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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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CASE REPORT
Year : 2005  |  Volume : 23  |  Issue : 1  |  Page : 35-37
 

Management of temporo-mandibular joint ankylosis in growing children


Department of Pedodontics and Preventive Dentistry, College of Dental Sciences, Davangere, India

Correspondence Address:
N D Shashikiran
Department of Pedodontics and Preventive Dentistry, College of Dental Sciences, Davangere
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.16025

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   Abstract 

Although temporo-mandibular joint (TMJ) ankylosis is one of the most common pathologies afflicting the facial skeleton, it is also the most overlooked and under-managed problem in children. The TMJ forms the very cornerstone of cranio-facial integrity and hence its ankylosis in growing children adversely affects the growth and development of the jaws and occlusion. Impairment of speech, difficulty in mastication, poor oral hygiene, rampant caries and acute compromise of the airway pose a severe psychologic burden on the tender minds of children. The aim of this article is to present an overview of efficient management strategies, based on a case report, so as to increase its awareness among all dental surgeons involved in the treatment of children.


Keywords: Condylar injury, Fibre-optic intubation, inter-positional arthroplasty, TMJ, ankylosis


How to cite this article:
Shashikiran N D, Reddy SV, Patil R, Yavagal G. Management of temporo-mandibular joint ankylosis in growing children. J Indian Soc Pedod Prev Dent 2005;23:35-7

How to cite this URL:
Shashikiran N D, Reddy SV, Patil R, Yavagal G. Management of temporo-mandibular joint ankylosis in growing children. J Indian Soc Pedod Prev Dent [serial online] 2005 [cited 2017 Jul 23];23:35-7. Available from: http://www.jisppd.com/text.asp?2005/23/1/35/16025


Ankylosis is a Greek terminology meaning 'stiff joint'.[1] It can be defined as "inability to open mouth due to either a fibrous or bony union between the head of the condyle and the glenoid fossa". Because of immobility of the joint, the jaw function gets affected. Due to better understanding of the management of condylar fractures, and also due to the decreased incidence of middle ear infections following the introduction of antibiotics, the incidence of temporo-mandibular joint (TMJ) ankylosis is decreasing in the west. However, in India the incidence of TMJ ankylosis is still high, and the onset is believed to be before the age of 10.[1]

Although TMJ ankylosis is one of the most common pathologies afflicting the facial skeleton, it is also the most over-looked and under-managed problem in children.[2] Ankylosis in children is a serious and disabling condition. Impairment of speech, difficulty with mastication, poor oral hygiene, rampant caries, disturbances of facial and mandibular growth, malocclusion and acute compromise of the airway, etc. present a unique challenge to pediatric dentists in terms of the patient's physical and psychological management.[3] TMJ ankylosis can be classified into various types [Table - 1][1] and the etiology is varied [Table - 2].[1]

Clinical features of TMJ ankylosis in childhood

  • Restricted mouth opening and its associated sequelae including poor oral hygiene and rampant caries.
  • Facial asymmetry
  • Mandibular micrognathia and bird face deformity
  • Class II malocclusion with posterior cross bite / anterior open bite.





   Case Report Top


A 6 year old child reported with the complaint of inability to open her mouth wide [Figure - 1]. History revealed that she had an episode of trauma to her chin due to a trivial fall during play time. She developed swelling infront of both her ear's subsequent to the trauma, which resolved in due course of time. After the resolution of swelling, her mouth opening started reducing gradually, for which she consulted a local doctor who seemingly missed the diagnosis and could only prescribe some pain-killing medications. When she was examined at our center, her mouth opening was as little as 10mm. She sported an old scar on her chin and her temperomandibular joints were tender on palpation. Though the condyles were not palpable, there was no apparent deviation of the mandible. However, she was showing signs of retrognathism and a budding bird-face deformity. Radiographic evaluation comprised of an orthopantomogram [Figure - 2] and a lateral cephalogram which revealed deformity of condylar heads and obliteration of the joint space. Based on all these findings, a diagnosis of TMJ ankylosis secondary to bilateral sub-condylar fracture was confirmed.

