PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 29 no. 2 July – december 2014

CASE REPORTS

28 PhiliPPine Journal of otolaryngology-head and neck Surgery

Philipp J Otolaryngol Head Neck Surg 2014; 29 (2): 28-31 c Philippine Society of Otolaryngology – Head and Neck Surgery, Inc.

ABSTRACT
Objectives: To present a case of bilateral temporomandibular joint ankylosis that was
managed successfully through gap arthroplasty.

Methods:
Design: Case Report
Setting: Tertiary Government Hospital
Patient: One

Results: A 25-year-old man presented with inability to open his mouth for 18 years after
direct trauma to his chin. CT scan showed bilateral bony fusion of condyles to glenoid
fossae, hypertrophic sclerosis and fusion of the condylar heads to the temporal bones.
He underwent bilateral gap arthroplasty via preauricular approach with creation of a
15 mm space on the mandibular fossa. As of latest follow up, the patient maintained an
inter-alveolar distance of 30 mm for five months postoperatively through continuous
aggressive mouth opening exercises.

Conclusion: Gap arthroplasty may be an efficient procedure for temporomandibular
joint ankylosis in achieving satisfactory post-operative inter-alveolar opening and
articular function. Early and meticulous rehabilitation is required to prevent relapse.
Long-term follow up is recommended to document possible recurrence.

Keywords: temporomandibular joint ankylosis, gap arthroplasty, TMJ ankylosis, ankylosis

Temporomandibular joint (TMJ) ankylosis is the union of articular surfaces
(mandibular condyle to the cranial base) by means of osseous and/or fibrous tissue
with partial or complete mandibular impediment.1 The most common etiologic factors
include trauma (13-100%), infections (10-49%), rheumathoid arthritis (10%), congenital
anomalies and neoplastic processes.2

It is a condition leading to problems in mastication, digestion, speech, facial and oral
hygiene. When acquired at childhood, devastating effects are observed during growth
and development of teeth and jaws. It can negatively influence the psychosocial
behavior of the patient due to the consequent facial deformity magnified as the child
grows.2 Various methods have been used to manage TMJ ankylosis including gap
arthroplasty, interpositional arthroplasty and joint reconstruction by bone grafts or
joint prosthesis.1,2,3 Recent studies advocate distraction osteogenesis in management
of TMJ ankylosis as it provides excellent cosmetic results.4

A local report in 1984 by Nolasco et al. involved a case of bilateral TMJ ankylosis
treated with interpositional arthroplasty wherein 5 mm length of the bone was removed
from edge to edge then interposed with temporalis fascia and muscle.4 The patient

Gap Arthroplasty of Bilateral
Temporomandibular Joint AnkylosisFerdinand Z. Guintu, MDAlexander T. Laoag, MD

Joselito F. David, MD

Department of Otorhinolaryngology
Head and Neck Surgery
Jose R. Reyes Memorial Medical Center

Correspondence: Dr. Joselito F. David
Department of Otorhinolaryngology - Head and Neck Surgery
Jose R. Reyes Memorial Medical Center
San Lazaro Compound, Rizal Avenue
Sta. Cruz, Manila 1003
Philippines
Phone: (632) 743 6921; (632) 711 9491 local 320
Email: entjrrmmc@yahoo.com
Reprints will not be available from the authors.

The authors declared that this represents original material
that is not being considered for publication or has not been
published or accepted for publication elsewhere, in full or in
part, in print or electronic media; that the manuscript has been
read and approved by all the authors, that the requirements
for authorship have been met by each author, and that each
author believes that the manuscript represents honest work.

Disclosures: The authors signed disclosures that there are no
financial or other (including personal) relationships, intellectual
passion, political or religious beliefs, and institutional affiliations
that might lead to a conflict of interest.

Presented at: Interesting Case Contest, Philippine Society of
Otolaryngology Head and Neck Surgery, Iloilo Grand Hotel,
Iloilo City, Philippines, April 28, 2012.

