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 Table of Contents  
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 115-120

Temporomandibular joint ankylosis pattern, causes, and management among pediatric patient attending a tertiary hospital in Bangladesh

1 Department of Oral and Maxillofacial Surgery, Rajshahi Medical College, Rajshahi, Bangladesh
2 Department of Oral and Maxillofacial Surgery, Dhaka Dental College and Hospital, Dhaka, Bangladesh

Date of Submission05-Jan-2021
Date of Acceptance11-May-2021
Date of Web Publication22-Jun-2021

Correspondence Address:
A F. M Shakilur Rahman
Department of Oral and Maxillofacial Surgery, Rajshahi Medical College, Rajshahi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jorr.jorr_3_21

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Background: Temporomandibular joint (TMJ) ankylosis is a pathological condition where mandibular condyle fused the glenoid fossa of the temporal bone. It causes distressing and disabling conditions to the patient. The purpose of our study is to determine the frequency of pediatric TMJ ankylosis attending at Oral and Maxillofacial Surgery Department, Dhaka Dental College and Hospital, Bangladesh.
Methodology: This was a retrospective, cross-sectional study for 18 patients (9 male and 9 female) aged up to 18 years old. Data assembled from the patient's surgical records reviewed from January 2016 to December 2018.
Results: Females and males were affected equally, the most affected age group was 7–12 as well as 13–18 years old (n = 7, 38.89%), bilateral ankylosis (n = 11, 61.11%) was more common than unilateral (n = 7, 38.89). Type III (34.48%) ankylosis (Sawhney's classification) was found to be the most frequent type. Trauma (n = 11, 61.10%) was the major etiologic factor for pediatric TMJ ankylosis. All patients were managed by surgical intervention. Gap arthroplasty (n = 9; 50.0%) was the most preferable treatment method followed by interpositional arthroplasty (n = 7, 38.89%) and condylectomy (n = 2, 11.11%).
Conclusion: The majority of the patient was affected by trauma. Most of the patients came with Type III ankylosis with having facial deformities. Absolute and proper management regarding mandibular condylar fracture and infection (middle ear) must be required to prevent TMJ ankylosis. Surgical intervention is the only treatment option for managing TMJ ankylosis. Aggressive physiotherapy is mandatory to prevent reankylosis, thus ensuring the patient's quality of life.

Keywords: Ankylosis, arthroplasty, pediatric, temporomandibular joint

How to cite this article:
Shakilur Rahman A F, Haider IA. Temporomandibular joint ankylosis pattern, causes, and management among pediatric patient attending a tertiary hospital in Bangladesh. J Oral Res Rev 2021;13:115-20

How to cite this URL:
Shakilur Rahman A F, Haider IA. Temporomandibular joint ankylosis pattern, causes, and management among pediatric patient attending a tertiary hospital in Bangladesh. J Oral Res Rev [serial online] 2021 [cited 2022 May 17];13:115-20. Available from: https://www.jorr.org/text.asp?2021/13/2/115/319018

  Introduction Top

Temporomandibular joint (TMJ) is a synovial ginglymoarthroidal joint that is formed between the condyle of the mandible and the glenoid fossa of the temporal bone, separated by an articular disc.[1] Ankylosis is a Greek term, means “stiffness of joint.”[2] By definition, TMJ ankylosis is a condition where obliteration of the joint space occurred with abnormal bone morphology leading to adhesion with opposite joint components.[3] TMJ ankylosis may cause difficulties in mastication, speech, and digestion. It may also cause facial disfigurement due to disturbances of mandibular growth, especially in children. It is troublesome to maintain oral cleanliness in this condition. This may also cause acute compromise of the airway invariably. This impact results in the physical and psychological disability of the patient.[4] TMJ ankylosis mostly occurs in the first two decades of life (35%–92%). It is frequently related to trauma (13%–100%), local or systemic infection (0%–53%), systemic diseases, for example, ankylosing spondylitis, rheumatoid arthritis, and psoriasis (28%). It may also occur as a postsurgical complication of TMJ.[5],[6] It may be congenital rarely,[7] and the etiology could be unidentified.[6]

