INTRODUCTION:

Ankylosis is a Greek terminology meaning ‘stiff joint‘. Temporomandibular joint (TMJ) ankylosis is an intracapsular union of the disc-condyle complex to the temporal articular surface that restricts mandibular movements including the fibrous adhesions or bony fusion between condyle, disc, glenoid fossa, and eminence. Temporomandibular joint (TMJ)TMJ ankylosis was classified by Kazanjian¹as either true or false. True ankylosis is a condition that results in osseous of fibrous adhesion between the surfaces of the TMJ, within the limits of the articular capsule. False ankylosis results from diseases not directly related to the joint. Patients have limited opening of the mouth, speech impairment, difficult with mastication, poororal hygiene, facial asymmetry, and mandibular micrognathia. TMJ ankylosis results from trauma, infection, and inadequate surgical treatment of the TMJ region. It is common condition in children following oro-facial trauma.²Management of TMJ ankylosis is through surgical intervention as soon as the condition is recognized. Early surgery can minimize the severity of the restriction of facial growth.

The basic techniques for surgical correction of ankylosis include the gap arthroplasty (ressection of the bony mass without interpositional material); joint reconstruction (ressection of the bony mass with reconstruction by bone grafts or joint prosthesis); or interpositional arthroplasty (ressection of the bony mass with interposition of a biological material or non-biological material).³According to Kaban⁴, the protocol for treatment of TMJ ankylosis are: aggressive resection of the ankylotic segment, ipsilateral coronoidectomy, contaletaral coronoidectomy when necessary, lining joint with temporal is fascia or cartilage, reconstruction of ramus with costocondral graft, rigid fixation of the graft, early mobilization and aggressive physiotherapy.Recently, the Kaban protocol has been modified to substitute ramus/condyle reconstruction using distraction osteogenesis, when possible, instead of costochondral grafting. This protocol has the major advantage of eliminating the donor site operation and allowing for immediate vigorous TMJ mobilization.

In this report, we describe a case of true (fibro-osseous) ankylosis of left TMJ which presented to us with reduced mouth opening.[7]

Case Report:

A 27 years old female reported to oral & maxillofacial department with a complaint of reduced mouth opening since past 7 years and pain in lower right side mandibular posterior region since 3-4 months. Pain is mild, dull, continuous in nature which aggrevated by chewing food and relieved by medication. Patient gives history of trauma due to fall of cupboard over her at the age of 7 months. At the time of incident patient became unconscious and was taken to the civil hospital, Ahmedabad where the needful treatment was given. Patient noticed gradual reduction in mouth opening which has further reduced since past 7 years.

Extraoral examination revealed facial asymmetry, flattening of face, elongation, discoloration of skin that is a red patch around 3-5 centimeters in size present on cheek region of face on right side and roundness and fullness of face on left side and chin appears less prominent [figure 1].. The mouth opening is reduced to 15 millimeters (mm).[figure 2]. TMJ movements are within normal limits on right side while movements cannot be palpated on left side and also there is deviation of mandible and chin on the left side of the face [figure 1]. Intraoral examination revealed carious 46 with pain on percussion and sinus opening on the buccal side of 46, deep hard palate, proclined upper anteriors, fractured crown in relation with 21 and red, swollen gingival with bleeding on probing present [figure 3]. Panoramic radiography showed a well demarked radiopacity present on left side temporomandibular region [figure 4]. 3D CT scan shows fusion of condyle, glenoid fossa, elongated coronoid process on left side.[figure 5] A diagnosis of unilateral TMJ ankylosis on left side was made (true fibro-osseous ankylosis in the left side). Surgical treatment with gap arthroplasty under general anaesthesia was selected.

Treatment: A surgical approach consisted of preauricular incisions as reported by Al-Kayat and Bramley⁵ [figure 6]. The zygomatic arch was exposed via an incision of the periosteum. On the left side, a condyle like structure and strong fibrous adhesions were found [Figure 7]. The coronoid process was not identified. A gap was created by removing the fibrous/osseus tissue with surgical burs and chisels [Figure 8,9]. Mouth opening of 27 mm was achieved [Figure 10]. Closure was done with 4-0-ethylon suture material.[Figure 11]

Postoperative course: The post-operative (PO) course was uneventful. Only PO pain medication was prescribed. There was no motor deficit on either side of the face. Vigorous PO physiotherapy was performed to maintain the mobility and to prevent hypomobility secondary to fibrous adhesions. The patient was followed at one month, 6 months intervals, with a maximum mouth opening of 26 mm (Figures 12). A panoramic radiograph showed no signs of recurrence(Figure 13).

Figure 1. Clinical extra oral photograph showing facial asymmetry, flattening of face, elongation, discoloration of skin present on cheek region of face on right side and roundness and fullness of face on left side and chin appears less prominent

Figure 2. Showing preoperative mouth opening

Figure 3. Showing proclined upper anteriors, fractured crown in relation with left maxillary central incisor.