PhiliPPine Journal of otolaryngology-head and neck Surgery 29

PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 29 no. 2 July – december 2014

CASE REPORTS

failed to follow up two weeks postoperatively and no further
documentation of success or recurrence could be made.4

Gap arthroplasty can be an additional armamentarium for
practicing otolaryngologists in developing countries where a
major reason for delayed management is the lack of adequate
resources. Our goal was to perform a simple yet effective
procedure amenable to our Filipino patients. We present a
case of bilateral temporomandibular joint ankylosis that was
managed successfully through gap arthroplasty. To the best of
our knowledge, this is the first such case documented in the
Philippines.

CASE REPORT

A 25-year-old man consulted due to inability to open his
mouth. At the age of 7 years, he hit his chin on the handlebar
of a jeepney during a vehicular accident. He was admitted with
multiple contusions and discharged on the fifth hospital day. A
week after discharge, he experienced gradual and progressive
limitation of jaw movement. He consulted his attending
physician and was advised that the limitation of jaw movement
was due to infection. Antibiotics did not improve his symptoms
and he ceased to follow-up. He had progressive loss of jaw
movement but was able to feed himself by inserting shredded
pieces of noodles and meat through the small space between
his teeth.

Physical examination revealed a classical ‘bird face
appearance.” (Figure 1A) There was excessive vertical overlap of
the maxillary incisors (overbite), horizontal extension anteriorly
of the maxillary incisors (overjet), dental caries and periodontal
disease. Mouth opening is measured via inter-incisal distance
but for edentulous cases, inter-alveolar distance is used. Our
patient had zero inter-alveolar distance. (Figure 1B) There were
no gliding, protrusion and lateral movements of the mandible.

mandibular bodies with inward displacement of the symphysis
mentum. (Figure 2)

Figures 1A. Retrognathia “bird face” appearance; B. Inter-alveolar distance of zero

A B

Facial CT scans revealed bilateral bony fusion of the condyles
to the glenoid fossae, hypertrophic sclerosis with fusion of the
condylar heads to the temporal bones and shortening of the

Figure 2. Hypertrophic sclerosis and fusion of the lateral aspect of condylar heads to the temporal
bone.

Figures 3A & B. Intraoperative finding of bilateral bony fusion of condyle and coronoid on the
temporal bone

After extensive literature review of the pros and con of the
three commonly used treatment modalities for TMJ ankylosis,
we decided on gap arthroplasty. It is cheap, yet effective in
achieving desired mouth opening, less invasive with no donor
site morbidity. The operation was explained to the patient and
he consented to the surgery. Under general anesthesia via
tracheostomy, both TMJ were exposed through a preauricular
approach taking care to preserve the branches of the facial

PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 29 no. 2 July – december 2014

CASE REPORTS

30 PhiliPPine Journal of otolaryngology-head and neck Surgery

nerve. After exposure and identification of the sites of ankylosis
(Figure 3), the fibrous and bony masses were aggressively
excised with round burs and chisels until adequate mandibular
movements were achieved. Bilateral coronoidectomies were
also performed. A gap of 15 mm was created between the re-
contoured glenoid fossa and mandible. (Figure 4) The cut sharp
edges were smoothened with diamond burs.

DISCUSSION
Ankylosis of the TMJ is a challenging problem for both the

patient and surgeon. Over the years, fundamental principles of
TMJ surgery and “trial and error” have shaped the evolution of
different techniques to correct the problem.6

In this case, trauma directed to the patient’s chin led to
bilateral condylar fractures. Neglected condylar fractures
resulted in TMJ ankylosis.

TMJ ankylosis is classified according to location (intra or extra-
articular), type of tissue (osseous, fibrous, or fibro-osseous) and
the degree of union (partial or complete) involved.1 It is further
classified into true and false ankylosis. True ankylosis results in
osseous or fibrous adhesion between the surfaces of the TMJ,
while false ankylosis results from diseases not directly related
to the joint. Sawhney in 1986 classified TMJ ankylosis into
four different types: Type I- presence of fibroadhesions at the
condyle; Type II – bone fusion with condyle remodeling and an
intact medial pole; Type III – anquilotic mass, mandibular ramus
union with the zygomatic arch and medial pole intact; and Type
IV – complete anquilotic mass, total union of the mandibular
ramus with the zygomatic arch.7 Our patient’s TMJ ankylosis was
classified as intra-articular, fibroosseus, partial union and type II
(only the lateral aspect has bony fusion).

