the electromyography in the arthroplasties of tmj ankylosis a

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THE ELECTROMYOGRAPHY IN THE ARTHROPLASTIES OF TMJ ANKYLOSIS
THE ELECTROMYOGRAPHY IN THE
ARTHROPLASTIES OF TMJ ANKYLOSIS
A ELETROMIOGRAFIA NAS ARTROPLASTIAS DE
ANQUILOSES DA ATM
Marcos Mauricio CAPELARI *
Clóvis MARZOLA **
Luis Fernando SIMONETI ***
Gustavo Lopes TOLEDO ****
João Lopes TOLEDO FILHO *****
Paulo Zupelari GONÇALVES ******
Juliana Dreyer da Silva de MENEZES *******
Bruna Alves FURQUIM ********
_____________________________________
* Doctor of Dental Science Applied FOB-USP. Teacher Residency Program in CTBMF and expertise of Bauru Regional APCD.
** Doctor of Dentistry from the Universidade Estadual Paulista Julio de Mesquita Filho, Residency Program Professor in CTBMF and expertise of Bauru
Regional APCD. Titular Professor of Surgery, FOB-USP retired.
*** Residence in CTBMF of Bauru-SP Base Hospital. Master of Dental Science Applied FOB-USP.
**** Doctor of Stomatology and Oral Biology FOB-USP. Teacher Residency Program in CTBMF and expertise of Bauru Regional APCD.
***** PhD in Morphofunctional Sciences USP. Teacher Residency Program in CTBMF and expertise of Bauru Regional APCD.
****** Residence in CTBMF of Bauru-SP Base Hospital. Master of Dental Science Applied FOB-USP.
******* PhD in CTBMF UNESP Araraquara. Specialist CTBMF APCD Bauru.
******** Doctorate of Dental Science Applied FOB-USP.
CAPELARI, M. M.; MARZOLA, C.; SIMONETI, L. F. et al., A eletromiografia nas artroplastias de anquiloses da ATM. Rev.
Odontologia (ATO), Bauru, SP., v. 16, n. 1, p. 35-44, jan. 2016.
36
THE ELECTROMYOGRAPHY IN THE ARTHROPLASTIES OF TMJ ANKYLOSIS
ABSTRACT
The temporomandibular joint ankyloses is a pathological condition in
which the articular tissue is replaced by scar tissue. Causing blocking of joint
movements, restricting the development and changing the stomatognathic system.
Their pathology is related to trauma, condylar fractures, infections, or derived from
rheumatoid arthritis, ankylosing spondylitis and psoriasis. Various techniques are
described for the treatment of ankylosis, among them, the gap arthroplasty, the
interpositional arthroplasty and the joint reconstruction using bone grafts or by
temporomandibular joint prosthesis. Given the above, the proposition of this study
was to report a case of a patient undergoing interpositional arthroplasty technique of
the left temporomandibular joint with temporalis muscle flap rotation for the treatment
of temporomandibular joint ankylosis after a car accident. The electromyographic
study of temporal and masseteric muscles were performed for this research. The
mean amplitude values were measured, peak contraction and rest where the
bioelectrical potentials of both muscles were compatible with the normal parameters.
Thus it is concluded that the interpositional arthroplasty is a viable option with a low
rate of recurrence and postoperative morbidity. And the electromyography is a
fundamental tool to evaluate the myoelectric potential of masticatory muscles.
RESUMO
A anquilose da articulação temporomandibular é uma patologia onde
tecidos articulares são substituídos por cicatriciais. Causam o bloqueio dos
movimentos articulares, restringindo o desenvolvimento e, desiquilibrando o sistema
estomatognático.
Sua etiologia relaciona-se ao trauma, fraturas condilares,
infecções, ou ainda, derivada da artrite reumatoide, espondilite anquilosante e,
psoríase. Técnicas são descritas para o tratamento da anquilose, como aquela da
artroplastia em gap, a interposicional e, a da reconstrução da articulação através de
enxertos ósseos, ou ainda por próteses totais da articulação temporomandibular. A
proposição deste trabalho foi relatar caso clínico de paciente submetido à técnica da
artroplastia interposicional da articulação temporomandibular esquerda com rotação
de retalho do músculo temporal, após acidente automobilístico, enaltecendo o
estudo eletromiográfico dos músculos temporais e massetéricos. Foram medidos os
valores da amplitude média, de pico de contração e repouso, onde os potenciais
bioelétricos de ambos os músculos foram compatíveis com os parâmetros de
normalidade. Concluiu-se que a artroplastia interposicional é opção viável, com
baixas taxas de recidiva e morbidade pós-operatória. O exame eletromiográfico é
fundamental para avaliação dos potenciais mioelétricos dos músculos mastigatórios.
