Page 355 - Demo

General discussion 35313group of patients, those treated with an extended TMJR proved more challenging. Elledge et al.(117) have suggested a classification system for these patients, based on the extension of both the fossa and condylar component, thus focusing on the eTMJR itself. We found however that this classification could be misleading, as the difficulty of surgery is not only determined by the extensiveness of the TMJR, but by the need of other secondary corrections as well. Thus, an improvement on the existing classification was suggested by including the need for contour correction, occlusal adjustment and simultaneous contralateral mandibular osteotomy as additional factors to keep in consideration when planning these patients. This improved classification allows for surgeons to better determine the complexity and feasibility of the surgery. This classification will need further evaluation and fine-tuning, as potential new obstacles are met.(50)Having extensively researched the pre- and intra-operative conditions to allow for the treatment to be successful, a final systematic literature analysis was performed to improve upon the post-operative phase. While we found that postoperative physiotherapy over a prolonged period of time is needed to achieve optimal results, no clear schedule had been described in the available literature.(118–120) Thus a physiotherapy protocol was designed, based on the different post-operative phases, with the first phase aiming to reduce joint inflammation and preventing abnormal adhesions. As the inflammatory response subsides, the second phase is aimed at further improving the range of motion, muscle control and coordination, to regain functional mobility. The third phase aims to deal with any remaining imbalances and asymmetrical movements, while also regaining muscle strength. A difficulty we encountered while developing this scheme, was the osseous integration of the LPM. Whilst immobilization during the first six weeks might greatly improve the possibility of the osseous integration, this would significantly increase the risk of adhesions being formed, lessened mobility and increased pain, as well as heterotopic ossification.(118,119,121,122) Whereas the results of one of our systematic reviews indicated that the use of autologous fat grafting to eliminate any periarticular negative space proved useful to prevent heterotopic ossification(123), this postoperative physiotherapy schedule will need to be further applied and reviewed, to allow for proper revalidation while not interfering with the LPM integration.Nikolas de Meurechy NW.indd 353 10-06-2024 11:12