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Table of Contents   
ORIGINAL RESEARCH  
Year : 2013  |  Volume : 24  |  Issue : 4  |  Page : 521
Facial nerve injury following surgery for temporomandibular joint ankylosis: A prospective clinical study


1 Department of Oral & Maxillofacial Surgery, Kothiwal Dental College & Research Centre, Moradabad, India
2 Department of Oral & Maxillofacial Surgery, Faculty of Dentistry, Jamia Millia Islamia University, New Delhi, India
3 Department of Oral & Maxillofacial Surgery, Dental College, Itaura, Chandeshwar, Azamgardh, India

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Date of Submission24-Apr-2012
Date of Decision06-Feb-2013
Date of Acceptance19-Mar-2013
Date of Web Publication19-Sep-2013
 

   Abstract 

Objective: The purpose of this prospective study was to evaluate the incidence and degree of facial nerve damage and time taken for its recovery following surgery for temporomandibular joint (TMJ) ankylosis.
Materials and Methods: A total of 30 subjects with the TMJ ankylosis with or without history of previous surgery were included in this prospective study. House-Brackmann grading system was used to assess the function of the facial nerve post-operatively.
Results: Most of the subjects were in the age range of 13-15 years. Eight subjects had bilateral ankylosis and remaining 22 had unilateral ankylosis. Out of 32 joints in which gap arthroplasty was performed, 4 had Grade 1 injury, 14 had Grade 2 injury, 12 had Grade 3, and 2 with the Grade 4 injury 24 h post-operatively. Whereas, out of 6 cases of interpositional arthroplasty 4 had Grade 1 injury and 2 had Grade 4 injury. According to House-Brackmann grading system, at 24 h, 78.9% patients had different grades of facial nerve injury, which gradually improved and came to normal limits within 1-3 months post-operatively. Comparison of change in the Grade of injury at 3 months follow-up as compared to baseline (24 h) showed full recovery in all the cases (100%) showing a statistically significant difference from baseline (P < 0.001).
Conclusion: When proper care is taken during surgery for TMJ ankylosis, permanent facial nerve injury is rare. However, the incidence and degree of temporary nerve injury could be either due to the heavy retraction causing compression and or stretching of nerve fiber resulting in neuropraxia.

Keywords: Ankylosis, facial nerve injury, facial nerve injury, temporomandibular joint, temporomandibular joint ankylosis surgery

How to cite this article:
Gokkulakrishnan S, Singh S, Sharma A, Singh AK, Borah R. Facial nerve injury following surgery for temporomandibular joint ankylosis: A prospective clinical study. Indian J Dent Res 2013;24:521

How to cite this URL:
Gokkulakrishnan S, Singh S, Sharma A, Singh AK, Borah R. Facial nerve injury following surgery for temporomandibular joint ankylosis: A prospective clinical study. Indian J Dent Res [serial online] 2013 [cited 2019 May 27];24:521. Available from: http://www.ijdr.in/text.asp?2013/24/4/521/118365
Temporomandibular joint (TMJ) ankylosis is usually seen during the first decade of life. The most common etiology of this condition is trauma; other causes may include infections from the middle-ear, inflammation, tuberculosis, etc. During growth period, it can cause gross facial deformities especially, when not identified in time or if treatment is delayed. Surgical treatment is the only choice of treatment in this condition. Most common surgical procedures advocated for this condition is either gap arthroplasty or interpositional arthroplasty. The approach for the joint is varied; however, preauricular incision and its modifications are mostly preferred. One main draw back in this approach is the Facial nerve and its branches, which courses along the entire length of the incision. Facial nerve is one of the most vulnerable anatomic structures that should be given utmost importance while performing the surgery for TMJ ankylosis. Despite extreme care taken during the procedure, the facial nerve may get affected. Most frequently involved are the temporal and zygomatic branches leading to weakness of frontal and orbicularis oculi muscle. Therefore, identification, evaluation, and follow-up of this surgical complication are very important. Among the clinical methods employed for evaluation of frequency and degree of nerve injury, the House-Brackmann grading system appears to be quick, comprehensive, and widely used. [1],[2],[3] Based on this, we conducted a study to evaluate the incidence and degree of the facial nerve damage and time taken for its recovery following surgery for TMJ ankylosis.


