|Year : 2009 | Volume
| Issue : 2 | Page : 116-120
Ankylosis of temporomandibular joint in children
UM Das, R Keerthi, DP Ashwin, R VenkataSubramanian, D Reddy, N Shiggaon
Department of Pedodontics and Preventive Dentistry and Department of Oral and Maxillofacial Surgery, V. S. Dental College and Hospital, Bangalore, Karnataka, India
|Date of Web Publication||31-Aug-2009|
U M Das
Department of Pedodontics and Preventive Dentistry, V. S. Dental College and Hospital, V. V Puram, K. R Road, Bangalore, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Temporomandibular joint (TMJ) ankylosis or hypomobility involves fusion of the mandibular condyle to the base of the skull. It is a major clinical problem that affects many patients suffering from facial trauma, infection, or systemic disease. The treatment of TMJ ankylosis poses a significant challenge because of technical difficulties and a high incidence of recurrence. Case Report: This report describes a case of a 4-year-old boy with inability to open mouth, diagnosed with unilateral right bony TMJ ankylosis. The surgical approach consisted of gap arthroplasty followed by vigorous physiotherapy. Conclusion: A detailed history, clinical and functional examination, radiographic examination facilitating correct diagnosis followed by immediate surgical intervention, and physiotherapy can help us to restore physical, psychological, and emotional health of the child patient.
Keywords: Bony ankylosis, gap arthroplasty, temporomanbibular joint
|How to cite this article:|
Das U M, Keerthi R, Ashwin D P, VenkataSubramanian R, Reddy D, Shiggaon N. Ankylosis of temporomandibular joint in children. J Indian Soc Pedod Prev Dent 2009;27:116-20
|How to cite this URL:|
Das U M, Keerthi R, Ashwin D P, VenkataSubramanian R, Reddy D, Shiggaon N. Ankylosis of temporomandibular joint in children. J Indian Soc Pedod Prev Dent [serial online] 2009 [cited 2016 Sep 26];27:116-20. Available from: http://www.jisppd.com/text.asp?2009/27/2/116/55338
| Introduction|| |
Ankylosis is a Greek terminology meaning "stiff joint." It can be defined as " inability to open mouth due to either a fibrous or bony union between the head of the condyle and glenoid fossa."  Temporomandibular joint (TMJ) ankylosis is a disorder that leads to a restriction of the mouth opening from partial reduction to complete immobility of the jaw. It is most commonly associated with trauma (13-100%), local or systemic infection (0-53%), or systemic disease, such as ankylosing spondylitis, rheumatoid arthritis, or psoriasis. ,
Although TMJ ankylosis is one of the most common pathologies afflicting the facial skeleton, it is also the most overlooked and undermanaged problem in children.  Impairment of speech, difficulty with mastication, poor oral hygiene, rampant caries, disturbances of facial and mandibular growth, malocclusion, and acute compromise of airway, etc. present a unique challenge to pediatric dentists in terms of the patient's physical and psychological management. 
This paper describes a case of unilateral bony ankylosis of TMJ causing problems in mastication, speech, appearance, and hygiene in a 4-year-old child.
| Case Report|| |
A 4-year-old boy reported with the complaint of inability to open mouth since 1 year. History revealed that he had a fall from the cradle and got injury on the face and back of his head 2 years back for which treatment was done. No bleeding from mouth or face was noted at the time of injury. Parents recognized the inability to open mouth only after the child started with solid diet. The child was then taken to a local doctor, and was referred to Department of Pedodontics and Preventive Dentistry, V. S Dental College and Hospital, Bangalore, for further evaluation and treatment planning. Extra oral examination revealed facial asymmetry with fullness of cheek on the right side [Figure 1]. Mandible was micrognathic and some ulceration was seen behind pinna. The child showed almost nil mouth opening [Figure 2].
Radiographic examinations comprised of orthopantomogram and computerized tomography that revealed a lack of structural organization and obliteration of right TMJ space [Figure 3]. Based on these findings, a diagnosis of unilateral right bony TMJ ankylosis was confirmed.
A sequential protocol for the treatment of TMJ ankylosis is based on aggressive resection of ankylotic mass. While resecting, a special approach has to be directed particularly from the medial aspect of the joint which is in close proximity with internal maxillary artery to ensure that bony, fibrous, and granulation tissues are completely removed.
After complete evaluation, a surgical treatment with gap arthroplasty on right TMJ was planned under general anesthesia. Gap arthroplasty is a term used to describe the operation in which a section of bone is removed and no substance is interposed between the two cut bony surfaces
The surgical approach consisted of alkayat and bramley preauricular incision. Full thickness mucoperiosteal flap was reflected and the ankylotic mass was exposed [Figure 4].
The section consisted of two horizontal osteotomy cuts which were placed at the level of joint (below the zygomatic arch) and removal of a bony wedge was done so that a gap is created between the roof of the glenoid fossa and ramus [Figure 5]. It is not possible to remove the entire block in toto; hence, the bone was removed carefully by using surgical burs until the bone is thinned which was then removed using chisel or osteotome [Figure 6].
The joint cavity was then irrigated with betadine, and the bony margins were smoothed using bone file. Forceful mouth opening of about 25 mm was done using Heister's jaw opener at the time of surgery. Suction drain was placed, and the flap was sutured using 3-0 vicryl for deeper layers and skin was closed using 4-0 prolene.
