An unusual caseof temporomandibular joint ankylosis William E. Davis, M.D.,’ Howard L. Muss&, M.D.,“” James R. Moore, D.D.S.,*** Columbia, MO. UNIVERSITY VETERANS
OF IMISSOURI ADMINISTRATION
AND
HARRY
S TRUMAN
and
MEMORIAL
HOSPITAL
An unusual cause of temporomandibular joint in the therapy of this case are discussed.
ankylosis
is presented.
Various
points
A
nkylosis of the temporomandibular joint results from fibrosis or bony union within the joint structure. A similar condition, referred to as false ankylosis, is due to conditions indirectly associated with the joint, such as infection or trauma, which also result in restriction or lack of mandibular motion. CASE REPORT
A 51-year-old Negro man came to the University of Missouri Otolaryngology Clinic with trismus secondary to pain when he tried to open his mouth. The patient was a poor historian but indicated that the trismus began approximately 3 years previously, after a prolonged period of drinking. The inability to open his mouth had been gradually worsening to the point where he now could not move his mandible and had severe pain upon active attempts at movement. He denied any traumatic episode. He stated that 1 month prior to this clinic visit he was evaluated at another hospital, where radiographs indicated the presence of a foreign object behind the jaw. Physical examination confirmed that he could not move his mandible; nor could it be moved by the examiner. No scars were apparent, and facial expressions indicated that the facial nerve was intact (Fig. 1). Plain radiographs and tomograms confirmed the presence of a foreign body (Figs. 2 and 3). The patient refused to submit to an arteriogram, which would have shown the foreign object’s relationship to major vessels. With the patient under nasotracheal tube general anesthesia, initial exposure and control of the left common carotid artery and left external carotid artery were achieved with place-
“Assistant Professor, Department of Surgery (Otolaryngology), University of Missouri. **Assistant Professor, Department of Surgery (General), University of Missouri. ***Chief of Dental Service, Harry S Truman Memorial Veterans Administration Hospital.
194
Volume 40 Number 2
Temporomandibular
joint
ankylosis
Fig. I. Preoperative view of patient with no visible scars.
Fig. 3. Lateral radiograph showing presence of foreign body.
195
196
on1i SUI’~:. August, 1975
L)avis, JLusseLl, uttd Moore
14g. 3. AI nte infer ,ior to the 23:
bsterior radiograph (atic arch.
Fig. 4. Postoperative
appearance
showing
demonstrating
foreign
body
preauricular
medial
incision
to the
dible
and
and neck incision.
Volume 40 Number 2
Temporomandibular
joint
ankylosis
197
Fig. 5. Specimen removed surgically. ment of polyethylene tapes after an incision was made anterior to the sternocleidomastoid muscle. A preauricular incision was then made to expose the space medial to the zygomatio arch, and the temporalis muscle was entered (Fig. 4). Extensive inflammatory fibrosis had taken place in this space, so that a great deal of the temporalis muscle had to be excised. The foreign body was found hooked under the posterior zygomatic arch at the temporozygomatic suture. One centimeter of zygomatic arch was resected and then, with a dental drill, part of the temporal bone inferior to the zygomatic arch was removed, so that the foreign body could be removed without lacerating the maxillary artery (Figs. 5 and 6). After removal of the foreign body, mandibular movement was still not possible. This was due to the extensive inflammatory reaction in the pterygoid and temporalis muscles. Dystrophic calcification was present in extensive areas of the muscle. Large amounts of temporalis and pterygoid muscle had to be removed. Even after this removal, mandibular movement could not be effected by force and it was thought that ankylosis had occurred in the joint. It was also thought that, since the inflammatory reaction was previously so intense, the ankylosis might recur in the future if fibrotic muscle and condyle remained. A condylectomy was therefore performed. Ivfandibular movement was then achieved but was not maximal. At this time a tracheostomy was also performed to circumvent any postoperative airway emergency. The tracheostomy was removed on the second postoperative day. NO evidence of facial nerve weakness was present. The patient was instructed in passive and active range-of-motion exercises, and his mandibular motion has increased markedly. There is some mandibular drift on opening.
