Ankylosis of the temporomandibular joint Follow-up of thirteen patients Gabriele Schobel, MD, Werner Millesi, MD, DDS, Ingeborg M. Watzke, MD, DDS, and Karl Hollmann, MD, DDS, Vienna, Austria DEPARTMENT
OF MAXILLOFACIAL
SURGERY,
UNIVERSITY
OF VIENNA
We undertook a postoperative clinical study of 13 patients with ankylosis of the temporomandibular joints. The study consisted of an evaluation of the surgical concepts of resection and subsequent surgical reconstruction by osteotomy in previous height of the joint space and lining of the glenoid fossa with lyophilized dura. Early mobilization and aggressive physiotherapy are mandatory postoperative measures. According to the theory of mandibular growth as a result of functional matrix, early surgical intervention to correct ankylosis should be performed, regardless of the age of the patient, to prevent recurrence and later asymmetry or distoclusion. (ORAL SURC ORAL MED ORAL PATHOL 1992;74:7-14)
0
ur clinical follow-up of 13 patients who had an ankylosis of the temporomandibular joint (TMJ) concentrates on the results after surgical relief. The study consistsof an evaluation of the surgical concept, emphasizing aggressive resection, osteotomy in previous height of the joint space, and lining of the glenoid fossa with lyophilized dura. Early mobilization and aggressive physiotherapies are without doubt as important as the surgical concept. Referring to the theory of mandibular growth as a result of functional matrix, early surgical intervention should be achieved, regardless of the age of the patient, to prevent recurrence and later asymmetry or distoclusion. Ankylosis of the TMJ is a serious complication mainly after trauma and local or systemic infection. ‘, 2 The infection causehas nearly disappearedin the era of antibiotics.3 In rare casesankylosis is associated with systemic disease such as ankylosing spondylitis, rheumatoid arthritis, and psoriasis.2,4 According to the functional restriction and the provoked disturbances of facial growth in the youth, an early and effective therapy is desirable.‘, 5-7 There are a wide variety of surgical approaches to TMJ ankylosis, ranging from chondro-osseousgrafts to polymer glenoid fossa prosthesis.‘, 4,‘, 9-14Nevertheless, the achieved results are similar. One standard surgical concept does not exist.t5 All surgical concepts are as good as the patient’s cooperation and discipline regarding the postoperative phys7/n/35049
iotherapy. Our study proved this but also emphasized that early surgical intervention is essential to the best results.
PATIENTSAND METHODS During the past 16 years, 25 patients were treated for ankylosis of the TMJ at the University Clinic of Maxillofacial Surgery, University of Vienna. Among the 13 patients available for the follow-up studies were four females and nine males (Table I). The average age when the ankylosis occurred was 13 years; the youngest was a neonate, the oldest was 28 years old. The cause of TMJ ankylosis was trauma in 12 cases.One single patient had bilateral ankylosis after birth, from either birth trauma and inflammation, and the cause could not be distinguished. Ankylosis of traumatic origin occurred bilaterally in seven cases and unilaterally in five cases. We were interested in the location of the fractures of the condyle and in the initial treatment. A classification of the causal fractures, depending on the location, was developed (Table I). Fractures of the capitulum occurred at an average age of 81, years in contrast to fractures of the collum (average age 18 years). A dislocated fracture of the condylar neck was present in nine joints, an intra-articular fracture of the condylar head in nine cases,and a fracture of the coronoid processin one case. An analysis of the initial posttraumatic treatment showed that eight patients were treated by intermaxillary splint fixation 7
8 Schobel et al.
ORAL SURGORAL MED ORAL PATHOL
July 1992
Type I
Type II
Type III
Type IV
L
Fig. 1. Grading of ankylosis.
Table I. TMJ ankylosis: Patient data and follow-up
Patient No.
