Significance of Medio-Lateral Depth (MLD) in TMJ ankylosis surgery - A newer severity index based surgical outcomes study

Significance of Medio-Lateral Depth (MLD) in TMJ ankylosis surgery - A newer severity index based surgical outcomes study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Significance of Medio-Lateral Depth (MLD) in TMJ ankylosis surgery - A newer severity index based surgical outcomes study Venkatesh Anehosur, Saurav Bhaduri., Akshay A Byadgi, Sayali Desai This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7681310/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Introduction Temporomandibular joint (TMJ) ankylosis is a debilitating disorder caused by fibrous or osseous fusion of the joint components, significantly restricting mandibular mobility. In children’s, TMJ ankylosis disrupts normal facial growth, resulting in persistent functional and aesthetic challenges. The Medio-Lateral Depth (MLD) of the bony ankylotic mass is a vital yet underexplored factor influencing the complexity of surgery. Increased depth and density of the ankylotic block exacerbate surgical difficulty and involved postoperative complications. This study aims to assess the role of the Medio-Lateral Depth (MLD) of the bony ankylotic mass in influencing surgical outcomes and specific indicators of morbidity. Materials and Methodology This study was designed as a prospective single centre, cohort study. The medio-lateral depth (MLD) was measured pre-operatively by CT scan and intra operatively by depth gauge scale. Intra operative depth was first correlated to the MLD on CT scan to check its validity. also, other post operative variables outcomes were correlated to the MLD. Results 34 patients were included in the study. MLD measured preoperatively from CT scan and intraoperatively measured depth has a mean value of 3.16cm and 2.93cm respectively. A strong correlation (Spearman R = 0.9637, p < 0.0001) was observed between depth in CT and depth measured intra-op. Significant correlations were also found between Depth intra-op and drain collection on POD-1 (R = 0.5793, p = 0.0003). The cases in this series were classified into mild, moderate and severe cases depending on the variability of MLD measured preoperatively by CT scan and Intra operative Depth therefore nomenclated as Venkatesh MLD severity index (VSI) for ankylotic mass. Mild- = 4.0cm. Conclusion Increasing MLD in ankylotic masses is strongly associated with surgical complexity, intraoperative challenges, and postoperative recovery. Depth remains a pivotal prognostic parameter, influencing operative time, blood loss, and recovery trajectories. Preoperative imaging, meticulous planning, and depth-informed surgical training are critical to optimizing outcomes. Medio-Lateral Depth (MLD) Temporomandibular Joint ankylosis (TMJa) Computed tomography scan (CT SCAN) Facial Asymmetry (FA) Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Temporomandibular joint (TMJ) ankylosis is a debilitating disorder caused by fibrous or osseous fusion of the joint components, significantly restricting mandibular mobility. This immobility compromises essential activities such as mastication, speech, and maintaining oral hygiene. In children’s, TMJ ankylosis disrupts normal facial growth, resulting in persistent functional and aesthetic challenges. 1,2 Restricted mouth opening hinders mastication, leading to dietary deficiencies and malnutrition, while poor oral hygiene increases the risk of secondary dental complications such as caries, periodontal disease, and malocclusion. 1,2 The Medio-Lateral Depth (MLD) of the bony ankylotic mass is a vital yet underexplored factor influencing the complexity of surgery. Increased depth of the ankylotic block exacerbate surgical difficulty, prolong operative time, elevate blood loss, and involved postoperative complications. Current surgical options, includes gap arthroplasty, interposition arthroplasty, and grafting techniques. This study aims to assess the role of the medio-lateral depth of the bony ankylotic mass in influencing surgical outcomes and specific indicators of morbidity. Material and Methodology Prospective single centre, cohort study was conducted in accordance with the declaration of Helsinki, abiding by the STROBE guidelines after obtaining institutional ethical clearance (IRB No: 2018/P/OS/101). All patients informed consents taken. 34 patients were included in the study with complete bony ankylosis of the joint - (Sawhney’s Type 4 and He’s Type A4) operated between 2018-2023 with 2 years follow up. Patients between 17-35 years, with restricted mouth opening of less than 1cm, with functional impairment were included. Patients excluded in the study were with Bilateral TMJ Ankylosis with concomitant any adjuvant procedures, Syndromic Patients, re-ankylosis, Fibrous ankylosis, Patients with blood Dyscrasias, history of haemodialysis, liver/kidney dysfunction and ASA III and IV. Preoperative assessment of Mediolateral depth (MLD) of ankylotic mass using CT scan. A 128 slice Plain multi detector computed tomography (Siemens SOMATOM Definition Edge; kVp:120, mA: 200) with slice Thickness of 1 mm and detailed reformatting images by dent scan software in sagittal, coronal planes and 3-dimensional reconstruction for detailed bony architecture was carried out as a part of the protocol. An isotropic Resolution of 0.4mm provided excellent image clarity and detail. The medio-lateral depth (MLD) was measured pre-operatively by a single senior consultant and specialized head and neck radiologist on the coronal sections of the CT at the point of maximum thickness of the ankylotic mass, with a line connecting a point on the lateral limit of the mass corresponding to the point of fusion to the inferolateral part of the root of the zygomatic arch to the most medial limit on the same section in Dent scan software to eliminate reliability bias, inter radiologist variability and institutional experience bias. [Figure 1] While the lateral limit of the mass was guided by the lateral extent root of zygoma, the medial point was an arbitrary one as most joints had their architecture grossly distorted with near complete obliteration of the sigmoid notch and fusion of the elongated coronoid to the ankylotic mass in almost half of the cases. All pre-operative calculations of depth were also verified by the senior operating surgeon and were discussed with the team members prior to the surgery. All surgeries were carried out by a single senior maxillofacial surgeon as the lead, assisted by a team of junior residents and registrars. Patients also underwent evaluation of the oropharyngeal airway and other comorbidities. A thorough pre-anaesthetic evaluation and clearance was obtained. All patients underwent Nasal intubation via an intubating fibre-optic laryngoscope, with an armoured cuffed naso-tracheal tube and induced under GA. The ankylotic mass was removed in a piecemeal fashion through an endaural approach often with a temporal extension [Figure 2] . A gap arthroplasty with a gap of 1.5-2 cms was created, protecting the underneath soft tissue and vital structures using malleable subperiosteally till the complete length of the ankylotic mass to achieve an obstruction free rotation of the Mandible [Figure 3 and 4] . Intra operative MLD was measured from the highest mark of osteotomy cut made to deepest width of the ankylotic mass (Supero inferiorly) with the help of customized malleable with engraved measurement in millimetres and centimetres which was recorded. The medial extent of the depth was defined as the soft tissue encountered after removing the last sliver of bone as it ensures the complete removal of the ankylotic mass medially. [Figure 5]. Bilateral coronoidectomy was also carried out with temporalis myotomy. This was followed by active jaw opening manoeuvres and a mouth opening of approximately 4 cms was achieved [Figure 6] . Haemostasis, closure in layers and insertion of mini-vac drains into the surgical site followed. Post-op Hb and PCV were noted on day 1 along with collection in the drain. Post-operative mouth opening was recorded as maximal pain-free mouth opening on day 7 after most of the edema had subsided. Intra operative MLD was first correlated to the MLD on CT (Coronal section) to check its validity. The variables that were observed during the various time points were Intra op time (hrs), Change in Hb (mg/dl), PCV, Post op MIO (cm), Drain collection on POD-1, Total no. of days drain was in situ, Blood loss (ml), Duration of hospital stay and were correlated to the MLD. Normality of all parameters were then verified with the Shapiro-Wilk’s Test to sort the outliers and confirm that the data to followed a normal Gaussian pattern. Results 34 patients were included in the study. The mean age presentation was 20.9 years (17-35 years) with male19(55.8%) predilection more when compared to females15(44.2%). incidence of ankylosis on right side was 20 (58.8%), followed by the left side 14 (41.2%). Trauma being the commonest cause for ankylosis in this study with 19(55.8%) , infection 7(20.6%) and 4(11.8%) were with congenital and other causes. (Table 1) MLD measured preoperatively from CT scan and intraoperatively measured depth has a mean value of 3.16cm and 2.93cm respectively. A strong correlation (Spearman R=0.9637, p<0.0001) was observed between depth in CT and depth measured intra-op. (Table 2). These suggest the medio-lateral depth significantly impacts postoperative outcomes. Haemoglobin levels: Pre-op mean 12.74 gm% vs post-op 11.31 gm% (p=0.0001). PCV values: Pre-op mean 38.22, post-op 34.1834 (p=0.0001), indicating statistically significant measurable blood loss and physiological impact during arthroplasties in joints with higher medio-lateral depths. (Table 3). To summarise non-parametric tests were appropriately applied for these variables the results Significant deviations from normality were observed in: Depth intra-op (p = 0.019) Intra-op time (p = 0.050) post op change in Hb (p = 0.015), post op changes in PCV p=0.9360 Post op MIO (P=0.2900), Drain collection on POD-1 (p = 0.017) Duration of hospital stay (p < 0.0001). Results suggested that increase in MLD has direct corelation with increased intra operative surgical difficulties and post operative complications. (Table 4 & Table 5) Complications were in 10 (29.41%) of cases, with re-ankylosis and jaw deviation being the most frequent at 5.88% each. The cases in this series were classified into mild, moderate and severe cases depending on the variability of MLD measured preoperatively by CT scan and Intra op Depth nomenclated as Venkatesh MLD severity index (VSI) for ankylotic mass. Mild- =4.0cm (Table 6) Discussion Surgery for temporomandibular joint ankylosis (TMJa) and other open TMJ procedures presents a range of challenges and complications, stemming from the distorted anatomy, proximity to critical neurovascular structures, and the extensive bony fusion. Additionally, while infectious, autoimmune, and biomechanical factors may occasionally contribute to complications, they represent a relatively minor subset, with infectious complications accounting for less than 2% of cases reported in the literature. 