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CLINICAL STUDY

Temporomandibular Joint Ankylosis: Algorithm

of Treatment
Rodrigo Fariña, DDS, Med,y Loreto Canto, DDS,z Renato Gunckel, DDS,z
Juan Pablo Alister, DDS, PhD,§ô and Francisca Uribe, DDS§ô

Temporomandibular joint ankylosis, according to age of onset,

causes severe functional and morphological disorders, as well as
T emporomandibular joint (TMJ) ankylosis is defined as fusion of
the joint’s component surfaces (hard and soft tissues). It tends to
occur in infants and adolescent patients. The most important clinical
stunted craniofacial growth and development. manifestation of TMJ ankylosis (TMJa) is the limitation or impos-
The primary goal of treatment is to resolve the functional and sibility of performing mandibular movements.1
morphological disorders. Treatment of TMJa is highly complex, due to its technical
Method: Pre- and posttreatment clinical and cephalometric difficulty and high rates of relapse. Knowledge of etiology, patho-
registries were conducted in 15 patients with temporomandibular physiology, and mandibular biomechanics is fundamental for ade-
joint ankylosis over a 10-year period (2002–2012). All the patients quate treatment, which must be conducted early to achieve
underwent complete removal of the ankylotic block, gap mandibular movement and prevent alterations in mandibular and
arthroplasty, and ipsilateral coronoidectomy. Distraction maxillary growth and development.1
osteogenesis was performed on 12 patients. The mandibular condyle is considered an important agent in
mandibular development due to its secondary cartilage.2 Accord-
Results: Fifteen patients, 8 female and 7 male, ranging from 3 to
ingly— as mandibular dynamics are restricted in people who have not
30 years of age, were included in this study. The posttreatment finished their craniofacial growth and development—vertical, sagit-
follow-up period ranged from 3 to 13 years. tal, and transverse development of the mandible on the affected side
The mean preoperative maximum mouth opening was 3  will be stunted, generating a facial asymmetry, and often, compromis-
1.7 mm, and the mean postoperative maximum mouth opening was ing correct growth and maxillary development. Furthermore, airway
36  6.5 mm. The labial inclination with respect to the true horizontal obstruction results from the lack of mandibular development.3
decreased considerably (6.28  2.38 preoperative to 18  1.68 post- Temporomandibular joint ankylosis can be classified in the follow-
operative). A correction of the mandibular deviation was measured ing ways: anatomically, as intracapsular or extracapsular; according to
at the symphysis with respect to the facial midline (88  28 pre- the tissue involved in the bone, as fibrous or fibro-osseous; and
operative to 28 postoperative). Finally, the height ratio of both according to the extent of fusion, as complete or incomplete.4
A new classification integrating both anatomical and functional
mandibular rami (the healthy side and the affected side) decreased
aspects was proposed by Chang, McCarthy, and Fariña in 2010.1
considerably (1.27  0.05 preoperative to 1.07  0.06 postoperative). Surgical treatment via arthroplasty is the only way to release a
Reankylosis only occurred in 2 patients, who were then suc- fused joint. Within the therapeutic alternatives, we mention those
cessfully treated by means of gap arthroplasty. performed within the ankylotic block and osteotomies performed at
Conclusions: The therapeutic algorithm proposed in the present a distance from the block,5 which consist of the resection of the
work provides favorable functional and morphological results. ipsilateral and eventually the contralateral coronoid process.1,4
Early and aggressive functional physiotherapy is essential to The main treatment objective of patients with ankylosis is to
minimize the risk of reankylosis. recover mandibular function; however, correcting the associated
facial deformity, improving the upper airway, reducing pain, and
preventing reankylosis are objectives that must be considered
Key Words: Ankylosis, distraction osteogenesis, gap arthroplasty, within the treatment.4,6 We divided the objectives into 2 funda-
mandibular distraction, temporomandibular joint, mental aspects that should be corrected in the same surgery and its
temporomandibular joint ankylosis, TMJ postoperative evolution:
(J Craniofac Surg 2017;00: 00–00) 1. Physiological:
 Mouth opening over 30 mm (interincisal distance consid-
ering maximum intercuspation as zero point)
From the Service of Oral and Maxillofacial Surgery Hospital del  Absence of pain in joint function
Salvador; yUniversidad de Chile; zDepartment of Oral and Maxillofacial
Surgery, Universidad de Chile, Santiago; §Department of Oral and  Recovery of respiratory function
Maxillofacial Surgery, Universidad de la Frontera, Temuco, Chile;  Recovery of masticatory function (normal diet)
and ôPhD in Medical Science, Faculty of Medicine, Universidad de  Prevention of reankylosis
La Frontera. Morphological:
Received July 10, 2017.  Allowance of normal mandibular growth and development
Accepted for publication August 19, 2017. 2.
Address correspondence and reprint requests to Rodrigo Fariña, DDS,  Reestablishment of facial equilibrium and balance
OMFS, Med, Hospital del Salvador, Providencia 2330, Appt. 23, (correcting the deficiency)
Santiago, Chile; E-mail: [email protected] The aim of this article is to establish a treatment algorithm for
The authors report no conflicts of interest.
Copyright # 2017 by Mutaz B. Habal, MD TMJa using bone transport for the reconstruction of the TMJ and
ISSN: 1049-2275 elongation of the mandibular ramus, with special emphasis on
DOI: 10.1097/SCS.0000000000004134 functional and morphological objectives.