UNITERMS: Ankylosis; Arthroplasty; Temporomandibular joint; Electromyography.
UNITERMOS:
Anquilose;
Eletromiografia.
Artroplastia;
Articulação
temporomandibular;
INTRODUCTION
The ankylosis of the temporomandibular joint is where pathology joint
tissues are replaced by scar bone or fibrous origin. Cause restrictions or total
blockage of joint movements, limited mouth opening, restricting the development and
CAPELARI, M. M.; MARZOLA, C.; SIMONETI, L. F. et al., A eletromiografia nas artroplastias de anquiloses da ATM. Rev.
Odontologia (ATO), Bauru, SP., v. 16, n. 1, p. 35-44, jan. 2016.
37
THE ELECTROMYOGRAPHY IN THE ARTHROPLASTIES OF TMJ ANKYLOSIS
culminating with the imbalance of stomatognathic system (MARZOLA, 2008 and
DIVYA; PRADHANB; MOHAMMADA et al., 2011). It can still cause micrognathia
and severe facial asymmetry aggravating the psychological stress of the patient with
the consequent decrease in quality of life (SANTOS-PESSOA; MAROTTAARAÚJO; SANTIAGO-VALE et al., 2011). It can be classified according as its
location in intra or extra articular, according to the type of tissue involved in bone and
fibrous and, as the extent of the merger in complete or incomplete
and MEHTAP; AHMET; NEVRA et
al., 2013).
Another classification method the call as true or false. Any condition
that results in a fibrous or bony adhesion between the surfaces of the
temporomandibular joint ankylosis is true.
False ankylosis is any unrelated
pathological condition directly with the joint (KAZANJIAN, 1955 and MARZOLA,
2008). The ankylosis of the temporomandibular joint was further classified into 4
different degrees, being the type I when there is a fibro-osseous mild or moderate
adhesion; type II bone when there is a bridge part of the ascending ramus of the
mandible to the skull base; type III when there is a provision of medial condyle
fracture and formation of a bone bridge starting from the branch to the zygomatic
arch, and finally the type IV when the ATM architecture is totally replaced by a bone
with involvement of the skull base (SAWHNEY, 1986 and MARZOLA, 2008).
The temporomandibular ankylosis may have their etiology related to
trauma, condylar fractures untreated local or systemic infection, improper surgical
treatment or even may arise due to systemic diseases such as rheumatoid arthritis,
ankylosing spondylitis and psoriasis (SANTOS-PESSOA; MAROTTA-ARAÚJO;
SANTIAGO-VALE et al., 2011).
It must be treated so that the condition is recognized, to minimize facial
growth restriction. Several techniques are described in the literature for the
treatment of ankylosis, may be cited arthroplasty consisting gap in the resection of
bone from the joint cavity and ramus without interposing material. The interpositional
arthroplasty carrying out a gap after resection of bone mass interposing a biological
material such as a flap of the temporal muscle and fascia, adipose body of the cheek,
or even may not be biological such as silicone, acrylic. It can still be the
reconstruction of the joint, being held resection of ankilotic mass and reconstruction
through bone grafts or through dentures temporomandibular joint (MANGANELLOSOUZA; MARIANI, 2003).
Given the above, the objective of this study was to report the clinical
case of a patient undergoing interpositional arthroplasty technique left
temporomandibular joint with the fascia flap rotation and temporal muscles for the
treatment of temporomandibular ankylosis after car accident. It was lauded here the
electromyographic study of the temporal and masseteric muscles, showing that this
technique is a very viable option, low cost, with low relapse rates, as well as discrete
postoperative morbidity.