2,3 One of the most significant intraoperative challenges is managing haemorrhage, particularly is due to the rich vascularity surrounding the joint. The vasculature, including branches of the maxillary artery and Pterygoid plexus of veins can be encountered as the depth of ankylosis mass increases. 4 Neurological structures surrounding the joint, derived from cranial nerves V and VII, and branches of the external carotid artery add further complexity. 5 Heavy instrumentation or excessive bleeding in this area must be avoided to prevent middle ear trauma. 6 For instance, the studies by Hoffman and Panetta 10 and Susarla et al 9 highlighted the importance of preoperative planning, managing Airway complications and haemorrhagic risks in TMJ surgeries. Advanced imaging techniques, such as CT angiography, combined with selective embolization, have emerged as more precise methods for managing inaccessible arterial bleeds. 8,10 Studies by Susarla et al. 9 and others have emphasized the role of preoperative embolization and intraoperative preparedness in reducing bleeding risks during TMJ surgeries. The work of Bouloux and Perciaccante 11 further elucidated the limitations of external carotid artery ligation in controlling blood loss, attributing continued haemorrhage to collateral circulation. McDonald and Pearson 12 advocated for direct ligation of the internal maxillary artery via a trans antral approach. Thornton 13 suggesting that in healthy patients, blood loss exceeding 500 mL warrants replacement. This threshold, however, is influenced by factors such as the duration of surgery, surgical technique and patient response to extensive procedures like wide gap arthroplasty. The intraoperative depth measured during surgery closely corresponded to the depth recorded on preoperative CT scans suggestive of good sensitivity and specificity. While CT measurements exhibited a tendency for mild overestimation, they demonstrated a strong positive correlation with intraoperative depths, as evidenced by Spearman's rank correlation coefficient (R = 0.9637, p < 0.05). The maximum discrepancy was 0.7 cm, with a mean difference of 0.3 cm, indicating that a meticulously performed CT scan can reliably forecast surgical complexity. MLD’s exceeding 2.5 cm were consistently associated with prolonged surgical duration and greater procedural challenges. While the intraoperative time correlated positively with depth, the trend was weaker, with significant variability due to outliers. However, cases with a depth greater or equal to 4.0 cm required exponentially longer operative times, highlighting the increasing complexity of managing severe bony ankylosis. Surgeries for these cases, even with standardized protocols, averaged 2–4 hours compared to 90 minutes for depths below 2.5 cm. the observed trends suggest that depths greater or equal to 2.5 cm necessitate heightened expertise and meticulous planning. The hemodynamic impact of managing severe ankylosis was evident, albeit with weak correlations. Depths beyond 4.0 cm showed increased postoperative haemoglobin (Hb) and packed cell volume (PCV) drops, the mean Hb drop on postoperative day one was 1.5 mg/dL, with depths below 2.5 cm rarely exceeding 1.4 mg/dL. Similarly, the average PCV reduction of 4.04% around the 2.5 cm mark did not translate to severe morbidity. Oral iron and hematinic supplementation were sufficient for recovery in most patients, though nutritional deficiencies such as vitamin B12 insufficiency were commonly observed. Four patients required one unit of packed red blood cell transfusion, all of whom had depths exceeding 2.5 cm and surgeries lasting over 90 minutes. Blood loss emerged as one of the most strongly correlated variables with increasing mediolateral depths (MLD). Average intraoperative blood loss was 350 mL for depths of 2.5 cm, with values closely aligning along a linear trend line. Four joints experienced arterial injury involving branches of the maxillary artery and anterior deep temporal artery. Prompt haemostasis was achieved using ligation and bipolar diathermy and further few cases with piezoelectric gap arthroplasty surgery. Nogami et 14 al., supports the use of piezo surgery for precise bone removal in such cases, as its oscillating mechanism minimizes soft tissue damage. Postoperative maximum incisal opening (MIO) at day 7 ranged from 2.5 cm to 4.7 cm, with a mean of 3.6 cm. Deeper ankylotic masses correlated with slightly reduced MIO values, particularly in cases with depths over 2.5 cm, this reduction may be attributed to organized hematomas and persistent inflammation limiting complete joint rotation. Increased drain output and edema further compounded this limitation. Day 1 drain collection averaged 25 mL, with depths above 2.5 cm exhibiting higher outputs. Drains were removed when output fell below 10 mL over two consecutive days, with an average removal time of 4 days. However, depths exceeding 4.0 cm often necessitated drain retention for up to 7 days, aligning with higher postoperative pain and restricted mouth opening. Hospitalization duration correlated positively with ankylotic depth, rising sharply beyond 2.5 cm. Patients with depths greater than 4 cm had prolonged stays, averaging 10 days compared to a minimum of 6 days for shallower cases. Increased hospital stays were attributed to higher incidences of wound complications, persistent drain output, and postoperative edema. 1(2.94%) patient was noted with persistent facial nerve weakness, A similar Study conducted by Belmiro Cavalcanti do Egito Vasconcelos et al 15 showed 2 patients, 12.5% (ie, 8% of the 50 approaches) showed signs of facial nerve injury after TMJ surgery. Despite robust findings, certain limitations warrant consideration. The relatively small cohort size (n = 34) may limit generalizability also relationship of TMJ ankylotic mass to internal maxillary artery is not determined due to financial constraints in this study. Furthermore, confounding variables such as patient comorbidities and age were not controlled. Prospective studies with larger samples and multivariate analyses are necessary to validate these conclusions and refine depth-based surgical protocols. Conclusion In conclusion, increasing MLD in ankylotic masses is strongly associated with surgical complexity, intraoperative challenges, and postoperative recovery. Depth remains a pivotal prognostic parameter, influencing operative time, blood loss, and recovery trajectories. Preoperative imaging, meticulous planning, and depth-informed surgical training are critical to optimizing outcomes. These findings by Venkatesh MLD severity index (VSI) provide a foundation for developing predictive and interventional strategies to improve the management of TMJ ankylosis. Declarations Conflict Of Interest: None Ethical Approval Clearance Section: All patients informed consents taken to participate in the study. The Institutional ethical clearance is obtained from college IRB committee IRB No: IEC No. 2018/P/OS/101 Clinical Trail-Not applicable Funding: This research did not receive any specific grant from funding agencies in the public, commercial, not-for-profit sector Acknowledgement - Authors would like to thank Dr Niranjan Kumar, Vice Chancellor, Shri Dharmasthala Manjunatheshwara University and Director of SDM Craniofacial Centre, Shri. Saket Shetty Director of Administration and Dr. Balaram Naik Principal, SDM college of Dental Sciences and Hospital for the support, encouragement and facilities provided. References Movahed R, Mercuri LG. Management of temporomandibular joint ankylosis. Oral Maxillofac Surg Clin North Am. 2015 Feb;27(1):27-35. doi:10.1016/j.coms.2014.09.003. PMID: 25483442. Gupta VK, Mehrotra D, Malhotra S, Kumar S, Agarwal GG, Pal US. An epidemiological study of temporomandibular joint ankylosis. National journal of maxillofacial surgery. 2012 Jan 1;3(1):25-30. Fariña R, Canto L, Gunckel R, Alister JP, Uribe F. Temporomandibular joint ankylosis: algorithm of treatment. Journal of Craniofacial Surgery. 2018 Mar 1;29(2):427-31. Gaba S, Sharma RK, Rattan V, Khandelwal N. The long-term fate of pedicled buccal pad fat used for interpositional arthroplasty in TMJ ankylosis. Journal of plastic, reconstructive & aesthetic surgery. 2012 Nov 1;65(11):1468-73. Gupta M, Sen S. Analysis for different functional results of TMJ ankylosis management by comparing ramus-condyle unit reconstruction using vertical ramus osteotomy and interpositional gap arthroplasty. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology. 