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Journal of Cranio-Maxillofacial Surgery (2006) 34, 100106 r 2005 European Association for Cranio-Maxillofacial Surgery doi:10.1016/j.jcms.2005.07.008, available online at http://www.sciencedirect.com

A clinical study on ankylosis of the temporomandibular joint$

RGU N Behc et EROL, Rezzan TANRIKULU, Belgin GO Department of Oral and Maxillofacial Surgery (Chairman; Prof. B. EROL), Faculty of Dentistry, University of Dicle, Diyarbakir, Turkey

SUMMARY. Introduction: Restoration of normal function and jaw movement in patients with temporomandibular joint (TMJ) ankylosis is difcult. Various techniques have been dened for the treatment of the condition. Patients: This study is based on the pre-, intra- and post-operative evaluation of 78 TMJ operations in 59 patients who were treated for TMJ ankylosis between 1985 and 2002. Methods: The patients in this study were evaluated with regard to age, gender, aetiology of ankylosis, ankylosis type/classication, existing facial asymmetry, maximal pre- and post-operative mouth opening, the arthroplasty methods (gap and interpositional arthroplasty) including complications and recurrence of ankylosis. Results: Falls represented the most widespread aetiological factor (85%), and women constituted the group with the highest incidence of ankylosis (61%). Forty cases were unilateral (68%) and 19 bilateral (32%); 82% (64 joints) were of the bony type. Gap arthroplasty was applied in 34 of the 59 cases (58%) and interpositional arthroplasty in the remaining 25 (42%). Pre- and post-operative mean mouth opening were 3.571.7 and 30.773.0 mm, respectively. Re-ankylosis was noted in 5%. Conclusion: In addition to radical and sufcient resection of the ankylosed bone, early postoperative exercises, appropriate physiotherapy and close follow-up of the patient play an important role in the prevention of post-operative adhesions and re-ankylosis. r 2005 European Association for Cranio-Maxillofacial Surgery

Keywords: TMJ ankylosis; gap arthroplasty; interpositional arthroplasty

INTRODUCTION Temporomandibular joint (TMJ) ankylosis is an important joint disorder which can result from trauma, or as a result of local and systemic infections (Sawhney, 1986; Kaban et al., 1990; MangenolloSouza and Mariani, 2003; Toyama et al., 2003). While modern antibiotic treatment has reduced the incidence, ankylosing spondylitis, rheumatoid arthritis and psoriasis may also lead to TMJ ankylosis, albeit rarely (Faerber et al., 1990; Kaban et al., 1990). The hypothesis has been proposed that in cases caused by trauma, intra-articular haematoma, scarring and excessive bone formation give rise to hypomobility (Kaban et al., 1990; Toyama et al., 2003). The majority of infections which give rise to ankylosis are secondary resulting from the spread of mastoiditis and otitis media (Kaban et al., 1990). However, it can also develop as the result of tuberculosis, gonorrhoea and scarlet fever by the haematogenous route (Kaban et al., 1990). Restoration of normal function and jaw mobility in patients with TMJ ankylosis is difcult. Various techniques have been dened for its treatment (Dattilo et al., 1986; Nwoku and Kekere-Ekun, 1986; Kaban et al., 1990; Schobel et al., 1992; Lata and Kapila, 2004; Matsuura et al., 2001; Ortak et al., 2001;
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Su-Gwan, 2001; Hong et al., 2002; Meyer, 2002; Lei, 2002; Piero et al., 2002; Saeed et al., 2002; Valentini et al., 2002; Mangenollo-Souza and Mariani, 2003; Gu ven, 2004; Karaca et al., 2004; Qudah et al., 2005). In addition, failures and variable results following the different methods employed have been reported (Dattilo et al., 1986; Kaban et al., 1990). According to the theory of functional matrix and mandibular development, early surgical intervention must be applied, no matter what the age of the patient, in order to prevent recurrence and the subsequent emergence of unilateral retrusion and asymmetry (Kaban et al., 1990). The most frequently encountered complication in the post-operative period is restriction in jaw mobility and recurrence of ankylosis (Kaban et al., 1990). This study is intended to report experience gained in operating 78 ankylotic TMJs on 59 patients for ankylosis in whom arthroplasty was performed. It also emphasizes the need for a radical and sufciently wide resection of ankylosed bone to avoid recurrence.