198
Davis, Nussell,
awd Moore
Oral Hurg. August, 1975
Fig. 6. Artist’s conception of foreign-body relationships. Dotted line represents area of temporal bone and zygomatic arch removed. The extent of the dissection was 1 em. lateral to foramen ovale and foramen spinosum.
DISCUSSION
Ankylosis of the temporomandibular joint is usually secondary to trauma. Ankylosis may occur secondary to joint injury (true ankylosis) , or it may occur from extra-articular causes (false ankylosis).2 This case represents false ankylosis, because periarticular fibrosis developed from an inflammatory reaction secondary to the foreign body. This periarticular fibrosis eventually resulted in true ankylosis of the temporomandibular joint. If left untreated, ankylosis may interfere with nutrition, oral hygiene, speech, and proper development of the mandible in children, and sometimes it may cause aspiration. Severe ankylosis of the temporomandibular joint is treated surgically. Condylectomy, osteoarthrotomy, and arthroplasty are the methods used. In this case more than the ankylosis had to be considered. We also had to consider (1) possible internal maxillary artery injury from the foreign body and (2) airway obstruction following anesthesia and during induction. An arteriogram which would have given valuable information concerning the position of the maxillary artery was refused. The carotid arteries were controlled in the neck, in the event
Volume Number
40 2
Tenzporollzandibula,r
joint
a&ylosis
199
that marked bleeding occurred. A tracheostomy was performed for airway control. This was removed without difficulty 2 days later. SUMMARY
An unusual cause of ankylosis of the temporomandibular joint is presented. The treatment plan took into account the potential hazards of major vessel hemorrhage and airway obstruction. The authors
wish to thank
Jane Gordon
of Medical
Illustrations
for
her assistance.
REFERENCES
1. Zegarelli, E. V., Kutscher, A. H., and Hyman, G. A.: Diseases of the Mouth and Jaw, Philadelphia, 1969, Lea & Febiger. 2. Waite, D. E.: Textbook of Practical Oral Surgery, Philadelphia, 1972, Lea & Febiger. Reprint reqzlests to: Dr. William E. Davis Department of Surgery (Otolaryngology) University of Missouri School of Medicine Columbia, Missouri 65201
OF IMISSOURI ADMINISTRATION
AND
HARRY
S TRUMAN
and
MEMORIAL
HOSPITAL
An unusual cause of temporomandibular joint in the therapy of this case are discussed.
ankylosis
is presented.
Various
points
A
nkylosis of the temporomandibular joint results from fibrosis or bony union within the joint structure. A similar condition, referred to as false ankylosis, is due to conditions indirectly associated with the joint, such as infection or trauma, which also result in restriction or lack of mandibular motion. CASE REPORT
A 51-year-old Negro man came to the University of Missouri Otolaryngology Clinic with trismus secondary to pain when he tried to open his mouth. The patient was a poor historian but indicated that the trismus began approximately 3 years previously, after a prolonged period of drinking. The inability to open his mouth had been gradually worsening to the point where he now could not move his mandible and had severe pain upon active attempts at movement. He denied any traumatic episode. He stated that 1 month prior to this clinic visit he was evaluated at another hospital, where radiographs indicated the presence of a foreign object behind the jaw. Physical examination confirmed that he could not move his mandible; nor could it be moved by the examiner. No scars were apparent, and facial expressions indicated that the facial nerve was intact (Fig. 1). Plain radiographs and tomograms confirmed the presence of a foreign body (Figs. 2 and 3). The patient refused to submit to an arteriogram, which would have shown the foreign object’s relationship to major vessels. With the patient under nasotracheal tube general anesthesia, initial exposure and control of the left common carotid artery and left external carotid artery were achieved with place-
“Assistant Professor, Department of Surgery (Otolaryngology), University of Missouri. **Assistant Professor, Department of Surgery (General), University of Missouri. ***Chief of Dental Service, Harry S Truman Memorial Veterans Administration Hospital.
194
Volume 40 Number 2
Temporomandibular
joint
ankylosis
Fig. I. Preoperative view of patient with no visible scars.
Fig. 3. Lateral radiograph showing presence of foreign body.
