomplete interpositioning leading to high risk of relapse (Fig. 1).
Fig. 1.
Full thickness temporalis myofascial flap with limited reach
To overcome this drawback, we propose JAIN technique of temporalis myofascial flap lengthening. Once the ankylotic mass is exposed, it is excised to create an adequate gap between the healthy bone of mandible and the skull base. The medial aspect of the ankylotic mass must be removed very carefully to avoid injury to the underlying soft tissue and vessels [4]. A full thickness finger-like temporalis muscle flap is harvested involving the fibers from anterior and middle temporalis muscle (Fig. 2). A horizontal incision up to the partial thickness of muscle is given 10–15 mm above the zygomatic arch at the proximal end of the flap. The incision is then extended towards the distal end of the flap to divide the muscle in two partial thickness flaps. The distal end is not cut completely maintaining the continuity of the superficial and deep flap. This technique increases the length of the flap to around 1.5-fold (Fig. 3).
Fig. 2.
Length of the conventional full thickness temporalis myofascial flap
Fig. 3.
Length of the extended temporalis myofascial flap (JAIN Technique)
The flap is turned over the zygomatic arch and inserted into the gap created (Fig. 4). The extended flap is then sutured with a few sutures to make sure it acts as a barrier to avoid bone to bone contact. In this technique, the fascia faces the condyle resulting in less friction as compared to the friction between condyle and muscle. Hence, it provides smooth movement of the condyle [3]. Due to increased length of the flap, it can be folded at the distal end and inserted in the gap providing cushioning effect due to increased bulk of the flap.
Fig. 4.
Extended temporalis myofascial flap inserted into the created gap
Funding
None.
Compliance with ethical standards
Conflict of interest
The authors declare that there are no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Majmudar A, Bainton R. Suture of temporalis fascia and muscle flaps in temporomandibular joint surgery. Br J Oral Maxillofac Surg. 2004;42:357. doi: 10.1016/j.bjoms.2004.04.004. [DOI] [PubMed] [Google Scholar]
- 2.Burggasser G, Happak W, Gruber H, Freilinger G. The temporalis: blood supply and innervation. Plast Reconstr Surg. 2002;109(6):1862–1869. doi: 10.1097/00006534-200205000-00012. [DOI] [PubMed] [Google Scholar]
- 3.Omura S, Fujita K. Modification of the temporalis muscle and fascia flap for the management of ankylosis of the temporomandibular joint. J Oral Maxillofac Surg. 1996;54(6):794–795. doi: 10.1016/S0278-2391(96)90707-7. [DOI] [PubMed] [Google Scholar]
- 4.Rai A, Jain A, Nagarkar N, Khan M. Use of Kerrison Rongeur for safe and effective removal of bone in temporomandibular joint ankylosis. Oral Maxillofac Surg. 2018;22(1):115–116. doi: 10.1007/s10006-018-0671-4. [DOI] [PubMed] [Google Scholar]