9 Inter Positional Arthroplasty by Using Temporalis Facia and Muscle for TMJ Ankylosis a Paediatric...

7/31/2019 9 Inter Positional Arthroplasty by Using Temporalis Facia and Muscle for TMJ Ankylosis a Paediatric Case Report

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Int J Dent Case Reports 2012; 2(3):43-47 IJDCR 2012. All rights reserved

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CAS E REPORT

INTER POSITIONAL ARTHROPLASTY BY US ING TEMPORALIS FASCIA AND MUSCLE FOR TMJ

ANKYLOSIS: A PAEDIATRIC CAS E REPORT

Kamaraj Loganathan1, Bindu Vaith ilingam2, Cyril Joseph3, Vijay Prabhu4

1Associate Professor, Penang International Dental College, Butterworth, Pulau Pinang, Malaysia-12000

2Senior Lecturer, Penang International Dental College, Butterworth, Pulau Pinang, Malaysia-12000

3Senior Lecturer, Penang International Dental College, Butterworth, Pulau Pinang, Malaysia-12000

4Senior Lecturer, Tagore Dental College

Address for Correspondence

Dr. Kamaraj Loganathan

Associate Proffesor

Penang International Dental College

Level 19-21, NB Tower, Jalan Bagan Luar,

Butterworth, Pulau P inang, Malaysia-12000

Ph- 0060125616517

E [email protected]

Fax-006043337070

ABSTRACT

The treatment of TMJ ankylosis continues to be a topic of current interest because of both the

difficulties encountered in surgical techniques and the high incidence of recurrence. Here we

present a case of a 10 year old girl who presented with difficulty in mouth opening and was

diagnosed with TMJ Ankylosis. Despite recent advances in managing TMJ Ankylosis with

distraction osteogenesis etc, we followed gold standard protocol with acceptable results.

Key words: TMJ; Arthroplasty; Ankylosis
mailto:[email protected]:[email protected]:[email protected]:[email protected]


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Loganathan, Vaithilinga m, Jos eph, Prabhu TMJ Ankylosis

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Int J Dent Case Reports May 2012, Vol.2, No. 3

INTRODUCTION

Ankylosis of the Temporomandibular joint involves

fusion of the mandibular condyle to the base of theskull. When it occurs in a child, it can have

devastating effects on the future growth and

development of the jaws and teeth. In many cases it

has a negative influence on the psychosocial

development of the patient, because of the obvious

fascial deformity, which worsens with growth.

Trauma and infection are the leading causes of

Ankylosis. Optimal results can be achieved only after

a complete assessment and development of a long-

term treatment p lan. We present a case report of TMJ

Ankylosis diagnosed and successfully treated.

Case report

A ten year old female patient came to our department

with the compliant of progressive inability to open

the mouth (fig 1 and 2). No complications had been

reported at birth, and her medical history revealed a

recurrent left ear infection.After recovering from the

ear infection, the patient experienced a slowly

increasing restriction of her mouth opening.

The clinical examination revealed a hypo plastic

mandible with a class II dental relationship on left

side. Fascial midline shifted to left side. The

Maximum opening was 15 mm, and there was no

palpable movement over the left TMJ. OPG

examination revealed a lack of s tructural organizat ion

on left side joint. A diagnosis of unilateral TMJ true

ankylosis was made.

The following treatment plan was developed:

1. Surgery

- Inter positional arthroplasty by using temporalis

fascia and muscle through preauricular approach.

- Coronoidectomy (ipsilateral).

2. Physiotherapy- Aggressive use of specially made p rosthesis and ice

cream sticks.

Figure 1: Pre-operative mouth opening

Figure 2: Pre-operative O.P.G.