1 2 3 4 5 6 7 8 9 10 11 12 13
Sex
Age (yr) at time of trauma
F
2
M F M M M M M F M M M F
1
4 8 Netmate 4 15 28 20 22 22 17 22
Cause of ankylosis
Fracture of condylar neck Fracture of condylar head Fracture of condylar neck Fracture of condylar head Unknown Fracture of condylar head Fracture of condylar neck Fracture of condylar neck Fracture of condylar head Fracture of coronoid process Fracture of condylar neck Fracture of condylar head Fracture of condylar neck
for 3 weeks. In three cases the trauma was treated on an outpatient basis. Only one patient had gone through a surgical reduction of the condyle initially. No patient had early mobilization or the benefit of aggressive physiotherapy. Each case was screened for the time gap between onset of the ankylosis and the final surgical therapy,
Bilateral
Initial therapy after trauma
Yes Yes No Yes Yes No Yes Yes Yes No Yes Yes No
None Nonsurgical Nonsurgical Nonsurgical Nonsurgical None Nonsurgical None Nonsurgical Nonsurgical Nonsurgical Nonsurgical Surgical
Age fyr) at time of surgical correction
15 10 9 13 3 18 24 29 40 23 23 19 24
for the preoperative maximal incisal opening (MIO), subjective discomfort, and esthetics. The degree of ankylosis was graded according to the types described by Sawhney’ (Fig. l), as follows: Type I: The condylar head was present but deformed. Fibrous adhesions made movement impossible. Type II: There was bony fusion of the misshaped head
Volume 74 Number 1
Ankylosis of the temporomandibular
joint
A = bony ankylosis CH = condylar head ZA = zygomatic arch F = temporalisfascia I = instruments E=ear Fig. 2. Top, Bony massesoverbridging from former condylar head to zygomatic arch. Exploration in deeper aspect of joint revealed fragments of condylar head on medial section conforming with type III ankyloses. Bottom, Schematic representation.
9
10 Schobel et al.
ORAL SURG ORAL MED ORAL PATHOL
July 1992
CH = condylar head P = Pin, not yet in position LD = lyphiliszed dura I = instruments Fig. 3. Left, Pin is used for reduction of traumatically dislocated fragment of condyle. Reshaped glenoid fossa is lined with lyophilized dura. Right, Schematic representation
Group A n = 7 LI GrouD B n = 6 n
P a e
n s
painless
good esthetics
Fig. 4. Criteria of therapeutic success. and the articular surface, which mainly concentrated on the outer edge of the articular surface either anteriorly or posteriorly. The medially located pole of the TMJ remained undamaged. Type III: A bony block was seen to bridge across the ramus of the mandible and the zygomatic arch. Medially an atrophic dislocated fragment of the former head of the condyle was still found. The up-
per articular surface and, in rare cases, the articular disk were intact on the deeper aspect. Type IV: The regular anatomy of the TMJ was totally destroyed by an expanded bony block between the ramus and the skull base. Our study included only ankylosis types III to IV (Fig. 2), except for the newborn infant who had a fibrous ankylosis of unknown genesis. True to biblio-
Ankylosis of the temporomandibular joint
Volume 74 Number 1 n q
i
11
Group A n = 7 Group B n = 6
4
e
n t
3
S
2-
I
Corrective
Asymmetry
Microgenia
RtXUIMlC.?
surgery
Fig. 5. Complications of TMJ ankylosis surgical correction and related therapy.
Fig. 6. Dissection was not done in former height of joint cavity. Therefore pseudoarthrosis occurred. Besides restriction of MIO, this patient also had arteriovenous fistula in region of ramus on left side. graphic data, a standard surgical method for treatment of an ankylosis of the TMJ does not exist.t5 In this study all patients were treated, by removal of the proliferation of the bone and recontouring of the condyle. The reshaped glenoid surface was covered by lyophilized dura. In four cases the fragments of the condyle were stabilized with pins (Fig. 3). In one case the condyle was reconstructed with an autogenous costochondral graft. A coronoidectomy was done with the one patient whose ankylosis originated from a fracture of the coronoid process of the mandible.
