Clinical Paper

TMJ Disorders
Reconstruction of ankylosed
temporomandibular joint:
Sternoclavicular grafting as an
approach to management
V. Singh, A. Verma, I. Kumar, A. Bhagol: Reconstruction of ankylosed
temporomandibular joint: Sternoclavicular grafting as an approach to management.
Int. J. Oral Maxillofac. Surg. 2011; 40: 260265. #2010 International Association of
Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
V. Singh
a
, A. Verma
b
, I. Kumar
a
,
A. Bhagol
a
a
Department of Oral and Maxillofacial
Surgery, Govt. Dental College, Post Graduate
Institute of Medical Science, Rohtak 124001,
Haryana, India;
b
Department of Oral and
Maxillofacial Surgery, P.D.M Dental College,
Bahadurgarh, Haryana, India
Abstract. A retrospective analysis of 15 cases of ankylosed temporomandibular joint
(TMJ) reconstructed, with sternoclavicular joint graft (SCG), during the period
20022007 was undertaken. All cases were analyzed for functional adaptation of the
graft, considering maximum interincisal opening, and protrusive and laterotrusive
movement of the jaw. Signicant improvement was noticed in all cases except one,
although maximum improvement was seen 36 months postoperatively.
Radiological evaluation was carried out at regular intervals for 23 years to assess
the anatomical adaptation of the graft. No major postoperative complications were
observed and all the cases showed complete regeneration of the clavicle during
follow up. This nding indicates that reconstruction of ankylosed TMJ with
sternoclavicular joint graft is a satisfactory method of treatment.
Keywords: temporomandibular joint; recon-
struction; ankylosed TMJ; sternoclavicular joint
graft.
Accepted for publication 22 September 2010
Available online 5 November 2010
The temporomandibular joint (TMJ) is a
complicated anatomical structure that is
concerned with mastication, deglution,
speech and head posture
27
. Ankylosis of
the TMJ occurs when the condyle is fused
to fossa by bony or brous tissue
18
. It is an
incapacitating problem, occurring in chil-
dren and commonly associated with
trauma or infection. It can impair mandib-
ular growth and function which may result
in severe facial asymmetry and mandibu-
lar retrusion
23,27
.
The impairment of orofacial function
may include restricted mouth opening,
limited chewing ability, impairment of
speech, compromised oral hygiene,
restricted airway problem and psycholo-
gical stress disrupting family life
1,10,29
.
Although this condition is uncommon in
developed countries, it is common in the
developing world
29
. Preservation of this
joint or construction of an articial one
that functions properly is of prime impor-
tance.
Surgery is the only effective method of
correction to restore and maintain normal
function. Gap arthroplasty, interpositional
arthroplasty and osteotomy across and
excision of the ankylotic mass within
the TMJ have been described. Good func-
tional results can be obtained with gap
arthroplasty if meticulous attention is paid
to postoperative physiotherapy
18,29,31
, but
increased chances of reankylosis and aes-
thetic problems, in the formof deviation of
mouth opening and associated asymmetry,
favor interpositional arthoplasty as the
preferred choice
23,14,18,31
.
A variety of interposition materials
have been used, such as temporalis fascia,
muscles, dermis auricular cartilage, fascia
lata, fat and costochondral graft as auto-
genous materials and non-biological mate-
rial such as methyl methacrylate, silastic,
silicone, and various metals
3,23,4,5,7
9,11,1519,28,29
. The inherent growth (adap-
tive) potential within the cartilage favors
the use of cartilaginous graft as the rst
choice for joint reconstruction among sur-
geons who advocate early surgical correc-
tion of growth deciencies
9
. Traditionally
Int. J. Oral Maxillofac. Surg. 2011; 40: 260265
doi:10.1016/j.ijom.2010.09.023, available online at http://www.sciencedirect.com
0901-5027/030260 +06 $36.00/0 # 2010 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
costochondral graft has been used for
reconstruction of TMJ ankylosis
15,18
, but
continued and harmonious growth follow-
ing rib grafting is the exception rather than
the rule. This may be due to the differ-
ences in the growth characteristics of the
costal cartilage and the condyle. The ster-
noclavicular graft, which has been intro-
duced as a good alternative for
reconstruction in ankylosed patients
9,12,33
, is similar developmentally and
structurally to the TMJ.
The purpose of this retrospective study
is to assess the usefulness of sternoclavi-
cular graft as interposition material in the
reconstruction of the ankylosed TMJ.
Materials and methods
[15] patients with TMJ ankylosis (8 males,
7 females) underwent release of the anky-
losed joint by the senior author, between
May 2002 and March 2007. The age of the
patients ranged from 10 to 18 years. Lim-
ited mouth opening and asymmetry was
the main complaint, while one patient
reported pain around the pre-auricular
region. In most cases traumatic injury
(13) in the chin region and ear infection
