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British Journal of Oral and Maxillofacial Surgery 50 (2012) 774–778

Available online at www.sciencedirect.com

ydroxyapatite/collagen block with platelet rich plasma inemporomandibular joint ankylosis: a pilot study in childrennd adolescents. Mehrotra ∗, S. Kumar, S. Dhasmana

epartment of Oral & Maxillofacial Surgery, CSMMU (Formerly King George’s Medical University), Lucknow, India

ccepted 6 January 2012vailable online 30 January 2012

bstract

he aim of this study was to evaluate the feasibility of using preshaped hydroxyapatite/collagen condyles as carriers for platelet-rich plasmafter gap arthroplasty in patients with temporomandibular ankylosis, to assess the aesthetic and functional outcomes, and to find out ifeocondylar regeneration was possible. We studied 19 patients with temporomandibular joint ankylosis (25 joints), in whom preshapedydroxyapatite/collagen condyles with platelet-rich plasma were fixed to the ramus with a titanium miniplate, and temporal fascia was placedn between. We evaluated the type of ankylosis, mouth opening before and after operation, deviation on mouth opening, lateral excursion,rotrusion, postoperative anterior open bite, radiographic assessment, and complications. All patients showed appreciable improvementsn mouth opening and excursion of the jaw. There were a few complications such as mild fever, and temporary involvement of the facialerve, which improved with time. No open bite or recurrence was reported during the 18 months’ follow up. Radiographic evaluation at 3onths showed a less opaque condyle, but the opacity at 18 months was more defined, suggesting a newly formed condyle. A preshaped

ydroxyapatite/collagen condyle with platelet-rich plasma improves both aesthetics and function. However, a long term study is required toollow the growth patterns to see if the patients develop any facial deformity as they grow.

2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

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eywords: Temporomandibular ankylosis; Hydroxyapatite; Collagen; Plate

ntroduction

ggressive resection of the bony or fibrous ankylotic seg-ent, with or without coronoidectomy, is the gold standard

or treatment of ankylosis of the temporomandibular jointTMJ).1 The many reconstructive options that are availableeflect the fact that no treatment is better than any other, and

ach technique has its own proponents, potential advantages,nd drawbacks.2

∗ Corresponding author at: 4/207, Vivek Khand, Gomtinagar, Lucknow26010, U.P., India. Tel.: +91 0522 2393841/4005152;obile: +91 9335902322.

E-mail addresses: divyamehrotra@hotmail.com,ivyamehrotra2000@yahoo.com (D. Mehrotra).

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266-4356/$ – see front matter © 2012 The British Association of Oral and Maxillofaciadoi:10.1016/j.bjoms.2012.01.002

plasma; Condylar regeneration

Autogenous grafts recommended for reconstruction ofhe ramus joint complex in juveniles include costochondralnd sternoclavicular bone grafts for their growth potential,ross anatomical similarity to the mandibular condyle, easef adaptation, and low morbidity.3 Total alloplastic recon-truction of the TMJ using titanium custom implants is nowhe standard treatment for disorders of the TMJ in adults, butt is expensive and not advocated for children. The new proto-ol for management of ankylosis of the TMJ in children nowncludes distraction osteogenesis,4 before or after release ofhe ankylosis, to correct secondary facial asymmetry.5

The next generation of TMJ implants are biological con-tructs that are fabricated by tissue engineering technology.

n this study we used a hydroxyapatite/collagen bioscaffoldor platelet-rich plasma to study the feasibility of using theioscaffold as a carrier for the plasma, to assess the aesthetic

l Surgeons. Published by Elsevier Ltd. All rights reserved.

D. Mehrotra et al. / British Journal of Oral and M

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ig. 1. Hydroxyapatite/collagen condylar scaffold with platelet-rich plasmaxed to the ramus with a titanium plate and screws after gap arthroplasty.

nd functional outcomes, and to see if there was a possibilityf neocondylar regeneration.

atients and methods

e studied 22 patients aged less than 18 years with anky-osis of the TMJ who visited our outpatient departmentrom 2008 to 2009. They were all given the choice of stan-ard condylar reconstruction with a sternoclavicular graftr the proposed option with a hydroxyapatite/collagen scaf-old impregnated with platelet-rich plasma. Only 3 patientspted for the standard reconstruction, whilst 19 opted for theroposed treatment.

Informed consent was obtained from parents before inclu-ion. The study was approved by the institution’s ethicsommittee. The TMJ was exposed through an Al-Kayatramley incision with the patient under general anaesthe-

ia, blind nasoendotracheal intubation, fibre-optic intubationr elective tracheostomy. The condylar segment was resectedggressively to create a gap of about 1 cm. In addition, we did

coronoidectomy on one or both sides to gain a minimum of5 mm intraoperative mouth opening.