CLINIC AND SURGICAL CASE
A. C. D. S. patient male, 14 years old, reports having been the victim of
a car accident three years ago, having attended the Surgery and Traumatology Oral
and Maxillofacial Service complaining of difficulty in mouth opening. After the
interview, clinical, laboratory and CT scans through the reconstruction in three
dimensions, was diagnosed ankilotic mass involving the left temporomandibular joint.
CAPELARI, M. M.; MARZOLA, C.; SIMONETI, L. F. et al., A eletromiografia nas artroplastias de anquiloses da ATM. Rev.
Odontologia (ATO), Bauru, SP., v. 16, n. 1, p. 35-44, jan. 2016.
38
THE ELECTROMYOGRAPHY IN THE ARTHROPLASTIES OF TMJ ANKYLOSIS
Also, it was noted in the mandibular symphysis region titanium plate with only three
holes and two screws probably inserted to fix mandibular fracture at the time of the
accident. The patient had a significantly lower mouth opening limit of only 9 mm
(Figures 1), clinical images demonstrating the reduced mouth opening. CT scans
and RX demonstrate the ankilotic mass involving the left TMJ.
Figures 1a to 1e - Clinical images showing the reduced mouth opening 9mm patient. CT scans and
RX demonstrate the ankilotic mass involving the left TMJ.
Source - Surgery and Maxillofacial Bauru.
Surgical approach advocated by access to better exposure of the
temporomandibular joint and left temporal muscle was planned to carry out
interpositional arthroplasty flap of muscle and temporal fascia (AL-KAYAT;
BRAMLEY, 1979). Due to decreased mouth opening limit of the corresponding
CAPELARI, M. M.; MARZOLA, C.; SIMONETI, L. F. et al., A eletromiografia nas artroplastias de anquiloses da ATM. Rev.
Odontologia (ATO), Bauru, SP., v. 16, n. 1, p. 35-44, jan. 2016.
39
THE ELECTROMYOGRAPHY IN THE ARTHROPLASTIES OF TMJ ANKYLOSIS
patient to ankylosis framework for Mallampati classification to the airways was
impaired, preventing laryngoscopy for intubation nasoorotraqueal. It was requested
evaluation team of head and neck surgery, performing a tracheotomy to maintain the
patient's airway. After tracheostomy and surgical treatment of temporomandibular
joint left the ankilotic mass was removed with surgical drills, fashioning a gap of 6
mm between the articular fossa and the mandibular condyle to the interposition of the
left temporal muscle.
Flap was made of the temporalis muscle I-shaped addressing the most
posterior fibers and its release to previous rotation and interposition between the
condyle and the articular fossa. The filing was planned with a lateral-medial condyle
drilling technique which went up 3.0 polyester yarn between the condylar drilling and
retail fascia and temporal muscle, which was set between the articular fossa and the
condyle with a mini anchor in the lateral region, ensuring the stability of the temporal
muscle during your drive.
The resulting spaces were filled with an autograft of fat from the fat of
the cheek body removed the intra oral access (Figures 2a to 2e) with a view of the
trans-operative surgical approach advocated by Al Kayat and Bramley, noting
ankylosis involving the left TMJ. It was performed by planes with suture thread 4.0 of
polyglactin 910 and intradémica skin suture with nylon 4.0.
Figures 2a to 2e - Trans-operative views of the surgical approach advocated by Al Kayat and
Bramley, where it is observed ankylosis involving the left TMJ. Surgical gap held between
the condyle and the articular fossa with the interposition flap of the temporalis muscle and
buccal fat pad.
Source - Surgery and Maxillofacial Bauru.
CAPELARI, M. M.; MARZOLA, C.; SIMONETI, L. F. et al., A eletromiografia nas artroplastias de anquiloses da ATM. Rev.
Odontologia (ATO), Bauru, SP., v. 16, n. 1, p. 35-44, jan. 2016.
40
THE ELECTROMYOGRAPHY IN THE ARTHROPLASTIES OF TMJ ANKYLOSIS
The patient was advised to start physical therapy on the second
postoperative day, noting a good progression of the disease, with good healing
aspect of the surgical approaches, the absence of signs or symptoms of infection,
maintenance and preservation of facial nerve branches and improved the mouth
opening limit of 51 mm in the postoperative period of 6 months and 53.4 mm in the
postoperative period of 1 year and 6 months, measured with a digital caliper.