Table II. Patient groups according to age at time of trauma
Average age of trauma Average age of recall Preoperative Postoperative
Group A (n = 7)
Group B (n = 6)
(yr) at time
OF MAXILLOFACIAL
SURGERY,
UNIVERSITY
OF VIENNA
We undertook a postoperative clinical study of 13 patients with ankylosis of the temporomandibular joints. The study consisted of an evaluation of the surgical concepts of resection and subsequent surgical reconstruction by osteotomy in previous height of the joint space and lining of the glenoid fossa with lyophilized dura. Early mobilization and aggressive physiotherapy are mandatory postoperative measures. According to the theory of mandibular growth as a result of functional matrix, early surgical intervention to correct ankylosis should be performed, regardless of the age of the patient, to prevent recurrence and later asymmetry or distoclusion. (ORAL SURC ORAL MED ORAL PATHOL 1992;74:7-14)
0
ur clinical follow-up of 13 patients who had an ankylosis of the temporomandibular joint (TMJ) concentrates on the results after surgical relief. The study consistsof an evaluation of the surgical concept, emphasizing aggressive resection, osteotomy in previous height of the joint space, and lining of the glenoid fossa with lyophilized dura. Early mobilization and aggressive physiotherapies are without doubt as important as the surgical concept. Referring to the theory of mandibular growth as a result of functional matrix, early surgical intervention should be achieved, regardless of the age of the patient, to prevent recurrence and later asymmetry or distoclusion. Ankylosis of the TMJ is a serious complication mainly after trauma and local or systemic infection. ‘, 2 The infection causehas nearly disappearedin the era of antibiotics.3 In rare casesankylosis is associated with systemic disease such as ankylosing spondylitis, rheumatoid arthritis, and psoriasis.2,4 According to the functional restriction and the provoked disturbances of facial growth in the youth, an early and effective therapy is desirable.‘, 5-7 There are a wide variety of surgical approaches to TMJ ankylosis, ranging from chondro-osseousgrafts to polymer glenoid fossa prosthesis.‘, 4,‘, 9-14Nevertheless, the achieved results are similar. One standard surgical concept does not exist.t5 All surgical concepts are as good as the patient’s cooperation and discipline regarding the postoperative phys7/n/35049
iotherapy. Our study proved this but also emphasized that early surgical intervention is essential to the best results.
PATIENTSAND METHODS During the past 16 years, 25 patients were treated for ankylosis of the TMJ at the University Clinic of Maxillofacial Surgery, University of Vienna. Among the 13 patients available for the follow-up studies were four females and nine males (Table I). The average age when the ankylosis occurred was 13 years; the youngest was a neonate, the oldest was 28 years old. The cause of TMJ ankylosis was trauma in 12 cases.One single patient had bilateral ankylosis after birth, from either birth trauma and inflammation, and the cause could not be distinguished. Ankylosis of traumatic origin occurred bilaterally in seven cases and unilaterally in five cases. We were interested in the location of the fractures of the condyle and in the initial treatment. A classification of the causal fractures, depending on the location, was developed (Table I). Fractures of the capitulum occurred at an average age of 81, years in contrast to fractures of the collum (average age 18 years). A dislocated fracture of the condylar neck was present in nine joints, an intra-articular fracture of the condylar head in nine cases,and a fracture of the coronoid processin one case. An analysis of the initial posttraumatic treatment showed that eight patients were treated by intermaxillary splint fixation 7
8 Schobel et al.
ORAL SURGORAL MED ORAL PATHOL
July 1992
Type I
Type II
Type III
Type IV
L
Fig. 1. Grading of ankylosis.
Table I. TMJ ankylosis: Patient data and follow-up
Patient No.
