Bilateral temporomandibular joint ankylosis as sequel of bilateral fracture of the mandibular condyle and symphysis

Size: px

Start display at page:

Download "Bilateral temporomandibular joint ankylosis as sequel of bilateral fracture of the mandibular condyle and symphysis"

Alice Lane
5 years ago
Views:

$Bilateral temporomandibular joint ankylosis as sequel of bilateral fracture of the$ Janayna G Paiva Oliveira & Jose Carlos Garcia Mendonça Oral and Maxillofacial Surgery

Janayna G Paiva Oliveira & Jose Carlos Garcia Mendonça Oral and Maxillofacial Surgery

1 Bilateral temporomandibular joint ankylosis as sequel of bilateral fracture of the mandibular condyle and symphysis Matheus B Benaglia, Ellen Cristina Gaetti-Jardim, Janayna G Paiva Oliveira & Jose Carlos Garcia Mendonça Oral and Maxillofacial Surgery ISSN Volume 18 Number 1 Oral Maxillofac Surg (2014) 18:39-42 DOI /s z 1 23

2 Your article is protected by copyright and all rights are held exclusively by Springer- Verlag Berlin Heidelberg. This e-offprint is for personal use only and shall not be selfarchived in electronic repositories. If you wish to self-archive your article, please use the accepted manuscript version for posting on your own website. You may further deposit the accepted manuscript version in any repository, provided it is only made publicly available 12 months after official publication or later and provided acknowledgement is given to the original source of publication and a link is inserted to the published article on Springer's website. The link must be accompanied by the following text: "The final publication is available at link.springer.com. 1 23

3 Oral Maxillofac Surg (2014) 18:39 42 DOI /s z ORIGINAL ARTICLE Bilateral temporomandibular joint ankylosis as sequel of bilateral fracture of the mandibular condyle and symphysis Matheus B Benaglia & Ellen Cristina Gaetti-Jardim & Janayna G Paiva Oliveira & Jose Carlos Garcia Mendonça Received: 1 October 2012 / Accepted: 20 December 2012 / Published online: 10 January 2013 # Springer-Verlag Berlin Heidelberg 2013 Abstract Background Temporomandibular joint (TMJ) ankylosis is an extremely disabling affliction that causes problems in mastication, digestion, speech, appearance, and hygiene. The disease also has an impact on the psychological development of the patients. Case report A 49-year-old male patient came to our unit with complaint of restriction in his alimentation and of mouth opening. In the anamnesis, the patient reported that this limitation began 11 years ago, soon after a serious car accident that caused trauma on the face. In the clinical examination, the patient s mouth opening was 1 mm, and there was satisfactory occlusion. He was diagnosed with bilateral temporomandibular joint (TMJ) ankylosis after an imaging examination. Discussion In order to confirm the post-traumatic etiology of the anquilose, we got the medical records from the hospital where the patient received the first treatment. The records, at that time, reported facial trauma with bilateral condylar fracture and comminuted symphyseal fracture which was reduced and fixed followed by maxillomandibular fixation that remained for 45 days. After collecting all the information needed for diagnosis, surgical treatment was proposed through arthroplasty. The patient was placed on immediate post-operative jaw physiotherapy, and 12 months after surgery, his mouth opening improved to 35 mm. Thus, in our case, ankylosis may have been developed as a sequel of the mandibular fractures. Keywords Ankylosis. Temporomandibular joint. Sequel of bilateral fracture of the mandibular condyle and symphysis M. B. Benaglia : E. C. Gaetti-Jardim (*) : J. G. P. Oliveira : J. C. G. Mendonça Department Oral and Maxillofacial Surgery, College Hospital of the Federal University of Mato Grosso do Sul, Campo Grande, Brazil ellengaetti@gmail.com Background Temporomandibular joint (TMJ) ankylosis is an extremely disabling affliction that causes problems in mastication, digestion, speech, appearance, and hygiene. The disease also has an impact on the psychological development of the patients and can put his or her life in danger by the impossibility of mouth opening [1, 2]. Limitation of mouth opening can be caused by bony or fibrous ankylosis of the temporomandibular joint such as trauma sequel, infection, surgical failures, or autoimmune disease [1, 3, 4]. The pathogenesis can be distinguished into primary when the pathological process affects TMJ directly, as in the case of septic arthritis or rheumatic disease; and secondary, as in traumatic injury of the mandible, this is the most common cause of ankylosis [5]. A post-traumatic ankylosis arises from intra-capsular condylar fractures, hemarthrosis and secondary hematoma organization, and subsequent fibrosis and calcification [3, 5]. The severity of ankylosis was classified according to SAWHNEY [3] with type I condylar head flattened or deformed but closely approximated to the upper articular surface with fibrous adhesions around the joint; type II condylar head misshaped or flattened but still distinguishable and in close approximation to the articular surface, bony fusion of the head to the outer edge of the articular surface; type III a bony block bridges across the ramus of the mandible and the zygomatic arch, and the displaced condylar head is atrophic and lying either free or fused to the medial side of the ramus; and type IV a wide bony block between the ramus and the upper articular surface completely replacing the architecture of the joint. The diagnosis of TMJ ankylosis established through physical examination and clinical evaluation, complemented by an imaging examination. The primary sign of this condition is the limitation of mouth opening, in view of the character of