The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017 1
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Fariña et al The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017

TMJA

Rami Height in affected side

Differences in mandibular Differences in mandibular

height < 10% height > 10%

< 10 years old > 10 years old

Interpositional GAP
Arthroplasty + DOG (until
levelling mandibular
angles)
Interpositional GAP
Interpositional
Arthroplasty + DOG (until
GAP Arthroplasty levelling mandibular angles)

Ipsilateral Coronoidectomy

Early and aggressive

physiotherapy

FIGURE 1. Treatment algorithm in temporomandibular joint ankylosis (TMJa).

DO, distraction osteogenesis.

METHODS
A surgical treatment protocol was administered to patients with
TMJa by the clinical practice of Dr Rodrigo Fariña (Hospital del
Salvador, Hospital Exequiel González Cortés, and private practice)
between 2002 and 2012 (Fig. 1).
Ankylosis was confirmed by a complete clinical study, radiog-
raphy, and computed tomography scan. Cephalometric studies
were performed on photographs, anteroposterior radiography, and
orthopantomography.
The clinical evaluation was done directly on the patient (mouth
opening) and with clinical frontal photographs that were standard-
ized with a digital grid (tilted lip commissure plane).
1. Maximum mouth opening: measured between incisal border of
upper and lower incisors with a caliper (Fig. 2A and B).
2. Tilted lip commissure plane: angle formed between a horizontal
line drawn from each pupil (bipupilar line) and bicommissure
plane (Fig. 2C and D).
The radiographic evaluation was done with a frontal and
panoramic X-ray
3. Deviation of the chin bone: the deviation of the chin was
measured in degrees by the angle formed by the skeletal midline
(vertical line in the middle of the base of the cristagalli
apophysis) and the straight line that connects the center of the
chin to the skeletal midline in the frontal x-ray (Fig. 2E and F).
4. Length of the mandibular ramus: this was determined by
measuring the distance in millimeters between the highest
condylar point and the gonial angle (total ramus height,
including the condyle) in the panoramic x-ray (Fig. 2G and H).
The same radiographic and computed tomography scan clinical
study was repeated 1 year after surgical treatment. FIGURE 2. (A) Maximum mouth opening before surgery. (B) Maximum mouth
The treatment algorithm is described in Figure 1. To achieve the opening after GAP arthroplasty and DOG. (C) Frontal view with tilted lip
commissure plane before surgery. (D) Frontal view with tilted lip commissure
aforementioned objectives, we propose that the treatment of TMJa
plane after GAP arthroplasty and DOG. (E) Posteroanterior cephalometric study
should consider: before surgery. (F) Posteroanterior cephalometric study after GAP arthroplasty
and DOG. (G) Panoramic x-ray before surgery. (H) Panoramic x-ray after GAP
1. Interpositional gap arthroplasty: consisting of the aggressive arthroplasty and DOG (patient 2).
removal of the ankylotic block that limits the mandibular
movement.
a. Aggressive resection of the ankylotic segment (Fig. 3A).

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The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017 Treatment of TMJa

of 0.5 mm every 12 hours, until symmetrization of both

mandibular rami is reached in accordance with the previous
clinical and imaging examination (Fig. 3B–D). The desired
clinical parameters such as maximum mouth opening, lip tilt,
correction of the mental deflection, and height of mandibular
angles are checked.
4. Early and aggressive physiotherapy, permanently: physiother-
apy is fundamental to ensure the stability of the results
achieved. It consists of opening and closing movements and
contralateral movements at least 4 times a day (30 repetitions of
the exercises each time).
This study was approved by the Ethics Committee of El
Salvador Hospital.