2021 Jul 1;132(1):10- Long X, Li X, Cheng Y, Yang X, Qin L, Qiao Y, Deng M. Preservation of disc for treatment of traumatic temporomandibular joint ankylosis. Journal of oral and maxillofacial surgery. 2005 Jul 1;63(7):897-902. Kaban LB, Perrott DH, Fisher K. A protocol for management of temporomandibular joint ankylosis. Journal of oral and maxillofacial surgery. 1990 Nov 1;48(11):1145-51. Chidzonga MM. Temporomandibular joint ankylosis: review of thirty-two cases. British Journal of Oral and Maxillofacial Surgery. 1999 Apr 1;37(2):123-6. Susarla SM, Peacock ZS, Williams WB et al. Role of computed tomographic angiography in treatment of patients with temporomandibular joint ankylosis. J Oral Maxillofac Surg 2014;72:267–76. 10.1016/j.joms.2013.09.024. Hoffman D, Panetta T. Treatment of TMJ ankylosis utilizing preoperative CT angiography, surgical navigation, and intraoperative ebolization. International Journal of Oral and Maxillofacial Surgery. 2011 Oct 1;40(10):e8. Bouloux GF, Perciaccante VJ. Massive hemorrhage during oral and maxillofacial surgery: ligation of the external carotid artery or embolization?. Journal of oral and maxillofacial surgery. 2009 Jul 1;67(7):1547-51. McDonald TJ, Pearson BW. Follow-up on maxillary artery ligation for epistaxis. Archives of Otolaryngology. 1980 Oct 1;106(10):635-8. Thornton JA. Estimation of blood loss during surgery. Annals of the Royal College of Surgeons of England. 1963 Sep;33(3):164. Nogami I, Shintani S, Kondo S, Kutsuna T, Katsuta H, Kurihara Y, Yoshihama Y. Resection of TMJ ankylosis using Piezosurgery®: Report of two cases. Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology. 2014 Oct 1;26(4):526-30. do Egito Vasconcelos BC, Bessa-Nogueira RV, da Silva LC. Prospective study of facial nerve function after surgical procedures for the treatment of temporomandibular pathology. Journal of oral and maxillofacial surgery. 2007 May 1;65(5):972-8. Tables Table 1: Demographic details of the patients. Gender No of patients % of patients Diagnosis No of patients % Of patients History/cause No of patients Male 19 55.882 Left 14 41.2 Congenital 4 (11.765%) Female 15 44.118 Right 20 58.8 Infection 7 (20.588%) Total 34 100.000 Total 34 100.000 Trauma 19 (55.882%) Unknown 4 (11.765%) Table 2: MLD measured preoperatively and intraoperatively with Correlation between depth in CT and Depth intra OP by Spearman rank correlation coefficient Summary Depth in CT (cm) Depth intra-op (cm) Min 0.68 0.62 Max 4.49 4.00 Mean 3.16 2.93 SD 0.68 0.62 Correlation between N Spearman R t-value p-value Depth in CT and Depth intra OP 34 0.9637 20.4268 0.0001* *p<0.05 Table 3: Correlation between Depth Intra-op (cm) with intra op time (hrs), change in Hb (mg/dl), change in PCV, post op MIO (cm), drain collection on POD-1, total no. of days drain was in situ, blood loss (ml) and duration of hospital stay by Spearman rank correlation coefficient with Comparison of pre operative and post operative Hb values by dependent t test. Variables Correlation between Depth Intra-op (cm) with N Spearman R t-value p-value Intra op time (hrs) 34 0.4699 3.0113 0.0050* Change in Hb (mg/dl) 34 0.2806 1.6540 0.1079 Change in PCV 34 0.3020 1.7917 0.0826 Post op MIO (cm) 34 -0.1992 -1.1501 0.2586 Drain collection on POD-1 34 0.5793 4.0202 0.0003* Total no. of days drain was in situ 34 0.6995 5.5378 0.0001* Blood loss (ml) 34 0.7165 5.8098 0.0001* Duration of hospital stay 34 0.6993 5.5337 0.0001* *p<0.0 Times Mean SD Mean Diff. SD Diff. % of change t-value p-value Pre operative 12.74 1.68 Post operative 11.33 1.50 1.41 0.73 11.08 11.2037 0.0001* *p<0.05 Table 4: Correlation between intra op time (hrs) with drain collection on POD-1, total no. of days drain was in situ, blood loss (ml) and duration of hospital stay by Spearman rank correlation coefficient. Variables Correlation between Intra op time (hrs)with N Spearman R t-value p-value Drain collection on POD-1 34 0.6001 4.2433 0.0002* Total no. of days drain was in situ 34 0.5761 3.9867 0.0004* Blood loss (ml) 34 0.5427 3.6555 0.0009* Duration of hospital stay 34 0.6254 4.5337 0.0001* *p<0.05 Table 5: Normality of all parameters by Shapiro-Wilk test. Parameters Shapiro-Wilk df P-value Depth in CT (cm) 0.9680 34 0.3980 Depth intra-op (cm) 0.9230 34 0.0190* Intra op time (hrs ) (mean 4.5hrs) 0.9390 34 0.0500* Hb pre OP 0.9750 34 0.6100 Hb post OP 0.9690 34 0.4290 Change in Hb (mg/dl) 0.9190 34 0.0150* PCV Pre OP 0.9580 34 0.2110 PCV post Op 0.9780 34 0.7100 Change in PCV 0.9860 34 0.9360 Post op MIO (cm) 0.9630 34 0.2900 Drain collection on POD-1 0.9210 34 0.0170* Total no. Of days drain was in situ 0.8600 34 0.0001* Blood loss (ml) 0.9570 34 0.2000 Duration of hospital stay 0.8550 34 0.0001* *p<0.05 indicates skewed distribution. Therefore, the non-parametric tests were applied Table 6: Venkatesh MLD severity index (VSI) for ankylotic mass Depth in CT (cm) Number % Mild (=4.0cm) 8 23.53 Total 34 100.00 Depth intra-op (cm) Number % Mild (=4.0cm) 8 23.53 Total 34 100.00 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 06 Apr, 2026 Reviews received at journal 11 Oct, 2025 Reviewers agreed at journal 05 Oct, 2025 Reviewers invited by journal 02 Oct, 2025 Editor assigned by journal 24 Sep, 2025 Submission checks completed at journal 24 Sep, 2025 First submitted to journal 22 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7681310","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":528232197,"identity":"35e7d55a-5c81-47ce-a0d6-cbd1a83587a5","order_by":0,"name":"Venkatesh Anehosur","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIie3Nv0rEMBzA8V+tpMvv7Joixleo/EYPn6Wh0Klv4ODBQbbuDkLfonRwiATsUt0di9CpgpN4g2DvKtxkrJtgvpA/hHwSAJfrb+bvZhasNXirr7NkDjnC++SXRPA83hNbcVMYWtxeCAb5G9/USwGB0dDVFtI+pin2KTF4qKKizQgwS0C235PoOieD2pfKKyq+UEauOMYglYWUw5ZcSeVjH33MISFHSlEbqRiy41m/hJjT2Y1uaBR0fqKycZMl2kZY0BIf9KU4LZ+7pxe1FGFg7rqNhWw7wGk95LtHxqHtAMB7n1b/9aebLpfL9T/7BLlpSkezw/XqAAAAAElFTkSuQmCC","orcid":"","institution":"SDM College of Dental Sciences \u0026 Hospital, A Constituent unit of Shri, Dharmasthala Manjunatheshwara University","correspondingAuthor":true,"prefix":"","firstName":"Venkatesh","middleName":"","lastName":"Anehosur","suffix":""},{"id":528232199,"identity":"dcb999b6-015e-49c7-af1c-2c56936e3bd8","order_by":1,"name":"Saurav Bhaduri.","email":"","orcid":"","institution":"SDM College of Dental Sciences \u0026 Hospital, A Constituent unit of Shri, Dharmasthala Manjunatheshwara University","correspondingAuthor":false,"prefix":"","firstName":"Saurav","middleName":"","lastName":"Bhaduri.","suffix":""},{"id":528232201,"identity":"710e9da9-ec8e-4cba-b6e4-9035713728e1","order_by":2,"name":"Akshay A Byadgi","email":"","orcid":"","institution":"SDM College of Dental Sciences \u0026 Hospital, A Constituent unit of Shri, Dharmasthala Manjunatheshwara University","correspondingAuthor":false,"prefix":"","firstName":"Akshay","middleName":"A","lastName":"Byadgi","suffix":""},{"id":528232202,"identity":"310f1ac5-9351-4ef0-83e4-86eb52af50e5","order_by":3,"name":"Sayali Desai","email":"","orcid":"","institution":"SDM College of Dental Sciences \u0026 Hospital, A Constituent unit of Shri, Dharmasthala Manjunatheshwara University","correspondingAuthor":false,"prefix":"","firstName":"Sayali","middleName":"","lastName":"Desai","suffix":""}],"badges":[],"createdAt":"2025-09-22 16:08:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7681310/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7681310/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":93574405,"identity":"787f38b8-62fb-4f41-8dc4-69b75a00cd18","added_by":"auto","created_at":"2025-10-15 09:16:10","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":2150365,"visible":true,"origin":"","legend":"","description":"","filename":"Figuresomfj.docx","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/075ac02ce87c2465bf601fbd.docx"},{"id":93574404,"identity":"2231f6df-4f84-4ba9-8562-984acf1d168b","added_by":"auto","created_at":"2025-10-15 09:16:10","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":36135,"visible":true,"origin":"","legend":"","description":"","filename":"ManuscriptTMJomfj.docx","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/4519e142520647dca0446143.docx"},{"id":93574408,"identity":"e05d4991-69aa-46c7-8abd-4bda341887fa","added_by":"auto","created_at":"2025-10-15 09:16:10","extension":"doc","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":78848,"visible":true,"origin":"","legend":"","description":"","filename":"TABLESomfj.doc","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/7bb92172c520c7d6691e99aa.doc"},{"id":93575812,"identity":"7ac1148f-0b3a-4a41-903b-5dc67d92b453","added_by":"auto","created_at":"2025-10-15 09:24:10","extension":"json","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":6829,"visible":true,"origin":"","legend":"","description":"","filename":"9e9ecb1f8af94726aca6938b6f79349e.json","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/c1183a86f35ba4ee57dac145.json"},{"id":93576360,"identity":"216a32ca-b38e-479b-9f17-454a2409d572","added_by":"auto","created_at":"2025-10-15 09:32:10","extension":"pdf","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":479119,"visible":true,"origin":"","legend":"","description":"","filename":"IRB2018.