After complete evaluation a bilateral TMJ arthroplasty with interposing temporalis muscle graft was done under general anaesthesia. The patient was intubated using a fibre-optic microscope, which is the recent technique of choice in patients who present with trismus. A Popowich modification of Alkayat and Bramley preauricular incision was employed. After exposing the joint space, an arthrotomy cut was given at the level of the sigmoid notch to remove the fractured condylar heads. A temporalis graft was harvested [Figure - 3] and sutured to the medial pterygoid muscle [Figure - 4] to act as an interposing sling. A mouth opening of >30 mm was achieved immediate postoperatively [Figure - 5]. The child then received oral physiotherapy to maintain the optimum results, she has now regained her beaming smile and is relishing her favourite foods with enthusiasm.




   Discussion Top


TMJ ankylosis protocols throughout the world suggest early surgical intervention, elaborate resection, early mobilization and aggressive physiotherapy for at least 6 months postoperatively.[1],[3]

In the present case both the child and her parents were provided comprehensive psychological rehabilitation before, during and after the surgical intervention. The child was made to realize that she was as normal as any other child of her age and she would soon regain her ability to throw a wide-open heartly smile. The parents were similarly motivated and encouraged to prepare their child for surgery.

On the surgical front, the team comprised of three pediatric dentists, an oral and maxillofacial surgeon and an pediatric anaesthetist. Fibre-optic intubation was contemplated as it is the technique of choice in children with trismus who cannot be intubated orally. TMJ arthroplasty followed by temporalis muscle interposing was planned.

The popowich modification of the Alkayat Bramley incision was selected keeping in mind the functional and cosmetic demands of the child.[1],[4],[5] The condylar heads were sacrificed to prevent reankylosis in growing years, in accordance with recent evidence which suggests that condyles are not the primary determinants of mandibular growth.[6]-[8] A temporalis sling was used as it is the technique of choice for lining the glenoid fossa and is a good interposing material to permit adaptive growth in children.[1],[4],[9] The child was finally subjected to aggressive physiotherapy to optimize the achieved results.

A timely gift from childrens smile architects!

It is said that a child learns to explore the world through his mouth! Any pathology that afflicts the TMJ and restricts the mouth opening, hence carries a mental stigma, that outweighs the physical disability posed by the problem in growing children. Such children are psychologically handicapped and hence call for a unique approach towards their rehabilitation. TMJ ankylosis, not only hinders the integrity of the cranio-facial skeleton, but also affects the normal growth and development of jaws and occlusion.[2] Every pediatric dentist, or every dentist who treats children is in a unique position to help such patients psychologically as well as physically. Speech aberrancies, poor oral hygiene, rampant caries and behavioural problem pose unique challenges to such dentists.[3],[5] But, the pure joy and satisfaction that is derived after treating such children is unparalled.

 
   References Top

1.Malik NA. Text book of Oral and Maxillofacial Surgery, 1st Ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.; 2002. p. 207-18.  Back to cited text no. 1    
2.Dimitroulis G. Condylar injuries in growing patients. Aust Dent 1997;42:367-71.  Back to cited text no. 2  [PUBMED]  
3.Chidzonga MM. Temporomandibular joint ankylosis: Review of thirty two cases. Br J Oral Maxillofac Surg 1999;37:123-6.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Brusati R, Raffaini M, Sesenna E, Bozzetti A. The Temporalis Muscle flap in Temporomandibular Joint Surgery. Cranio Max Fac Surg 1990;18:352-8.  Back to cited text no. 4  [PUBMED]  
5.Manganello-Souza LC, Mariani PB. Temporomandibular joint ankylosis; Report of 14 cases. Int J Oral Maxillofac Surg 2003;32:24-9.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Available at www.tambcd.edu/bms/Carlson-RPI.pdf. Accessed Nov 5th 2004.  Back to cited text no. 6    
7.Available at www.cwru.edu/dental/web/facial growth/ textbook, Chapter 4. html. Accessed Nov 5th 2004.  Back to cited text no. 7    
8.Available at www.beautifullastingsmiles.com/does FACIAL_WJR.pdf. Accessed Nov 5th 2004.  Back to cited text no. 8    
9.Su-Gwan K. Treatment of temporomandibular joint ankylosis with temporalis muscle and fascia flap. Int J Oral Maxillofac Surg 2001;30:189-93.  Back to cited text no. 9  [PUBMED]  


Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]

Tables

[Table - 1], [Table - 2]


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