Treatment of TMJ ankylosis

Two-stage treatment protocol for management of temporomandibular joint ankylosis with secondary deformities in adults: our institution's experience

PURPOSE

Treatment of adult patients with temporomandibular joint (TMJ) ankylosis and secondary deformities is a challenging problem. Although various techniques, including arthroplasties, orthognathic surgery, autogenous bone graft, and distraction osteogenesis, have been described for the management of patients with this condition, an appropriate treatment protocol has not been established. The purpose of this report is to describe a 2-stage treatment protocol, comprising TMJ reconstruction as the initial surgery, followed by orthodontic treatment, and correction of secondary deformities as the second surgery, for the management of TMJ ankylosis with secondary deformities in adults.

PATIENTS AND METHODS

From January 2003 to December 2009, 24 adult patients (30 joints) with TMJ ankylosis and secondary deformities underwent TMJ reconstruction as the initial surgery, followed by orthodontic treatment and correction of secondary deformities as the second surgery. Clinical outcome was assessed based on oral function, radiography, and medical photography.

RESULTS

Patients were followed up for a minimum of 12 months to a maximum of 32 months (mean, 18.6 months). No relapse of TMJ ankylosis occurred in any patient during the follow-up period. Oral function and skeletal deformities were significantly improved in all patients. Satisfactory occlusion was achieved with the help of orthodontic treatment. Most of the patients were satisfied with the final outcome.

CONCLUSIONS

The 2-stage treatment protocol described not only restores oral function but also improves the patient's esthetic appearance. We believe that it is a good approach for management of TMJ ankylosis with secondary deformities in adult patients.

Clinical implications of the innervation of the temporomandibular joint

The successful management of temporomandibular joint (TMJ) pain remains elusive. Often, the initial relief of pain is complicated by recurrence of the symptoms. This time frame suggests that the pain may be related to neuromas of the nerves that innervate the TMJ. The current study attempted to define the innervation pattern of the TMJ as identified in 16 embalmed and 8 fresh-frozen specimens. In each specimen, the auriculotemporal nerve, a branch of the mandibular portion (V3) of the trigeminal nerve, was found to innervate the lateral capsule of the TMJ. In 75% of the specimens, the masseteric nerve, a branch of the maxillary portion (V2) of the trigeminal nerve, was found to innervate the anteromedial capsule of the TMJ. In 33% of the specimens, there was a branch coming through the mandibular notch to innervate the anteromedial capsule that was not from the masseteric nerve; this nerve is believed to have passed through the lateral pterygoid muscle after leaving V2. These consistent patterns of innervation of the TMJ suggest that diagnostic nerve blocks can be done to determine the pain pathway in these patients. It is suggested that if the nerve blocks are successful, TMJ denervation may be a future method of pain relief in patients with recalcitrant or recurrent TMJ pain.

A clinical study on temporomandibular joint ankylosis

OBJECTIVE

Temporomandibular joint (TMJ) ankylosis results from trauma, infection and inadequate surgical treatment of the condylary area. Many techniques for treatment have been described so far. However, none of them gave uniformly successful results. A limited range of intrinsical opening due to relapse, loss of vertical height of the affected ramus, foreign body reactions and reankylosis are expected complications. However, wide bone resection, the use of interpositional spacer, insensitive and aggressive physiotherapy immediately after the operation are the basic principles as agreed by many authors. In this article, a review of the historical background of the treatment has been discussed.

METHODS

A clinical and retrospective evaluation of 42 patients treated for this disorder showed that 89% of all patients had unilaterally and 11% had bilateral ankylosis. From the viewpoint of the techniques we used, patients fell into three groups. In two groups, two different type of spacers were used, and in the third group gap arthroplasty were performed for the treatment of TMJ ankylosis.

RESULTS

Our results revealed a predominance of traumatic aetiology. The highest incidence was between the ages of 11 and 20. A total of 45.24% of the patients were treated by interpositional arthroplasty by using acrylic spacer, 11.90% of the patients by sylastic sheet used as an interpositional material and the rest of the cases (42.86%) were treated only by gap arthroplasty.

CONCLUSION

The advantages of the spherical acrylic spacer and gap arthroplasty were discussed. The advantages of the techniques are, shorter operating time, and more importantly its very low cost.