J Oral Maxillofac Surg 60:985-987, 2002

Auricular Cartilage Graft Interposition After Temporomandibular Joint Ankylosis Surgery in Children
Zhou Lei, DDS*
After surgery for temporomandibular joint (TMJ) ankylosis, relapse is frequently due to brosis and ossication occurring in the space of the joint. The object of this study was to evaluate the use of autogenous auricular cartilage graft as an interposition material after arthroplasty of the TMJ ankylosis. Patients and Methods: Seven patients with TMJ ankylosis were treated with autologous auricular cartilage graft interposition arthroplasty. With 4 to 6 years of follow-up, the function of the TMJ was evaluated. Results: In 7 patients with TMJ ankylosis treated with autologous auricular cartilage graft interposition arthroplasty, the function of the TMJ recovered well. At 6-year follow-up, no relapse had occurred and no deformities resulted in the ear from which the cartilage had been harvested. Conclusion: Autologous auricular cartilage interposition arthroplasty is an ideal method for the prevention of relapse of TMJ ankylosis. 2002 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 60:985-987, 2002 Recurrence is a major problem after release of temporomandibular joint (TMJ) ankylosis. Relapse of ankylosis postoperative rates are as high as 50%.1 Many investigators believe that the choice of interposition material is important in preventing recurrence.2,3 Alloplastic and autogenous graft interpositions have been used to prevent postoperative ossication of the joint, but enthusiasm for the use of alloplastic implants has been dampened by their unpredictable behavior, resulting in implant fragmentation, migration, foreign body reaction, etc.4-7 A variety of autogenous materials have been used, such as costochondral grafts, dermis, and temporalis muscle or fascia. However, besides the increase in operative time and sophistication of the procedure, complications at the donor site (eg, pneumothorax, pleuritic pain, infection) and at the recipient site (eg, resorption of the graft, infection, brosis, and ossication) have been reported.8-11 In an experimental study, Takatsuka et al12 found that the structure and function of the condyle could be preserved by auricular cartilage grafting after discectomy in the rabbit craniomandibular joint. This suggests the auricular cartilage could be used in interpositional arthroplasty. The focus of this study was to evaluate the use of the auricular cartilage grafts as an interposition material after arthroplasty for TMJ ankylosis.
Purpose:

Patients and Methods

SUBJECTS

*Professor, Department of Oral and Maxillofacial Surgery, Guangdong Provincial Stomatological Hospital, Guanzhou City, Guangdong Province, PR China. This study was supported by Grant 20041 from the Guangdong Educational Department, Guangdong, PR China. Address correspondence and reprint requests to Dr Lei: Department of Oral and Maxillofacial Surgery, Guangdong Provincial Stomatological Hospital, 366 S Jiangnan Blvd, Guanzhou City, Guangdong Province 510280 - PR China; e-mail: zho668@263.net
2002 American Association of Oral and Maxillofacial Surgeons

During the period of November 1994 through November 1996, a total of 7 patients who had TMJ ankylosis for 1 to 2 years underwent gap arthroplasty along with auricular cartilage graft interposition. None of the patients had previous surgical interventions before the operation. Demographic information and the reason for ankylosis were recorded.
SURGICAL TECHNIQUE

0278-2391/02/6009-0003$35.00/0 doi:10.1053/joms.2002.34400

Each joint was approached via a preauricular incision. In all cases of ankylosis, ossication took place between the condyle and fossa. The condyle was then loosened with a chisel and removed. The stump of the condyle was smoothed. The cross section of the con985

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AURICULAR CARTILAGE GRAFT IN TMJ SURGERY

Table 1. GENERAL DATA ON THE PATIENTS

Patient 1 2 3 4 5 6 7

Gender F M F M F F F

Age (yr) 16 18 10 6 10 14 6

Affected Side Right Right Right Left Left Both Right

Duration (yr) 3 2 1 1 2 3 1

Etiology Trauma Trauma Ear infection Ear infection Trauma Trauma Trauma

Follow-Up (yr) 4 4 5 6 6 5 4

T1 (mm) 28 20 28 26 25 26 26

T2 (mm) 28 30 28 30 35 26 32

Abbreviations: T1, maximal mouth opening at the immediate postoperative period; T2, maximal mouth opening at the follow-up times.

dyle was shaped into an area no larger than 1 2 cm2. This allowed the newly formed condyle process to be tted to the auricular cartilage grafts. The auricular cartilage grafts were harvested through a 3- to 4-cm incision on the posterior of the auricle. Along the rim of the auricular concha, the proximal boat-like portion of the concha cartilage was removed with the antehelical rim maintained. The perichondrium was left attached to the convex surface of the graft. This was thought to be advantageous because the grafts theoretically maintain chondrogenic potential, and leaving 1 layer of perichondrium at the donor site could also conceivably lead to regeneration. The removed cartilage graft is convex and ts the fossa well. A piece measuring 1 2 cm2 is adequate to line the fossa. The grafts were inserted into the appropriate position between the condyle and fossa and rmly sutured to anterior, lateral, and posterior peripheral soft tissues with 4 to 6 resorbable sutures. The mandible was then manipulated to assess the degree of mobility and to ensure the grafts were stable and not interfering with condylar process movement. The wounds were then closed in layers, and a small rubber band drain was left in the recipient site wound. The drains were removed the rst day postoperatively. Early, sustained postoperative jawopening exercise was encouraged.

jaw-opening exercises (Table 1). There is little or no donor site deformity noted postoperatively.

