Temporomandibular Joint Reconstruction with Coracoid Transplantation

Treatment of diseases: temporomandibular joint rigidity Indication Condylar graft temporomandibular joint reconstruction is suitable for temporomandibular joint ankylosis. Contraindications 1. The temporomandibular joint has a coagulation. 2, temporomandibular joint external rigidity. Preoperative preparation 1, routine bilateral X-ray examination, to determine the location, nature and extent of the lesion, and to identify no external joint adhesion lesions, in order to make a preoperative design. 2, pay attention to check the external auditory canal for secretions, those with otitis media should be treated first. 3, plan to put the insert in the surgery, prepare the insert material in advance, disinfection and standby. Regular blood matching. Surgical procedure 1. Incision The submandibular incision revealed the mandibular ascending branch and the ankylosing lesion. Starting from 1cm below the earlobe, the posterior margin of the lower mandibular ascending branch, going down the mandibular angle, paralleled forward from the lower edge of the lower jaw 1, 5cm, and made an arc-shaped incision 2cm before the chewing muscle. The skin, subcutaneous and platysma were cut open, and the mandibular branch of the facial nerve was dissected at the mandibular angle or anterior incision. The external maxillary artery and the anterior vein were ligated. Then, along the sternocleidomastoid muscle and the parotid gland, sharp separation is performed outside the parotid fascia, so that the parotid gland is separated from the sternocleidomastoid and deep tissue, and then the periosteum of the lower mandible and the chewing muscle are attached, and the periosteum is used. The stripper is peeled off from the bone surface and cuts off the periosteum of the ascending branch. Since the lower pole of the parotid gland has been dissociated, when the lateral soft tissue flap of the ascending branch is pulled upward, the parotid gland also rises upward with the soft tissue flap, and the resistance of the upward traction is reduced, so that the upper part of the mandibular ascending branch and the condyle can be obtained. Better revealed. 2, interception of the conflict From the sigmoid incision, the upper part of the ascending branch is longitudinally cut through the mandibular hole. At the level corresponding to the mandibular hole, the condylar bone is cut obliquely. The medial bone plate should be located above the mandibular hole, and the lateral plate is cut. The bone line should be below the mandibular hole. According to the design line, drill with electric drill, then use the osteotome to completely cut the condyle, cut off the diaphragm and attach the tendon to the tip of the condyle or wrap it around the tip of the condyle. The wire is fixed by sewing, and the inner bone plate is trimmed to fit the outer side of the ascending branch. 3, strong straight area high bone First, use the electric drill or bone to cut the bone above the plane of the mandibular hole, and then gradually stratify and cut the bone from the low position to the high position until it is close to the plane of the original joint socket. The overhang or spur around the bone section must be smoothed, especially the broken end. Removal of medial bone. 4, implanted condyle bone The tip of the condyle is pointed upwards, as far as possible against the cross-section of the temporal bone, so that the mandible has a reliable fulcrum, and the lower part of the condyle is placed on the outer side of the ascending branch, and the hole is fixed by a wire. 5, suture wound Rinse, stop bleeding, layer suture the wound, and set the flow strip. complication 1. Condylar transplantation is the same as other bone grafts, which may lead to failure due to concurrent infection. Therefore, it is necessary to pay attention to aseptic operation during operation, reliably fix the condyle, reset the muscles as much as possible, eliminate the invalid cavity, completely stop bleeding, and prevent infection. 2, respiratory obstruction The pharyngeal cavity of the patients with ankylosis is narrow. After the osteotomy, especially in patients with bilateral joint stiffness, the pharyngeal cavity is further reduced due to the mandibular retreat. If the anesthesia cannula is removed after the operation, it is easy to fall due to the tongue falling. asphyxia. In addition, pediatric patients, due to blind intubation injury or long operation time, are also prone to laryngeal edema and cause airway obstruction. Therefore, it must be completely awake before extubation, at the same time prepare for tracheostomy, and actively prevent laryngeal edema, to avoid airway obstruction. 3, after surgery After the mandibular oblique joint is straight and osteotomy, the fulcrum is shortened, the fulcrum is moved forward, and the mandible is rotated backward. The bilateral patients develop open jaw. The unilateral ones mainly show the mandibular deviation from the affected side. It can be improved by inter-maxillary traction, and the mandibular deviation can be corrected with a beveled guide. 4, postoperative wound infection If the joint stiffness surgery occurs, it may lead to postoperative recurrence. Therefore, skin preparation must be done before surgery, and strict aseptic operation should be performed during the operation to actively prevent wound infection. After the operation, the wound should be closely observed, and the local swelling should be noticed. The signs of infection should be treated in time. For example, the whole body should be switched to broad-spectrum antibiotics, local drainage, blood accumulation, and effusion. If the wound has been purulent, it should be drained in time. If the foreign material is inserted, it should be taken out. 5, joint rigidity recurrence According to reports in the literature, the recurrence rate is between 10% and 25%. The recurrence is the most in 1 to 2 years after surgery, and the chance of recurrence tends to decrease with the prolongation of time. The cause of recurrence is not fully understood, but it is closely related to the patient's age, surgical methods, and techniques.