The diagnostic process consists of physical and radiographic
examinations (CT with three-dimensional (3D) reconstruction).
Radiographic findings include condylar deformation, narrowing
or irregularities at the inter-articular space. Early diagnosis and
treatment are pivotal to avoid sequelae.3 In our case, financial
constraints wasted 18 years without treatment. The best results
can be achieved after complete evaluation and establishment of
long-term treatment planning.

A variety of treatment techniques have been described in the
literature. The three most commonly used are gap arthroplasty,
interpositional arthroplasty and excision of ankylosed bone
with articular reconstruction.1,2,3 Vasconcelos et al. reported

Figures 4A & B. A 15mm space created on bilateral mandibular fossa

One week postoperatively, the patient had an inter-alveolar
distance of 30 mm. (Figure 5) Physiotherapy included stretching
and electrical stimulation of muscles of mastication and the
contract-hold-relax technique for masticatory muscles. At five
months post-physiotherapy, he had gained weight and was
well satisfied with the operation. Inter-alveolar distance then
remained at 30 mm. (Figure 6)

Figure 5. One week postoperative inter-alveolar distance of 30 mm

Figure 6. A 30mm interalveolar distance 5 months post operatively

PhiliPPine Journal of otolaryngology-head and neck Surgery 31

PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 29 no. 2 July – december 2014

CASE REPORTS

REFERENCES

1. de Andrade LH, Cavalcante MA, Raymundo R Jr, de Souza IP. Temporomandibular joint
ankylosis in children. J Dent. Child. 2009 Jan-Apr; 76(1): 41-5.

2. Vasconcelos BC, Porto GG, Bessa-Noguiera RV, Nascimento MM. Surgical treatment of
temporomandibular joint ankylosis: follow-up of 15 cases and literature review. Med
Oral Patol Oral Cir Bucal. 2009 Jan 1; 14(1): 34-8.

3. Balaji SM. Modified temporalis anchorage in craniomandibular reankylosis. Int J Oral
Maxillofac Surg. 2003 Oct; 32(5): 480-5.

4. Mehrotra D, Dhasmanaa S, Kumar S. Management of temporomandibular
ankylosis with temporal fascia inter-positional arthroplasty and distraction
osteogenesis: report of 30 cases. J Long Term Eff Med Implants. 2009;19 (2):139-48.

5. Nolasco F, Cosalan E, dela Cruz R. Bilateral ankylosis of the temporomandibular joint.
Philipp J Otolaryngol Head Neck Surg. 1984: 309-11.

6. Felstead AM, Revington PJ. Surgical management of temporomandibular joint
ankylosis in ankylosing spondylitis. Int J Rheumatol. 2011 Jan; 2011: 854167.

7. Sawhney CP. Bony ankylosis of the temporomandibular joint: follow-up of 70 patients
treated with arthroplasty and acrylic spacer interposition. Plast. Reconstr. Surg. 1986
Jan; 77(10): 29-40.

eight cases of TMJ ankylosis managed by gap arthroplasty with
no recurrence within a 24-month period.2

There is still no agreed standard treatment for TMJ ankylosis.
Results of frequently reported operations like gap arthroplasty,
interpositional arthroplasty and joint reconstruction with
autogenous or alloplastic materials have been variable and
often less than satisfactory because of documented recurrences.
The interposition of autogenous or alloplastic materials at
the osteotomy site may lead to morbidity at the donor site,
unpredictable resorption and risk of a foreign body reaction.6

Gap arthroplasty is a frequently used surgical option that is
less invasive and requires less surgical time. The postoperative
condition is more comfortable because no donor site is required,

reducing the risk of lesions to other structures. The recurrence
rate for gap arthroplasty is 13%. Relapse usually occurred in
Sawhney type IV ankylosis. Aggressive physiotherapy after
surgery will reduce recurrence.2,6

Meticulous preoperative planning, perioperative
management and diligent postoperative care remain the keys
to successful surgery. Gap arthroplasty may be an efficient
procedure for temporomandibular joint ankylosis in achieving
satisfactory post-operative inter-alveolar opening and articular
function. Early and meticulous rehabilitation is required to
prevent relapse. Long-term follow up is recommended to
document possible recurrence.