1 2 3 4 5 6 7 8 9 10 11 12 13
Sex
Age (yr) at time of trauma
F
2
M F M M M M M F M M M F
1
4 8 Netmate 4 15 28 20 22 22 17 22
Cause of ankylosis
Fracture of condylar neck Fracture of condylar head Fracture of condylar neck Fracture of condylar head Unknown Fracture of condylar head Fracture of condylar neck Fracture of condylar neck Fracture of condylar head Fracture of coronoid process Fracture of condylar neck Fracture of condylar head Fracture of condylar neck
for 3 weeks. In three cases the trauma was treated on an outpatient basis. Only one patient had gone through a surgical reduction of the condyle initially. No patient had early mobilization or the benefit of aggressive physiotherapy. Each case was screened for the time gap between onset of the ankylosis and the final surgical therapy,
Bilateral
Initial therapy after trauma
Yes Yes No Yes Yes No Yes Yes Yes No Yes Yes No
None Nonsurgical Nonsurgical Nonsurgical Nonsurgical None Nonsurgical None Nonsurgical Nonsurgical Nonsurgical Nonsurgical Surgical
Age fyr) at time of surgical correction
15 10 9 13 3 18 24 29 40 23 23 19 24
for the preoperative maximal incisal opening (MIO), subjective discomfort, and esthetics. The degree of ankylosis was graded according to the types described by Sawhney’ (Fig. l), as follows: Type I: The condylar head was present but deformed. Fibrous adhesions made movement impossible. Type II: There was bony fusion of the misshaped head
Volume 74 Number 1
Ankylosis of the temporomandibular
joint
A = bony ankylosis CH = condylar head ZA = zygomatic arch F = temporalisfascia I = instruments E=ear Fig. 2. Top, Bony massesoverbridging from former condylar head to zygomatic arch. Exploration in deeper aspect of joint revealed fragments of condylar head on medial section conforming with type III ankyloses. Bottom, Schematic representation.
9
10 Schobel et al.
ORAL SURG ORAL MED ORAL PATHOL
July 1992
CH = condylar head P = Pin, not yet in position LD = lyphiliszed dura I = instruments Fig. 3. Left, Pin is used for reduction of traumatically dislocated fragment of condyle. Reshaped glenoid fossa is lined with lyophilized dura. Right, Schematic representation
Group A n = 7 LI GrouD B n = 6 n
P a e
n s
painless
good esthetics
Fig. 4. Criteria of therapeutic success. and the articular surface, which mainly concentrated on the outer edge of the articular surface either anteriorly or posteriorly. The medially located pole of the TMJ remained undamaged. Type III: A bony block was seen to bridge across the ramus of the mandible and the zygomatic arch. Medially an atrophic dislocated fragment of the former head of the condyle was still found. The up-
per articular surface and, in rare cases, the articular disk were intact on the deeper aspect. Type IV: The regular anatomy of the TMJ was totally destroyed by an expanded bony block between the ramus and the skull base. Our study included only ankylosis types III to IV (Fig. 2), except for the newborn infant who had a fibrous ankylosis of unknown genesis. True to biblio-
Ankylosis of the temporomandibular joint
Volume 74 Number 1 n q
i
11
Group A n = 7 Group B n = 6
4
e
n t
3
S
2-
I
Corrective
Asymmetry
Microgenia
RtXUIMlC.?
surgery
Fig. 5. Complications of TMJ ankylosis surgical correction and related therapy.
Fig. 6. Dissection was not done in former height of joint cavity. Therefore pseudoarthrosis occurred. Besides restriction of MIO, this patient also had arteriovenous fistula in region of ramus on left side. graphic data, a standard surgical method for treatment of an ankylosis of the TMJ does not exist.t5 In this study all patients were treated, by removal of the proliferation of the bone and recontouring of the condyle. The reshaped glenoid surface was covered by lyophilized dura. In four cases the fragments of the condyle were stabilized with pins (Fig. 3). In one case the condyle was reconstructed with an autogenous costochondral graft. A coronoidectomy was done with the one patient whose ankylosis originated from a fracture of the coronoid process of the mandible.
Table II. Patient groups according to age at time of trauma
Average age of trauma Average age of recall Preoperative Postoperative
Group A (n = 7)
Group B (n = 6)
(yr) at time