   Materials and Methods Top


A total of 30 patients (38 joints) with TMJ ankylosis, who reported to our center, were operated, using the different approaches and different techniques. The House-Brackmann grading system [Table 1] was used to assess motor function of the facial nerve. Pre-operatively, orthopantomogram (OPG) and computed tomography scans were taken to confirm the diagnosis. Additional radiographs were taken when required. Pre-operative frontal and lateral photographs were taken using a Nikon 1100 D camera with 55-250 mm lens and a macro lens with image stabilizer up to 3.6 ft. on a tripod. Facial nerve function was also assessed pre-operatively. Post-operatively, OPG was taken after 24 h and post-operative photographs (same manner as described above) of the patients were taken at: 24 h, 1 week, 1 month and 3 months interval.
Table 1: House - Brackmann grading system

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The pre- and post-operative photographs were taken by the same photographer using the same camera and magnification. The patients were photographed facing the camera in the following positions: At rest [Figure 1], closing the eyes with minimum effort [Figure 2] and tightly [Figure 3], raising the eyebrows [Figure 4] and with maximum mouth opening [Figure 5]. A descriptive method using the tables and the graphs were employed, which show absolute distributions and percentage data.
Figure 1: At rest

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Figure 2: Eyes closed with minimum effort

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Figure 3: Eyes tightly closed

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Figure 4: Eyebrows raised

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Figure 5: Maximum mouth opening

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   Results Top


A total of 30 patients (38 joints) were enrolled in the study. The observations made were as follows:

A total of 40% subjects each were in the age range of 13-15 years and 5-9 years followed by 13.3% cases in the age range of 10-12 years and 6.7% in the age range of 16-18 years. The mean age of patients was 11.00 ± 4.16 (SD) years with a minimum age of 5 years and a maximum of 18 years [Graph 1]. Majority (60%) of the patients were females with female to male ratio 1.5:1 [Graph 2]. There were 8 (26.7%) subjects with bilateral TMJ ankylosis, and 22 (73.3%) with unilateral ankylosis (left side 8 and right side 14) [Graph 3]. Rowe's incision [Figure 6] was used in 60% of the subjects while Al-Kayat and Bramley incision [Figure 7] was used in remaining 40% cases [Graph 4]. 20% study subjects had a history of the previous operation of TMJ ankylosis [Graph 5].
Figure 6: Rowe's incision

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Figure 7: Al-Kayat and Bramley incision

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Out of 38 joints operated upon, according to the House-Brackmann grading system at 24 h (n = 38) post-operatively, maximum number of operated joints had Grade 2 nerve injury (36.8%), followed by Grade 3 (31.6%), Grade 1 (21.1%), and Grade 4 (10.5%) respectively [Table 2]. Significant association between the higher grades (Grade 3 and 4) of nerve injury and Al-Kayat Bramley incision was seen 24 h post-operatively [Graph 1]. None of the patients who were previously operated had Grade 1 rating at baseline. However, there was no statistically significant association between previously operated joints and the grade of nerve injury [Graph 2].
Table 2: Distribution of nerve injuries based on House-Brackmann grading system at 24 h

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Out of 32 joints in which gap arthroplasty was performed, 4 had Grade 1 injury, 14 had Grade 2 injury, 12 had Grade 3, and 2 with Grade 4 injury 24 h post-operatively. Whereas, out of 6 cases of interpositional arthroplasty 4 had Grade 1 injury and 2 had Grade 4 injury [Graph 3].

Comparison of change in the Grade of injury at 1 week follow-up and at baseline (24 h) showed that [Table 3], there was no change in 8 cases with the Grade 1 injury at baseline. Out of 14 cases with baseline Grade 2 injury, 6 cases (42.9%) showed an improvement and attained Grade 1 whereas; in remaining 8 (57.1%) patients no change was observed. In 12 patients with Grade 3 injury at baseline, 6 (50%) improved to Grade 2, and in remaining 6 (50%) cases it was unchanged. Out of 4 cases with Grade 4 nerve injury at baseline, in 2 (50%) cases, the grade of injury became Grade 3, and in the other 2 cases it became Grade 2. On statistical comparison of data, a statistically significant change in the grade of injury was seen at 1 week.
Table 3: Change in the Grade of Injury at 1 week follow-up as compared to baseline (24 h)

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Comparison of change in the Grade of injury at 1 month follow-up as compared to baseline (24 h) showed [Table 4] that in all the 8 cases with Grade 1 injury at baseline, no change was observed. 14 cases with Grade 2 injury at baseline showed full improvement [returning to Grade 1] at 1 month. Out of 12 patients with Grade 3 injury at baseline, 8 patients (66.7%) improved to Grade 1 while in remaining 4 cases (33.3%), the grade of injury was Grade 2. Of the 4 cases with Grade 4 nerve injury at baseline, 2 (50%) cases showed full improvement [diminishing to Grade 1], and in the other two it was Grade 2. On statistical comparison of the data, a statistically significant change in the grade of injury was seen at 1 month (P < 0.001).
Table 4: Change in the grade of injury at 1 month follow-up as compared to baseline (24 h)

