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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 13  |  Issue : 2  |  Page : 80-83

Management of unilateral temporomandibular joint ankylosis with facial asymmetry


Department of Oral and Maxillofacial Surgery, SRM Dental College, Chennai, Tamil Nadu, India

Date of Submission07-Feb-2022
Date of Decision06-May-2022
Date of Acceptance07-May-2022
Date of Web Publication20-Jun-2022

Correspondence Address:
Dr. Sasikala Balasubramanian
Reader Department of Oral and Maxillofacial Surgery, SRM Dental College, Ramapuram, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/srmjrds.srmjrds_24_22

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  Abstract 

Long-standing temporomandibular joint (TMJ) ankylosis may compromise facial form and function. Treatment planning needs to address both the ankylosis and the facial deformity. A 21-year-old male patient with unilateral TMJ ankylosis of the right side with gross facial asymmetry was planned for a two-stage surgical procedure. First-stage surgery was done to release fibrous ankylosis, create a new functional joint and achieve adequate mouth opening. A vertical ramus osteotomy with superior repositioning of the proximal ramal segment and interpositional temporalis myofascial flap was done to achieve a functional joint and correct the facial height discrepancy. As the mouth opening was <35 mm, ipsilateral coronoidectomy was done and the resected coronoid process was used a graft in the mandibular angle region. 35 mm of mouth opening was achieved intraoperatively.

Keywords: Facial deformity, temporomandibular joint ankylosis, vertical ramus osteotomy


How to cite this article:
Sharma AK, Balasubramanian S, Raghavan SL, Singh SS, Krishnakumar Raja V B. Management of unilateral temporomandibular joint ankylosis with facial asymmetry. SRM J Res Dent Sci 2022;13:80-3

How to cite this URL:
Sharma AK, Balasubramanian S, Raghavan SL, Singh SS, Krishnakumar Raja V B. Management of unilateral temporomandibular joint ankylosis with facial asymmetry. SRM J Res Dent Sci [serial online] 2022 [cited 2022 Jul 3];13:80-3. Available from: https://www.srmjrds.in/text.asp?2022/13/2/80/347814


  Introduction Top


Temporomandibular joint (TMJ) ankylosis is defined as bony or fibrous adhesion of the anatomic joint components accompanied by a limitation in opening the mouth, causing difficulties with mastication, speech and oral hygiene as well as inadvertently influencing mandibular growth.[1] It can be classified as fibrous or bony ankylosis and unilateral or bilateral. The most common etiology is trauma and infection.[1] In unilateral ankylosis, mandibular growth on the affected side is restricted, while growth on the contralateral side remains normal. This disproportionate growth gives rise to an obvious facial deformity. The commonly observed findings of unilateral ankylosis are restricted mouth opening, reduced vertical facial height on the affected side and deviation of the chin toward the affected side.

In this case report, a case of unilateral TMJ ankylosis with dentofacial deformity treated by release of ankylosis and extraoral vertical ramus osteotomy (EVRO) as first-stage intervention has been discussed.


  Case Report Top


A 21-year-old male patient reported to our unit with restricted mouth opening since childhood and facial asymmetry. The patient also gave a history of snoring.

On examination, restricted mouth opening was noticed (16 mm) when measured from the upper incisal edge to the lower incisal edge [Figure 1]. Gross facial asymmetry, decreased vertical ramus height, fullness of the face, deviation of chin toward the right side, hypoplastic mandible, elongated and flattened face on the left side, maxillary cant, and convex facial profile were observed [Figure 2]a. On palpation, the right side exhibited weak condylar movement and a prominent antegonial notch. Bilateral Angle's class 2 malocclusion and upper and lower anterior crowding were present.
Figure 1: Preoperative mouth opening

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Figure 2: (a) Preoperative frontal view (b)postoperative frontal view

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Orthopantomograph showed an abnormal joint morphology, an elongated coronoid process and a prominent antegonial notch on the right side. The contralateral side was normal [Figure 3]a. Computed tomography (CT) with three-dimensional reconstruction showed fibrous ankylosis on the right side extending in both anteroposterior and mediolateral direction. Diagnosis was made as Sawhney's type-1 TMJ ankylosis on the right side with a secondary facial deformity.
Figure 3: (a) Preoperative POG (b) postoperative OPG.

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Under general anesthesia, fiberoptic assisted endotracheal nasal intubation was done. On the right side, Al-Kayat and Bramley preauricular incision was made. Layer-wise surgical dissection was done to expose the temporalis fascia, 45° angulation incision was made on temporalis fascia from the root of zygomatic arch toward the anterosuperior corner of the flap and further dissection was done to expose the fibrous ankylotic mass. Osteotomy cut was made on the ankylotic mass from the base of the sigmoid notch to the posterior border using 702 bur and osteotome and the ankylotic mass was removed. Coronoidectomy was performed on the right side through the same preauricular incision as the mouth opening was <35 mm. Condylar movement was checked and mouth opening of 35 mm was achieved intraoperatively. Submandibular incision was made and layer-wise dissection was done to expose the ramus and angle. A surgical template was used as a guide for EVRO that extended from the sigmoid notch to the lower border of the mandible. The osteotomized proximal segment was mobilized 1 cm superiorly with simultaneous inferior distraction of the distal segment. The resected coronoid graft was reshaped and fixed in the space created by the superior movement of the proximal segment at the angle region with miniplates [Figure 4]. IMF was done maintaining the interocclusal gap bilaterally. EVRO site fixation was done using miniplates. Inferiorly based pedicled temporalis myofascial flap was harvested and brought under zygomatic arch and interposed between the glenoid fossa and condylar head. The flap was sutured anteriorly and posteriorly to the adjacent tissue using 3-0 vicryl. The preauricular and submandibular incisions were closed in layers. The postoperative physiotherapy was started from the first postoperative day using Heister's mouth gag and ice cream sticks to maintain a satisfactory mouth opening. The patient was followed for 6 months. Mouth opening by the end of 6 months was 32 mm [Figure 2]b and [Figure 5]. Postoperative OPG is shown in figure 3b. Postoperatively, improvement was seen in mouth opening as well as facial asymmetry.
Figure 4: Osteotomy site and coronoid graft fixation with miniplates