RESULTS
Fifteen patients participated in this study, 8 female and 7 male, with
an average age of 11.4 years (ages ranged from 5 to 30 years). The
characteristics of the group are described in Table 1.
Out of the 15 patients, 3 underwent gap arthroplasty alone and
FIGURE 3. (A) Intraoperatory GAP arthroplasty. (B) Computed tomography 12 underwent gap arthroplasty associated with distraction osteo-
scan with temporomandibular joint ankylosis and coronoid hyperplasia. (C)
Panoramic x-ray, showing 20 mm of distraction osteogenesis. (D) Computed
genesis (DO) for mandibular reconstruction (Figs. 2–4).
tomography scan after GAP arthroplasty and distraction osteogenesis Patients were followed up postoperatively for an average period
(patient 2). of 6.9 years (3–13 years). The postoperative course was without
adverse effects such as bleeding, infection, or motor complications
b. Formation of a space between the bony surfaces (10 mm due to facial nerve damage.
approx.), which allows free movement of the mandibular There were 2 patients of reankylosis during the follow-up period
segment. who were treated by a second gap arthroplasty with favorable
c. Joint covering: interpositional element with temporal fascia outcomes (1 in the first year of follow-up, the other in the
or disc remnant. 5th year of follow-up).
2. Ipsilateral coronoidectomy: after the removal of the ankylotic The maximum mouth opening increased significantly in all the
block, an ipsilateral coronoidectomy should be performed, patients from 3 mm SD  1.7 mm preoperative to 36 mm (SD 
which is in a higher position; with the removal of the ankylotic 6.5) postoperative. The labial inclination to the true horizontal
block it would move to the cephalic. decreased considerably from 6.168 (SD  2.3) preoperative to
3. Mandibular reconstruction: through the use of a bone transport 1.068 (SD  1.6) postoperative. The deviation of the chin was
disc, in case of severe asymmetries where the difference in corrected by relating it to the midfacial line, from 88 (SD  2)
height of both mandibular rami is greater than 10%. The goal of preoperative to 28 (SD  0.01) postoperative. Finally, the height
this reconstruction is to match the facial height of the ratio of both mandibular rami (healthy/affected side) decreased
diminished posterior affected side to the healthy side. The considerably from 1.266 mm (SD  0.047) preoperative to
transport disc is designed based on a reverse L-osteotomy, 1.071 mm (SD  0.063) postoperative (Table 2).
beginning in the sigmoid recess and ending at the posterior
border of the mandibular ramus. The internal distraction device DISCUSSION
is installed to separate the transport disk with a vertical vector. Temporomandibular joint ankylosis is a difficult pathological
After a 5-day latency period, the distractor is activated at a rate condition to address, due to the multiple consequences that it

TABLE 1. Patient Distribution According to Gender, Age, Side of Ankylosis, Treatment, Complication, Solution, and Total Follow-Up

Patient Gender Age Side of Ankylosis Treatment Complication Solution Follow-Up (Years)

1 F 12 Left GAP þ DOG Reankylosis Secondary gap arthroplasty 8

2 F 13 Right GAP þ DOG No 11
3 F 5 Left GAP No 8
4 F 30 Left GAP þ DOG No 13
5 M 6 Left GAP þ DOG Reankylosis Secondary gap arthroplasty 9
6 F 10 Bilateral GAP þ DOG No 7
7 M 13 Left GAP þ DOG No 6
8 M 8 Right GAP þ DOG No 5
9 M 10 Right GAP þ DOG No 5
10 F 9 Left GAP No 8
11 F 11 Right GAP þ DOG No 6
12 M 12 Right GAP þ DOG No 4
13 M 10 Left GAP þ DOG No 7
14 F 13 Left GAP þ DOG No 3
15 M 9 Left GAP No 4
Average 8F/7M 11.4 9 left/ 5 right/1 bilateral 3 GAP /12 GAP þ DOG 2 (13.3%) 6.9

