the electromyography in the arthroplasties of tmj ankylosis a
Transcrição
the electromyography in the arthroplasties of tmj ankylosis a
35 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. REFERENCES * AL-KAYAT, A.; BRAMLEY, P. A modified pre-auricular approach to the temporo mandibular joint and molar arch. Brit. J. oral Surg., v. 17, n. 2, p. 91-103, nov., 1979. DIVYA, M.; PRADHANB, R.; MOHAMMADA, S. et al., Complications associated with different surgical modalities for management of temporomandibular ankylosis in a series of 791 cases. Asian J. oral Maxillofac. Surg., v. 23, p. 122-7, apr., 2011. EROL, B.; TANRIKULU, R.; , B. A clinical study ankylosis of the temporomandibular joint. J. Craniomaxillofac. Surg., v. 34, n. 2, p. 100-6, mar., 2006. KAZANJIAN, V. H. Temporomandibular joint ankylosis. Am. J. Surg., v. 90, p. 905, dec., 1955. MANGANELLO-SOUZA, L. C.; MARIANI, P. B. Temporomandibular joint ankylosis: Report of 14 cases. Int. J. oral Maxillofac. Surg., v. 32, p. 24-9, jun., 2003. MARZOLA, C. Fundamentos de Cirurgia Buco Maxilo Facial. São Paulo: Ed. Big Forms, 2008, 6 vs. MEHTAP, K.; AHMET, D.; NEVRA, S. et al., Management of temporomandibular joint ankylosis with temporalis fascia flap and fat graft. J. Craniomaxillofac. Surg., v. 41, n. 8, p. 789-93, dec., 2013. SANTOS-PESSOA, M. B.; MAROTTA-ARAUJO, M.; CAVALIERI, I. et al., 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. 44 THE ELECTROMYOGRAPHY IN THE ARTHROPLASTIES OF TMJ ANKYLOSIS Tratamento de anquilose da articulação temporomandibular: Relato de um caso. Rev. PortEstomatol. Med Dent Cir Maxilofac., v. 52, n. 4, p. 205-11, nov., 2011. SAWHNEY, C. P. Bony ankylosis of the temporomandibular joint: follow-up of 70 patients treated with arthroplast and acrylic spacer interposition. Plast. Reconst. Surg., v. 77, p. 29-49, jan., 1986. URAM-TUCULESCU, S.; COOPER, L. F.; FOEGEDING, E. A. et al., Electromyographic evaluation of masticatory muscles in dentate patients versus conventional and implant-supported fixed and removable denture wearers - A preliminary report comparing model foods. Int. J. oral Maxillofac. Surg., v. 28, n. 1, p. 79-92, jan.,/feb., 2015. DIMITROULIS, G.; SLAVIN, J.; MORRISON, W. Histological fate of abdominal dermis-fat grafts implanted in the temporomandibular joint of rabbit following condylectomy. Int. J. oral Maxillofac. Surg., v. 40, n. 2, p. 177-83, feb. 2011. ______________________________________ * 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.
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