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Figure 5: Postoperative mouth opening

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  Discussion Top


While the options for the treatment of unilateral ankylosis are diverse, it is complicated by associated dentofacial deformity, retrognathic mandible, and airway obstruction.[2] Disproportionate growth of the maxilla and mandible bilaterally leads to facial deformity. Due to the lack of uniformity in the treatment protocol, careful planning of treatment is needed.[2] Treatment protocols can be single or multistage. In single-stage surgery, both joint ankylosis and facial deformities are addressed simultaneously. Multistage surgery focuses on releasing the ankylosis, orthodontic intervention and correction of facial deformity in various stages.[2] Single-stage surgery is more satisfactory and cost-effective for the patient, while staged procedure gives a more stable and better surgical outcome. Both single-stage and multistage treatment protocols had favorable results with their own advantages and disadvantages.[3],[4],[5],[6] Single-stage surgery may be indicated for mild to moderate cases whereas multistage surgery is recommended for severe cases. Anchlia et al. conducted a study on single-stage correction for TMJ ankylosis, including two groups; inverted L osteotomy and vertical sliding of posterior part of mandibular ramus was done in one group of patients, this created a space between the ramus and angle which was filled with autogenous coronoid graft.[7] Vertical ramus osteotomy and vertical sliding of posterior part of mandibular ramus were done, in cases of prominent antigonial notch and the excess bone was removed from angle region. This avoids complications associated with donor site and prevents bone resorption, causing lesser decrease in height of mandibular ramus and mouth opening deviation.[7] Previous surgeries and clinical experiments have shown resorption of coronoid process graft, especially in adults, but this tendency stabilizes with time without any obvious malocclusion. In this study, resected coronoid was used as a graft along the inferior border at the angle region to maintain the vertical ramus height in the posterior region. Vertical ramus osteotomy along with the reconstruction of the ramus condylar unit has also been done.[8] This can also be achieved by transport distraction of the ramus condylar unit after “L” osteotomy in posterior ramus.[9] The advantages of DO are no donor site morbidity and graft resorption.[8],[9] In our technique, EVRO and interpositional arthroplasty was done to increase the posterior ramal height and the ipsilateral coronoid was used as a graft in the angle region, which helped by improving the facial deformity and achieving a mouth opening of 35 mm.


  Conclusion Top


Treatment protocol should be tailor-made and individualized for the patient based on the nature of tissue involved in ankylosis, age of the patient, extent of ankylotic mass, degree of facial deformity, availability of the surgical skills, patient's expectation, and affordability.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sporniak-Tutak K, Janiszewska-Olszowska J, Kowalczyk R. Management of temporomandibular ankylosis-compromise or individualization – A literature review. Med Sci Monit 2011;17:A111-6.  Back to cited text no. 1
    
2.
Zhu S, Wang D, Yin Q, Hu J. Treatment guidelines for temporomandibular joint ankylosis with secondary dentofacial deformities in adults. J Craniomaxillofac Surg 2013;41:e117-27.  Back to cited text no. 2
    
3.
Zhu S, Li J, Luo E, Feng G, Ma Y, Hu J. Two-stage treatment protocol for management of temporomandibular joint ankylosis with secondary deformities in adults: Our institution's experience. J Oral Maxillofac Surg 2011;69:e565-72.  Back to cited text no. 3
    
4.
Li J, Zhu S, Wang T, Luo E, Xiao L, Hu J. Staged treatment of temporomandibular joint ankylosis with micrognathia using mandibular osteodistraction and advancement genioplasty. J Oral Maxillofac Surg 2012;70:2884-92.  Back to cited text no. 4
    
5.
Zhang XH, Yang C, Fang B, Chen MJ, Wu Y, Wang BL. Simultaneous costochondral graft and distraction osteogenesis in unilateral TMJ ankylosis associated with mandibular retrognathia and asymmetry. J Craniofac Surg 2012;23:682-4.  Back to cited text no. 5
    
6.
Zhu S, Jiang Y, Pokhrel N, Hu J. Simultaneous correction of temporomandibular joint ankylosis and secondary dentofacial deformities in adult patients: Surgical technique, treatment outcomes, and a consideration of the factors involved. J Craniofac Surg 2015;26:2351-6.  Back to cited text no. 6
    
7.
Anchlia S, Vyas SM, Dayatar RG, Domadia HL, Nagavadiya V. Guidelines for single-stage correction of TMJ ankylosis, facial asymmetry and OSA in adults. J Maxillofac Oral Surg 2019;18:419-27.  Back to cited text no. 7
    
8.
Parmar BS, Garg B, Mehta RD, Midha A, Thakkar DK. Ramus condyle unit reconstruction using vertical ramus osteotomy in temporomandibular joint ankylosis. J Maxillofac Oral Surg 2015;14:630-6.  Back to cited text no. 8
    
9.
Schwartz HC. Transport distraction osteogenesis for reconstruction of the ramus-condyle unit of the temporomandibular joint: Surgical technique. J Oral Maxillofac Surg 2009;67:2197-200.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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