The CT scan of the right and left temporomandibular joint where you
can observe that the flap of the left temporal muscle still brought because the space
maintained between the articular fossa and the mandibular condyle without ankylosis
signs of recurrence was performed.
The patient was also submitted in the postoperative period of 60 days
and 1 year and 6 months of arthroplasty interpositional temporomandibular joint flap
of the fascia and the temporalis muscle to the electromyographic examination of the
temporal muscles and masseteric right and left. To capture the signal we used a
surface electromyography Miotec brand, Miotool 400 model 4 channels with 14 bits
of resolution of dynamic range, connected to the muscle studied through individual
electrodes infant double Meditrace Ag / AgCl (solid gel, hydrogel , adhesive and
conductor) with distance between the poles of 20 mm. The data were interpreted
with Miograph software Miotec. The average amplitude values and peak contraction
and rest expressed in uV RMS (Root Mean Square) were measured (Figs. 3a to 3g).
CAPELARI, M. M.; MARZOLA, C.; SIMONETI, L. F. et al., A eletromiografia nas artroplastias de anquiloses da ATM. Rev.
Odontologia (ATO), Bauru, SP., v. 16, n. 1, p. 35-44, jan. 2016.
41
THE ELECTROMYOGRAPHY IN THE ARTHROPLASTIES OF TMJ ANKYLOSIS
Figures 3a to 3g - Intraoral views and patient profile performing electromyography, after 1 year and 6
months after surgery, showing mouth opening 53.4 mm. Averages of graphics contractions
of the temporal muscles demonstrating a lower electrical activity of the TE.
Source - Surgery and Maxillofacial Bauru.
DISCUSSION
The temporomandibular ankylosis developed in childhood or in early
stages of development is a condition that results in a large facial deformity usually is
associated as a result of a trauma not handled properly (MARZOLA, 2008 and
DIVYA; PRADHANB; MOHAMMADA et al., 2011). This fact corroborates the
clinical case, where a condylar fracture culminated with ankylosis of the patient's left
CAPELARI, M. M.; MARZOLA, C.; SIMONETI, L. F. et al., A eletromiografia nas artroplastias de anquiloses da ATM. Rev.
Odontologia (ATO), Bauru, SP., v. 16, n. 1, p. 35-44, jan. 2016.
42
THE ELECTROMYOGRAPHY IN THE ARTHROPLASTIES OF TMJ ANKYLOSIS
temporomandibular joint with 14 years old. The use of alloplastic materials brought
in the operating gap is a safe way to prevent the relapse of ankylosis frame, but
some drawbacks such as infection and displacement of material are widely
complications reported in the literature (MARZOLA, 2008 and MEHTAP; AHMET;
NEVRA et al., 2013).
The joint reconstruction using bone grafts such as costochondral
grafting technique is advantageous because of its biological compatibility, growth
potential and functional adaptation (MANGANELLO-SOUZA; MARIANI, 2003). But
the unpredictable growth of the graft can cause unsatisfactory results (MEHTAP;
AHMET; NEVRA et al., 2013). Treatment of ankylosis with the use of dentures
temporomandibular joint has been currently used, and the benefits the restoration of
facial contours and jaw function. However is contraindicated in active or chronic
infections, insufficient bone quality or quantity to support the prosthetic components,
only partial reconstruction of the ATM, allergic reaction to any component of the
prosthesis, patients with extensive drilling in the mandibular fossa and also patients
with skeleton immature. The patient in this case report was still in skeletal
development, counter indicating the reconstruction of the joint through the
temporomandibular joint prosthesis.
The flap of the fascia and the temporalis muscle has been widely used
for the treatment of temporomandibular ankylosis frame (DIVYA; PRADHANB;
MOHAMMADA et al., 2011). It is a superior bringing material to other materials
because of their autologous vascularized tissue characteristics, providing an effective
blood supply and is anatomically located near the temporomandibular joint facilitating
its interposition between the remaining condylar and articular fossa (MEHTAP;
AHMET; NEVRA et al., 2013). However, the maintenance and preservation of the
myoelectric potential of the temporalis muscle submitted to retail interpositional are
not widely understood and surface electromyography a complementary determining
examination to verify the power and motor muscle task postoperatively (URAMTUCULESCU; COOPER; FOEGEDING et al., 2015).
