Temporomandibular joint reconstruction with costal cartilage and rib transplantation

Costal cartilage rib grafting for temporomandibular joint reconstruction for the treatment of true temporomandibular joint ankylosis. During the growth and development period, the costal cartilage and rib joints have the potential to grow. The rib cage with rib cartilage is used to treat the temporomandibular joint ankylosis, and the costal cartilage head is used instead of the condyle to reconstruct the joint, which can restore the height of the mandible ascending branch. The mandible continues to grow. Therefore, this surgical procedure, which began in the 1970s, was widely used in the 1980s. Treatment of diseases: temporomandibular joint rigidity Indication Costal cartilage rib graft temporomandibular joint reconstruction is applicable to: 1. The temporomandibular joint is unilateral or bilateral true tonic, especially in the range of large bone adhesion and mandibular retraction deformity, especially for children. 2. Recurrent temporomandibular joint ankylosis. Contraindications The general condition is poor and cannot tolerate the operator. Preoperative preparation 1. Determine the location, nature and extent of the lesion by X-ray and clinical examination. Understand the chest and chest wall with or without lesions. 2. The upper and lower jaw teeth are hooked on the buccal surface for intraoperative intermaxillary traction. Regular blood matching and skin preparation for the neck and chest. Surgical procedure 1. Incision and exposure Revealed by a modified submandibular incision. Starting from 1cm below the earlobe, the posterior margin of the lower mandibular ascending branch, going down the mandibular angle, paralleled forward 1.5cm from the lower edge of the lower jaw, 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. Osteotomy The lower cut bone is above the level of the mandibular hole, and the upper boundary is as close as possible to the plane of the original joint. The condyle is included in the resection range. The electric bone drill (gas drill) or osteotome is used to remove the bone layer along the lower cut bone line, close to the medial bone plate. When using a bone chisel to shake open, the mandible can be pulled down at this time, and then the other part of the bone is bitten with a rongeur. The skull section was trimmed, smoothed with a ball drill, slightly concave, and the lower end of the bone was narrowed. Then, the lateral cortical bone of the ascending branch is removed to form a bone wound to receive the bone piece. 3. Take the rib Generally, the ribs are taken from the ribs on the right side of the 6, 7, and 8. The length of the costal cartilage is 0.5 to 1 cm, and the length of the ribs is 5 to 6 cm. After cutting, the cartilage head is trimmed to form a hemispherical surface. 4. Bone graft Temporary intermaxillary ligation, implantation of ribs, so that the cartilage head is in the joint socket, the rib portion and the outer edge of the ascending branch are fixed with stainless steel wire. 5. Mandibular advancement If the ribs are L-shaped and the bone graft can reach the mandibular body, the mandible can be moved forward. Bilateral torsion for L-shaped bone grafting on both sides can advance the mandibular retraction and correct the small jaw deformity. Unilateral tonic for L-shaped bone grafting, but also need to lift the bone in the healthy side, in order to make the mandible symmetrically forward. 6. Stitching As far as possible, the external muscles of the pterygium are sutured and fixed in the original position, the chewing muscles, the deep fascia of the neck and the skin are sutured, the rubber sheet is placed for drainage, and the wound is pressure-wrapped. complication It is basically the same as high temporomandibular joint angioplasty. In addition, strict aseptic operation should be performed during operation, and proper braking should be performed after operation to prevent infection of bone graft. 1. Respiratory obstruction The rigidity of the pharyngeal cavity 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 remove the anesthesia. Suffocation occurs after falling. 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. 2. After the operation of the open jaw and mandibular oblique joint, the fulcrum is shortened, the fulcrum is moved forward, and the mandible is rotated backward. The bilateral patients develop open jaw, and the unilateral side mainly shows the mandibular to the affected side. Skewed. The open jaw can be improved by intermaxillary traction, and the mandibular deviation can be corrected with a beveled guide. 3. Postoperative wound infection Joint stiffness surgery If infection occurs, it may lead to postoperative recurrence. Therefore, skin preparation must be done before surgery, and strict aseptic operation should be performed during 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. 4. Recurrence of joint rigidity 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.

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