Download Temporomandibular joint Ankylosis – A Case Report

CASE REPORT
Temporomandibular joint Ankylosis – A Case
Report
Manoj Meena*, Nigel R. Figueiredo*, Amit Soni **
Abstract
Temporomandibular Joint (TMJ) ankylosis is a condition in which condylar movement is limited
by a mechanical problem in the joint ("true ankylosis")or by a mechanical cause not related to joint
components ("false ankylosis"). True ankylosis may be bony or fibrous. In bony ankylosis, the
condyle or ramus is attached to the temporal or zygomatic bone by an osseous bridge. In fibrous
ankylosis a soft tissue (fibrous) union of joint components occurs; the bone components appear
normal. False ankylosis may result from conditions that inhibit condylar movement, such as muscle
spasm, myositis ossificans, or coronoid process hyperplasia.
Most unilateral cases are caused by mandibular trauma or infection. The most common cause of
bilateral TMJ ankylosis is rheumatoid arthritis, although in rare cases bilateral fracture may be the
cause.
Here we report a case of TMJ ankylosis in a 10 year-old male patient showing most of the
characteristic features of this condition.
(Meena M, Figueiredo NR, Soni A. Temporomandibular
www.journalofdentofacialsciences.com, 2013; 2(4): 35-39).
Joint
Ankylosis
–
A
Case
Report.
Key words:
Introduction
Temporomandibular joint (TMJ) Ankylosis
involves fusion of the mandibular condyle to the
*Oral & Radiology Department, Goa Dental College &
Hospital, Bambolim, Goa
**Oral Medicine and Radiology Department, Darshan
Dental College & Hospital, Udaipur, Rajasthan
Address for Correspondence:
**Dr Manoj Meena, D/o Mr Kirodemal Meena
Ward No. 3, Brij Colony, V.P.O. Ratan Nagar
District Churu, Rajasthan
e-mail: [email protected]
base of the skull. When it occurs in a child, it can
have devastating effects on the future growth and
development of the jaws and teeth. Furthermore,
in many cases it has a profoundly negative
influence on the psychosocial development of the
patient, because of the obvious facial deformity,
which worsens with growth. Trauma and infection
are the leading causes of ankylosis.1 However, in a
young patient a joint injury may not be noticed
immediately. The first sign of a significant problem
may be increasing limitation of jaw opening,
usually noticed by the dentist. Pain is uncommon.
Early diagnosis and treatment are crucial if the
worst sequelae of this condition are to be avoided.
Meena et al.
36
Optimal results can be achieved only after a
complete assessment and development of a longterm treatment plan. We present a case report of
TMJ ankylosis diagnosed and successfully treated
in the early teen years2.
Case Report
A 10-year-old male patient reported to our
department with a chief complaint of difficulty in
opening his mouth and pain in lower left front
teeth region since 1 month.
Patients’ mother gave history of normal
delivery, No H/o forceps using during delivery, No
H/o trauma. She also gave history of fever and
vomiting after 4 days of birth because of that
patient was hospitalized than she noticed facial
asymmetry. History of difficulty in eating food and
habit of mouth breathing. No relevant history of
ear infection, weight loss, drug history and family
history.
General physical examination demonstrated
with medium built, height was 4 feet; weight was
33 kg with normal gait. No signs of icterus, pallor
and anaemia.
On extra oral examination obvious facial
asymmetry,( fig.1 ) Flattening on the right side of
the face, Fullness, roundness on left side (affected
side of face), (fig.2) Deviation of mandible toward
the left side (Affected side), (fig. 1). Prominent
antigonial notch present on left side of face.
Retrognathic mandible with TMJ movements was
restricted.
Intraoral examination revealed mouth opening
was restricted 0.9 cm, (fig.3 ) and lower left
deciduous canine was grade II mobile.
Figure 2: Profile view ( left side)
Figure 3: Interincisal opening (0.9 cm)
On the basis of clinical examination, the
patient
was
diagnosed
as
having
left
Temporomandibular ankylosis for which the
differential diagnoses included condylar tumour
muscle spasm and fracture of mandible.
Radiological investigations included an
orthopantomogram, computed tomography and
blood investigation were carried out.
Figure 4: Orthopantomograph
Figure 1: Exra-oral view
www.journalofdentofacialsciences.com
The orthopantomogram, (Fig. 4) revealed
elongation of left coronoid process of mandible
with prominent antigonial notch on affected side
and narrow joint space.
Vol. 2 Issue 3
Meena et al.
37
CT scan, (Fig. 5) revealed joint space
preserved, irregular erosion of articulating surface
suggesting of fibrous ankylosis.
Figure: 7 Exra–oral view
(post-perative)
Figure 8: Profile view
(post-operative)
Figure: 9
Interincisal
opening (1.5
cm)
Figure 5: CT- scan OF TMJ (Coronal Section)
Haematological investigations were normal in
range except eosinophil count was high 8%. Liver
and renal functions were normal in limit.
Six month follow-up (Post-operative)
Figure: 6 MRI of TMJ (panoramic view) : One month
follow-up (Post- operative )
After
completing
all
the
necessary
investigations, the patient was confirmed as having
fibrous ankylosis of left Temporomandibular joint.
After complete evaluation, release of fibrous
ankylotic mass, gap arthroplasty,on left TMJ, right
and left side coronoidectomy and interposition
with costochondral graft and exraction of lower
left deciduous canine followed by regular follow–
up till one year, and mouth opening is increased
3cm (fig.5), scaling and polishing , physiotherapy
and orthodontic consultation for functional
appliances.
www.journalofdentofacialsciences.com
Figure: 10 Exra–oral view
Figure: 11 Profile view
Discussion
Ankylosis is a condition in which condylar
movement is limited by a mechanical problem in
the joint (‘true’ ankylosis) or by mechanical cause
not related to joint components (‘false’ ankylosis).3
¾ True Ankylosis - is of two types:
Bony: condyle or ramus is attached to the
temporal bone by an osseous bridge
Vol. 2 Issue 3
Meena et al.