PATIENTS AND METHODS This study is based on the pre-, intra- and postoperative evaluation of 59 patients who presented with TMJ ankylosis between 1985 and 2002, and on whom arthroplasties were performed.
100

Review of 78 arthroplasties in 59 patients

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The patients were evaluated with history, physical, and radiological examinations (panoramic, bilateral joint radiographs and coronal and axial CTs). Also specically recorded were age, gender, aetiology of ankylosis, existing facial asymmetry, maximal preand post-operative mouth opening and complications encountered. The criteria listed for cases with facial asymmetry were age at the time of trauma, the interval between trauma and development of ankylosis, and the interval between age at operation and age 18 years (when mandibular development is thought to be completed). In addition, patients masticatory abilities and mouth opening have been subjected to functional analysis. Surgically the pre-auricular approach was preferred in all cases. Gap arthroplasty was applied to one group, soft tissue or costochondral graft and interpositional arthroplasty to the other group of cases. The surgical protocol for TMJ ankylosis was as follows: 1 Resection of ankylosed bone. 2 Ipsilateral and contralateral coronoidectomy or coronoidotomy when necessary. 3 Interposition of soft tissue (temporal muscle and fascia ap), or of a costochondral graft (especially in children) to the TMJ area. Costochondral grafts in cases with bilateral ankylosis (children or adults) and in children it permission was given for unilateral ankylosis (to enable further development of the mandible). 4 Early mobilization and aggressive physiotherapy to the tolerated limit. Whenever possible, physiotherapy was initiated for most cases on day 3 post-operatively. In all cases, active physiotherapy was started 5 days post-operatively and continued over a period of 3 months. However, if malocclusion had been observed and a chostochondral graft applied, maxillomandibular xation was applied for 3 weeks. All cases were followed-up for at least 1 year. Patients were divided into 4 groups according to trauma and age of operation (110, 1115, 1618 and over 18). Patients were also divided into 3 groups according to pre-operative mouth opening and the average post-operative maximal interincisal opening was calculated for all of the last 3 groups. The Sawhney criteria were taken as the basis of ankylosis type and classication (Sawhney, 1986): Type I: The condylar head present but deformed. Fibrous adhesions make movement impossible.

Type II: Bony fusion of misshaped head and articular surface, mainly concentrated on outer edge of articular surface either anteriorly or posteriorly. The medially located pole of the TMJ remained undamaged. Type III: A bony block bridging from ascending ramus of the mandible to the zygomatic arch. Medially atrophic and dislocated fragment of the former head of the condyle still to be found. The upper articular surface and, in rare cases, the articular disc were intact medially. Type IV: Regular anatomy of TMJ totally destroyed by an expanded bony block between ramus and skull base.

RESULTS Fifty-nine out of 71 cases operated on for TMJ ankylosis were included in this study. The other 12 cases were not operated on for various reasons, such as oeconomic problems, refusal of surgery or the recommendation of mechanotherapy, and hence were excluded from the study. Aetiology and gender There were 36 female (61%) and 23 male (39%) patients. Aetiologically, falls were reported in 50 cases (85%), 3 cases of rheumatoid arthritis, 2 of otitis media, and 1 case each of landslide, trafc accident, birth forceps trauma. In several cases there was no known cause. Age Patients were divided into 4 groups according to (A) age at trauma and (B) age at surgery (Table 1). Average ages at the time of trauma were 8.475.2 (between 0 and 25 years) and at the time of surgery 1876.4 (between 7 and 40 years). (A) Group 1 with an age at the time of trauma of 010 years (mean 6.4 years) comprised 45 patients (76%). Average age in group 2 (1115 years) was 13.4 years, 16.5 in group 3 (1618 years) and 22 years in the over-18 group. (B) A total of 14 patients (24%) were operated on at age 712 years, 10 patients (17%) at age 1315

Table 1 Age distributions at the time of trauma (A) and at surgical treatment (B) (A) According to time of trauma Age at time of trauma (years) 010 1115 1618 418 Total Average age (years) 6.4 13.4 16.5 22 8.4 Patients (number) 45 7 4 3 59 % 76 12 7 5 100 (B) According to time of surgery Age at time of surgical correction (years) 712 1315 1618 418 Total Average age (years) 10.4 12.1 17.2 18.9 18.0 Patients (number) 14 10 12 23 59 % 24 17 20 39 100

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years, 12 patients (20%) at age 1618 years and 23 patients (39%) over-18 years (Table 1).