40 Oral Maxillofac Surg (2014) 18:39 42 asymptomatic disease. Imaging diagnosis is essential in differentiating and in evaluating of the degree of ankylosis.

Coronal CT scans are helpful in elucidating the delayed state of the pathological hard tissue and can also change the plan of treatment in accordance with the imaging diagnosis [5].

4 40 Oral Maxillofac Surg (2014) 18:39 42 asymptomatic disease. Imaging diagnosis is essential in differentiating and in evaluating of the degree of ankylosis. Currently, the computer tomography (CT) scan is the gold standard for assessment of TMJ hard tissue. Coronal CT scans are helpful in elucidating the delayed state of the pathological hard tissue and can also change the plan of treatment in accordance with the imaging diagnosis [5]. The treatment of choice for ankylosis of the TMJ is always surgical. This treatment permits the removal of all rigid bone mass that involves the articulation, creating enough space to allow the interposition or even full reconstruction of TMJ with customized prostheses. However, there are no consensuses in the existing literature of the best treatment for TMJ ankylosis. Several authors studied and developed different techniques, but recurrence still remains as the major problem when treating TMJ ankylosis [2]. The critical factor of successful treatment of TMJ ankylosis, at long term, is early detection, implementation of an intensive physiotherapy program, and a good post-operative conduct. Long period of physical therapy is essential for obtaining good results in treatment. The main objective of this treatment is to prevent bone neoformation in articulations, as well as to minimize fibrosis and to prevent scar retraction, trismus, atrophy, and muscle spasms [6]. Knowing that literature is dynamic, in terms of revealing new cases of this disease with different forms of treatment, the goal of this work was to link bilateral condyle fracture with symphysis mandibular as a risk factor for the development of bilateral ankylosis TMJ, as well as to present the treatment proposed for our case. Case report A 49-year-old white man was referred to the College Hospital of the Federal University of Mato Grosso do Sul, Brazil, with complaint of restriction in his alimentation, limited mouth opening of about 1 mm, impossibility to get appropriate dental treatment, and difficulty in oral hygiene. In the anamnesis, the patient reported a history of facial trauma 11 years ago due to a car accident. In the current clinical and physical examination, his maximal mouth opening was 1 mm, absence of some teeth due to their earlier loss with satisfactory occlusion and without complaint of pain (Fig. 1a). There was a palpable bilateral bone prominence on the preauricular region. Meantime, in a frontal view, the patient did not present face widening. The diagnostic hypothesis was TMJ ankylosis. A panoramic radiography helped in the diagnosis and showed the synthesis material used for treating of the symphytic fracture (Fig. 4b). Coronal CT scans confirmed diagnosis of bilateral ankylosis of the TMJ. In this examination, we observed various dense radiopaque masses, with bilateral union of the mandibular Fig. 1 a Absence of some teeth due to their earlier loss with satisfactory occlusion and without complaint of pain. b Ankylosis was classified as type III on the left and type IV on the right side condylar to the temporal bone. The fusion of the TMJ bone was more severe on the right side than on the left, where displacement of the condylar medial head with ossification extending to the zygomatic arch and to the lateral base of the skull could be observed. Based on these transoperative findings (Fig. 2a, b) and on the images, the ankylosis was classified as type III on the left and type IVon the right side [2](Fig.1b). In order to confirm post-traumatic etiology of the ankylosis, we got the medical records from the hospital where the patient received the first treatment. The diagnosis, at that time, was a bilateral condylar fracture, comminuted symphyseal fracture, and fracture of the left femur. The proposed treatment for mandibular fractures was exploratory surgery of the two condyles with preauricular access, however, without fixation or reduction of the fracture. On the mentum, the fracture was reduced and fixed with steel wire with intra-oral access (Fig. 4b). The maxillomandibular fixation (MMF) was removed 45 days after surgery, and Fig. 2 a, b The fusion of the TMJ bone was more severe on the right side than on the left, where displacement of the condylar medial head with ossification extending to the zygomatic arch and to the lateral base of the skull could be observed

Oral Maxillofac Surg (2014) 18:39 42 41 Fig. 3 a, b A gap of at least 15 mm between the top of the fossa and the mandible soon after, a severe restriction in the opening of mouth was present.