(2) was the main etiology (Table 1). Of 15
patients, 13 (7 on the left and 6 on the right
side) required unilateral release and ster-
noclavicular reconstruction, while in 2
patients with bilateral ankylosis, recon-
struction was carried out with sternocla-
vicular grafts (SCGs) and costochondral
grafts (CCGs) simultaneously on each
side.
Preoperative assessment included a
thorough history and physical examina-
tion to determine the cause of ankylosis,
measurement of maximal incisor opening
(MIO), photographs and orthodontic eva-
luation of skeletal pattern, occlusion and
facial symmetry. Assessment of clinical
parameters included mouth opening, lat-
eral excursion, and protrusive movements
at regular follow up. Radiographic analy-
sis included panoramic, cephalograms, CT
scan and a posteroanterior (PA) view of
chest. CT scanning was used to clarify the
status of the TMJ and for outlining the
osseous mass. The PA chest radiograph
was taken to assess the thickness of the
clavicle and any abnormality.
Cephalometric analysis was carried out
using SASSOUNI and SOTEREANOS analysis of
a PA cephalogram
22
. The difference in
length between the two mandibular rami
was assessed by dropping a perpendicular
from the mastoidale to the bigonial line on
each side and measuring the distance
(Fig. 1). Lateral cephalograms were
analyzed pre- and postoperatively to
Reconstruction of ankylosed temporomandibular joint: Sternoclavicular grafting as an approach to management 261
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determine the length of the graft to restore
the height of the ramus and to determine
mandibular growth following grafting.
The condylargonion and condylon
pogonion lengths were measured on the
lateral cephalogram to assess any signi-
cant changes subsequent to grafting
(Fig. 2).
Surgical technique
All the patients were operated on under
general anesthesia with blind or ber-optic
assisted naso-endotracheal intubation. In
all cases, access to the TMJ was by an
ALKAYAT and BRAMLEY incision
2
, using CT
scans as a guide to determine the extent
and dimension of the ankylotic mass.
After exposing the union site, a gap of
1.52 cm was created by removal of a
bony wedge between the roof of the gle-
noid fossa and ramus. In 3 unilateral and 1
bilateral cases, intra oral coronoidectomy
was also performed to achieve desirable
mouth opening.
SCG was harvested from the ipsilateral
side by using supraclavicular incision, 1
2 cm above the clavicle. In female
patients, the incision was kept 12 cm
inferiorly for cosmetic reason. It extends
from the condylar head of SCJ, 810 cm
laterally as described by WOLFORD et al.
33
Muscle attachments and periosteum were
dissected from the superior and medial
aspects of the clavicle. It is essential to
maintain the integrity of the ligamentous
attachment of the articular disc to the head
of the clavicle. The superior half of the
clavicle was used as a graft leaving the
inferior part intact in all cases, noticeably
this was found more adaptable to the
glenoid fossa. The graft was prepared
for insertion after shaping the cartilage
to simulate the head of the condyle ana-
tomically. It is advisable to harvest the
graft after osteoarthrotomy of the anky-
losed bony part has been completed.
The recipient bed was prepared to
receive the graft by decorticating the lat-
eral aspect of the ramus and preparing a
groove wide enough to receive the graft.
Multiple holes were made throughout the
harvested graft for rapid revascularization.
The graft was xed on the lateral aspect of
the ramus using 2.5 mm lag screws
(Fig. 3). A negative suction drain was then
placed in the wound for 2436 h after
obtaining hemostasis.
Physiotherapy was started 1 week post-
operatively and continued for 2 months.
Patients were instructed not to lift any-
thing heavy and to avoid using the arm for
lifting themselves out of bed until 3
months postoperatively. To minimize the
chances of post-surgical fracture of the
clavicle, a gure of eight bandage was
used for 3 months to support the shoulder.
Children were instructed not to ride
bicycles for at least 3 months. Regular
follow up was carried out weekly for a
month, then at 3 month intervals for 1 year
and yearly for the next 3 years.
Results
The study evaluated 15 patients with fol-
low-up checks from 8 months to 3 years
(mean 27.4 months). Facial deformity
associated with ankylosis was found
mostly in those 1520 years of age
(60%). Patients had a preoperative maxi-
mal interincisal opening of 05 mm (mean
2.4 mm) (Fig. 4). Postoperatively, the aver-
age mouth opening achieved immediately
after surgery was 34.9 mm (range 28
39 mm) (Fig. 5). At regular follow up,
every year for 3 years, no reduction in
mouth opening was noted except in one
case in which mouth opening reduced from
38 mm to 5 mm 1 year postoperatively due
to reankylosis. A signicant improvement
was also noted in the protrusive and lateral
excursive movement of the jaw; maximum
improvement was seen 36 months post-
operatively (Table 1).
262 Singh et al.