Pre-operative ndings There was deviation of the mandible to one side in 52 (88%) of the 59 cases of TMJ ankylosis. A bird-face appearance (serious deformity) existed in 6 of the 59 cases, and mandibular retrognathia (less serious deformity) of varying degrees in 8. In 2 of the cases with a bird-face and in 2 of the 8 cases of retrognathic appearance, there was an additional asymmetry to the left. There was no facial deformity in 7 cases who were 18 years or older at the time of trauma. Radiologically, destruction of the mandibular head in non-ankylosed joints was seen in 12 of the 59 cases, 2 of which had bird-face appearances. The oral ndings in cases with no mouth opening or mouth opening of only a few millimetres included considerable tooth decay, together with supragingival and subgingival calculus and gingivitis. There was no history of initial treatment (fracture treatment) in the early post-traumatic period in any case. Location and classication of the 78 ankylosed TMJs A total of 40 cases (68%) were unilaterally, and 19 (32%) were bilaterally affected. Of the unilateral cases, 24 (41%) were left-sided, and 16 (27%) rightsided (Table 2). Bony ankylosis was present in 64 (82%) of the 78 TMJs, and brous ankylosis (type I), according to Sawhneys classication in 14 (18%). A total of 16 of the bony ankylosis were type II, 34 were type III, and 14 type IV (Table 3). Methods of arthroplasty and recurrences Distinction of the different anatomical units was impossible radiologically or intra-operatively as the
Table 2 Distribution of TMJ ankylosis according to location Location Unilateral Left Right Bilateral Total Number of patients 40 24 16 19 59 % 68 41 27 32 100 Number of joints 40 24 16 38 78 % 51 31 20 49 100

64 ankylosed joints were fused to the temporal bone with a dense mass of bone along the condyle and the glenoid fossa. For that reason the term ostectomy was preferred to condylectomy. Patients were divided into two groups, according to the treatment applied. Gap arthroplasty was applied in 34 of the 59 cases (58%; Fig. 1). Ostectomy and interpositional arthroplasty using autogenous material was employed in the other 25 cases (42%). In 10 (40%) of these 25 cases a costochondral graft was used to reconstruct the condyle and to restore the height of the ramus (Fig. 2). Soft tissue aps were interposed in the other 15 (60%) cases (Fig. 3). Interpositional arthroplasties were located on the right in 9 of the 25 cases, in 7 on the left, and in the other 9 bilaterally (Table 4). Re-ankylosis was observed in 3 (5%) bilateral cases of the 34 (58%) in whom gap arthroplasty had been used.

Fig. 1 Pre- and post-operative panoramic radiographs of unilateral TMJ ankylosis treated with gap arthroplasty.

Table 3 Classication of ankylosis according to Sawhney (1986) Types of ankylosis Type I (brous) Type II Type III Type IV Total Number of joints 14 16 34 14 78 % 18 20 44 18 100 Fig. 2 Costochondral grafts used for reconstruction of condyle.

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Pre-operative and post-operative mouth opening Average pre-operative mouth opening in the 59 cases was 3.571.7 mm. They were divided into 3 groups according to mouth opening; in 27 cases (46%) there was no mouth opening at all; in 15 (25%) the mean pre-operative maximal mouth opening was 3.7 mm (range 15 mm), and 6.9 mm (range 615 mm) in 17 (29%) cases. Cases were also divided into 3 groups according to post-operative mouth opening: 2032 mm (group 1), 3340 mm (group 2) and 41 mm and over (group 3; Table 5). Average post-operative maximal interincisal opening was 27.5 mm in the 39 cases (66%) of group 1, 36.2 mm in the 18 cases (31%) of group 2, and 43.5 mm in the 2 cases (3%) of group 3. Average post-operative maximal interincisal opening was 30.773.0 mm in the 59 cases (Table 5).

It was noticed that both masticatory and joint functions were corrected in the wake of improved post-operative mouth opening, and all patients were pleased (Fig. 4). Seven of the 59 cases diagnosed as TMJ ankylosis and operated on at this clinic had previously been operated on at other centres, but had presented to this clinic due to re-ankylosis. Post-operative complications and follow-up In all 78 joints, the pre-auricular approach was preferred, and no aesthetic problem was encountered post-operativelly in any case. Temporary and mild degree facial nerve paresis continuing for 24 weeks post-operatively was observed in 10 cases, a mild degree of open bite existed in 5 of these cases (Table 6). There was no permanent facial nerve damage. Obvious facial asymmetry in the post-operative period was the most important sequel (but not a complication) encountered in cases with ankylosis, which had started in childhood and early adolescence. Freys syndrome was noted 3 years post-operatively in 1 case of bilateral ankylosis, and recurrence of ankylosis in three bilateral cases. All patients were followed-up for at least 1 year, the longest follow-up period being 15 years. Facial asymmetry was most evident when the patients had been much younger than 18 years at the time of trauma or operation. Mandibular growth insufciency due to trauma at an early age was observed especially in patients in the 014 age group. Different intervals between trauma and surgery led either to severe (long time period) or only mild facial deformity (short time period).