TMJ ankylosis may be classified in different ways: according to the location (intra-articular or extra-articular), type of involved tissue in ankylosis (bony, fibrous, or fibro-osseous), the extension of ankylosis (complete or incomplete), and involvement of side (unilateral or bilateral).[5] Moreover, Sawhney classified TMJ ankylosis into four categories such as Type I, Type II, Type III, and Type IV based on radiological findings. In Type I, the condylar head is present without much deformation, but TMJ movement is unattainable due to fibrous adhesions; Type II, in which there is a bony union of the misshaped head of the condyle and articular surface, the sigmoid notch, and the coronoid process remain intact; Type III, in which there is a bony block bridging across the mandibular ramus and the zygomatic arch, the medial pole remains intact, the coronoid process is seen elongated; and Type IV, in which the TMJ is completely replaced by a bony block.[8]

Clinical presentation depends on the age of the patient, site, and duration of ankylosis. The clinical presentations of unilateral TMJ ankylosis reveal deviation and fullness of the chin to the affected side with flatness on the unaffected side. Bilateral ankylosis manifests with “bird-face” deformity [Figure 1] due to mandibular retrognathism.[5] The diagnosis of TMJ ankylosis is made through a combination of clinical and radiographic assessments. Clinically, patients present with a limited mouth opening [Figure 2]a and [Figure 2]b.[9] TMJ imaging includes plain radiography, panoramic radiography [Figure 3], computed tomography (CT) [Figure 4], arthrography, cone-beam CT, magnetic resonance imaging, and ultrasonography.[10],[11]
Figure 1: Clinical photograph shows “Bird-face” deformity in temporomandibular joint ankylosis patient

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Figure 2: (a) Clinical photograph shows limited preoperative inter incisal mouth opening in a patient with bilateral temporomandibular joint ankylosis. (b) Clinical photograph shows restricted preoperative inter incisal mouth opening in a patient with left side temporomandibular joint ankylosis

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Figure 3: Orthopantomograph shows right-sided temporomandibular joint ankylosis

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Figure 4: Computed tomography (Coronal section) shows bilateral temporomandibular joint ankylosis

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Surgical management of TMJ has significance in the pediatric patient. Mandibular growth impairment in these patients results in some problems. The treatment objective of TMJ ankylosis in children is to preserve the normal development of the mandible and the improvement of the face as well as to regain a palatable mouth opening.[12] Pediatric TMJ ankylosis is difficult as well as challenging to treat surgically. Postsurgical reankylosis is the major complication. Kaban et al.[13] introduced a seven-step protocol to treat pediatric TMJ ankylosis. It consists of (1) aggressive excision of the fibrous and/or bony ankylotic mass, (2) excision of coronoid process on the ipsilateral side, (3) coronoidectomy on the contralateral side, if the first two steps do not achieve in a maximal mouth opening more than 35 mm, (4) a temporalis myofascial flap or the native disc can be used for the lining of TMJ, (5) TMJ reconstruction may be done with either distraction osteogenesis or costochondral graft (CCG), and (6) early physiotherapy is advocated for the jaw. Physiotherapy begins on the 1st postoperative day if distraction osteogenesis is used to recreate the ramus condyle unit. The patient receives physiotherapy after the 10th postoperative day of maxillomandibular fixation if the CCG is used to reconstruct TMJ. The final step (Step 7) consists of aggressive physiotherapy for all patients.[13] Surgical interventions for TMJ ankylosis fall into three basic methods: condylectomy, gap arthroplasty, and interpositional arthroplasty with joint reconstruction. Condylectomy is indicated in the case of fibrous ankylosis where there is not much deformity of the condylar head. Gap arthroplasty [Figure 5]a and [Figure 5]b involves the resection of ankylosed material to create a space for joint mobilization. Interpositional arthroplasty refers to the insertion of an interpositional material within the joint space after resection of the ankylotic mass. Both autogenous and alloplastic materials have been reported to be utilized as interpositional materials.[2],[14],[15] Various autogenous and/or alloplastic materials can be used to reconstruct TMJ, for example, CCG, temporalis muscle/fascia flap, skin, dermis, clavicular osteochondral graft, iliac crest graft, silicone, Teflon, and alloplastic condylar implant.[4],[16],[17]
Figure 5: (a) Intraoperative photograph shows gap arthroplasty. (b) Intraoperative photograph shows satisfactory mouth opening