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Comparison of change in the Grade of injury at 3 months follow-up as compared to the baseline (24 h) showed [Table 5] full recovery in all the cases (100%) showing statistically significant difference from baseline (P < 0.001).
Table 5: Change in the grade of injury at 3 months follow-up as compared to baseline (24 h)

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   Discussion Top


Ankylosis, developing in childhood or the early stages of development results in major facial deformity, [4],[5],[6],[7],[8] According to Schobel et al. trauma is the main cause of ankylosis in their series and it occurred at an average age of 13 years. [9] In the present study, trauma contributed for 70% of cases and, rest 30% were either due to infection or unknown etiology. [10]

TMJ ankylosis involves fusion of the mandibular condyle to the base of the skull. In a study conducted by Al-Kayat in 1976 and Adekeye in 1980, [11] incidence of ankylosis in children less than 13 years was comparatively less, similarly 20 out of 30 patients, in this study, were less than 13 years of age, which is statistically significant. The condition is a distressing affliction that denies the benefits of a normal diet, and causes severe facial disfigurement as well as significant psychological stress. [12]

Kaban et al. (1990) [4] recommended a protocol for treatment of unilateral ankylosis in which they recommended the use of temporalis fascia as a lining material. Kaban (1990) and many other researchers have stressed the importance of early mobilization and aggressive physiotherapy for successful treatment, [4],[8],[13] which was followed in this series of patients also.

According to a study conducted by Roychoudhury et al., [10] the long-term functional results of gap arthroplasty alone is satisfactory and comparable to those obtained through the use of other treatment methods. In the present study, 80% of the patients were treated by the same modality with the good functional stability.

For interpositional arthroplasty, temporalis myofascial flap is an autogenous graft that has the advantages of being at close proximity to the TMJ, with minimal surgical morbidity, and successful clinical results. It was found to be a valuable option for the TMJ reconstruction in joints in which alloplastic, allogenic, or autogenous materials have previously been placed unsuccessfully. [14] Temporalis myofascial flap was used as an interpositional graft material in 20% of patients in this study as interpositional material.

In this study, we used Al-Kayat and Bramley [15] incision in 12 patients (40%) and Rowe's incision in 18 patients (60%).

Do Egito Vasconcelos et al. [16] in prospective study of facial nerve function after surgical procedures for the treatment of temporomandibular pathology in 32 patients concluded that the prevalence of post-operative injury was significantly greater in the patients who had ankylosis. Although no patient showed total nerve paralysis, forehead was the most affected area measured. The facial nerve impairment was shown to be temporary in nature and at 3 months all patients had recovered their normal facial nerve function. In this study also all cases completely recovered the facial nerve function within 3 months period.

Roychoudhury et al., [10] reported that of 50 cases of ankylosis operated 20% presented post-operative injury to the facial nerve. Study performed by Nogueira et al. [17] showed that there were four cases of facial nerve injury, amounting to 31%. The percentage distribution of facial nerve lesion in relation to gender showed that the males presented a larger number of nerve injuries (40%). In the present study, 16% cases showed post-surgical facial nerve injury after 1 month follow-up. The highest grade of nerve injury (Grade 4) was seen post-operatively in 4 male patients; however, no significant association between gender and the grade of nerve injury could be proven statistically.

Nogueira et al. [17] in the year 2002 found that following interpositional arthroplasty, 2 out of 3 patients had Grade 4 facial nerve injury after 24 h of surgery, which recovered to Grade 3 after 1 week, after 1 month it improved to Grade 1; however, one patient had grade 1 injury after 24 h of surgery, and it remained the same. In this study, out of 6 patients in whom interpositional arthroplasty was performed, 2 patients had Grade 4 facial nerve injury after 24 h of surgery, which recovered to Grade 2 after 1 st week and Grade 1 after 1 month. Both patients of this study and of Nogueira et al. who had Grade 4 injury 24 h after surgery were subjected to previous surgery also. Rest 4 patients with interpositional arthroplasty had Grade 1 facial nerve injury from 24 h of surgery and no injury thereafter. This finding is significant in the sense that it lends support to the studies conducted by earlier researches that the causes of nerve injury in previously operated TMJ cases is more frequent.

According to Nogueira et al. [17] study, out of the 9 patients in whom gap arthroplasty was carried out, 2 patients had Grade 4 injury of which 1 patient recovered to Grade 3 after 1 week, Grade 1 after 1 month. The second patient showed no recovery after 1 week; however, recovered to Grade 2 after 1 month and Grade 1 after 3 months. In contrast, in this study, out of 32 joints in which gap arthroplasty was performed, 2 patients had Grade 4 facial nerve injury after 24 h of surgery which recovered to Grade 3 injury after 1 week and remained so after 1 month. However, 3 months later it recovered to Grade 1.