195
196
on1i SUI’~:. August, 1975
L)avis, JLusseLl, uttd Moore
14g. 3. AI nte infer ,ior to the 23:
bsterior radiograph (atic arch.
Fig. 4. Postoperative
appearance
showing
demonstrating
foreign
body
preauricular
medial
incision
to the
dible
and
and neck incision.
Volume 40 Number 2
Temporomandibular
joint
ankylosis
197
Fig. 5. Specimen removed surgically. ment of polyethylene tapes after an incision was made anterior to the sternocleidomastoid muscle. A preauricular incision was then made to expose the space medial to the zygomatio arch, and the temporalis muscle was entered (Fig. 4). Extensive inflammatory fibrosis had taken place in this space, so that a great deal of the temporalis muscle had to be excised. The foreign body was found hooked under the posterior zygomatic arch at the temporozygomatic suture. One centimeter of zygomatic arch was resected and then, with a dental drill, part of the temporal bone inferior to the zygomatic arch was removed, so that the foreign body could be removed without lacerating the maxillary artery (Figs. 5 and 6). After removal of the foreign body, mandibular movement was still not possible. This was due to the extensive inflammatory reaction in the pterygoid and temporalis muscles. Dystrophic calcification was present in extensive areas of the muscle. Large amounts of temporalis and pterygoid muscle had to be removed. Even after this removal, mandibular movement could not be effected by force and it was thought that ankylosis had occurred in the joint. It was also thought that, since the inflammatory reaction was previously so intense, the ankylosis might recur in the future if fibrotic muscle and condyle remained. A condylectomy was therefore performed. Ivfandibular movement was then achieved but was not maximal. At this time a tracheostomy was also performed to circumvent any postoperative airway emergency. The tracheostomy was removed on the second postoperative day. NO evidence of facial nerve weakness was present. The patient was instructed in passive and active range-of-motion exercises, and his mandibular motion has increased markedly. There is some mandibular drift on opening.
198
Davis, Nussell,
awd Moore
Oral Hurg. August, 1975
Fig. 6. Artist’s conception of foreign-body relationships. Dotted line represents area of temporal bone and zygomatic arch removed. The extent of the dissection was 1 em. lateral to foramen ovale and foramen spinosum.
DISCUSSION
Ankylosis of the temporomandibular joint is usually secondary to trauma. Ankylosis may occur secondary to joint injury (true ankylosis) , or it may occur from extra-articular causes (false ankylosis).2 This case represents false ankylosis, because periarticular fibrosis developed from an inflammatory reaction secondary to the foreign body. This periarticular fibrosis eventually resulted in true ankylosis of the temporomandibular joint. If left untreated, ankylosis may interfere with nutrition, oral hygiene, speech, and proper development of the mandible in children, and sometimes it may cause aspiration. Severe ankylosis of the temporomandibular joint is treated surgically. Condylectomy, osteoarthrotomy, and arthroplasty are the methods used. In this case more than the ankylosis had to be considered. We also had to consider (1) possible internal maxillary artery injury from the foreign body and (2) airway obstruction following anesthesia and during induction. An arteriogram which would have given valuable information concerning the position of the maxillary artery was refused. The carotid arteries were controlled in the neck, in the event
Volume Number
40 2
Tenzporollzandibula,r
joint
a&ylosis
199
that marked bleeding occurred. A tracheostomy was performed for airway control. This was removed without difficulty 2 days later. SUMMARY
An unusual cause of ankylosis of the temporomandibular joint is presented. The treatment plan took into account the potential hazards of major vessel hemorrhage and airway obstruction. The authors
wish to thank
Jane Gordon
of Medical
Illustrations
for
her assistance.
REFERENCES
1. Zegarelli, E. V., Kutscher, A. H., and Hyman, G. A.: Diseases of the Mouth and Jaw, Philadelphia, 1969, Lea & Febiger. 2. Waite, D. E.: Textbook of Practical Oral Surgery, Philadelphia, 1972, Lea & Febiger. Reprint reqzlests to: Dr. William E. Davis Department of Surgery (Otolaryngology) University of Missouri School of Medicine Columbia, Missouri 65201
