|Year : 2015 | Volume
| Issue : 2 | Page : 166-169
Temporomandibular joint ankylosis in child: A case report
Rahul J Hegde1, Vishakha N Devrukhkar2, Sumedh S Khare1, Tanvi A Saraf1
1 Department of Pediatric and Preventive Dentistry, Bharati Vidyapeeth Dental College and Hospital, Navi Mumbai, Maharashtra, India
2 Department of Oral and Maxillofacial Surgery, Bharati Vidyapeeth Dental College and Hospital, Navi Mumbai, Maharashtra, India
|Date of Web Publication||15-Apr-2015|
Dr. Rahul J Hegde
Department of Pediatric and Preventive Dentistry, Bharati Vidyapeeth Dental College and Hospital, Navi Mumbai - 400 614, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Ankylosis of the temporomandibular joint (TMJ) 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. It is a serious and disabling condition that may cause problems in mastication, digestion, speech, appearance, and hygiene. Case Report: This report describes a case of a 12-year-old girl with inability to open her mouth, diagnosed with unilateral right bony TMJ ankylosis. The surgical approach consisted of gap arthroplasty with interpositional temporalis muscle flap followed by vigorous physiotherapy. Conclusion: The treatment of TMJ ankylosis poses a significant challenge because of technical difficulties and a high incidence of recurrence. Its treatment includes the orthodontist, oral and maxillofacial surgeon, pediatric dentist, and psychologist and physical therapist as part of the healthcare team.
Keywords: Ankylosis, case report, gap arthroplasty, temporomandibular joint
|How to cite this article:|
Hegde RJ, Devrukhkar VN, Khare SS, Saraf TA. Temporomandibular joint ankylosis in child: A case report. J Indian Soc Pedod Prev Dent 2015;33:166-9
|How to cite this URL:|
Hegde RJ, Devrukhkar VN, Khare SS, Saraf TA. Temporomandibular joint ankylosis in child: A case report. J Indian Soc Pedod Prev Dent [serial online] 2015 [cited 2019 Jul 22];33:166-9. Available from: http://www.jisppd.com/text.asp?2015/33/2/166/155136
| Introduction|| |
The temporomandibular joint (TMJ) ankylosis involves fusion of the mandibular condyle to the base of the skull. It is a debilitating condition usually effecting children and young adults. It causes problems in mastication, digestion, speech, appearance, and oral hygiene. In growing patients; it may result in deformities of mandible and maxilla causing malocclusion. Due to the growth deformity, the child may become shy and reclusive and have a low self-esteem. TMJ ankylosis earlier in 1938 was classified into two types by Kazanjian  as intra-articular and extra-articular ankylosis. Present classification includes bony, fibrous, fibro-osseous, complete, and incomplete. ,
In children, unilateral ankylosis of TMJ causes facial asymmetry due to deviation of the chin towards the affected side. The effective treatment of TMJ ankylosis is based on a detailed preoperative radiographic assessment of the type and extent of ankylosis.
A case report of unilateral TMJ ankylosis and its successful management in the early teen years is presented.
| Case Report|| |
A 12-year-old girl, reported to Bharati Vidyapeeth Dental College and Hospital, Navi Mumbai, with a chief complaint of inability to open her mouth. History revealed that the patient had a fall when she was 7-years-old and had a blow on right side of her face. She had pain and swelling on right TMJ area which progressively subsided. However, there was also gradual reduction of mouth opening seen, as a result of which she was unable to eat properly.
The initial clinical examination revealed an obviously hypoplastic mandible with class II dental relationship [Figure 1] and [Figure 2]. Extraoral examination revealed facial asymmetry with fullness of cheek on the right side. There was deviation of chin to right side [Figure 3]. The patient had almost nil mouth opening [Figure 4]. There was no palpable involvement over the right TMJ and only slight rotation on the left side. Radiographic investigation included orthopantomogram and computed tomography (CT) that revealed a lack of structural organization and obliteration of right TMJ space. Based on these finding, a diagnosis of unilateral grade III bony ankylosis of TMJ on right side was confirmed [Figure 5] and [Figure 6].
|Figure 1: Clinical examination revealing facial asymmetry and hypoplastic mandible|
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|Figure 5: CT scan showing lack of structural organization and obliteration of right TMJ space. CT = Computed tomography, TMJ = temporomandibular joint|
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After complete clinical and radiographical evaluation, a surgical treatment of gap arthroplasty with interpositional temporalis muscle flap on right TMJ was planned under general anesthesia. The postoperative course was uneventful. A mouth opening of 25 mm was noted postoperatively. Vigorous postoperative physiotherapy was started to maintain the mobility of the joint. After 2 weeks of physiotherapy using wooden spatula, mouth opening was noted to be 35 mm. Later mouth opening exercises were given by using Hister's mouth gag [Figure 7].
