Treatment and management of temporomandibular joint ankylosis-A Review

 

Kiruthika Patturaja¹*, Dr. Karpagam Krishnamoorthy²

¹I BDS, Saveetha Dental College and Hospitals, Saveetha University,162, P.H. Road, Chennai-600077.

²Department of Anatomy, Saveetha Dental College and Hospitals, Saveetha University,162, P.H. Road, Chennai-600077.

 

ABSTRACT:

To review the treatment and postoperative management of temporomandibular joint ankylosis. To correlate the different treatment procedures performed to treat the temporomandibular joint ankylosis. Temporomandibular joint is formed by condylar process of mandible and mandibular fossa in the base of the skull.TMJ is one of the joints of the human body which is more prone to ankylosis. Ankylosis is due to abnormal adhesion and rigidity of bones and joints which may be a result of injury or a disease.Ankylosis of the temporomandibular joint (TMJ) most often results from trauma due to fracture in neck of mandible, congenital because of forceps delivery (during labour) or from infection. Hence, Interpositional arthroplasty followed by physiotherapy has been widely adopted treatment procedure for TMJ ankylosis.

 

 

INTRODUCTION:

The Temporomandibular joint (TMJ) is a bilateral synovial articulation between the mandible and temporal bone .It provides the  jaw movements ^(1). The temporomandibular joint (TMJ) forms the very cornerstone of craniofacial integrity. Ankylosis means” stiff joint” due to bony or fibrous fusion between head of condyle and glenoid fossa  ⁽²⁾ .TMJ ankylosis causes  partial or complete immobilisation of jaw leading to limited  opening of mouth .It may be associated with  trauma ,infection , congenital defects ⁽³⁾ rheumatoid arthritis and psoriasis.TMJ ankylosis causes facial deformities which affects speech, mastication and  appearance.

 

The prevalence of TMJ ankylosis in male to female was found to be 1:9 of age group 10-15 yrs ⁽⁴⁾. The methods for treatment  of TMJ ankylosis are gap arthroplasty (GA), interpositional gap arthroplasty (IPG), reconstruction of  TMJ using a costochondral graft (CCG), and alloplastic joint reconstruction (AJR) ⁽⁵⁾.The treatment of TMJ ankylosis is a major challenge because of its high rate of recurrence ⁽¹⁰⁾. Early diagnosis and treatment of TMJ ankylosis is necessary to avoid worst consequences in future.

 

MATERIALS AND METHODS :

Scholarly articles related to treatment and management of  temporomandibular joint ankylosis were explored in web . When narrowed down the  search to peer reviewed indexed journals 17 articles were collected and referred  from the year  1994 to 2015 . As per the articles they mostly consists of case reports revolving around  the etiology, type, treatment and management of TMJ ankylosis. The aim of this review is to analyse which treatment procedure is preferred widely and beneficial for treating TMJ ankylosis.

RESULTS:

Author and year	Age/sex	Etiology and Diagnosis	Type of ankylosis	Treatment	Post operative Course
Das UM ,2009 (2)	4 yrs/male	Trauma. Inability to open the mouth	complete, bony, unilateral true ankylosis	Gap arthroplasty	Improved mouth opening to about 16mm.
Rishiraj B, 2001 (6)	12yr /male	Congenital.Hypoplastic right mandible, shift of mandibular midline towards right,minimal opening of mouth	bony ankylosis of the right TMJ with bilateral elongation of the coronoid processes.	Right gap arthroplasty and coronoidectomy	Interincisal opening increased to 35mm  and good jaw movement.
Zu ̈htu ̈ Demir 2001(7)	22yrs/female	Unknown.difficulty with speech, mastication, or oralhygiene.de- creased ramus height and an anterior open bite.	Bilateral tmj ankylosis	Arthroplasty and preserved costal cartilage homograft	No evidence of recurrence , no difficulty with speech, mastication, or oral hygiene.
Hassan SS 2013 (14)	28-years/male	Trauma. Difficulty in mouth opening	Complete bilateral  tmj ankylosis	Coronoidectomy, interpositional grafts and condylar prosthesis	Mouth opening increased to 29 mm.
Hegde RJ 2015(8)	12yrs/female	Trauma.Facial assymetry towards right side ,hypoplastic mandible.Inability to open the mouth	Unilateral tmj ankylosis on right side	interpositional arthroplasty of temporalis muscle flap	Mouth opening improved to 35mm
Shetty p 2014 (9)	5yrs/male	Trauma.Reduction in mouth opening and inability to protrude the mandible.	unilateral ankylosis	coronoidectomy and costochondral graft replacement	Improved mouth opening
Vibhute PJ 2011. (10)	20yrs/female	inability to open mouth, restricted jaw movement, and poor esthetics	Unilateral tmj ankylosis on right side	gap arthroplasty and interpositioning of temporalis graft	Mouth opening and aesthetics were improved
Shashikiran N D 2005 (11)	6yrs/female	Trauma.mouth opening was reduced (10mm).	Bilateral tmj ankylosis	Interpositional arthroplasty with temporalis graft	Mouth opening      ( greater than 30mm)
Sharma A. 2016(12)	47yrs/female	Trauma.facial asymmetry and limitation of mouth opening.	Unilateral tmj ankylosis	Gap arthroplasty and distractor	Improved facial symmetry and mouth opening maintained
Yew CC 2015 (13)	3yrs /femAle	Infection.limited mouth opening.	Unilateral left tmj ankylosis.	Interpositional arthroplasty of temporalis flap	Mouth opening was reduced and under review

 

 

DISCUSSION :

The main cause for TMJ ankylosis is trauma in most of the cases ^{(2, 8,9)}. Roychoudhury et al studied 50 patients and found that trauma was the cause of ankylosis in 86% of the cases ⁽¹⁵⁾.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, lysis of adhesions of the pterygoid space during exploration for a foreign body, autogenous CCG and free vascularized whole-joint transplants ⁽⁶⁾.

 

Gap arthroplasty involves the removal of ankylotic bone.It is preferred treatment because of its shorter operating time and simplicity .It has been associated with the disadvantage of recurrence⁽¹³⁾ . There has been improved mouth opening to about 16mm postoperatively  in patient unable to open the mouth due to ankylosis ⁽²⁾. Gap arthroplasty combined with intraoral distractor was used to correct fibrous type ankylosis ⁽¹²⁾.

 

Studies show  that use of Interpositional autogenous or alloplastic materials prevents the recurrence of ankylosis  and recorded maximum interincisal opening of about  30-35mm ^(8,11). Autogenous material with temporalis flap is less bulky, aesthetic advantage ⁽¹³⁾ adequate blood supply and resilient⁽¹⁴⁾ . There are drawback of morbidity at the donor site and unpredictable resorption when autogenous material is used ;the risk of a foreign body reaction ⁽³⁾ and  wear at articular surfaces when alloplastic material is used ⁽¹⁶⁾.

 

Costochondral graft offers several advantages, including biologic and anatomic similarity to the mandibular condyle, low morbidity of the donor site, ease in obtaining and adapting the graft, and regenerative potential in the growing child ⁽⁶⁾.The disadvantage includes resorption, fracture and donor site morbidity ⁽¹⁷⁾. Preserved homologous costal cartilage grafts for the treatment of TMJ ankylosis has been encouraging. The technique seems to be an time- saving, effective, and simple alternative to other methods of joint reconstruction in adults. ⁽⁷⁾

 

The treatment of TMJ ankylosis involves diagnosis, surgical intervention, elaborate resection followed by aggressive physiotherapy to promote harmonious jaw function. Orthodontic treatment  may be  required post physiotherapy to stabilise occlusion and restore dentition to maintain good oral hygiene.

