Fibrous Ankylosis of the Temporomandibular Joint:Report of a Case With Atypical Presentation

Jeffrey J.Moses, DDSMedical DirectorPacific Clinical Research FoundationEncinitas. Califomiaand Adjunct Assistant ProfessorUniversity of California, Los AngelesSchool of DentistryLos Angeles. California

Henry H. Lo, DMDPostdoctoral FellowPacific Clinical Research FoundationEncinitas, California

Correspondence lo;Dr Jeffrey J. MosesPacific Clinical Research Foundation355 Santa Fe Drive. Suite 100Encinitas. California 92024

A case cf chronic unilateral mandibular dislocation with develop-ment of fibrous ankylosis is presented. This was an unusual pre-sentation of intracapsular tissue ankylosis to the eminentia, as wellas retrocondylar cicatrix combined with contralateral mandihularosseous compensations and remodeling with resulting ramusimpingements upon relocation of the condyle. Various diagnosticand therapeutic considerations are reviewed and discussed.J OROFACIAL PAIN 1995;9Í3SO-3B5.

key words: fibrous ankylosis, temporomandibular joint,mandibular dislocation

Ankylosis of the tcmporomandibular joint (TMJ) can beclassified as osseous or fibrous, and as intracapsular orextracapsular.' According to the literature, trauma in early

childhood is tbe most common cause of TMJ ankylosis,'"^ and it isoften associated with growth disttirbances that lead to mandibularbypoplasia and asymmetry. Tbe incidence varies from 31% to98%, depending on the study.'"'' Local or systemic infection,mostly secondary to contiguous spread from mastoiditis or otitismedia, account for 107o to 49% of cases. Systemic disease, suchas ankylosmg spondylitis, rheumatoid arthritis, and psoriasis,accounts for about 10% of cases.'"^ The present study reports acase of fibrous ankylosis of the TMJ witb unusual clinical presen-tation. Tbe study shows that the importance of evaluation for con-current asymmetric remodeling of the mandible with resultantramus impingements must not be overlooked during initial treat-ment planning.

Report of a Case

The patient, a girl aged 14 years, presented witb a bistory of painin her mandible and TMJs for about 4 to 5 years. This painreportedly occurred in a gradual manner. However, the patient didnot seek treatment until she consulted an orthodontist regardingber malocclusion. Tbe orthodontist immediately noticed a severeasymmetry of her mandible and limited range of mandibularmotion and referred her for evaluation.

Tbe mother of rhe patient could not recall any significant inci-dent of trauma to the jaws, except that tbe patient did fall off of aswing when she was about 9 or 10 years old. It was uncertainwhether her TMJ problem was related to the trauma.

Initial clinical examination revealed marked deviation of themandible to tbe right side. There was bilateral crossbite .secondary

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Fig 1 Patient with mandilniLir deviation and bilateralcrossbite at initial clinical examination.

Fig 2 Limited interincisjl opening ai initial clinicalexamination.

Fig 3 Tomograph of left TMJ reveals subluxation ofthe condyie in closed-mouth position.

Fig 4 Tomograph of lefr TMJ reveals slight translationof the condyle at an inrerincisal opening of 15 mm.

to the deviation ¡Fig 1), There was also occiusa!instability, and the patient was unable to occludeher teeth into a comfortable and stable position.The dentition was in good condition withoutcaries, Tbere was a significant diastema betweenthe maxillary central incisors. The patient's maxi-mum interincisal opening was 15 mm (Fig 2) witha protrusive excursion of 1 to 2 mm, lateral excur-sion to the right of 2 mm, and no iatera! excursionto the left.

The patient complained of pain around the leftTMJ and mandible, althotigh neither TMJ emittedpain on loading when hiting on a tongue blade.

Ko joint noises were audible on examination. Thepatient claimed that her pain was exacerbated withchewing, and she reportedly had to cut her foodinto small pieces to eat. The patient's general med-ical condition was unremarkable,

A panoramic radiograph and an axially cor-rected sagittal tomograph were taken. The radio-graphs showed anterior subluxation of the leftmandible condyle at around the 5-o'clock positionof the eminence in centric occlusion (Fig 3], Onopen-mouth position, the condyle translated to the6-o'clock position of the eminence (Fig 4]. Theright condyle seemed slightly anceroinferiorly dis-

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Fig 5 Magnetic resonance imAgmg reveals snbluxatedleft condyle with normal disc relationship.

Fig 6 Magnetic resonance imaging reveals maintenanceuf normal condyle-disc relationship when the leftcondyle translated from its subluxated position.

placed. The amount of condyiar translation againwas limited as a result of the inability of thepatient to open widely.

Magnetic resonance imaging (MRI| revealed theright TMJ to be normal with rhe exception of thedecrease in condylar translation. The MRI of rheleft TMJ showed anterior subluxarion of thecondyle with the teeth in occlusion. The condyleand disc were normal in shape. In the subluxaredposition, a normal relarionship between thecondyle and disc remained (Fig 5}. This normalrelationship was maintained on opening of themourh, although again, the amount of translationof the condyle was limited (Fig 6).