|Figure 7: After 2 weeks of physiotherapy mouth opening was noted to be 35 mm|
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| Discussion|| |
The causes and treatment of TMJ ankylosis have been well-documented,  with trauma and infection identified as the two leading causes.  In general, trauma is the most predominant etiologic factor of TMJ ankylosis. If the cause is trauma, it is hypothesized that intra-articular hematoma, along with scarring and formation of excessive bone, leads to the hypomobility.
In children, TMJ ankylosis can result in mandibular retrognathism with associated esthetic and functional deficits. Therefore, treatment should be initiated as soon as the condition is recognized, with the main objective of reestablishing joint function and harmonious jaw function. ,
Raveh et al.,  presented their retrospective experience with 26 cases of full bony TMJ ankylosis using aggressive bone removal. Aggressive resection, early mobilization, and intensive postoperative physiotherapy will produce satisfactory movement. This technique has some disadvantages as anterior open bite deformity due to removing a massive amount of bone from the ramus and the possibility of damage to internal maxillary artery. Among the advantages of this technique is the very less relapse rate.
A seven-step protocol that has been developed for the treatment of TMJ ankylosis;  (i) aggressive resection of the ankylotic segment, (ii) ipsilateral coronoidectomy, (iii) contralateral coronoidectomy when necessary, (iv) lining of the joint with temporalis fascia or cartilage, (v) reconstruction of the ramus with a costochondral graft (CCG), (vi) rigid fixation of the graft, and (vii) 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 two of 18 joints. 
The above reported case is of complete, bony, unilateral true ankylosis. This was considered to be caused by trauma as the parents presented with a history of fall at 7 years of age. Limited mouth opening was the chief complaint of the patient. Immediate surgical intervention was undertaken, which improved the mouth opening from 1-2 mm to around 35 mm 2 weeks after surgery. It is of prime importance that rigorous physiotherapy is undertaken to further improve the mouth opening and mainly to prevent reankylosis. In this case, simple exercises by use of wooden spatulas were undertaken and Hister's mouth gag appliance was later given, which was found to significantly increase the ease and the degree of mouth opening.
| Conclusion|| |
TMJ ankylosis in children is a challenging problem. Traumatic injury to the TMJ should be considered as a risk for ankylosis in children. A careful surgical technique and meticulous long-term physiotherapy are considered essential to achieve a satisfactory result.  Reankylosis may occur as a result of incomplete or inadequate primary release; reossification or inadequate jaw stretching for any reason. 
| References|| |
Kazanjian VH. Ankylosis of temporomandibular joint. Surg Gynaecol Obstet 1938;67:333-48.
Rowe NL. Ankylosis of the temporomandibular joint. J R Coll Surg Edinb 1982;27:67-79.
Sawhney CP. Bony ankylosis of the temporomandibular joint: Follow-up of 70 patients treated with arthroplasty and acrylic spacer interposition. Plast Reconstr Surg 1986; 77:29-40.
Miller GA, Page HL Jr, Griffith CR. Temporomandibular joint ankylosis: Review of the literature and report of 2 cases of bilateral involvement. J Oral Surg 1975;33:792-803.
Straith CL, Lewis JR Jr. Ankylosis of the temporo-mandibular joint. Plast Reconstr Surg (1946) 1948;3:464-77.
Kaban LB, Perrott DH, Fisher K. A protocol for management of temporomandibular joint ankylosis. J Oral Maxillofac Surg 1990;48:1145-51.
Guyuron B, Lasa CI Jr. Unpredictable growth pattern of costochondral graft. Plast Reconstr Surg 1992; 90:880-6.
Raveh J, Vuillemin T, Ladrach K, Sutter F. Temporomandibular joint ankylosis: Surgical treatment and long-term results. J Oral Maxillofac Surg 1989;47:900-6.
Manganello-Souza LC, Mariani PB. Temporomandibular joint ankylosis: Report of 14 cases. Int J Oral Maxillofac Surg 2003;32:24-9.
Jagannathan M, Munoli AV. Unfavorable results in temporomandibular joint ankylosis surgery. Indian J Plast Surg 2013;46:235-8.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]