Hydroxyapatite/collagen (Surgiwear®), marketed as alock, in a 60:40 ratio and with 60% porosity, was carved

e4mm

ig. 2. Postoperative orthopantomogram taken after 6 months with a superimpoydroxyapatite/collagen condyle in the right temporomandibular joint.

axillofacial Surgery 50 (2012) 774–778 775

o the shape of the condyle, impregnated with 2 ml freshlyrepared platelet-rich plasma, and fixed to the ramus by an-shaped, four-hole, titanium miniplate and screws (Fig. 1).he temporal fascia was interposed between the two articu-

ating surfaces and the wound closed in layers. Physiotherapyas started on the third postoperative day.The type of ankylosis as described by Sawhney was

ecorded,6 as were interincisal mouth opening before andfter operation, deviation on opening, lateral excursion,rotrusion, and any associated complications. Preoperativeadiographs were recorded, and compared at initial postoper-tive week, 3 months, and then every 6 months (Figs. 2 and 3)or 18 months. All radiographs were interpreted and scored on

scale of 1–4. Bone density was recorded from the orthopan-omogram using Emago software by the same radiologist,ho was unaware of the treatment being studied. Grids were

uperimposed on the radiographs to note the radio-opaquequares. Standard references were set to assess radio-opacity,hich was expressed in grey pixels.7 An overall score of 3r more was considered to be successful regeneration.

Data were analysed with the help of the Statistical Pack-ge for the Social Sciences (version 15.0, SPSS Inc., Chicago,L, USA). The data about mouth opening were checked forormality using the Kolmogorov–Smirnov test and foundo be normally distributed. Student’s paired t test was usedo assess the significance of the differences between mouthpening before and after operation. The significance of dif-erences between radio-opacity scores was assessed usinghe Wilcoxon signed rank test. The confidence interval was5%, and probabilities of less than 0.05 were accepted asignificant.

esults

mongst the 19 cases of ankylosis of the TMJ, 6 were bilat-

ral (25 joints) with 9:10 male:female ratio, and age range–16 years (median 11) (Table 1). Type III ankylosis was theost common (n = 11). All cases showed significant improve-ent (p < 0.001) in mouth opening (mean (SD) preoperative

sed grid in the condylar region in the open mouth position showing a

776 D. Mehrotra et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) 774–778

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ig. 3. Postoperative orthopantomogram taken after 6 months with a sydroxyapatite/collagen condyles in both temporomandibular joints.

istance 3.47 (1.95) mm, postoperative 38.3 (1.8) mm). Theange of mandibular movements improved considerably inhe postoperative phase, protrusion and lateral excursion fromil to 4.4 mm and 2.8 mm, respectively. There was no devi-tion on mouth opening, anterior open bite, or recurrence at8 months’ follow-up.

Baseline radiographic score at the condylar head dur-

ng the immediate postoperative phase was 2. Evaluationt 3 months showed a less opaque condyle, but the opac-ty became more defined by 18 months, suggesting a newly

tco

able 1etails of 19 patients with TMJ ankylosis who had hydroxyapatite/collagen condyl

ase no. Sex Age (years) Side Type Mout

Befo

1 M 4 B/L II 3

2 F 6 R III 4

3 F 7 B/L IV 0

4 M 8 R II 2

5 F 9 L III 4

6 F 10 B/L IV 2

7 F 10 L III 6

8 M 11 B/L III 2

9 M 12 R IV 4

0 F 12 B/L III 1

1 M 12 L III 5

2 F 12 R III 4

3 M 13 R III 4

4 F 13 R II 6

5 F 12 L III 3

6 M 13 B/L III 4

7 M 13 L III 3

8 F 14 L II 8

9 M 16 R IV 1

he only complications were mild fever (cases 5 and 19) and slight temporary invohe difference between mouth opening before and after operation was significant (

osed grid in the condylar region in the open mouth position showing

ormed condyle (Table 2(a)). If a score of 3 or more at theondylar head and the interface (Table 2(a) and (b)) is con-idered successful, we had a 96% success rate. The changesn radio-opacity at different times were significant (p < 0.001n each case). There were a few complications such as tem-orary involvement of the facial nerve, and mild fever, whichmproved with time (Table 1). Open bite, which is usually

he result of a bilateral arthroplasty, was seen in none of ourases, as both joints were functional with the vertical heightf the ramus restored.

es.

h opening (mm) Protrusion Lateral excursion

re After

36 4 236 3 339 5 337 4 238 5 342 4 338 5 236 4 242 4 139 4 340 3 240 5 338 5 441 4 338 5 439 5 342 4 334 6 432 4 3

lvement of the facial nerve (cases 7 and 18).p < 0.001).

D. Mehrotra et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) 774–778 777

Table 2Radiographic evaluation at various intervals postoperatively (n = 25). Data are number of patients.