Surgery was done under general anesthesia. A

surgical approach through Al-Kayat Bramley incision

(fig 3), zygomatic arch was exposed. On the left side,

a condyle like structure and strong fibrous adhesions

were found. A bone cut was made 8 mm inferior and


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parallel to the zygomatic arch and 1 cm gap (fig 4)

created. Ipsilateral Coronoidectomy was done. Intra

operatively mouth opening was 30 mm. A U shaped

Temporalis fascia and muscle flap elevated and

turned down over the zygomatic arch. Then covered

glenoid fossa and sutured to the medial tissues with

3-O Vicryl (fig 5).

Figure 3: Al Kayat Bramley Incision

Figure 4: Resection of ankylotic mass

Post operatively antibiotics and pain medication was

prescribed. There was a mild motor deficit on left

side of the face (temporal branch of fascial nerve).

Vigorous Post operative physiotherapy was

performed to maintain the mobility and to prevent

hypo mobility Secondary to fibrous adhesions. The

patient was discharged from hospital 7days after

surgery with good range of motion.

DISCUSS ION

Temporomandibular joint ankylosis is a Structural

disease that can cause asymmetry resulting in severe

fascial disfigurement as well as difficulties in eating,

breathing, and speech. Post traumatic ankylosis is

more frequently seen in Children; In addition, local

infections such as otitis media and mastoiditis, as

well as systemic infections such as tuberculosis,

scarlet fever and gonorrhoea, can also give rise to

ankylosis by the haematogenous route. TMJ

ankylosis was classified by Kazanjian as either true

or false. True ankylosis is a condition that results in

osseous or fibrous adhesion between the surfaces of

the TMJ. False ankylosis results from diseases not

directly related to the joint. Management of TMJ

ankylosis is through surgical intervention as soon as

the condition is recognized. Early surgery can

minimize the severity of fascial asymmetry.

Figure 5: Interposition with temporalis


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According to Laskin, the principles of treatment of

TMJ ankylosis are:

Operate as early as possible

Keep the ramus high

Prevent recurrence by using an interpositional

material in growing patients, to replace the condylar

growth centre

Maintain a post-operative program of active jaw

exercises.

CONCLUS ION

The treatment of TMJ ankylosis continues to be a

topic of current interest because of both the

difficulties encountered in surgical techniques and

the high incidence of recurrence. Various techniques

have been defined, and three basic techniques are

currently employed:

1. Gap arthroplasty: The resection of the osseous

mass between the articular cavity and the mandibular

ramus; this resection field is left e mpty.

2. Interpositional arthroplasty: following resection of

the osseous mass, the interpositional placement of

biological (temporal muscle, fascia, skin or auricular

cartilage) or non-biological (acrylic and silastic)

materials in the operation space.

3. Joint reconstruction: reconstruction by autogenic

Costochondral graft or total joint prosthesis following

resection of the osseous mass.

Satisfactory surgical correction of

temporomandibular joint ankylosis is limited by a

high recurrence rate, particularly in patients who

underwent surgery without use of interpositional

material. Our experience, indicates that among the

various surgical options available for treating TMJ

ankylosis, use of interpositional surgery with

temporalis fascia and/or muscle provides the most

satisfactory results.

Simple gap arthroplasty appears

to be of limited value in TMJ ankylosis surgery,

particularly due to the high risk of recurrent joint

ankylosis. Silastic sheet interposition carries the risk

of infection and extrusion in the long term.

Interpositional Gap Arthroplasty is a highly effectiveand safe surgical management option for TMJ

ankylosis with acceptable immediate and long term

outcome, particularly when temporalis fascia and

muscle are used. The principal advantages of the

temporalis muscle and fascia flap are their

autogenous nature, resilience, and adequate blood

supply. Its proximity to the joint allows for a pedic led

transfer of vascularized tissue into the joint area.

Rotation under the zygomatic arch prevents bulkiness

and avoids the need for surgically reducing the

thickness of the zygomatic arch, when compared to

the muscle over the arch.

Vigorous Postoperative Physiotherapy is very

important for the success of the treatment and the

prevention of recurrence in TMJ ankylosis patients .

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