Excessive swelling and or hematoma formation may also result in the transient facial nerve injury. Corticosteroids should be used to reduce the swelling and nerve sheath edema, and good hemostasis should be established before a layered wound closure to obliterate dead space and minimize hematoma formation. Pressure dressing with an elastic gauze bandage is also recommended for the same. In all these cases, we routinely placed a suction drain before layered closure, and also placed a pressure dressing to reduce swelling.

Other possible causes of facial nerve injury include excessive or heavy-handed retraction causing compression and or stretching of nerve fibers resulting in neuropraxia. Facial nerve injury may also be caused by inadvertent suture ligation of the facial nerve branches, particularly during wound closure. Care must be exercised during wound closure to avoid taking deep blind bites with the suture needle. The use of electrocautery in deep sites that are potentially close to the facial nerve branches, or within the parotid gland, also should be avoided. Furthermore, one should avoid crushing or clamping tissue indiscriminately, particularly during episodes of brisk bleeding. [18]

High frequency of nerve injury (24 h post-operatively) in our study could have been either due to heavy retraction causing compression and or stretching of nerve fiber resulting in neuropraxia.

If nerve damage occurs, one should determine which nerve is affected and whether microsurgical repair is indicated. Baker and Conley [19] have suggested that if the nerve damage is left unrepaired by microsurgery, then the persistent muscle paralysis will result in frontalis and or orbicularis oculi muscle atrophy and permanent ptosis of the brow and upper eyelid. If the choice is simply to observe the situation, serial testing by electroneurography and electromyography may help in determining whether the affected muscles have the capability of rehabilitating themselves spontaneously or not. However, in the present study, full recovery was obtained by the end of 3 months and there was no further deterioration.


   Conclusion Top


Permanent facial nerve injury following the TMJ ankylosis surgery is a rare complication provided one follows proper dissecting technique, in the preauricular and temporal region. However, temporary nerve injury is a relatively common finding due to swelling, edema, hematoma in this region, and more commonly due to heavy retraction. The incidence and degree of temporary nerve injury in this study could be either due to heavy retraction causing compression and or stretching of nerve fiber resulting in neuropraxia and this has been a significant finding in the present study.

 
   References Top

1.Evans RA, Harries ML, Baguley DM, Moffat DA. Reliability of the House and Brackmann grading system for facial palsy. J Laryngol Otol 1989;103:1045-6.  Back to cited text no. 1
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2.Kang TS, Vrabec JT, Giddings N, Terris DJ. Facial nerve grading systems (1985-2002): Beyond the House-Brackmann scale. Otol Neurotol 2002;23:767-71.  Back to cited text no. 2
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3.Satoh Y, Kanzaki J, Yoshihara S. A comparison and conversion table of 'the House-Brackmann facial nerve grading system' and 'the Yanagihara grading system'. Auris Nasus Larynx 2000;27:207-12.  Back to cited text no. 3
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4.Kaban LB, Perrott DH, Fisher K. A protocol for management of temporomandibular joint ankylosis. J Oral Maxillofac Surg 1990;48:1145-51.  Back to cited text no. 4
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5.Manganello-Souza LC, Mariani PB. Temporomandibular joint ankylosis: Report of 14 cases. Int J Oral Maxillofac Surg 2003;32:24-9.  Back to cited text no. 5
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10.Roychoudhury A, Parkash H, Trikha A. Functional restoration by gap arthroplasty in temporomandibular joint ankylosis: A report of 50 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:166-9.  Back to cited text no. 10
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11.Al-Aboosi K, Perriman A. One hundred cases of mandibular fractures in children in Iraq. Int J Oral Surg 1976;5:8-12.  Back to cited text no. 11
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13.Su-Gwan K. Treatment of temporomandibular joint ankylosis with temporalis muscle and fascia flap. Int J Oral Maxillofac Surg 2001;30:189-93.  Back to cited text no. 13
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14.Smith JA, Sandler NA, Ozaki WH, Braun TW. Subjective and objective assessment of the temporalis myofascial flap in previously operated temporomandibular joints. J J Oral Maxillofac Surg 1999;57:1058-65.  Back to cited text no. 14
    
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19.Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy. Anatomical variations and pitfalls. Plast Reconstr Surg 1979;64:781-95.  Back to cited text no. 19
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Correspondence Address:
S Gokkulakrishnan
Department of Oral & Maxillofacial Surgery, Kothiwal Dental College & Research Centre, Moradabad
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.118365

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    Figures

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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