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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. 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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