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/3684e1e204513680b94c9fd4.pdf"},{"id":93575814,"identity":"945885b6-8982-46be-875c-03f2d42732b6","added_by":"auto","created_at":"2025-10-15 09:24:10","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":81622,"visible":true,"origin":"","legend":"","description":"","filename":"9e9ecb1f8af94726aca6938b6f79349e1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/d5db04f10ac99bf73dbdc636.xml"},{"id":93577652,"identity":"645c05bd-71a4-41ff-bc36-3fe65376a371","added_by":"auto","created_at":"2025-10-15 09:40:10","extension":"jpeg","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":378594,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/19e78f9a258d325cdfb71496.jpeg"},{"id":93576361,"identity":"fa60939f-5bb9-4a17-bc67-2001eb3f9084","added_by":"auto","created_at":"2025-10-15 09:32:10","extension":"jpeg","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":353504,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/66c8ccfcb384865c39f69106.jpeg"},{"id":93574424,"identity":"a6a5ec93-4329-4fa5-b392-98f567f3ab50","added_by":"auto","created_at":"2025-10-15 09:16:10","extension":"jpeg","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1011512,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/cf06d3ef2ef6bd6258073c6e.jpeg"},{"id":93575815,"identity":"589dfb39-9dab-4b7f-865f-9e9fa84502a5","added_by":"auto","created_at":"2025-10-15 09:24:10","extension":"jpeg","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":416557,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/017842c6fe5c134e554ed521.jpeg"},{"id":93574426,"identity":"9086150f-62bc-4469-9018-108efcb7791b","added_by":"auto","created_at":"2025-10-15 09:16:11","extension":"jpeg","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1733450,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/0416747221907264ca7280fb.jpeg"},{"id":93574414,"identity":"ee2df205-4e10-4cdb-9b57-40cd3fd11492","added_by":"auto","created_at":"2025-10-15 09:16:10","extension":"jpeg","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1074,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage6.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/d5102589c75077939c0d2c92.jpeg"},{"id":93574420,"identity":"ab149fc3-c198-4fb2-835e-0ea1d911630d","added_by":"auto","created_at":"2025-10-15 09:16:10","extension":"jpeg","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":350311,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage7.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/7cd689b082a83e8cead9deed.jpeg"},{"id":93574418,"identity":"1f42406a-83a0-4dea-9a1f-ed328dcc2648","added_by":"auto","created_at":"2025-10-15 09:16:10","extension":"png","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":122641,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/e8f0d9d284bba662e1db56b4.png"},{"id":93575821,"identity":"7e9f233b-c31a-4b00-b239-fc89ef659024","added_by":"auto","created_at":"2025-10-15 09:24:10","extension":"png","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":168295,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/db8e3e5739d769826a5fae14.png"},{"id":93574429,"identity":"3a994dfa-cdbe-4a13-885b-6cadf8e53490","added_by":"auto","created_at":"2025-10-15 09:16:11","extension":"png","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":315143,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/4ff0842dbe5684888a0c125c.png"},{"id":93574422,"identity":"93db8216-a16d-4f33-a24a-11fbab5ed2d6","added_by":"auto","created_at":"2025-10-15 09:16:10","extension":"png","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":270824,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/27885e15d8dc85e1a608fd51.png"},{"id":93575822,"identity":"12c5d252-0ff2-4a22-b7e4-05e8183f0aba","added_by":"auto","created_at":"2025-10-15 09:24:11","extension":"png","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":684799,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/2624aa068b5edaa9f1596359.png"},{"id":93574421,"identity":"09816a6c-450d-4392-a14f-0ece7406d1e7","added_by":"auto","created_at":"2025-10-15 09:16:10","extension":"png","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":935,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/ba7d8c79c023e3656a7f901d.png"},{"id":93574430,"identity":"75065961-e1b8-4194-9b28-d1d727e964ca","added_by":"auto","created_at":"2025-10-15 09:16:11","extension":"png","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":246499,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/9415836690f0ef185acfb9d5.png"},{"id":93576363,"identity":"02ba7898-612c-468f-b284-198978366073","added_by":"auto","created_at":"2025-10-15 09:32:11","extension":"xml","order_by":20,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":78286,"visible":true,"origin":"","legend":"","description":"","filename":"9e9ecb1f8af94726aca6938b6f79349e1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/5b3cedb3246db3e437d78ee7.xml"},{"id":93574425,"identity":"ee69f2c3-c99e-40c0-b99b-1e86b04f6a3f","added_by":"auto","created_at":"2025-10-15 09:16:10","extension":"html","order_by":21,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":90164,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/1f8907ae95e703529f282f35.html"},{"id":93574403,"identity":"082f0e59-0f60-4554-82be-b135f7b1927d","added_by":"auto","created_at":"2025-10-15 09:16:10","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":34611,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePreoperative measurement of Medio lateral width of ankylotic mass using CT scan coronal section.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/d27848da2ab5732c4b8df533.jpeg"},{"id":93575810,"identity":"3cfc6af7-c741-47b8-b305-73443043e911","added_by":"auto","created_at":"2025-10-15 09:24:10","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":353504,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eEndaural approach with a temporal extension marking for TMJ ankylotic surgery.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/1e5dab8d5505c4f657c7bdfb.jpeg"},{"id":93575811,"identity":"0c545d14-31e4-406f-815a-78f0bad1224c","added_by":"auto","created_at":"2025-10-15 09:24:10","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":352942,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTMJ ankylotic mass identification\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/a95b1a4f6ea5aec0b2d15247.jpeg"},{"id":93574410,"identity":"4b9ce17d-5cd7-49b7-8227-7edf4725fed5","added_by":"auto","created_at":"2025-10-15 09:16:10","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":416557,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTMJ gap arthroplasty.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/9db574530dfd4895a8678e80.jpeg"},{"id":93575818,"identity":"031a5281-a2e8-4975-be67-6e5cbad2b3fb","added_by":"auto","created_at":"2025-10-15 09:24:10","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":610515,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIntra operative MLD measurement of TMJa\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePoint A- deepest width of the ankylotic mass(inferiorly)- coinciding with CT scan medial Limit\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePoint B- the highest mark of osteotomy cut made(superiorly)- coinciding with CT scan lateral limit\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRED LINES – Representing the osteotomy cuts made\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWHITE LINE- Representing the width of the ankylotic mass\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/6917b69c206835f09a3788ee.jpeg"},{"id":93574413,"identity":"c88f42c3-633c-4856-98a0-de349e368324","added_by":"auto","created_at":"2025-10-15 09:16:10","extension":"jpeg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":350311,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIntraoperative maximal inter incisal mouth opening achieved\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image6.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/8e61f401945d4fcc9278df53.jpeg"},{"id":93577894,"identity":"89a7cf2e-522f-40d6-b3e0-604f9dc5dfa8","added_by":"auto","created_at":"2025-10-15 09:48:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3361694,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7681310/v1/c9771911-1e08-4a04-bee6-75c18dd28f41.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eSignificance of Medio-Lateral Depth (MLD) in TMJ ankylosis surgery - A newer severity index based surgical outcomes study\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTemporomandibular joint (TMJ) ankylosis is a debilitating disorder caused by fibrous or osseous fusion of the joint components, significantly restricting mandibular mobility. This immobility compromises essential activities such as mastication, speech, and maintaining oral hygiene. In children\u0026rsquo;s, TMJ ankylosis disrupts normal facial growth, resulting in persistent functional and aesthetic challenges.\u003csup\u003e1,2\u0026nbsp;\u003c/sup\u003eRestricted mouth opening hinders mastication, leading to dietary deficiencies and malnutrition, while poor oral hygiene increases the risk of secondary dental complications such as caries, periodontal disease, and malocclusion.\u003csup\u003e\u0026nbsp;1,2\u003c/sup\u003e\u0026nbsp; The Medio-Lateral Depth (MLD) of the bony ankylotic mass is a vital yet underexplored factor influencing the complexity of surgery. Increased depth of the ankylotic block exacerbate surgical difficulty, prolong operative time, elevate blood loss, and involved postoperative complications. Current surgical options, includes gap arthroplasty, interposition arthroplasty, and grafting techniques. This study aims to assess the role of the medio-lateral depth of the bony ankylotic mass in influencing surgical outcomes and specific indicators of morbidity.\u003c/p\u003e"},{"header":"Material and Methodology","content":"\u003cp\u003eProspective single centre, cohort study was conducted in accordance with the declaration of Helsinki, abiding by the STROBE guidelines after obtaining institutional ethical clearance (IRB No: 2018/P/OS/101). All patients informed consents taken. 34 patients were included in the study with complete bony ankylosis of the joint - (Sawhney\u0026rsquo;s Type 4 and He\u0026rsquo;s Type A4) operated between 2018-2023 with 2 years follow up. Patients between 17-35 years, with restricted mouth opening of less than 1cm, with functional impairment were included. Patients excluded in the study were with Bilateral TMJ Ankylosis with concomitant any adjuvant procedures, Syndromic Patients, re-ankylosis, Fibrous ankylosis, Patients with blood Dyscrasias, history of haemodialysis, liver/kidney dysfunction and ASA III and IV.