Fig. 1. Assessment of difference in length of
two mandibular rami.

Fig. 2. Condylargonion and condylon
pogonion length measurement to assess any
signicant changes subsequent to grafting.

Fig. 3. Fixation of graft on lateral aspect of
ramus.

Fig. 4. Preoperative frontal view showing
reduced mouth opening.
Temporary paresis of the frontal branch
of the facial nerve was observed in 6
patients, which resolved at follow up in
the third month. No postoperative bleed-
ing occurred in any of the cases. Wound
infection occurred in one case and parotid
stula occurred in one patient, which was
controlled by antibiotics and an antisialo-
logue. Transient pre-auricular paresthesia
was reported by two patients who recov-
ered within 6 months.
Radiological analysis showed complete
adaptation of the graft. It remodeled to
gain the shape of the condyle and the
glenoid fossa also reformed (Fig. 6). On
radiographic examination, clavicle frac-
ture was observed in 2 cases; complete
regeneration occurred at 1 year follow up
in all cases (Fig. 7).
Discussion
Early ankylosis of TMJ in children can be
a deterrent to normal mandibular growth.
Early diagnosis of TMJ ankylosis and
early surgical intervention are important.
The authors agree with others that onset of
ankylosis of the TMJ usually occurs
before 10 years of age and surgical correc-
tions usually takes place after that
10
.
TOPAZIAN
31
advised use of interposi-
tional arthroplasty instead of gap arthro-
plasty to prevent recurrence.
Condylotomy or gap arthroplasty changes
the mandible to a rst class lever in which
the molar becomes the fulcrum and now
lies anterior to the working force
13
. This
creates an unstable relation where the
mandible is allowed to rotate posteriorly
and upwards and may predispose the
patient to development of an open bite
deformity; moreover shortening of mus-
cles also fails to produce a normal growth.
In order to maintain the class 3 lever,
restorations of reduced ramal height
become essential.
The temporalis muscle ap, a soft tissue
ap, the most commonly used interposi-
tional graft
14,20,24,31,32
; fails to provide
adequate vertical ramal height. The use
of rigid interposition materials prevents
recurrence and restores adequate ramal
height. Both allogenic and autogenous
rigid interposition materials have been
used for reconstruction of the TMJ, but
allogenic materials lack the adaptive
growth potential. Several different growth
Reconstruction of ankylosed temporomandibular joint: Sternoclavicular grafting as an approach to management 263

Fig. 5. Postoperative frontal view showing
increased mouth opening.

Fig. 6. (a) Immediate postoperative OPG showing reconstruction of right side joint with SCG.
(b) OPGat 20 month followup, complete adaptation of graft taking the shape of the condyle with
articular space.