Discussion
There is a cartilage covering on the normal condyle surface that separates the condyle from the nearby tissues. However, on the new condyle formed after arthroplasty, there is a freshly wounded bone surface. Fibrosis and ossication occur frequently in this raw surface. In other places in the body, autogenous cartilage implantation is usually successful due to the low metabolism characteristic of cartilage and no foreign body reaction. Eisemann13 reported that there is an increase in the surface area and weight of the cartilage grafts after implantation. Tucker et al14 found that concerning the use of interpositional auricular cartilage in monkeys after discectomy and high condylar shave, the cartilage survived and degenerative changes of the joint were less than those on the control side in which the disc was removed and no interpositional graft was placed. Ioannides and Maltha15 studied cartilage grafts placed into guinea pigs after discectomy. All of the auricular cartilage survived and showed rapid primary healing. The attractiveness of auricular cartilage in TMJ arthroplasty is obvious. It is readily available autogenous tissue within the same operative eld and is much more convenient than that harvested from other sites of the body, such as the graft from the costochondral cartilage. In the 7 patients, the harvested auricular cartilage measured more than 1 2 cm2, and no deformities were seen at the donor sites in the immediate postoperative period and later. The contour of the cartilage t the condyle process well. On the basis of clinical observation, the size of the condylar processes in the ankylotic joint is increased, but during the operation, the condyle can be easily shaped into a smaller anatomic form. Then, the raw surface of the condyle can be covered conveniently by the harvested auricular cartilage. This successfully prevents the relapse of the ankylosis in our patients. The re-

Results
The causes of the TMJ ankylosis could be traced to trauma in 5 cases and to ear infection in 2 cases. The TMJ ankylosis occurred on 1 side in 6 cases and on both sides in 1 case. There were 5 girls and 2 boys. The average age at the time of TMJ reconstruction was 11.4 years. No complications were observed in the immediate or late postoperative periods. At 4- to 6-year follow-up, results were successful in all of the 7 patients. All have maintained the range of jaw movements as that in the immediate postoperative period, and some of them even increased as a result of the

ZHOU LEI

987
7. Bronstein SL: Retained alloplastic temporomandibular joint implants: A retrospective study. Oral Surg 64:135, 1987 8. Raveh J, Vuillemin T, Ladrach K, et al: Temporomandibular joint ankylosis: Surgical treatment and long term results. J Oral Maxillofac Surg 47:900, 1989 9. Lindquist C, Pihakari A, Tasanen A, et al: Autogenous costochondral grafts in temporo-mandibular joint arthroplasty: A survey of 66 arthroplasties in 60 patients. J Maxillofac Surg 14:143, 1986 10. Kaban LB, Perrot DH, Fisher K: A protocol for management of temporomandibular joint ankylosis. J Oral Maxillofac Surg 48: 11, 1990 11. Meyer RA: The autogenous dermal graft in temporomandibular joint disc surgery. J Oral Maxillofac Surg 46:948, 1988 12. Takatsuka S, Narinobou M, Nakagawa K, et al: Histologic evaluation of auricular cartilage grafts after discectomy in the rabbit craniomandibular joint. J Oral Maxillofac Surg 54:1216, 1996 13. Eisemann ML: The growth potential of autograft cartilage: An experimental study. Arch Otolaryngol 7:109, 1983 14. Tucker MR, Kennady MC, Jacoway JR: Autologous auricular cartilage implantation following discectomy in the primate temporomandibular joint. J Oral Maxillofac Surg 48:38, 1990 15. Ioannides C, Maltha JC: Replacement of the interarticular disc of the craniomaandibular joint with fresh autogenous stermal or auricular cartilage. J Craniomaxillofac Surg 16: 343, 1988

sults from this study suggest that the autologous auricular cartilage interposition arthroplasty is a good method for successful treatment of TMJ ankylosis.

References
1. Topazian RG: Comparison of gap and interposition arthroplasty in the treatment of temporomandibular joint ankylosis. J Oral Surg 24:405, 1966 2. Chossegros C, Guyot L, Cheynet F, et al: Full-thickness skin graft interposition after temporomandibular joint ankylosis surgery: A study of 31 cases. Int J Oral Maxillofac Surg 28:330, 1999 3. Miyamoto H, Kurita K, Ogi N, et al: The role of the disk in sheep temporomandibular joint ankylosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 88:151, 1999 4. Dolwick MF, Aufdemorte TB: Sillione-dnduced foreign body reaction and lymphadenopathy after temporomandibular joint arthroplasty. Oral Surg 59:449, 1983 5. Helfrick JF: Temporomandibular joint meniscus replacements with alloplasts: A retrospective styudy disclosing failure in 14 of 22 cases. Presented at the Ninth International Conference on Oral and Maxillofacial Surgery, Vancouver, British Columbia, Canada, May 1986 6. Fontenot MG, Kent JN: In vitro wear performance of Proplast TMJ disc implants. J Oral Maxillofac Surg 50:133, 1992