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePreoperative assessment of Mediolateral depth (MLD) of ankylotic mass using CT scan.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 128 slice Plain multi detector computed tomography (Siemens SOMATOM Definition Edge; kVp:120, mA: 200) with slice Thickness of 1 mm and detailed reformatting images by dent scan software in sagittal, coronal planes and 3-dimensional reconstruction for detailed bony architecture was carried out as a part of the protocol. An isotropic Resolution of 0.4mm\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eprovided excellent image clarity and detail. The medio-lateral depth (MLD) was measured pre-operatively by a single senior consultant and specialized head and neck radiologist on the coronal sections of the CT at the point of maximum thickness of the ankylotic mass, with a line connecting a point on the lateral limit of the mass corresponding to the point of fusion to the inferolateral part of the root of the zygomatic arch to the most medial limit on the same section in Dent scan software to eliminate reliability bias, inter radiologist variability and institutional experience bias. \u003cstrong\u003e[Figure 1]\u0026nbsp;\u003c/strong\u003eWhile the lateral limit of the mass was guided by the lateral extent root of zygoma, the medial point was an arbitrary one as most joints had their architecture grossly distorted with near complete obliteration of the sigmoid notch and fusion of the elongated coronoid to the ankylotic mass in almost half of the cases.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll pre-operative calculations of depth were also verified by the senior operating surgeon and were discussed with the team members prior to the surgery. All surgeries were carried out by a single senior maxillofacial surgeon as the lead, assisted by a team of junior residents and registrars. Patients also underwent evaluation of the oropharyngeal airway and other comorbidities. A thorough pre-anaesthetic evaluation and clearance was obtained. All patients underwent Nasal intubation via an intubating fibre-optic laryngoscope, with an armoured cuffed naso-tracheal tube and induced under GA. The ankylotic mass was removed in a piecemeal fashion through an endaural approach often with a temporal extension\u003cstrong\u003e\u0026nbsp;[Figure 2]\u003c/strong\u003e. A gap arthroplasty with a gap of 1.5-2 cms was created, protecting the underneath soft tissue and vital structures using malleable subperiosteally till the complete length of the ankylotic mass to achieve an obstruction free rotation of the Mandible\u003cstrong\u003e\u0026nbsp;[Figure 3 and 4]\u003c/strong\u003e. Intra operative MLD was measured from the highest mark of osteotomy cut made to deepest width of the ankylotic mass (Supero inferiorly) with the help of customized malleable with engraved measurement in millimetres and centimetres which was recorded. The medial extent of the depth was defined as the soft tissue encountered after removing the last sliver of bone as it ensures the complete removal of the ankylotic mass medially.\u003cstrong\u003e\u0026nbsp;[Figure 5].\u0026nbsp;\u003c/strong\u003eBilateral coronoidectomy was also carried out with temporalis myotomy. This was followed by active jaw opening manoeuvres and a mouth opening of approximately 4 cms was achieved\u003cstrong\u003e\u0026nbsp;[Figure 6]\u003c/strong\u003e. Haemostasis, closure in layers and insertion of mini-vac drains into the surgical site followed. Post-op Hb and PCV were noted on day 1 along with collection in the drain. Post-operative mouth opening was recorded as maximal pain-free mouth opening on day 7 after most of the edema had subsided. \u0026nbsp;Intra operative MLD was first correlated to the MLD on CT (Coronal section) to check its validity. The variables that were observed during the various time points were Intra op time (hrs), Change in Hb (mg/dl), PCV, Post op MIO (cm), Drain collection on POD-1, Total no. of days drain was in situ, Blood loss (ml), Duration of hospital stay and were correlated to the MLD. Normality\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eof all parameters were then verified with the Shapiro-Wilk\u0026rsquo;s Test to sort the outliers and confirm that the data to followed a normal Gaussian pattern.\u003cstrong\u003e\u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Results","content":"34 patients were included in the study. The mean age presentation was 20.9 years (17-35 years) with male19(55.8%) predilection more when compared to females15(44.2%). incidence of ankylosis on right side was 20 (58.8%), followed by the left side 14 (41.2%). Trauma being the commonest cause for ankylosis in this study with 19(55.8%) , infection 7(20.6%) and 4(11.8%) were with congenital and other causes. (Table 1) \nMLD measured preoperatively from CT scan and intraoperatively measured depth has a mean value of 3.16cm and 2.93cm respectively. A strong correlation (Spearman R=0.9637, p\u003c0.0001) was observed between depth in CT and depth measured intra-op. (Table 2). These suggest the medio-lateral depth significantly impacts postoperative outcomes. Haemoglobin levels: Pre-op mean 12.74 gm% vs post-op 11.31 gm% (p=0.0001). PCV values: Pre-op mean 38.22, post-op 34.1834 (p=0.0001), indicating statistically significant measurable blood loss and physiological impact during arthroplasties in joints with higher medio-lateral depths. (Table 3). To summarise non-parametric tests were appropriately applied for these variables the results Significant deviations from normality were observed in: Depth intra-op (p = 0.019) Intra-op time (p = 0.050) post op change in Hb (p = 0.015), post op changes in PCV p=0.9360 Post op MIO (P=0.2900), Drain collection on POD-1 (p = 0.017) Duration of hospital stay (p \u003c 0.0001). Results suggested that increase in MLD has direct corelation with increased intra operative surgical difficulties and post operative complications. (Table 4 \u0026 Table 5)\nComplications were in 10 (29.41%) of cases, with re-ankylosis and jaw deviation being the most frequent at 5.88% each. The cases in this series were classified into mild, moderate and severe cases depending on the variability of MLD measured preoperatively by CT scan and Intra op Depth nomenclated as Venkatesh MLD severity index (VSI) for ankylotic mass. Mild- \u003c2.5cm, Moderate -2.5cm to 4.0cm and Severe \u003e=4.0cm (Table 6)\n"},{"header":"Discussion","content":"\u003cp\u003eSurgery for temporomandibular joint ankylosis (TMJa) and other open TMJ procedures presents a range of challenges and complications, stemming from the distorted anatomy, proximity to critical neurovascular structures, and the extensive bony fusion. Additionally, while infectious, autoimmune, and biomechanical factors may occasionally contribute to complications, they represent a relatively minor subset, with infectious complications accounting for less than 2% of cases reported in the literature.\u003csup\u003e2,3\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne of the most significant intraoperative challenges is managing haemorrhage, particularly is due to the rich vascularity surrounding the joint. The vasculature, including branches of the maxillary artery and Pterygoid plexus of veins can be encountered as the depth of ankylosis mass increases.\u003csup\u003e4\u003c/sup\u003e Neurological structures surrounding the joint, derived from cranial nerves V and VII, and branches of the external carotid artery add further complexity.\u003csup\u003e5\u003c/sup\u003eHeavy instrumentation or excessive bleeding in this area must be avoided to prevent middle ear trauma.\u003csup\u003e6\u0026nbsp;\u003c/sup\u003eFor instance, the studies by Hoffman and Panetta\u003csup\u003e10\u003c/sup\u003e and Susarla et al\u003csup\u003e9\u003c/sup\u003e highlighted the importance of preoperative planning, managing Airway complications and haemorrhagic risks in TMJ surgeries.\u003c/p\u003e\n\u003cp\u003eAdvanced imaging techniques, such as CT angiography, combined with selective embolization, have emerged as more precise methods for managing inaccessible arterial bleeds.\u003csup\u003e8,10\u0026nbsp;\u003c/sup\u003eStudies by Susarla et al.\u003csup\u003e9\u003c/sup\u003e and others have emphasized the role of preoperative embolization and intraoperative preparedness in reducing bleeding risks during TMJ surgeries. The work of Bouloux and Perciaccante\u003csup\u003e11\u003c/sup\u003e further elucidated the limitations of external carotid artery ligation in controlling blood loss, attributing continued haemorrhage to collateral circulation. McDonald and Pearson\u003csup\u003e12\u003c/sup\u003e advocated for direct ligation of the internal maxillary artery via a trans antral approach.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThornton\u003csup\u003e13\u003c/sup\u003e suggesting that in healthy patients, blood loss exceeding 500 mL warrants replacement. This threshold, however, is influenced by factors such as the duration of surgery, surgical technique and patient response to extensive procedures like wide gap arthroplasty.