Gap arthroplasty of temporomandibular joint ankylosis by transoral access: a case series

Abstract

This article describes a technique of gap arthroplasty in temporomandibular joint (TMJ) ankylosis performed by transoral access. The treatment of TMJ ankylosis by creating an adequate gap is of paramount importance in preventing any future recurrence and this can be achieved only when good access is gained to this complex anatomical joint. Five patients with TMJ ankylosis (eight TMJ) were treated by gap arthroplasty using an intraoral approach. The average mouth opening before surgery was 8.6 mm and the average mouth opening achieved postsurgery was 37.9 mm. The average follow-up time was 13 months and none of the patients had any recurrence or significant complications during or after surgery. Our technique relies on the use of a stable landmark to trace the superior-most extent of the ankylotic mass thereby facilitating the removal of the entire mass including the medial extent. We found that even though transoral access is technically challenging and took an average time of 84 min, it has many advantages over conventional extraoral approaches in terms of facial scars and facial nerve injury. The authors also emphasize the importance of good postoperative physiotherapy and presurgical patient counselling to prevent future recurrences.

Temporomandibular joint (TMJ) ankylosis is a common condition in India. In spite of attempts to prevent its incidence by timely and appropriate management of mandibular condyle fractures in both paediatric and adult populations, it is still seen quite frequently. Ankylosis of the TMJ is an extremely debilitating condition, especially when it affects the joint in its growing stages. Apart from causing severe facial disfigurement, it also alters the patient’s eating habits and speech ability. It aggravates psychological stress, prevents the patient from maintaining good oral hygiene resulting in dental decay and the loss of multiple teeth, and negatively affects quality of life.

The treatment of ankylosis is often challenging and many surgical techniques have been reported in the literature. Since the times of Esmarch (1851), who was credited with performing the first ever osteotomy for ankylosis, to the times of Abbe (1880) and Risdon (1934), who introduced the concepts of gap arthroplasty and interpositional arthroplasty, respectively, to the present day, the debate regarding the ideal choice of treatment still rages on. In 1990, Kaban et al. outlined a protocol for the management of TMJ ankylosis that was then universally followed; this was later modified by the same author in 2009. A myriad of extraoral incisions and techniques have so far been reported for gaining access to the temporomandibular apparatus or the ankylotic mass, all of which have been a challenge to the surgeon in terms of gaining adequate visibility, minimizing the facial scar, negotiating the facial nerve and auriculo-temporal nerves to prevent injury, reducing intraoperative and postoperative haemorrhage, and the occurrence of occasional anatomical deformity of the ear, surgical infection, and salivary fistula and sialocele. Many authors have tried to circumvent these complications by approaching the joint transorally. However, in 2009, Ko et al. were the first and only authors to report transoral access for the treatment of TMJ ankylosis. In the current article the authors share their experiences of transoral access to TMJ ankylosis and describe the surgical technique, which differs from that of Ko et al. in a certain important aspect.

Patients and methods

A series of five patients with TMJ ankylosis, two unilateral and three bilateral, underwent gap arthroplasty by transoral approach between February 2012 and August 2013 ( Table 1 ). The average age of the patients at the time of surgery was 14.4 years and none of them were recurrent cases. Two of the patients had Sawhney’s type I ankylosis and three of them had type II ankylosis. The average mouth opening at the time of surgery was 8.6 mm, with the lowest being 4 mm and the highest 14 mm. All patients had a history of trauma to the mandible, with two of them reporting a history of prolonged maxillomandibular fixation. Follow-up ranged from 7 to 24 months, with a mean follow-up of 13 months. No interpositioning material or substance was used in any of the cases. Physiotherapy and mouth opening exercises were started on day 1 postoperative and were performed with increasing intensity towards day 7. Patients were generally discharged on the third postoperative day and were reviewed once a week for the first month and once a month for the rest of the follow-up period. Condylar reconstruction is generally contemplated after an ankylosis-free period of 1 year; this is achieved using ramus distractors.

Table 1
Details and outcomes of the patients treated.
Patient No. Age Sex Ankylosis Aetiology Type (Sawhney) Preop. mouth opening Mouth opening immediately postop. Follow-up period Mouth opening at the last follow-up Decrease in mouth opening Complications Duration of surgery
1 8 M Bilateral Trauma II 8 mm 35 mm 24 months 32 mm 3 mm 90 min
2 12 M Unilateral Trauma I 14 mm 38 mm 12 months 36 mm 2 mm 45 min
3 24 F Unilateral Trauma I 12 mm 42 mm 12 months 38 mm 4 mm 80 min
4 16 M Bilateral Trauma II 5 mm 33.6 mm 10 months 26 mm 7 mm Significant decrease in postoperative mouth opening 120 min
5 12 M Bilateral Trauma II 4 mm 41 mm 7 months 38 mm 3 mm 85 min
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Jan 19, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Gap arthroplasty of temporomandibular joint ankylosis by transoral access: a case series
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