Table 5 Grouping of cases according to pre- (A) and postoperative mouth opening (B) (A) Distance (mm) (pre-op.) Group I: 0 mm Group II: 15 Group III: 615 Total Mean (mm) 0 3.7 6.9 3.571.7 Number of pts. % 27 46 15 25 17 29 59 100 Number of pts. % 39 66 18 31 2 3 59 100

Fig. 3 Interposition of soft tissue (temporalis muscle) ap used in treating ankylosis.

(B) Distance (mm) (post-op.) Mean (mm) Group I: 2032 27.5 Group II: 3340 36.2 Group III: 441 43.5 Total 30.773.0

Table 4 Types of arthroplasty Treatment Gap A+Phy IP A+Phy Total Right (no. of pts. and %) 8 (14%) 9 (15%) 17 (29%) Left (no. of pts. and %) 13 (22%) 7 (12%) 20 (34%) Bilateral (no. of pts. and %) 13 (22%) 9 (15%) 22 (37%) Total (no. of pts. and %) 34 (58%) 25 (42%) 59 (100%)

A: Arthroplasty, IP: Interpositional, Phy: Physiotherapy

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Fig. 4 Pre- and post-operative interincisal opening.

Table 6 Post-operative complications in 59 cases Complications Temporary paresis of facial nerve Open-bite Re-ankylosis Freys syndrome Total Number of cases 10 5 3 1 19

DISCUSSION Pathological conditions concerning the TMJ are similar to those in other joints of the body. They result in damage to the articular surface and facial asymmetry in children and young adolescents (Laskin, 1993). Ankylosis, developing in childhood or the early stages of development is a joint disorder which results in major facial deformity, and is most commonly due to trauma (Nwoku and Kekere-Ekun, 1986; Sawhney, 1986; Kaban et al., 1990; Piero et al., 2002; Mangenollo-Souza and Mariani, 2003). The loss of mandibular function and major dento-facial sequelae cause various psycho-social problems. For that reason, the study and correction of TMJ ankylosis are important.

Early and effective treatment to repair function and facial development is therefore desirable (Sawhney, 1986; Enlow, 1990; Schobel et al., 1992). There are many reported surgical procedures like chondroosseous grafts and glenoid fossa polymer prostheses (Sawhney, 1986; Faerber et al., 1990; Gu ven, 2004). There is no standard concept for treatment, but general agreement that patient cooperation and postoperative physiotherapy are important (Schobel et al., 1992). Schobel et al. (1992) stressed in their study on 13 patients that they did not adopt this discipline but that early surgical intervention was essential for good results. Trauma was the cause in 12 of their 13 cases and had occurred at an average age of 13 years; ankylosis was bilateral in 7 and unilateral in 6, of those. Apart from a neonate, the ankylosis had consisted only of types III and IV ankylosis (Schobel et al., 1992). Kaban et al. (1990) recommended aggressive resection and physiotherapy, early mobilization, ipsilateral coronoidectomy and, if necessary, coronoidectomy of the opposite side. The application of temporal fascia or cartilage to the arthroplasty zone and reconstruction of the ramus using a costochondral graft are among the other methods that these authors recommended. Many researchers have also stressed the importance of early mobilization and aggressive physiotherapy for successful treatment (Sawhney, 1986; Kaban et al., 1990; Su-Gwan, 2001). Frequently applied surgical methods for TMJ ankylosis are: gap arthroplasty, interpositional arthroplasty, and reconstruction of the joint using autogenous or alloplastic materials (Kummoona, 1986; Kaban et al., 1990; Schobel et al., 1992; Feinerman and Piecuch, 1993; Matsuura et al., 2001; Su-Gwan, 2001; Karaca et al., 2004). In contrast to such disadvantages as shortening of the ramus and increased recurrence rates following gap arthroplasty, complications such as donor site morbidity and foreign body reaction in cases of alloplastic material have been reported following interpositional arthroplasty (Kaban et al., 1990; Feinerman and Piecuch, 1993; Piero et al., 2002). Intraoral distraction osteogenesis and autogenous bone grafts can be used for adjustment of secondary post-operative deformities (Dattilo et al., 1986; Kummoona, 1986; Lindqvist et al., 1986; Erol et al., 1999; Hong et al., 2002; Piero et al., 2002). Lindqvist et al. (1986) obtained an average maximal interincisal opening of 30.05 mm following costochondral grafts in 27 cases, and Munro et al. (1986) reported maximal interincisal opening of more than 35 mm in 3 (18%) out of 17 cases. Whatever the technique employed, it has been reported that an average incisal opening of more than 35 mm is rare. In most studies maximal incisal opening has been grouped into 1020 mm, 2030 mm or more than 30 mm, and the percentage of patients with an interincisal opening of more than 30 mm has been reported to be between 10% and 81%, with a recurrence rate of 0100% (Kaban et al., 1990). However, Kaban et al. (1990) stated that in their own