However, according to records, the patient progressed well and without signs or symptoms of infection. The surgical procedure was performed under general anesthesia.

5 Oral Maxillofac Surg (2014) 18: Fig. 3 a, b A gap of at least 15 mm between the top of the fossa and the mandible soon after, a severe restriction in the opening of mouth was present. This clinical report did not improve with postoperative physiotherapy and only worsened over the years. However, according to records, the patient progressed well and without signs or symptoms of infection. The surgical procedure was performed under general anesthesia. The use of nasofibroscopy was required during the nasotracheal intubation process. The surgical exposure was by means of a combined preauricular and an extended temporal incision. The ankylosis bone was widely exposed, and an aggressive resection of the bone mass was done. A gap of at least 15 mm between the top of the fossa and the mandible was created (Fig. 3a, b), and passive interincisal mouth opening of at least 30 mm was achieved. A tight dressing was done on the preauricular region. Mandibular movements began immediately after the patient became conscious, and rigorous physiotherapy was done during a period of 6 months post-surgery. After 12 months of follow-up, mouth opening of 35 mm was established (Fig. 4a). The morphology of TMJ post-ankylosis of 26 patients was evaluated on the coronal CT scan to determine if the condylar fracture originated from a disease. In this study, the authors concluded that patients who suffered medially dislocated condylar fracture, especially in bilateral cases, are more likely to develop this disease when compared with other kinds of condyle fractures. Slight jaw mobility could be associated with this kind of fracture, which could contribute to the development of the disease. This combination, according to the authors, requires strict monitoring and physiotherapy, particularly in pediatric patients. Moreover, it was noted that ankylosis often developed lateral to the condylar head which is located at the medial portion of the glenoid fossa. Though, the condylar head is united to the medial portion of the ramus, it remained separated from the cranial base [3, 7]. The tomographic findings of our study were similar to this study (Fig. 1b). A retrospective study with 50 patients, with ages ranging from 0 to 30 years, assessed the causes of the TMJ ankylosis. They pointed out that trauma was the primary causative factor of ankylosis, representing 86 % of the cases. Results found in other similar studies [1 5, 7 10]. However, it was noted that Discussion Ankylosis of the TMJ can occur at any age; however, it has a higher incidence in younger patients [3]. Moreover, the evolution of the pathological process is more severe in children because of the defective cartilage osteogenesis damaged by the ankylotic process and of the loss of muscle guidance over the mandibular growth process [4]. In adults, the changes of secondary maxillofaciais alterations due to the ankylotic blockage are less complex and can be resolved after restoration of the joint function [4]. Some etiologies of TMJ ankylosis are common to both adults and children, such as long-term immobilization for facial fracture; commitment of the articulate disk; fractures of the condyle; fractures of the middle third of the face, especially those involving the zygomatic arch and mandibular coronoid process; intrinsic and extrinsic conditions that can cause contacts between the bone surfaces of the TMJ next to the bruising, which can stimulate the local osteogenesis and facilitate immobility [3, 4]. Fig. 4 a After 12 months of follow-up, mouth opening of 35 mm was established. b A panoramic radiography helped in the diagnosis and showed the synthesis material used for treating of the symphytic fracture