 

CONCLUSION:

Restoring the function of mandible affected by TMJ ankylosis is very important. The most preferred treatment of choice for TMJ ankylosis is interpositional arthroplasty with autogenous or alloplastic materials in most of the cases reviewed  due to its efficiency  in preventing recurrence,  maximal incisal opening and articular function. Therefore, immediate treatment is necessary to promote proper growth and prevent reankylosis of TMJ.

 

REFERENCES:

1.   https://en.m.wikipedia.org/wiki/Temporomandibular_joint

2.   Das U M, Keerthi R, Ashwin D P, Venkata Subramanian R, Reddy D, Shiggaon N. Ankylosis of temporomandibular joint in children. J Indian Soc Pedod Prev Dent 2009;27:116-20 DOI: 10.4103/0970-4388.55338

3.   Valentini, Valentino; Vetrano, Stefano ;Agrillo, Alessandro ; Torroni, Andrea ; Fabiani, Francesco ; Iannetti, Giorgio. Surgical Treatment of TMJ Ankylosis: Our Experience (60 Cases). Journal of Craniofacial Surgery: January 2002 - Volume 13 - Issue 1 - pp 59-67

4.   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;3(1):25-30. doi:10.4103/0975-5950.102146.

5.   E.A. Al-MoraissiT.M,  El-Sharkawy R.M, Mounair T.I,  El-Ghareeb. A systematic review and meta-analysis of the clinical outcomes for various surgical modalities in the management of temporomandibular joint ankylosis. International Journal of Oral and Maxillofacial Surgery, Volume 44, Issue 4, Pages 470-482.

6.   Bob Rishiraj, Leland R. McFadden. Treatment of Temporomandibular Joint Ankylosis: A Case Report. J Can Dent Assoc 2001; 67(11):659-63

7.   Zu ̈htu ̈ Demir et al. Preserved Costal Cartilage Homograft Application for the Treatment of Temporomandibular Joint Ankylosis. Research gate. August 2001 Impact Factor: 2.99 · DOI: 10.109l7/00006534-200107000-00008 · Source: PubMed

8.   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

9.   Shetty P, Thomas A, Sowmya B. Diagnosis of temporomandibular joint (TMJ) ankylosis in children. J Indian Soc Pedod Prev Dent 2014;32:266-70

10.           Vibhute PJ,  Bhola N,Borle RMTMJ Ankylosis: Multidisciplinary Approach of Treatment for Dentofacial Enhancement-A Case Report. Case report in dentistry. 2011;2011:187580. doi: 10.1155/2011/187580

11.           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

12.           Sharma A ,Paeng JY, Yamada T , Kwon TG. Simultaneous gap arthroplasty and intraoral distraction and secondary contouring surgery for unilateral temporomandibular joint ankylosis. Maxillofac Plast Reconstr Surg. 2016 Mar 3;38(1):12. eCollection 2016

13.           Ching Ching Yew, Shaifulizan Ab Rahman, and Mohammad Khursheed Alam. Temporomandibular joint ankylosis in a child: an unusual case with delayed surgical intervention. BMC Pediatr. 2015 Nov 6;15:169. doi: 10.1186/s12887-015-0495

14.           Hassan SS, Rai M. Treatment of Long Standing Bilateral Temporomandibular Joint Ankylosis with Condylar Prosthesis. Journal of Maxillofacial and Oral Surgery. 2013;12(3):343-347. doi:10.1007/s12663-010-0105-9.

15.           Roychoudhury A, Parkash H, Trikha A. Functional restoration by gap arthrosplasty in temporomandibular joint ankylosis: A report of 50 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:166-9. 

16.           Vasconcelos BCE, Bessa-Nogueira RV, Cypriano RV. Treatment of tempo-romandibular joint ankylosis by gap arthroplasty. Med Oral Patol Oral CirBucal 2006;11:E66-9.

17.           Wolford,L.M. Et al. Sternoclavicular grafts for temporomandibular joint reconstruction. J. Oral Maxillofac. Surg. 52: 119, 1994.

 

 

 

Accepted on 02.07.2016           © RJPT All right reserved

Research J. Pharm. and Tech 2016; 9(10):1668-1670.