38
Fibrous: soft tissue union of joint components
occurs, bone components appear normal
¾ False Ankylosis - may result from conditions
that inhibit condylar movement like muscle
spasm, myositis ossificans or coronoid process
hyperplasia.
One year follow-up (Post- operative)
Figure: 12
Interincisal
opening (3
cm)
Figure: 13 Orthopantomograph (post-operative)
Figure 14:
Lateral
cephalograph
(postoperative)
Causes
Inflammatory destruction of synovial lining of
joint. Inflammation may result from,4
www.journalofdentofacialsciences.com
- Primary infection of joint
- Extension from neighbouring infection such as
otitis media, mastoiditis, osteomyelitis of
mandible
- Blood-borne infection from several sources
- Trauma to the joint
- Rheumatoid diseases like rheumatoid arthritis,
ankylosing spondylitis, Reiter’s syndrome
- Hemarthrosis (such as those occurring in
haemophiliacs)
Children are more prone to ankylosis because
of greater osteogenic potential and an
incompletely formed disc. Ankylosis frequently
results from prolonged immobilization following
condylar fracture.5
Moreover in case of TMJ ankylosis, an
appropriate worldwide accepted protocol is to be
administered which includes surgical intervention,
elaborate resection early mobilization and
aggressive physiotherapy for at least 6 months to
one year postoperatively.6
It is said that a child learns to explore the world
through his mouth! Any pathology that afflicts the
TMJ and restricts the mouth opening carries a
mental stigma that overweighs the physical
disability posed by the problem in growing
children. Speech aberrancy, poor oral hygiene,
rampant caries and behavioural problem pose
unique challenge to dentist.7
Early aggressive postoperative physiotherapy
has been recognized as an essential for the
prevention or treatment of TMJ hypo mobility or
ankylosis. The biological and physiological basis
for increasing the range of motion using dynamic
exercise in restoring normal functions after surgery
and prolonged immobilization has been well
documented in trauma, orthopaedic and physical
therapy literature. The potential benefits of TMJ
opening and closing exercises are improved
muscle vascularity, increased muscle mass and
protein metabolism, decreased muscle fatigue and
increased strength, reversal of the atrophic and
degenerative changes within the joints and
restoration of the normal internal fibrous structure
anatomy.8
Vol. 2 Issue 3
Meena et al.
Interpositional Gap Arthroplasty is a highly
effective and safe surgical management option for
TMJ ankylosis with acceptable immediate and long
term outcome, particularly when temporalis fascia
and muscle are used for adults and costochondral
grafts with fascia interposition used for children.9
A 7-step protocol has been developed for the
treatment of TMJ ankylosis: 1) aggressive resection
of the ankylotic segment, 2) ipsilateral
coronoidectomy, 3) contralateral coronoidectomy
when necessary, 4) lining of the joint with
temporalis fascia or cartilage, 5) reconstruction of
the ramus with a costochondral grafts 6) rigid
fixation of the graft and 7) early mobilization and
aggressive physiotherapy.10
Conclusion
Ankylosis of the TMJ is a worrisome condition
of children and adolescent which prevents normal
feeding habits, impairs speech and causes facial
deformity; but if proper diagnosis, adequate
surgical intervention is carried out on time and
with an intensive follow-up, prognosis is good.
References
1. Treatment of Temporomandibular JoinAnkylosis: A
Case Repo Bob Rishiraj, Leland R. McFadden, J
Can Dent Assoc 2001; 67(11):659-63
2. Treatment of Temporomandibular joint ankylosis :
A Case Report Geetanjali Mandlik etal. Scientific
Journal Vol. II – 2008
www.journalofdentofacialsciences.com
39
3. White & Pharoah. Textbook of Oral Radiology 6th
edition , Diagnostic imaging of Temporomandibular
joint page no 500.
4. principles & practice of oral radiologic
interpertation
,H.M
Worth
TH
,
The
Temporomandibular joint page no,663-665.
5. Ankylosis of temporomandibular joint in children A
Case report Indian Soc Pedod Prev Dent Year :
2009 Volume : 27 Issue : 2 Page : 116-120
6. Temporomandibular Joint Ankylosis with incidental
findings of Odontogenic
keratocyst and Mucous
Retention Cyst: Report of a Case Pawan Motghare,
Aarti Bedia, Sumit Bedia Sangeeta Bhattacharya
IOSR Journal of Dental and Medical Sciences
(IOSR-JDMS) Volume 4, Issue 2 (Jan. - Feb.
2013), PP 27-33
7. Shashukiran ND, Reddy SVV, Patil R. Yavagal C.
Management o temperomandibular
joint
ankylosis in growing children. J IndianSoc Pedo
Prev Dent 2005; 35-37
8. Chun-Li L, Yu-Chan K, Lun-Jou L. Design,
Manufacture and clinical evaluation of a new TMJ
exerciser. Biomed Eng Appl Basis Comm 2005; 17:
135-140.
9. Iram A, Muhammad J, Muhammad J, Shah MG.
Temporomandibular joint ankylosis: Experience
with interpositional gap arthroplasty at Ayub
Medical College Abbottabad. J Ayub Med Coll
Abbottabad 2005; 17: 67-69.
10. Westermark AH, Sindet-Pedersen SS, Boyne PJ.
Bony ankylosis of the temporomandibular
joint:Case report of a child treated with Delrin
Condylar implants. J Oral Maxillofac Surg
1990;48:861-5.
Vol. 2 Issue 3