The initial impression was that the left TMJ waschronically subluxated with fibrous ankylosis.However, it was the possibile rhat the right TMJmight also he fihrosed secondary to chronic immo-bility. The surgical plan was to perform bilateralTMJ open arthroplasty with release of the fibrousankylosis.

"When the patient was placed under generalanesthesia, her maximal interincisal opening couldbe stretched to 50 mm. The left condyle remainedon the eminence, and it was not possible to reducethe condyle back to the fossa. However, it waspossible to move the mandible about 12 mm to theright side. Attempts to translate the right condyleand move the mandible to the left were only mod-erately successful. The mandible could be movedto the left no farther than 7 mm.

Intraoral palpation around the right posteriormaxilla and ascending ramus areas confirmed thediagnosis of contralateral coronoid impingementagainst the maxillary buttress. It was decided atthis time that a right TMJ open arthroplastywould not be required, hut rather a right coro-noidectomy was necessary because of the bonyremodeling that had occurred during the years ofchronic asymmetric mandibular subluxation.

The left TMJ was approached via an endauralincision in the usual manner for exposure of theTMJ, When the lateral capsule was entered, thesuperior joint compartment was found to befibrosed. The fibrous ankylosis had to be releasedwith both blunt and sharp dissection. In the bilam-inar zone area, there was also substantial fibroustissue that was debrided and partially resected.The disc was found to be in good condition, andthe condyle was not exposed. Lateral capsular anddistal restraining sutures were then placed usingO-Ethibond sutures (Ethicon). These were placedto help restrain the tendency for extreme anteriorsubluxation of the condyle-disc relationship to thefossa-eminence. The TMJ surgical site was thenclosed in a routine fashion.

Attention was then focused on the right intraoralarea. A right coronoidectnmy was performed via anintraoral retromolar incision. The coronoid processwas found ro be long and fin shaped. Additionalbone removal medially was necessaiy at the base ofthe process to assure freedom from impingement.

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Fig 7 ¡Left) Maximum intcrincisal opening of 50 turn 6months postoperatioii.

Fig 8 íBetoir) Occlusion ot the patient 6 miintlis post-

Fig 9 Postoperative tomograph uf the left TMJ dis-plays centric condylar position.

Fig 10 Postoperative tomograph of the left TMJ dis-plays good condyle translation on opening.

After the coronoidectomy was cotnpleted, thetnandible could be translated to the left 11 to 12mm. This could be well mobilized with the rightlateral movement. Maximum interincisal openingwas at 50 mm, and the patient's occlusion wasreduced to a satisfactory condition. Arch bars wereplaced on the rnaxillary and mandibular dentition,and light elastic occlusal guidance was utilized. Atthe 1-week postoperative visit, the patient's inter-incisai opening was 27 mm, the protrusive excur-

sion was 5 mm, and the lateral excursion was 6 to7 mm. The patient was placed under physical ther-apy management to aid in joint tnobilization.

After 6 months, the patient had a maximuminterincisai opening of 50 mm with protrusive andlateral excursions of 8 mtn. The occlusion remainsgood to this date (Figs 7 and 8). Six-rnonth foHow-up tomographs showed that the left condyle wascentricaliy situated in the fossa with good ttansla-tion on opening (Figs 9 and 10).

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Discussion

Treatment of TMJ ankylosis has varied from openartliropksty itnd frotn placement of a temporaryelastic sheet to the lining of the fossa with differentautogenotis or alloplastic materials and to com-plete TMJ reconstruction with costochondral graftor joints.̂ "'-'' Kaban et al'^ emphasized the impor-tance of aggressive ankylosis resection, early mobi-lization, coronoidectoniies, and the use of costo-ehondral graft and the lining of the fossa withautogenous materials in the successful treatment ofTMJ ankylosis. Success in preventitig reankylosisalso is said to depend on long-tertn patient compli-ance in undertaking frequent and usually painfulmandibular tiiovement exercises.'^

The patient in the present study had a fibrousankylosis, and although the condyle was normaland the disc was in good shape, major reconstruc-tion was needed. The interesting feature of thiscase is Its unusual clinical presentation, includingtbe rnandibular ascending ramus and eonrralateralcoronoid remodeltng in a transverse dimension.Trauma as the cause of the ankylosis and subluxa-tion is uncertain, yet likely.

It is interesting to note that the left condyle wasfibrosed to the 5-o'clock position of the eminencebut was not disloeated beyond tbe eminence. Thisposition is usually noT a very stable position, andone wovtid e.xpect the condyle to be able to reduceitself back into the fossa. One may surmise thattbe deviated occlusion might have retained themandible in tbis awkward position. However, clin-ical examination revealed an unstable malocclu-sion without locking interdigitation between thedentition. Another interesting feature of this case isthat the lefr condyle was able to translate forwardfrom its sublu.xated position but unable to go backto tbe fossa. Since the patient's mandible could bemanipulated to open up to 50 mm tinder generalanesthesia (with deviation), the clinical restrictionof the mandibular opening most likely was a resultof pam and muscle splinting.