6 42 Oral Maxillofac Surg (2014) 18:39 42 the results obtained by simple arthroplasty and creation of a 15- mm gap between the glenoid cavity and the mandibular ramus, associated with mandibular coronoidectomy and immediate post-operative exercises, were satisfactory, regardless of the patient s age [2]. In our case, the ankylosis also developed after trauma, and the result after treatment, except for conducting the coronoidectomy, was similar and also satisfactory. In a retrospective study of TMJ ankylosis, 25 patients were evaluated. Of these patients, 52 % (13 of 16 cases) already received treatment in other fractured regions before developing the disease. All the cases of ankylosis were associated with condylar fracture. However, surgical treatment for restoration of the mandibular arch was inappropriate in most cases (11 of 13 cases). The locations of the ankylosis in these patients were usually between the raw edge of the condylar with the lateral and inferior portion of the zygomatic arch. The lateral pole of the condyle was laterally or superior laterally located, indicating that the treatment of the symphyseal or body fracture(s) was inadequate. The very treatment of the anterior jaw fractures could help prevent the development of TMJ ankylosis [8]. Meanwhile, the association between TMJ ankylosis and other mandibular fractures is rarely discussed in the literature. Treatment should be properly directed in order to reduce fractures of the mandibular body and the mandibular symphysis to achieve a correct intercondylar distance [8]. This, by itself, should prevent the lateral displacement of the ramus stump so that it does not move superiorly, over the edge of the glenoid fossa, where it could merge with the zigoma [8]. However, most patients in the study suffered under-reduction fractures of the anterior mandible, accompanied by increase in the intercondylar distance, resulting in superolateral or lateral displacement of the condyle, wide face, or crossbite [8]. This occurs most often because these patients are treated by surgeon who had little experience in the treatment of facial fractures [8]. Inexperience may be the main reason of the long period of MMF [5, 8]. Therefore, if the problem was adequately cared for, the development of the ankylosis might have been partly iatrogenic. This assumption was confirmed in our case report. Regardless of the procedure performed, the literature unanimously found that anatomical restoration of the mandibular condyle associated with early mobilization with aggressive physical therapy is the best way to avoid a new temporomandibular ankylosis. The same is also true in condylar fractures regardless of the technique used, with an open or closed, a regimen of exercise mandibular is essential for a successful outcome as demonstrated by Hlawitschka et al. [11] and Eckelt et al. [12]; physiotherapy can also be used with positive effect on pain relief and restoration of function. In our study, we observed that ankylosis of the TMJs developed after a bilateral fracture of the condyle and of the mandibular symphysis. Thus, we can conclude that when associated, these fractures promote the development of articulated ankylosis. We also observed that inadequate treatment of these fractures could lead to the development of the disease. Ethical approval The approval of the Committee on Ethics in Research/CEP/UFMS granted approval of this work through the free informed consent given to the patient responsible for the reporting of this case. Number of protocol: References 1. He D, Yang C, Chen M, Yang X, Li L (2012) Effects of soft tissue injury to the temporomandibular joint: report of 8 cases. Br J Oral Maxillofac Surg doi: /j.bjoms Roychoudhury A, Parkash H, Trikha A (1999) Functional restoration by gap arthroplasty in temporomandibular joint ankylosis: a report of 50 cases. Oral Surg Oral Med Oral Pathol 87: Sawhney CP (1986) Bony ankylosis of the temporomandibular joint: follow-up of 70 patients treated with arthroplasty and acrylic spacer interposition. Plast Reconstr Surg 77: Valentini V, Vetrano S, Agrillo A, Torroni A, Fabiani F, Iannetti G (2002) Surgical treatment of TMJ ankylosis: our experience (60 cases). J Craniomaxillofac Surg 13: Toyama M, Kurita K, Koga K, Ogi N (2003) Ankylosis of the temporomandibular joint developing shortly after multiple facial fractures. Int J Oral Maxillofac Surg 32: Friedman MH et al (1993) Postsurgical temporomandibular joint hypomobility: rehabilitation. Rev Cir Traumatol Buco-Maxilo-Fac 5(4): Ferretti C, Bryant R, Becker P, Lawrence PC (2005) Temporomandibular joint morphology following post-traumatic ankylosis in 26 patients. Int J Oral Maxillofac Surg 34: He D, Ellis E III, Zhang Y (2008) Etiology of temporomandibular joint ankylosis secondary to condylar fractures: the role of concomitant mandibular fractures. J Oral Maxillofac Surg 66: Rattan V (2002) Superolateral dislocation of the mandibular condyle: report of 2 cases and review of the literature. J Oral Maxillofac Surg 60: Vasconcelos BCE, Bessa-Nogueira RV, Cypriano RV (2006) Treatment of temporomandibular joint ankylosis by gap arthroplasty. Med Oral Patol Oral Cir Bucal 11: Hlawitschka M, Loukota R, Eckelt U (2005) Functional and radiological results of open and closed treatment of intracapsular (diacapitular) condylar fractures of the mandible. Int J Oral Maxillofac Surg 34(6): Eckelt U, Schneider M, Erasmus F, Gerlach KL, Kuhlisch E, Loukota R, Rasse M, Schubert J, Terheyden H (2006) Open versus closed treatment of fractures of the mandibular condylar process a prospective randomized multi-centre study. J Craniomaxillofac Surg 34(5):

Conventional radiograph verses CT for evaluation of sagittal fracture of mandibular condyle

$Conventional radiograph verses CT for evaluation of sagittal fracture of mandibular condyle$ Case Report: Conventional radiograph verses CT for evaluation of sagittal fracture of mandibular condyle Dr Anjali Wadhwa, Dr Gaurav Shah, Dr Shweta Sharma, Dr Anand Bhatnagar, Dr Pallavi Malaviya NIMS