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There are very few studies to evaluate the importance of pediatric TMJ ankylosis in Bangladesh as well as other South Asian nations. The authors conducted this study to determine the pattern, etiology, type, and management regarding pediatric TMJ ankylosis at a tertiary health center in Bangladesh.

  Methodology Top

This retrospective, cross-sectional, hospital-based study was conducted to determine the pattern and management of TMJ ankylosis among pediatric patients attending the Department of Oral and Maxillofacial Surgery of Dhaka Dental College Hospital, Bangladesh, during the period from January 2016 to December 2018. A total of 18 pediatric patients were enrolled for the treatment of TMJ ankylosis during the 3 years. No ethical committee approval was obtained as this was a retrospective study and data were taken from departmental medical records. Data collection contained the following variables as age, sex, side, type of ankylosis, mouth opening (preoperative and per-operative), and treatment modalities. Patients who were diagnosed with TMJ ankylosis (clinically and radiologically) and experienced surgical treatment included in the study. We included patients below 18 years old. Patients were excluded who had TMJ disorder other than ankylosis or deficient records.

Statistical analysis

Data were analyzed using the SPSS software version 22 (SPSS Inc., Chicago, IL, USA). Tables were used to show the frequency distribution in the results. The quantitative data were shown as mean ± standard deviation (SD), and qualitative data reported as numbers and frequencies.

  Results Top

Eighteen patients were included in our study during the period from January 2016 to December 2018. Our result showed equal distribution in gender with nine patients (male: female = 1:1) on each side. The age of the patients ranged from 0 to 18 years old; the highest percentage group was from 7 to 12 years, 42.10% shown in [Table 1]. In this study, the most common etiology of TMJ ankylosis was trauma (n = 11, 61.10%) followed by infection and unknown etiology with equal distribution and frequencies (n = 3, 16.67%), as shown in [Table 2]. The present study showed that bilateral ankylosis was the predominant (n = 11, 61.11%). Right-sided unilateral ankylosis (n = 4, 22.22%) was more common than the left side (n = 3, 16.67%), as shown in [Table 3]. According to Sawhney's classification (1986), Type III (n = 10, 34.48%) TMJ ankylosis was predominant in the majority of the patients followed by Type I (31.03%), Type II (27.59%), and Type IV (6.9%), as shown in [Table 4]. Surgical management was done in all patients. The most common treatment method was gap arthroplasty (n = 9, 50%) followed by interpositional arthroplasty (n = 7, 38.89%) and Condylectomy (n = 2, 11.11%), as shown in [Table 5]. The mean preoperative maximal inter incisal opening (MIO) was 4.83 mm with the predominant reading was 0–5 mm (66.67%), as illustrated in [Figure 6]. The intra-operative MIO was achieved ranged from 0 mm to 50 mm, the predominant reading was from 31 mm to 40 mm were 61.11% (n = 11), as shown in [Figure 7].
Table 1: The age distribution of the study sample (n=18)

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Table 2: The etiology of the study sample (n=18)

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Table 3: The distribution of the affected side among study sample (n=18)

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Table 4: The types of ankylosis among study cases (n=29)

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Table 5: The types of treatment modality recorded among study sample (n=18)

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Figure 6: Shows the preoperative maximal inter-incisal opening (MIO)

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Figure 7: Shows the intra-operative maximal inter-incisal opening (MIO)