Figure 4: Panoramic radiograph showing well demarked radiopacity present on left side temporomandibular region

Figure 5: 3D CT scan showing fusion of condyle, glenoid fossa, elongated coronoid process on left side

Figure 6. Preauricular incision as reported by Al-Kayat and Bramley

Figure 7. Ankylosis of left TMJ

Figure 8. Gap arthroplasty

Figure 9. Fibrous/osseus tissue

Figure 10 Intraoperative mouth opening

Figure 11 Suturing

Figure 12. Mouth opening after 6 months

Figure 13. Postoperative OPG

DISCUSSION

The primary etiology of TMJ ankylosis includes traumas and infection of TMJ.² It has been recently proven that TMJ trauma (especially fracture of the condyle) was the most important cause of TMJ ankylosis. Roy choudhury et al⁶ retrospectively studied 50cases of TMJ ankylosis and showed that TMJ traumawas documented as a major etiologic factor in 86% of cases. TMJ ankylosis also occurs following inadequately treated mandible fractures. The mechanism of ankylosis is most likely caused by intracapsular injury followed by insufficient jaw movement.⁷

TMJ ankylosis was divided into 4 types by Sawhney⁸ in 1986. Type I is fibriotic ankylosis, in which fibrous adhesions in and around the joint restricted the motion of mandible, the condyle was flattened and in close approximation to the glenoid fossa, and the joint space is reduced. Type II is also characterized by a flattened condyle inclose approximation to the glenoid fossa, and the lateral surface was bridged with bone. In both types, the more medial structures of the articular surface and disc are undamaged. Type III ankylosis usually resulted from a medially displaced fracture dislocation of the condyle with bone bridging the ramus of the mandible to the zygomatic arch. In type IV ankylosis, the TMJ architecture is completely replaced by bone, with fusion of the condyle, sigmoid notch, and coronoid process to the zygomatic arch and glenoidfossa.⁴ Here it is Sawhney Type III Ankylosis. Goldman⁹suggested that the extra vasation of blood into the joint, along with the disruption of fibrocartilage integrity, permits the in growth of fibrous connective tissue into the joint, which subsequently results in ossification.

It is very important to take the ankylosis image examination for evaluation of the type and extent of the deformity preoperatively.³ The image examinations (including the 3D computer tomography, and panoramic radiography) were used in this study. Compared with the surgical findings, we have found that the 3D computer tomography were very helpful methods for evaluation of the type and extent of the ankylosis preoperatively^]

Surgical treatment of TMJ ankylosis is usually the only means of remobilizing the joint. Surgical treatment can be divided into the procedures that enter the ankylotic section to correct the abnormality and ostectomies in sites remote from the ankylotic section. There are different kinds of operations including gap arthroplasty, interpositional arthroplasty, joint reconstruction, and so on, but the results were variable. The gap arthroplasty included condylectomy, resulting in a false joint space. In this report we treated the left TMJ ankylosis with gap arthroplasty.

Recurrence is a major problem after release of TMJankylosis.³ Many factors such as operation methods, patient age, time of medical history, number of cases, and follow-up time can affect the recurrence rate. In the patients of condyle fracture, especially with fragment and disc displacement, in addition to restoring the anatomy of TMJ through operation, it is important to operate early in patients with mouth-opening limitations, and mouth opening exercise as early as possible is necessary. In this report TMJ ankylosis occurred during childhood because of facial trauma. Postoperatively, radiographic images showed that the joint space was clear on left side.

CONCLUSION:

In conclusion, childhood facial trauma is one of the common cause of TMJ ankylosis. Children with long-standing TMJ ankylosis can achieve facial asymmetry and occlusal disharmony because early ankylosis of TMJ can be a deterrent to normal mandibular growth. So the early diagnosis of TMJ ankylosis is important and early surgical intervention is an accepted mode of treatment. The early operation can restore joint function, improve esthetic appearance, and relieve respiratory obstruction.

REFERENCES:

1. Kazanjian VH. Temporomandibular ankylosis. Am J Surg 1955; 90: 905.

2. Laskin DM. Role of the meniscus in the etiology of postraumatic temporomandibular joint ankylosis. Int J Oral Surg 1978;7:340-345.

3. Behcet E, Rezza T, Belgin G. A clinical study on ankylosis of the temporomandibular joint. Journal of Cranio-Maxillofacial Surgery (2006) 34, 100–106

4. Kaban LB, Perrot D, Fisher K. A protocol for management of temporomandibular joint ankylosis. J Oral Maxillofac Surg 1990; 48:1145-1151.

5. Al Kayat A, Bramley P. A modified pre-auricular approach to the temporomandibular joint and malar arch. Br J Oral Surg 1979; 17:91-103.

6. Roychoudhury A, Parkash H, Trikha A: Functional restoration by gap arthroplasty in temporomandibular joint ankylosis: A report of 50 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 87:166, 1999

7. Chidzonga MM: Temporomandibular joint ankylosis: Review of thirty-two cases. Br J Oral Maxillofac Surg 37:123, 1999

8. Sawhney CP: Bony ankylosis of the temporomandibular joint: Follow-up of 70 patients treated with arthroplasty and acrylic spacer interposition. Plast Reconstr Surg 77:29, 1986

9. Goldman JR: Soft tissue trauma, in Kaplan AS, Assael LA (eds). Temporomandibular Disorders Diagnosis and Treatment. Philadelphia, PA, Saunders, 1991, pp 235-236

Received on 30.12.2015 Modified on 19.01.2016

Res. J. Pharmacology & P’dynamics. 8(1): Jan.-Mar., 2016; Page 05-09

DOI: 10.5958/2321-5836.2016.00002.1