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Fariña et al The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017

reported the use of mandibular body DO to correct micrognathia;

however, by his method it is not possible to recuperate the lost
posterior facial height, thus failing to achieve adequate facial sym-
metry in patients of unilateral ankylosis. The same is true of the DO
technique used by Kaban et al,4 because distraction is intended to
reconstruct the joint. We propose a vertical distraction whose vector is
planned to bring the transport disk to the desired area to establish the
new TMJ, in addition to the reconstruction of the mandibular ramus,
achieving a suitable posterior facial height.8
The use of external distractors offers disadvantages compared
with submerged devices, as they are less rigid and the distraction
rate is not 1:1 between the activation device and bone separation;
we do not recommend the use of these devices.9
It is important to mention that with the use of submerged
distractors located in the mandibular ramus, it becomes complex
to withdraw the device once the desired height is obtained. There-
fore, it is recommended to use Fariña screws because it facilitates
their removal, reduces manipulation of the recently distracted bone
segment, and reduces surgery time.10
While the ipsilateral coronoidectomy is mandatory, in our
experience it has not been necessary, under any circumstances,
to perform contralateral coronoidectomy.4
The stability of the treatment fundamentally depends on 2
factors:
1. Complete removal of the ankylotic block.
2. Active physiotherapy, together with serial control (in our
series of patients, 2 patients had relapse at the first and fifth
postoperative years).
Some authors propose the use of autologous grafts for the
reconstruction of the TMJ and mandibular ramus.4,11–14 Numerous
publications demonstrate the unpredictability of growth and devel-
opment with significant rates of relapse.12,15–18 Acute enlargement
of the vertical dimension, stretching of the soft tissues, and com-
pression of the graft with the skull base would be important factors
that increase the risk of reankylosis.
A gradual pace of distraction allows for a better adaptation of the
FIGURE 4. (A) Frontal view before surgery. (B) Maximum mouth opening
soft tissues, while giving a suitable time frame for physiotherapy
before surgery. (C) Computed tomography scan of external TMJ ankyloses. without compression of the transport disc with the base of the skull.
(D) Frontal view after GAP arthroplasty (3 years after surgery). (E) Maximum Finally, it is significant to mention the importance of postopera-
mouth opening after GAP arthroplasty (3 years after surgery). (F) Panoramic x- tive orthopedic management. The open bite that is generated by
ray of left external TMJ ankylosis before surgery. (G) Panoramic x-ray 3 years
after GAP arthroplasty (patient 10). TMJ, temporomandibular joint.
achieving the posterior facial height through DO should be con-
tained with an acrylic occlusal plane or by resin stops at the level of
posterior teeth. Such containment aims to avoid excessive com-
pression of the reconstructed TMJ or distracted bone tissue, thereby
entails, both functionally and aesthetically. Depending on the age of reducing the possibility of reankylosis and/or loss of the verticality
onset, it is associated with craniofacial asymmetry in the 3 senses of gained through DO due to bone compression.
space, further complicating the treatment. In still-growing patients, these containment stops gradually wear
The literature describes several therapeutic alternatives depend- out to allow vertical growth of the maxilla. If necessary, once the
ing on the age it appears, degree of deformation, and relapse. maxillofacial growth and development has been completed, the
The main objective of treatment is to recover adequate mastica- maxillary vertical deficit should be compensated by a Le Fort I
tory function; to this end, different authors have proposed the use of osteotomy, similar to that described by Fariña et al19 in the
DO as a complementary method in the treatment of ankylosis. Li et al7 treatment of craniofacial microsomia.

TABLE 2. Maximum Mouth Opening, Tilted Lip Commissure Pane, Deviation of the Chin Bone, and Length of the Mandibular Ramus, Before and After Surgery

TMJ Ankylosis Maximum Mouth Tilted Lip Commissure Deviation of the Length of the Mandibular Ramus
(n ¼ 15 Opening (mm) Plane (8) Chin Bone (8) (Health Side/Affected Side)

Before surgery 3  1.732 6.167  2.309 82 1.266  0.047

After surgery 36  6.557 1.06  1.607 2  0.01 1.071  0.063

TMJ, temporomandibular joint.

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The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017 Treatment of TMJa

CONCLUSIONS 9. Molina F, Ortiz Monasterio F. Mandibular elongation and re-modeling

The therapeutic algorithm proposed in the present work provides by distraction. A farewell to major osteotomies. Plast Reconstr Surg
favorable functional and morphological results. Early and aggres- 1995;41:825–841
10. Fariña R, Hinojosa A, Sánchez M, Olate S. A new screw design for
sive functional physiotherapy is essential to minimize the risk securing buried distractors usefulness and ease of removal. J Craniofac
of reankylosis. Surg 2015;26:e437–e438
11. Wolford L, Cottrell DA, Henry C. Sterno-clavicular grafts for
temporomandibular joint reconstruction. J Oral Maxillofac Surg
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