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  Discussion Top

This study was conducted at a tertiary health center in Bangladesh to find out the pattern of TMJ ankylosis in pediatric patients. The mean age of the sample on the basis of our analysis was 11.31 ± 4.09 (mean ± SD) years. The result coincides with previous studies.[18],[19] The result is in contrast with Zakaria et al. findings in which the mean age was 22.9 years.[3] In the present study, the male-to-female ratio was 1:1. Our result is in contrast with other studies. Males are affected more than females, as documented in most of the studies.[5],[6],[19] Females are predominantly affected, stated in some studies.[3],[18] Most of the patients were presented with bilateral ankylosis which coincides with other results.[3],[18] Our result differs from a study where the majority of the patients had unilateral TMJ ankylosis.[15] In most patients, the etiology of ankylosis was trauma, which coincides with previous findings,[3],[12],[20] but the result is in contrast with Vasconcelos et al. findings,[4] where the infection was the predominant cause. Type III ankylosis was the most prevalent in children which coincided with the findings of other scholars.[4],[12]

In the present study, the preoperative mean mouth opening was 4.83 mm. The mean MIO achieved 38.42 mm intraoperatively, which coincides with Elgazzar et al. results.[6] In our study, the most used surgical treatment modality was gap arthroplasty (n = 9, 50.0%) which is consistent with other studies as published earlier.[21],[22] Interpositional arthroplasty (n = 7, 38.89%) and condylectomy (n = 2, 11.11%) were also done in our center. Excision of the coronoid process, either ipsilateral (n = 5) or bilateral (n = 9) was done to achieve in a MIO more than 35 mm. Our result is in contrast with a study, where interpositional arthroplasty is preferred over gap arthroplasty.[23] Eltohami et al.[19] reported condylectomy as the most preferable surgical option for pediatric TMJ ankylosis. TMJ reconstruction arthroplasty is primarily used in pediatric patients and in adults who has pronounced facial deformity.[6] The CCG is preferred by most of the surgeon for the reconstruction of TMJ in the pediatric patient due to its growth potential. The cartilage portion of CCG must be shorter (3–5 mm) to prevent overgrowth of the graft.[24],[25] It has also been reported that temporalis myofascial flap (TMF) attains acceptable success rates in the pediatric patient (more than 83%), due to its rich blood supply and near proximity to the reconstructed site.[13],[26] The CCG (n = 4) was used to reconstruct TMJ in our center. TMF was utilized in six patients as an interposition material to prevent reankylosis. A comparative study was conducted between two surgical options such as CCG and TMF in Jordanian children with TMJ ankylosis. Both CCG and TMF showed a similar success rate in the treatment of pediatric TMJ ankylosis.[27] The mouth opening can be improved through exercise using either ice-cream sticks or mouth gag.[28] We advise our patient for mouth opening exercise by either ice-cream sticks or mouth gag. In our center, we managed all pediatric patients with TMJ ankylosis following the Kaban et al.[13] protocol.

  Conclusion Top

Ankylosis of the TMJ in the pediatric patient is a disabling condition due to its' adverse impact on function and the facial structure. TMJ ankylosis in pediatric patients impedes the growth of the mandible consequential in esthetic and functional deformities. The consequence has an unpleasant psychological effect on the child. The most common causes were trauma, followed by infection revealed in this study. Females and males are affected equally in this study. In our study, bilateral ankylosis was present in the majority of the patient. Type III TMJ ankylosis (Sawhney's classification) was predominant among the study samples. Gap arthroplasty as well as interpositional arthroplasty was the most preferred modality of treatment in our center. Surgical interventions led to an improvement in mouth opening ranging from 31 mm to 40 mm (n = 11, 61.11%) during surgery. The mouth opening can be maintained and increased by postoperative physiotherapy. Postoperative physiotherapy plays an important role to prevent reankylosis.

Early and absolute management is required to treat the condylar fracture of the mandible, infection (Middle ear) in pediatric patients to prevent TMJ ankylosis. Improvement of awareness regarding the etiologic factor of TMJ ankylosis should be enhanced among the people. Continuous follow-up with the patients after surgery to prevent a recurrence. The surgeons have to become skilled at newer surgical skills and techniques to decrease postoperative complications. Distraction osteogenesis, orthognathic surgery, and other advanced surgical technique should be implemented to reduce the impact of facial deformity.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

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


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