The surgical approach advocated by Al Kayat and Bramley was used
for better exposure of the temporomandibular joint and the temporal muscle. The
incision was started at the bottom of the ear portion rising to its upper portion with a
caudal extension in the temporal region for posterior and anterior seeking a better
exposure of bundles of fibers and posterior temporal making of retail in the form of ''I''
(AL-KAYAT; BRAMLEY, 1979).
The completion of the remaining spaces with autogenous graft of
adipose cheek body was carried out after the action and securing the flap of the
temporalis muscle between the remaining condylar and articular fossa ensuring that
this muscle during his movement remained between the proximal and distal regions
of the joint. Although fatty grafts undergo resorption, they assist in reducing voids
and reduce the compression on the temporal muscle and fascia, preventing the
formation of a hematoma facilitating hemostasis and consequently decreasing the
risk of scar tissue formation (DIMITROULIS; SLAVIN; MORRISON, 2011).
Complications occur more after surgery ankylosis of the
temporomandibular joint include the reduction of mouth opening, Frey syndrome,
temporary paresthesia of the facial nerve, recurrence of ankylosis, laterognathism
and anterior open bite (EROL; TANRIKULU; GRGÜN, 2006). In this case report
was not observed any complications. In the analysis of imaging in postoperative 1
year and 6 months is possible to observe that the temporal muscle remains
interposed between the condyle and the articular fossa without showing signs of
CAPELARI, M. M.; MARZOLA, C.; SIMONETI, L. F. et al., A eletromiografia nas artroplastias de anquiloses da ATM. Rev.
Odontologia (ATO), Bauru, SP., v. 16, n. 1, p. 35-44, jan. 2016.
43
THE ELECTROMYOGRAPHY IN THE ARTHROPLASTIES OF TMJ ANKYLOSIS
recurrence. Electromyographic findings postoperative 60 days revealed that the
amplitude values of action potentials in the right temporal muscle (TD) were higher
than those recorded in the left temporal muscle (TE) in all types of activity.
Regarding the fatigue time a considerably lower value found in TE. The
amplitude of the action potentials of the right masseter muscle (MD) also were higher
than those recorded in the left masseter (ME) in all types of activity, except at home.
Most electrical activity of the MD and TD can be explained by the phenomenon of
"protective contraction", the contralateral muscles operated next to become
overloaded due to the deviation of the activities for the non-operated side in an
attempt to preserve the hand operated against pain (URAM-TUCULESCU;
COOPER; FOEGEDING et al., 2015).
The range of amounts recorded in the left temporal muscle in
postoperative 1 year and 6 months decreased compared to the previous survey,
especially at home. Averages of graphics contractions of the temporal muscles
showed less electrical activity of the TE. This result suggests an adjustment of the
muscles of mastication to the occlusal new condition over time (Figures 3). On the
other hand, the amplitude of the maximum voluntary contraction in the right temporal
muscle increased sharply, where the phenomenon of "protective contraction" causes
the contralateral muscle operated side to present a greater electromyographic
recording in an attempt to preserve the surgically manipulated muscle.
FINAL CONSIDERATIONS
The treatment of temporomandibular ankylosis provides a challenge for
the surgeon Oral and maxillofacial given the anatomical and physiological complexity
of atm. Among the various treatment options, the technique of interpositional
arthroplasty with retail fascia and the temporalis muscle is a viable option, with low
recurrence rates and postoperative morbidity. Surface electromyography is a
complementary fundamental examination to verify the myoelectric potential of the
masticatory muscles.
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THE ELECTROMYOGRAPHY IN THE ARTHROPLASTIES OF TMJ ANKYLOSIS
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* De acordo com as normas da ABNT e da Revista de Odontologia da ATO.
o0o
CAPELARI, M. M.; MARZOLA, C.; SIMONETI, L. F. et al., A eletromiografia nas artroplastias de anquiloses da ATM. Rev.
Odontologia (ATO), Bauru, SP., v. 16, n. 1, p. 35-44, jan. 2016.