Fig. 7. (a) Radiograph showing donor site
(clavicle) after graft harvesting. (b) Radio-
graph showing complete regeneration of bone
at donor site.
(adaptive) centers have been used to
reconstruct the ankylosed joint
29
. Use of
autogenous materials, such as CCG, cla-
vicular graft, iliac crest and metatarsal
25
,
requires a longer surgical time and pre-
sents a risk of morbidity
18
of the donor
site; however these grafts have advan-
tages, including biocompatibility, adapta-
tion of graft to articular fossa, and
potential growth
14
. The results of these
attempts have not resolved the arguments
over the nature of mandibular growth.
Some authors see the necessity to nd a
replacement for the condylar growth cen-
tre
27
while others see the need to stimu-
late the functional matrix formed by the
soft tissue
29
.
Sir Harold Gillies was the rst to use a
CCG joint for TMJ reconstruction
26
. The
long term results of costochondral grafting
with lengthening of the shortened ramus in
the growing child tend to support the
argument of those who see the condyle
as a site for secondary adaptive and remo-
deling responses to changes in the envel-
oping soft tissue
29
. The efciency of
CCGs in compensating for mandibular
growth defects has been reported. The
greatest problems with CCGs are unpre-
dictability of growth
9,25
, exibility and
elasticity of the bone, warpage with con-
tinuous loading causing occlusal changes
and fracture
18
. This demands careful
handling to avoid splitting and precautions
with immediate mobilization following
grafting. All these problems with most
traditionally used grafts have created a
background of dissatisfaction and
prompted a search for an alternative.
SARNET and LASKIN noted that in humans
the sternoclavicular joint and TMJ are
similar anatomically and physiologically
9
.
These factors have encouraged various
authors to use SCGs in reconstructions
of TMJ ankylosis. The sternoclavicular
articulation has a growth center, and an
interarticular brocartilage articular disc
that simulates the meniscus of the
TMJ
6,9,27
. The good functional outcome
in the present study supports the conclu-
sion that functional motion achieved using
SCG as an interpositional material is as
versatile as that of the TMJ.
ROWE
21
laid down certain criteria for the
restoration of ankylosed TMJ. He empha-
sized the release of ankylosis by cutting
1.52 cm of ankylosed bone, thus achiev-
ing functional articulation with adequate
mouth opening. He noted that lost growth
capability can be restored in young chil-
dren by using an autogenous graft with
growth potential, improving existing
facial deformity. A similar treatment pro-
tocol was followed in the present study
using SCG as an interpositional material.
The graft can be placed on the mandib-
ular ramus in any of the following posi-
tions for reconstruction: lateral aspect,
along the posterior border and on the
medial side
33
. The authors placed the graft
in a decorticated groove on the lateral
surface of the ramus in all cases; for
revascularization and better graft adapta-
tion. The additional advantage was to
compensate for medial placement of the
ramus with respect to the base of the skull
in ankylosis. The graft was xed to the
ramus in all cases by lag screws or posi-
tional screws in the same way as SIEMS-
SEN
25
and WOLFORD et al.
33
WOLFORD et al.
33
stated that the success
rate in patients with a non-Proplast-Teon
(PT) prosthesis or non-inammatory TMJ
pathology was 93% (only 1 failure out of
14 patients). In the present study the suc-
cess rate was 93% (only 1 failure out of 15
patients). The authors agree that the use of
the SCG for TMJ reconstruction must be
reserved for patients who have not had
problems with a TMJ alloplastic PT pros-
thesis or TMJ rheumatoid diseases.
In the present study, all the cases using
the SCG showed complete regeneration of
the clavicle during follow up. Cephalo-
metric data were not available for all
patients, but for those whose data were
available, signicant improvement was
found (Table 2). There was conspicuously
signicant adaptation and remodeling,
which was conrmed by the appearance
of the condyle. Even though facial asym-
metry was improved, the deformity was
not completely corrected in some patients.
Final improvement of facial deformity has
to be corrected by orthognathic surgery for
esthetically better results.
In conclusion, SCG is a satisfactory
method of treatment for reconstructing
ankylosed TMJ in terms of cost, morbidity
and degree of complexity. Adaptive
changes can be assessed easily in terms
of functional and radiographic outcomes
while using SCG as interpositional mate-
rial. Afurther long termprospective trial is
needed to judge the superiority of SCG
over other grafts, especially the CCG,
accurately.
Funding
None.
Competing interests
None declared.
Ethical approval
Not required.
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mandibular joint and malar arch. Br J
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P 0.00 0.03 0.00
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Address:
Department of Oral and Maxillofacial Surgery
Govt
Dental College
Post Graduate Institute of Medical Science
Rohtak 124001
Haryana
India
Tel.: +919896326781
Fax: +91 1262 213876
E-mail: drvirendrasingh1@yahoo.co.in
Reconstruction of ankylosed temporomandibular joint: Sternoclavicular grafting as an approach to management 265