\u003c/p\u003e\n\u003cp\u003eThe intraoperative depth measured during surgery closely corresponded to the depth recorded on preoperative CT scans suggestive of good sensitivity and specificity. While CT measurements exhibited a tendency for mild overestimation, they demonstrated a strong positive correlation with intraoperative depths, as evidenced by Spearman\u0026apos;s rank correlation coefficient (R = 0.9637, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05). The maximum discrepancy was 0.7 cm, with a mean difference of 0.3 cm, indicating that a meticulously performed CT scan can reliably forecast surgical complexity. \u0026nbsp;MLD\u0026rsquo;s exceeding 2.5 cm were consistently associated with prolonged surgical duration and greater procedural challenges. While the intraoperative time correlated positively with depth, the trend was weaker, with significant variability due to outliers. However, cases with a depth greater or equal to 4.0 cm required exponentially longer operative times, highlighting the increasing complexity of managing severe bony ankylosis. Surgeries for these cases, even with standardized protocols, averaged 2\u0026ndash;4 hours compared to 90 minutes for depths below 2.5 cm. the observed trends suggest that depths greater or equal to 2.5 cm necessitate heightened expertise and meticulous planning.\u003c/p\u003e\n\u003cp\u003eThe hemodynamic impact of managing severe ankylosis was evident, albeit with weak correlations. Depths beyond 4.0 cm showed increased postoperative haemoglobin (Hb) and packed cell volume (PCV) drops, the mean Hb drop on postoperative day one was 1.5 mg/dL, with depths below 2.5 cm rarely exceeding 1.4 mg/dL. Similarly, the average PCV reduction of 4.04% around the 2.5 cm mark did not translate to severe morbidity. Oral iron and hematinic supplementation were sufficient for recovery in most patients, though nutritional deficiencies such as vitamin B12 insufficiency were commonly observed. Four patients required one unit of packed red blood cell transfusion, all of whom had depths exceeding 2.5 cm and surgeries lasting over 90 minutes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBlood loss emerged as one of the most strongly correlated variables with increasing mediolateral depths (MLD). Average intraoperative blood loss was 350 mL for depths of 2.5 cm, with values closely aligning along a linear trend line. Four joints experienced arterial injury involving branches of the maxillary artery and anterior deep temporal artery. Prompt haemostasis was achieved using ligation and bipolar diathermy and further few cases with piezoelectric gap arthroplasty surgery. Nogami et\u003csup\u003e14\u003c/sup\u003e al., supports the use of piezo surgery for precise bone removal in such cases, as its oscillating mechanism minimizes soft tissue damage. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePostoperative maximum incisal opening (MIO) at day 7 ranged from 2.5 cm to 4.7 cm, with a mean of 3.6 cm. Deeper ankylotic masses correlated with slightly reduced MIO values, particularly in cases with depths over 2.5 cm, this reduction may be attributed to organized hematomas and persistent inflammation limiting complete joint rotation. Increased drain output and edema further compounded this limitation. Day 1 drain collection averaged 25 mL, with depths above 2.5 cm exhibiting higher outputs. Drains were removed when output fell below 10 mL over two consecutive days, with an average removal time of 4 days. However, depths exceeding 4.0 cm often necessitated drain retention for up to 7 days, aligning with higher postoperative pain and restricted mouth opening.\u003c/p\u003e\n\u003cp\u003eHospitalization duration correlated positively with ankylotic depth, rising sharply beyond 2.5 cm. Patients with depths greater than 4 cm had prolonged stays, averaging 10 days compared to a minimum of 6 days for shallower cases. Increased hospital stays were attributed to higher incidences of wound complications, persistent drain output, and postoperative edema. 1(2.94%) patient was noted with persistent facial nerve weakness, A similar Study conducted by Belmiro Cavalcanti do Egito Vasconcelos et al\u003csup\u003e15\u003c/sup\u003e showed 2 patients, 12.5% (ie, 8% of the 50 approaches) showed signs of facial nerve injury after TMJ surgery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite robust findings, certain limitations warrant consideration. The relatively small cohort size (n = 34) may limit generalizability also relationship of TMJ ankylotic mass to internal maxillary artery is not determined due to financial constraints in this study. Furthermore, confounding variables such as patient comorbidities and age were not controlled. Prospective studies with larger samples and multivariate analyses are necessary to validate these conclusions and refine depth-based surgical protocols.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, increasing MLD in ankylotic masses is strongly associated with surgical complexity, intraoperative challenges, and postoperative recovery. Depth remains a pivotal prognostic parameter, influencing operative time, blood loss, and recovery trajectories. Preoperative imaging, meticulous planning, and depth-informed surgical training are critical to optimizing outcomes. These findings by \u003cstrong\u003eVenkatesh MLD severity index (VSI)\u003c/strong\u003e provide a foundation for developing predictive and interventional strategies to improve the management of TMJ ankylosis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict Of Interest:\u003c/strong\u003e None\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval Clearance Section:\u0026nbsp;\u003c/strong\u003eAll patients informed consents taken to participate in the study. The Institutional ethical clearance is obtained from college IRB committee IRB No: IEC No. 2018/P/OS/101\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eClinical Trail-Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This research did not receive any specific grant from funding agencies in the public, commercial, not-for-profit sector\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e- Authors would like to thank Dr Niranjan Kumar, Vice Chancellor, Shri Dharmasthala Manjunatheshwara University and Director of SDM Craniofacial Centre, Shri. Saket Shetty Director of Administration and Dr. Balaram Naik Principal, SDM college of Dental Sciences and Hospital for the support, encouragement and facilities provided.\u003c/p\u003e"},{"header":"References","content":"\n\u003col\u003e\n\u003cli\u003eMovahed R, Mercuri LG. Management of temporomandibular joint ankylosis. Oral Maxillofac Surg Clin North Am. 2015 Feb;27(1):27-35. doi:10.1016/j.coms.2014.09.003. PMID: 25483442.\u003c/li\u003e\n\u003cli\u003eGupta VK, Mehrotra D, Malhotra S, Kumar S, Agarwal GG, Pal US. An epidemiological study of temporomandibular joint ankylosis. National journal of maxillofacial surgery. 2012 Jan 1;3(1):25-30.\u003c/li\u003e\n\u003cli\u003eFari\u0026ntilde;a R, Canto L, Gunckel R, Alister JP, Uribe F. Temporomandibular joint ankylosis: algorithm of treatment. Journal of Craniofacial Surgery. 2018 Mar 1;29(2):427-31. \u003c/li\u003e\n\u003cli\u003eGaba S, Sharma RK, Rattan V, Khandelwal N. The long-term fate of pedicled buccal pad fat used for interpositional arthroplasty in TMJ ankylosis. Journal of plastic, reconstructive \u0026amp; aesthetic surgery. 2012 Nov 1;65(11):1468-73. \u003c/li\u003e\n\u003cli\u003eGupta M, Sen S. Analysis for different functional results of TMJ ankylosis management by comparing ramus-condyle unit reconstruction using vertical ramus osteotomy and interpositional gap arthroplasty. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology. 2021 Jul 1;132(1):10-\u003c/li\u003e\n\u003cli\u003eLong X, Li X, Cheng Y, Yang X, Qin L, Qiao Y, Deng M. Preservation of disc for treatment of traumatic temporomandibular joint ankylosis. Journal of oral and maxillofacial surgery. 2005 Jul 1;63(7):897-902.\u003c/li\u003e\n\u003cli\u003eKaban LB, Perrott DH, Fisher K. A protocol for management of temporomandibular joint ankylosis. Journal of oral and maxillofacial surgery. 1990 Nov 1;48(11):1145-51.\u003c/li\u003e\n\u003cli\u003eChidzonga MM. Temporomandibular joint ankylosis: review of thirty-two cases. British Journal of Oral and Maxillofacial Surgery. 1999 Apr 1;37(2):123-6.\u003c/li\u003e\n\u003cli\u003eSusarla SM, Peacock ZS, Williams WB et al. Role of computed tomographic angiography in treatment of patients with temporomandibular joint ankylosis. J Oral Maxillofac Surg 2014;72:267\u0026ndash;76. 10.1016/j.joms.2013.09.024.\u003c/li\u003e\n\u003cli\u003eHoffman D, Panetta T. Treatment of TMJ ankylosis utilizing preoperative CT angiography, surgical navigation, and intraoperative ebolization. International Journal of Oral and Maxillofacial Surgery. 2011 Oct 1;40(10):e8.\u003c/li\u003e\n\u003cli\u003eBouloux GF, Perciaccante VJ. Massive hemorrhage during oral and maxillofacial surgery: ligation of the external carotid artery or embolization?. Journal of oral and maxillofacial surgery. 2009 Jul 1;67(7):1547-51.\u003c/li\u003e\n\u003cli\u003eMcDonald TJ, Pearson BW. Follow-up on maxillary artery ligation for epistaxis. Archives of Otolaryngology. 1980 Oct 1;106(10):635-8.\u003c/li\u003e\n\u003cli\u003eThornton JA. Estimation of blood loss during surgery. Annals of the Royal College of Surgeons of England. 1963 Sep;33(3):164.\u003c/li\u003e\n\u003cli\u003eNogami I, Shintani S, Kondo S, Kutsuna T, Katsuta H, Kurihara Y, Yoshihama Y. Resection of TMJ ankylosis using Piezosurgery\u0026reg;: Report of two cases. Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology. 2014 Oct 1;26(4):526-30.\u003c/li\u003e\n\u003cli\u003edo Egito Vasconcelos BC, Bessa-Nogueira RV, da Silva LC. Prospective study of facial nerve function after surgical procedures for the treatment of temporomandibular pathology. Journal of oral and maxillofacial surgery. 2007 May 1;65(5):972-8.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Demographic details of the patients.