The patient's TMJ could be hypermobile andeasily dislocated. One can surmise that after thetranma and subluxarion of the left condyle, musclesplinting might have prevented its reducrion.Hematoma formation at the posterior attachmentof the disc could have led to fibrosis and thtis pre-vented subsequent reduction of the condyle backto the fo.ssa.

This case illustrates tbe importance of evaluatingthe contralateral mandibular skeletal symmetry forpossible coronoid impingement in unilateral anky-losis cases;. With chronic right mandibular devia-tion secondary to left temporomandibular jointsubluxation and retrodiscal fibrosis, contralateralmandibular osseous compensation may occur inthe ascending ramus and coronoid areas, leadingto necessary diagnostic observation and planningboth preoperatively and intraoperatively.

References

1. Sarma UC, Dave PK. Temporomandibuiar joint ankylosis;An Indian experience. Oral Surg Oral Med Oral Pathol1991;72:660-664.

2. Laskin DM. Role of the meniscus in the etiology of post-traumatic temporomandibular joint ankylosis. Int J OralSurg197S;7:340-345.

3. Sawhney CP. Bony ankylosis of the temporomandibularjoint: Follow-up of 70 patients treated with artbroplastyand acrylic spacer Interposition. Plast Reconstr Surg1986;77:29-40.

4. Guralnick WC, Kaban LB. Surgical treatment of mandibu.lar hypotnobility. J Oral Surg 1976;34;343-348.

5. Tideman H, Doddridge M. Tetnporomandibular ¡ointankylosis. Aust Dent J 1987;32;171-177.

6. Norman JE. Ankylosis of the temporomandihular joint.Aust DentJ 1978;23;56-6&.

7. iVIunro IR, Chen YR, Park BY. Simultaneous total correc-tion of temporotnandibular ankylosis and facial asymme-try. Plast Reconstr Surg 1986;77;517-529.

S. Posnick JC, Jacobs JS, Magee Wl' Jr. Prostbetic replace-ment of the condylar head for temporomandibular jointdisease. Pkst Reconstr Surg 1987;80:531-.546.

9. Moortby AP, Finch LD. Interpositionai arthroplasty forankylosis of tbe temporomandibular joinr. Oral Surg OralMed Oral Parbol 1983;55;545-552.

10. Given |W, Sanders B. Surgical management of longstand-ing temporomandibular ¡oint ankylosis and resultantskeletal deformity. J Granioniandih Disord Facial OralPainl9B7;l;127-135.

11. DeChamplain RW, Gallagher CS Jv, Marshall ET Jt.A11 to polymerizing Silastic for interpositiotial arthroplasty.J Oral Maxillofac Surg 198S;4É:.S22-5i5.

12. Kent JN, Misiek DJ, Akin RK, Hinds EC, Homsy GA.Temporomandibuiar joint condylar prosthesis: A ten-yearreport. J Oral Maxillofac Surg 1 9 8 3 ; 4 1 Í 2 4 5 - 2 . 5 4 .

I .Î. Kabati LB, Perrott DH, Fisher K. A protocol for manage-ment of temporoiTiandibular joint ankylosis. J Oral Maxil-lofac Surg 1990;48;1145..-]151.

14. Westermark AH, Sindet-Pedcrscn S, Boyne PJ. Bony anky-losis of the temporomandibular joint; Case report of achild treated with Delrin condylar implant. J Oral Maxil-lofac Surg 1990;48:S61-865.

15. Leilo GE. Surgical correction of temporotnandibular jointankylosis. JCraniomaxillofac Surg 1990;18; 19-26.

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Resumen

Anquibsis fibrosa de la articulación lemporomandibularReporte de un caso con una presentación atípica

Se presenta un caso de dislocación mandibular unilateraicrónica con el desarrollo de una anquilosis fibrosa Esta fue unapresentación inusuai de anquilosis de tejido intracapsuiar a laeminencia, lo mismo que la presencia de una cicatriz retrocondi-lar combinada con compensaciones óseas mandibulares con-traiateraies y remodeiación. Esto tra|o como consecuenciachoques en la rama cuando ei cóndilo se colocaba en una njevaposición Se revisan y se discuten varias consideraciones diag-nósticas y terapéuticas.

Zusammenfassung

Fibröse Ankylose des Kiefergelenkes. Präsentation einesatypischen Falles

Ein Fail von chronischer einseitiger Verschiebung desUnterkiefers mi( Entwicklung einer fibrösen Ankyiose wirdbeschrieben Es war ein ungewöhnliches Auftreten einerAnkylose aus intrakapsularem Gewebe im Bereich derEminentia, zusammen mit knöcherner mandibularer Kom-pensation und Remodelljerung der Gegenseile. Daraus resul-tierte eine Ramusverlängerung und eine Verlagerung desKondylus. Verschiedene diagnostische und therapeutischeÜberlegungen werden diskutiert.

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