The width of the bone removal is considered crucial. It is recommended to create a gap of at least 1 cm to prevent reankylosis. It is also important to create a gap of equal dimension both laterally and medially, so that the possibility of reankylosis due to bone contact is avoided.
The post-operative course was uneventful. A mouth opening of 12 mm was noted 2 days after surgery. Vigorous post-operative physiotherapy was started to maintain the mobility of the joint. After 5 days with physiotherapy using wooden spatula, mouth opening was noted to be 16 mm [Figure 7]. Later mouth opening exercises using Shekarrapa's appliance was started. The patient was instructed to continue with exercises using Shekarrapa's appliance for at least a period of 1 year.
| Discussion|| |
Ankylosis of the TMJ involves fusion of the mandibular condyle to the base of the skull. When it occurs in a child, it can have devastating effects on the future growth and development of the jaws and teeth. It also has a profoundly negative influence on the psychosocial development of the patient, because of the obvious facial deformity, which worsens with growth. 
TMJ ankylosis may be classified according to the site (intra or extra-articular), type of tissue involved (bony, fibrous or fibro-osseous tissue), and the degree of fusion (complete or incomplete). , It was also classified by Kazanjian  as either true or false. True ankylosis is a condition that results in osseous or 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.
The most common etiological factors are trauma and infection.  If the cause is trauma, it is hypothesized that intra-articular hematoma, along with scarring and formation of excessive bone, leads to the hypomobility. Infection of the TMJ most commonly occurs secondary to contiguous spread from otitis media or mastoiditis, but it may also result from hematogenous spread of infectious conditions such as tuberculosis, gonorrhea, or scarlet fever. Systemic causes of TMJ ankylosis include ankylosing spondylitis, rheumatoid arthritis, and psoriasis. 
Su-Gwan  studied seven operated patients and found that trauma was the main cause of ankylosis (85.7%). Roychoudhury et al ,  studied 50 patients and found that trauma was the cause of ankylosis in 86% of the cases.
A variety of techniques for the treatment of TMJ ankylosis have been described including intraoral coronoidectomy, ramus osteotomy, high condylectomy, forceful opening of the jaw under general anesthesia, autogenous Costochondral graft (CCG  ), and free vascularized whole-joint transplants.  In addition, several prosthetic options for TMJ reconstruction exist, including Silastic sheeting material (Vitek Inc., Houston, TX, USA), the TMJ condylar prosthesis, custom glenoid fossa implants, articular eminence implants, and mandibular reconstruction plates with condylar heads. 
TMJ ankylosis treatment throughout the world suggest early surgical intervention, elaborate resection, early mobilization, and aggressive physiotherapy for atleast 6 months postoperatively. ,,
A 7-step protocol that has been developed for the treatment of TMJ ankylosis is:  (1) aggressive resection of the ankylotic segment, (2) ipsilateral coronoidectomy, (3) contralateral coronoidectomy when necessary, (4) lining of the joint with temporalis fascia or cartilage, (5) reconstruction of the ramus with a CCG, (6) rigid fixation of the graft, and (7) early mobilization and aggressive physiotherapy. With this protocol, Kaban and others  achieved a mean maximum postoperative interincisal opening at 1 year of 37.5 mm, with lateral excursions present in 16 of 18 joints and pain present in 2 of 18 joints. 
In children, TMJ ankylosis results in impaired mandibular growth and mandibular retrognathism. These problems have functional and esthetic implications, as well as difficulties pertaining to nutrition and oral hygiene. 
Treatment should be initiated as soon as the condition is recognized, with the main objective of re-establishing joint function and harmonious jaw function. , Therefore, immediate treatment is necessary to promote proper growth and function of mandible and to facilitate the positive psychological development of the child.
The case reported above is of complete, bony, unilateral true ankylosis. This was considered to be caused by trauma in early childhood as the parents presented with a history of fall at 2 years of age. Limited mouth opening was not noticed until then thereby confirming the probability of trauma in causing ankylosis. Here, the above-mentioned treatment protocol formed the basis of the treatment plan that was undertaken in this patient, except for coronoidectomy, and also, the joint was not lined with temporalis fascia or cartilage or reconstructed with CCG. Immediate surgical intervention was undertaken which improved the mouth opening of the child from 1-2 mm to around 16 mm 1 week after surgery.
It is of prime importance that rigorous physiotherapy is undertaken to further improve mouth opening and mainly to prevent re-ankylosis. In this case, simple chewing gum exercises were started on the second day after surgery followed by use of wooden spatulas and Shekarrapa's appliance which was found to significantly increase the ease and the degree of mouth opening.
| Conclusion|| |
Any pathology that afflicts the TMJ and restricts the mouth opening carries a mental stigma that overweighs the physical disability posed by the problem in growing children. Such children are psychologically handicapped and hence call for a unique approach toward their rehabilitation. Every pediatric dentist or every dentist who treats children is in a unique position to help such children physically as well as psychologically.  A detailed history, clinical and functional examination, radiographic examination facilitating correct diagnosis followed by immediate surgical intervention, and physiotherapy can help us to restore physical, psychological, and emotional health of the child patient.
| Acknowledgements|| |
The authors thank Dr Suma, Dr Chandan, Dr Shakthi Singh, and Dr Anup for their help and support.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
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