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"119%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0935%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.3364%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo of patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.3364%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7103%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.6542%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo of patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.6542%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e% Of patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.9439%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory/cause\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.271%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo of patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0935%;\"\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3364%;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3364%;\"\u003e\n \u003cp\u003e55.882\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7103%;\"\u003e\n \u003cp\u003eLeft\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.6542%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.6542%;\"\u003e\n \u003cp\u003e41.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.9439%;\"\u003e\n \u003cp\u003eCongenital\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.271%;\"\u003e\n \u003cp\u003e4 (11.765%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0935%;\"\u003e\n \u003cp\u003eFemale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3364%;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3364%;\"\u003e\n \u003cp\u003e44.118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7103%;\"\u003e\n \u003cp\u003eRight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.6542%;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.6542%;\"\u003e\n \u003cp\u003e58.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.9439%;\"\u003e\n \u003cp\u003eInfection\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.271%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e(20.588%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0935%;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3364%;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3364%;\"\u003e\n \u003cp\u003e100.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7103%;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6542%;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6542%;\"\u003e\n \u003cp\u003e100.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.9439%;\"\u003e\n \u003cp\u003eTrauma\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.271%;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003cp\u003e(55.882%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0935%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3364%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3364%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7103%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6542%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6542%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.9439%;\"\u003e\n \u003cp\u003eUnknown\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.271%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e(11.765%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: MLD measured preoperatively and intraoperatively with Correlation between depth in CT and Depth intra OP by Spearman rank correlation coefficient\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1475%;\"\u003e\n \u003cp\u003eSummary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.7869%;\"\u003e\n \u003cp\u003eDepth in CT (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 36.0656%;\"\u003e\n \u003cp\u003eDepth intra-op (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1475%;\"\u003e\n \u003cp\u003eMin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.7869%;\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 36.0656%;\"\u003e\n \u003cp\u003e0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1475%;\"\u003e\n \u003cp\u003eMax\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.7869%;\"\u003e\n \u003cp\u003e4.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 36.0656%;\"\u003e\n \u003cp\u003e4.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1475%;\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.7869%;\"\u003e\n \u003cp\u003e3.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 36.0656%;\"\u003e\n \u003cp\u003e2.93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.1475%;\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.7869%;\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 36.0656%;\"\u003e\n \u003cp\u003e0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"left\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 36.3636%;\"\u003e\n \u003cp\u003eCorrelation between\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.1515%;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003eSpearman R\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.1515%;\"\u003e\n \u003cp\u003et-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.1515%;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 36.3636%;\"\u003e\n \u003cp\u003eDepth in CT and Depth intra OP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.1515%;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.9637\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.1515%;\"\u003e\n \u003cp\u003e20.4268\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.1515%;\"\u003e\n \u003cp\u003e0.0001*\u003c/p\u003e\n \u003cp\u003e*p\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Correlation between Depth Intra-op (cm) with intra op time (hrs), change in Hb (mg/dl), change in PCV, post op MIO (cm), drain collection on POD-1, total no. of days drain was in situ, blood loss (ml) and duration of hospital stay by Spearman rank correlation coefficient with Comparison of pre operative and post operative Hb values by dependent t test.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003eCorrelation between Depth Intra-op (cm) with\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003eSpearman R\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003et-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eIntra op time (hrs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.4699\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e3.0113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.0050*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eChange in Hb (mg/dl)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.2806\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1.6540\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.1079\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eChange in PCV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.3020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1.7917\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.0826\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003ePost op MIO (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e-0.1992\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e-1.1501\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.2586\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eDrain collection on POD-1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.5793\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e4.0202\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.0003*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eTotal no. of days drain was in situ\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.6995\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e5.5378\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.0001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eBlood loss (ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.7165\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e5.8098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.0001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eDuration of hospital stay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.6993\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e5.5337\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.0001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*p\u0026lt;0.0\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003eTimes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10px;\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10px;\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13px;\"\u003e\n \u003cp\u003eMean Diff.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11px;\"\u003e\n \u003cp\u003eSD Diff.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e% of change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003et-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003ePre operative\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10px;\"\u003e\n \u003cp\u003e12.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003ePost operative\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10px;\"\u003e\n \u003cp\u003e11.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13px;\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15px;\"\u003e\n \u003cp\u003e11.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10px;\"\u003e\n \u003cp\u003e11.2037\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.0001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*p\u0026lt;0.05\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Correlation between intra op time (hrs) with drain collection on POD-1, total no. of days drain was in situ, blood loss (ml) and duration of hospital stay by Spearman rank correlation coefficient.