Radio-opacity score Postoperatively At 3 months At 6 months At 12 months At 18 months

(a) At the condylar head1 (0–25%) 0 0 0 0 02 (25–50%) 25 9 3 3 23 (50–75%) 0 16 22 6 74 (75–100%) 0 0 0 16 16

(b) At the interface1 (0–25%) 24 4 0 0 02 (25–50%) 1 14 3 0 03 (50–75%) 0 7 14 9 74 (75–100%) 0 0 8 16 18

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iscussion

iological compatibility, workability, functional adaptability,nd growth potential, make the costochondral graft the idealhoice for condylar reconstruction in children,1 but donorite morbidity, adaptation of the graft to sit medially into theossa, fracture, reankylosis, and variable growth are poten-ial problems.8 Sternoclavicular grafts offer the advantagef a histological similarity to the condyle, and predictablerowth.9 Composite costochondral-iliac crest bone grafts,10

nd use of the coronoid process11 and an excised ankyloticass5 have been reported as techniques for reconstruction of

he TMJ.Homologous bank tissue or free flaps using vascularised

etatarsal or fibular grafts can easily be shaped, have a softissue paddle, and a remote donor site, but drawbacks includeesthetic deformity at the donor site and the complexity ofhe procedure.12

Titanium total joint systems developed for use in recon-truction of the TMJ allow a closer reproduction of the normalnatomy, restoration of the vertical dimension, no donor siteorbidity, reduced operating time, lower risk of recurrence,7

mproved subjective and objective outcomes, and feweromplications.13,14 Custom-made prostheses, combined withrafts of autogenous peri-implant fat have been reported as

viable option for reconstruction, with improvements in jawunction and aesthetics.15 Temporal fascia and a buccal fatad have been used as interposition material to allow for freeovement of the condyle against the glenoid fossa.16

A vertical sliding osteotomy for neocondylar formationeaves enough bone in contact to form a fracture callus, restoreontinuity, resist masticatory forces, and avoid donor-siteorbidity, resorption, and progressive ankylosis.3 Transport

istraction for reconstruction of the ramus-condyle unit of theMJ has been reported to match a costochondral graft witho significant difference in the calcification scores or recur-ence, but with discomfort associated with the distractor, andhe need for two operations.17,18

Recently tissue engineering has been used to regen-rate lost parts. Craniomaxillofacial bony defects areeing reconstructed using computer-aided design and

mIa

ficant (p < 0.001).

anufacturing processes, and scaffolds are being designedsing three-dimensional computed tomographic images andapid-prototyping.19 The mandibular condyle has also beeneported to have been successfully engineered in vitro.20,21

Platelet-rich plasma, an autologous source of platelet-erived growth factor, transforming growth factor �-1, andnsulin-like growth factor, is thought to play a pivotal part inhe regulation of osteoblast proliferation.22 A high concentra-ion of white cells in platelet-rich plasma provides an addedntimicrobial effect, a watertight seal, and an augmented ratef deposition of extracellular matrix.23

Implantation of hydroxyapatite/fibrin has resulted in theormation of bone comparable to normal bone.24 Hydroxya-atite is extremely biocompatible, and does not stimulate aoreign body reaction. Platelet-rich plasma induces osteo-enesis in the osteoconductive hydroxyapatite, which isncorporated into host bone more readily because its surfacencorporates the biological apatite.25 Collagen provides addi-ional space for bone to form as it resorbs, makes material lessrittle, and can be screwed to the stump of the ramus. Ourwn clinical experience of the successful use of the hydrox-apatite/collagen combination in small maxillofacial cysticefects encouraged us to use it in the condylar region.

Although fractures of the condyle require fixation with plates to prevent rotation, the use of such extra hardwareould split the material, so we used a single L-shaped plateor stability. The radiographic interpretation at various timeshowed a significant increase in radio-opacity both at theondylar stump and at the interface, which suggested osteo-enesis.

It is debatable whether the technique used is tissue engi-eering or simply the use of another alloplastic material. Wehink at 18 months’ postoperatively that it may be a bony

ass or just a calcified substitute of condylar head rather than normal condyle without a covering layer of fibrocartilage,etabolic activity, or other features.Anterior open bite, which usually results from a bilat-

ral gap arthroplasty because of downward rotation of the

andible and shortening of the ramus, may cause reankylosis.

n our series, bilateral reconstruction with a hydroxyap-tite/collagen scaffold with platelet-rich plasma in patients

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craniofacial surgery. J Cranio-Maxillofac Surg 1997;25:124–35.25. Kandaswami D, Ramachandran G, Maheshwari S, Mohan B. Bone

regeneration using hydroxyapatite crystals for periapical lesions.

78 D. Mehrotra et al. / British Journal of Ora

ith bilateral ankylosis prevented postoperative anterior openite.

Although this method gave satisfactory results in termsf function and aesthetics, it is difficult to prove that a neo-ondyle has regenerated. Inducing osteogenesis, may alsoisk reankylosis, so long-term follow-up is essential. Thistudy should inspire many research workers to evaluate theong term effects of such condyles, before rushing to adopt its a standard treatment.

An appropriate randomised trial should compare this tech-ique with costochondral and sternoclavicular grafts. As inhis study we did not compare hydroxyapatite/collagen with-ut platelet-rich plasma, the actual role of the plasma itselfould not be evaluated, so another study with and withoutlatelet-rich plasma could be planned. An animal study maylso help to assess bone healing at various times using histo-orphometry.

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