Korean J Orthod.  2019 Nov;49(6):413-426. 10.4041/kjod.2019.49.6.413.

Longitudinal management of recurrent temporomandibular joint ankylosis from infancy to adulthood in perspective of surgical and orthodontic treatment

• Lim SW
• Choi JY
• Baek SH

• KMID: 2464204
• DOI: http://doi.org/10.4041/kjod.2019.49.6.413

Abstract

This study was performed to describe the longitudinal management of recurrent temporomandibular joint (TMJ) ankylosis from infancy to adulthood in perspective of surgical and orthodontic treatment. A 2-year-old girl was referred with chief complaints of restricted mouth opening and micrognathia due to bilateral TMJ ankylosis. For stage I treatment during early childhood (6 years old), high condylectomy and interpositional arthroplasty were performed. However, TMJ ankylosis recurred and symptoms of obstructive sleep apnea (OSA) developed. For stage II treatment during early adolescence (12 years old), gap arthroplasty, coronoidectomy, bilateral mandibular distraction osteogenesis, and orthodontic treatment with extraction of the four first premolars were performed. However, TMJ ankylosis recurred. Because the OSA symptoms reappeared, she began to use a continuous positive airway pressure device. For stage III treatment after completion of growth (20 years old), low condylectomy, coronoidectomy, reconstruction of the bilateral TMJs with artificial prostheses along with counterclockwise rotational advancement of the mandible, genioglossus advancement, and orthodontic treatment were performed. After stage III treatment, the amount of mouth opening exhibited a significant increase. Mandibular advancement and ramus lengthening resulted in significant improvement in the facial profile, Class I relationships, and normal overbite/overjet. The OSA symptoms were also relieved. These outcomes were stable at the one-year follow-up visit. Since the treatment modalities for TMJ ankylosis differ according to the duration of ankylosis, patient age, and degree of deformity, the treatment flowchart suggested in this report could be used as an effective guideline for determining the appropriate timing and methods for the treatment of TMJ ankylosis.

Keyword

Temporomandibular joint ankylosis; Distraction osteogenesis; Reconstruction; Artificial prosthesis

MeSH Terms

Adolescent
Ankylosis*
Arthroplasty
Bicuspid
Child, Preschool
Congenital Abnormalities
Continuous Positive Airway Pressure
Female
Follow-Up Studies
Humans
Mandible
Mandibular Advancement
Micrognathism
Mouth
Osteogenesis, Distraction
Prostheses and Implants
Sleep Apnea, Obstructive
Software Design
Temporomandibular Joint*

Figure

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  Figure 1 Initial visit. Facial and intraoral photographs (A, B, C), posteroanterior and lateral cephalograms (D, E), and a panoramic radiograph (F) obtained at age of 2 years and 4 months.

• 

  Figure 2 Stage I treatment. Computed tomographic images obtained before high condylectomy and interpositional arthroplasty (A; age, 6 years and 1 month), a panoramic radiograph obtained just after high condylectomy and interpositional arthroplasty (B; age, 6 years and 3 months), and a lateral cephalogram obtained at one year after high condylectomy and interpositional arthroplasty (C; age, 7 years and 2 months).

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  Figure 3 Stage II treatment. Computed tomographic images obtained before (A; age, 11 years and 10 months) and after gap arthroplasty of the right temporomandibular joint and bilateral coronoidectomy (B; age, 11 years and 11 months).

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  Figure 4 Stage II treatment. Facial and intraoral photographs and a hand-wrist radiograph obtained just before bilateral mandibular distraction osteogenesis (age, 12 years and 5 months). The dotted line in the intraoral photograph indicates the mandibular dental midline.

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  Figure 5 Stage II treatment. Facial and intraoral photographs, posteroanterior and lateral cephalograms, and a panoramic radiographs obtained at the end of the distraction period (30 mm of distraction on the right side and 19 mm on the left side) and in the middle of post-bilateral mandibular distraction osteogenesis orthodontic treatment (age, 12 years and 6 months).

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  Figure 6 Stage II treatment. Facial and intraoral photographs, posteroanterior and lateral cephalograms, and a panoramic radiographs obtained at the first debonding (age, 14 years and 8 months).

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  Figure 7 Facial and intraoral photographs, posteroanterior and lateral cephalograms, and a panoramic radiograph obtained one year after stage II treatment (age, 15 years and 8 months).

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  Figure 8 Stage III treatment. Computed tomographic images obtained at 4 years and 8 months after stage II treatment (A), facial and intraoral photos (B), and posteroanterior and lateral cephalograms and a panoramic radiograph (C) obtained after low condylectomy on the right side and coronoidectomy on the left side (age, 19 years and 4 months).

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  Figure 9 Stage III treatment. Intraoral photographs (A, upper low: 6 months after preoperative orthodontic treatment, lower low: 3 weeks after temporomandibular joint (TMJ) reconstruction surgery), posteroanterior and lateral cephalograms, and panoramic radiographs (B) obtained before and after TMJ reconstructive surgery of both sides and three dimensional facial computed tomographic images (C) obtained after reconstruction of TMJs using artificial prostheses.

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  Figure 10 Stage III treatment. Facial and intraoral photographs, posteroanterior and lateral cephalograms, and a panoramic radiograph obtained at the second debonding (age, 20 years and 5 months).

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  Figure 11 Stage III treatment. Changes in the total volume and minimum area of the upper airway before (A; age, 19 years and 4 months) and after reconstruction of temporomandibular joints using artificial prosthesis (B; age, 20 years and 5 months).

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  Figure 12 Facial and intraoral photographs, posteroanterior and lateral cephalograms, and a panoramic radiograph obtained one year after debonding (age, 21 years and 5 months).

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  Figure 13 Superimpositions of lateral and posteroanterior cephalograms within each treatment stage. BMDO, Bilateral mandibular distraction osteogenesis; TMJ, temporomandibular joint; pre-op. Orthod. Tx., pre-operative orthodontic treatment.

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  Figure 14 Treatment flowchart for the management of TMJ ankylosis according to the growth stage. TMJ, Temporomandibular joint; MDO, mandibular distraction osteogenesis; Orthod. Tx, orthodontic treatment; Max. Occl., maxillary occlusal.

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