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003eCorrelation between Intra op time (hrs)with\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003eSpearman R\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003et-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eDrain collection on POD-1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.6001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e4.2433\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.0002*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eTotal no. of days drain was in situ\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.5761\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e3.9867\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.0004*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eBlood loss (ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.5427\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e3.6555\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.0009*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eDuration of hospital stay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.6254\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e4.5337\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.0001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*p\u0026lt;0.05\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5: Normality of all parameters by Shapiro-Wilk test.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eShapiro-Wilk\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cstrong\u003edf\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003eDepth in CT (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.9680\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e0.3980\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003eDepth intra-op (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.9230\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e0.0190*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003eIntra op time (hrs\u003cstrong\u003e) (mean 4.5hrs)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.9390\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e0.0500*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003eHb pre OP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.9750\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e0.6100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003eHb post OP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.9690\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e0.4290\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003eChange in Hb (mg/dl)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.9190\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e0.0150*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003ePCV Pre OP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.9580\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e0.2110\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003ePCV post Op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.9780\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e0.7100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003eChange in PCV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.9860\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e0.9360\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003ePost op MIO (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.9630\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e0.2900\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003eDrain collection on POD-1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.9210\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e0.0170*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003eTotal no. Of days drain was in situ\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.8600\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e0.0001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003eBlood loss (ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.9570\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e0.2000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003eDuration of hospital stay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.8550\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e0.0001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*p\u0026lt;0.05 indicates skewed distribution. \u0026nbsp; Therefore, the non-parametric tests were applied\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6: Venkatesh MLD severity index (VSI) for ankylotic mass\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"101%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eDepth in CT (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eMild (\u0026lt;2.5mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e17.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eModerate (2.5 to 4.0cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e58.82\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eSevere (\u0026gt;=4.0cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e23.53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eDepth intra-op (cm)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eMild (\u0026lt;2.5mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e17.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eModerate (2.5 to 4.0cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e58.82\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eSevere (\u0026gt;=4.0cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e23.53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"oral-and-maxillofacial-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"omfs","sideBox":"Learn more about [Oral and Maxillofacial Surgery](http://link.springer.com/journal/10006)","snPcode":"10006","submissionUrl":"https://submission.nature.com/new-submission/10006/3","title":"Oral and Maxillofacial Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Medio-Lateral Depth (MLD), Temporomandibular Joint ankylosis (TMJa) Computed tomography scan (CT SCAN), Facial Asymmetry (FA)","lastPublishedDoi":"10.21203/rs.3.rs-7681310/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7681310/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTemporomandibular joint (TMJ) ankylosis is a debilitating disorder caused by fibrous or osseous fusion of the joint components, significantly restricting mandibular mobility. In children’s, TMJ ankylosis disrupts normal facial growth, resulting in persistent functional and aesthetic challenges. The Medio-Lateral Depth (MLD) of the bony ankylotic mass is a vital yet underexplored factor influencing the complexity of surgery. Increased depth and density of the ankylotic block exacerbate surgical difficulty and involved postoperative complications. This study aims to assess the role of the Medio-Lateral Depth (MLD) of the bony ankylotic mass in influencing surgical outcomes and specific indicators of morbidity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methodology\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was designed as a prospective single centre, cohort study. The medio-lateral depth (MLD) was measured pre-operatively by CT scan and intra operatively by depth gauge scale. Intra operative depth was first correlated to the MLD on CT scan to check its validity. also, other post operative variables outcomes were correlated to the MLD.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e34 patients were included in the study. MLD measured preoperatively from CT scan and intraoperatively measured depth has a mean value of 3.16cm and 2.93cm respectively. A strong correlation (Spearman R = 0.9637, p \u0026lt; 0.0001) was observed between depth in CT and depth measured intra-op. Significant correlations were also found between Depth intra-op and drain collection on POD-1 (R = 0.5793, p = 0.0003). The cases in this series were classified into mild, moderate and severe cases depending on the variability of MLD measured preoperatively by CT scan and Intra operative Depth therefore nomenclated as \u003cstrong\u003eVenkatesh MLD severity index (VSI)\u003c/strong\u003e for ankylotic mass. Mild- \u0026lt;2.5cm, Moderate − 2.5cm to 4.0cm and Severe \u0026gt; = 4.0cm.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIncreasing MLD in ankylotic masses is strongly associated with surgical complexity, intraoperative challenges, and postoperative recovery. Depth remains a pivotal prognostic parameter, influencing operative time, blood loss, and recovery trajectories. Preoperative imaging, meticulous planning, and depth-informed surgical training are critical to optimizing outcomes.\u003c/p\u003e","manuscriptTitle":"Significance of Medio-Lateral Depth (MLD) in TMJ ankylosis surgery - A newer severity index based surgical outcomes study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-15 09:16:05","doi":"10.21203/rs.3.rs-7681310/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-07T02:55:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-11T18:18:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"90657184232981269050670353333671787748","date":"2025-10-06T01:48:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-02T04:07:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-24T23:20:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-24T23:19:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"Oral and Maxillofacial Surgery","date":"2025-09-22T11:15:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"oral-and-maxillofacial-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"omfs","sideBox":"Learn more about [Oral and Maxillofacial Surgery](http://link.springer.com/journal/10006)","snPcode":"10006","submissionUrl":"https://submission.nature.com/new-submission/10006/3","title":"Oral and Maxillofacial Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"09c21a6b-b06f-4959-8fd4-fc61b10f920a","owner":[],"postedDate":"October 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T11:54:34+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-15 09:16:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7681310","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7681310","identity":"rs-7681310","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}