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series of 14 cases, maximal incisal opening was greater than 35 mm. The post-operative maximal interincisal opening obtained (mean: 30.7 mm) is similar to the results in the literature. This is true in each of the 3 groups (Table 5), classied into 2032 mm it was 27.5 mm (mean) for those between 33 and 40 mm it was 36.2 (mean) and for those greater than 41 mm it was 43.5 (mean). A maximal interincisal opening 612 months postoperatively that was lower than the opening obtained intra-operatively was interpreted as an indication of recurrence. The use of chondro-osseous iliac bone, costochondral graft, metatarsal, metatarsophalangeal, clavicular and sternoclavicular joints, muscle, fascia, auricular cartilage and dermis as autogenous interpositional arthroplasty materials intended for TMJ reconstruction have been reported (Kummoona, 1986; Lindqvist et al., 1986; Lei, 2002). Lindqvist et al. (1986) reported that costochondral grafts had been the preferred method in their clinic since 1969. Raveh et al. (1989) had used lyophilized cartilage in 20 out of 26 cases of TMJ ankylosis, and Schobel et al. (1992) had applied lyophilized dura to the glenoid fossa. Lyophilized dura is not currently used in some countries due to the risks of transmissable diseases. The nding that trauma was the cause in 88% of TMJ ankylosis is similar to the data of Schobel et al. (1992). The 5% incidence of recurrence in this study may be regarded as low when compared with other reported results (0100%). Alloplastic interpositional arthroplasty materials (silastic, acrylic, etc.) were not utilized in this series to avoid foreign body reactions; plus their xation to the arthroplasty region are still the subject of debate; Valentini et al. (2002) reported that in 5 cases they removed silastic as it had induced the formation of foreign body granulomas. Gap and interpositional arthroplasties had only little different effects on outcome (Erol, 1993). Despite there being no standard surgical concept in TMJ ankylosis surgery, a sufcient wide surgical exposure, a sufcient and radical resection, early mobilization, aggressive physiotherapy and good cooperation from the patient are widely regarded as factors positively inuencing success (Yoon and Kim, 2002; Mercuri and Auspach, 2003). These factors were also important in the series of patients reported in this study, helping to prevent post-operative adhesions and recurrence of ankylosis. In unilateral ankylosis in particular, resection of the ankylosed bone in a sufciently radical manner and appropriate physiotherapy can prevent recurrence. Despite a small number of cases, the results noted during an 18-month follow-up of 2 girls aged 10 and 11 years in whom the condyles were reconstructed with costochondral grafts support the view that this method is very satisfactory in preventing facial asymmetry and providing a functional articulation (Erol et al., 1999).

CONCLUSION This study is based on the pre-, intra- and postoperative evaluation of 78 TMJ operations in 59 patients. A total of 34 cases (58%) were treated by gap arthroplasty and in the remaining 25 cases (42%) interpositional arthroplasties were used. Pre- and post-operative mean mouth openings were 3.571.7 and 30.773.0 mm, respectively. Radical and sufcient resection of the ankylosed bone, early post-operative exercises, appropriate physiotherapy and close follow-up of the patient play important roles in the prevention of postoperative adhesions and re-ankylosis. References
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Dr. Rezzan TANRIKULU niversitesi Dicle U Dis i Faku -hekimlig ltesi 21280 Diyarbakir, Tu rkiye Tel.: +90 2488101 06 Fax: +90 41222 88198 E-mail: rezzantanrikulu@hotmail.com Paper received 17 July 2003 Accepted 13 July 2005