Detailed discussion on diagnosis and management of TMJ ankylosis. Surgical anatomy and applied aspects of TMJ is discussed. Reconstruction of ramus-condyle unit is also discussed. Compications of TMJ surgery are also discussed

1. Presented by: Dr Dibya Falgoon Sarkar
3rd year Postgraduate student
Department of Oral & Maxillofacial Surgery

2. Introduction
• Temporomandibular joint ankylosis is a
pathologic condition where the mandible
is fused to the fossa by bony/ fibrotic
tissues.
(Movahed R, Mercuri LG. Management of temporomandibular joint
ankylosis. Oral and Maxillofacial Surgery Clinics. 2015 Feb
1;27(1):27-35.)
• Ankylosis is a Greek word that literally
means “stiff joint”.
• TMJ ankylosis interferes with:
1. Mastication
2. Speech
3. Oral hygiene
4. Growth & development
• Ankylosis can be potentially life-
threatening when we want to acquire an
airway during an emergency.

3. Epidemiology of TMJ ankylosis in India
• Overall prevalence: 0.46 per 1000 in the 3-15 years’ age group.
• Age distribution: 3-63 years.
• Most common age group: 10-15 years.
• Male : Female: 1:9
• Birth/ childhood trauma was the major causative factor.
(Gupta VK, Mehrotra D, Malhotra S, Kumar S, Agarwal GG, Pal
US. An epidemiological study of temporomandibular joint ankylosis.
National journal of maxillofacial surgery. 2012 Jan;3(1):25.)

4. Etiology of Ankylosis of TMJ
1. Trauma :
• At birth (forceps delivery)
• Haemarthrosis
• Condylar fracture
2. Infections
• Chronic suppurative otitis
media
• Abscess around joint
• Osteomyelitis of jaw
• Actinomycosis
• Parotitis
3. Inflammation:
• Rheumatoid arthritis
• Osteoarthritis
• Septic arthritis
4. Systemic diseases:
• Small pox
• Ankylosis spondylitis
• Beri beri
5. Other causes:
• Bifid condyle
• Prolonged trismus
• Burns

5. Trauma- The predominant cause of TMJ ankylosis
• Rowe’s series of 46 cases, out of which 31 resulted from trauma
• Sada et al study of 146 cases, out of which 58% accounted from
trauma
• Sawhney’s series of 70 cases, out of which 69 were the result of
trauma.
Factors contributing to ankylosis:
1. Age of patient
2. Site and type of condylar fracture
3. Length of immobilization
4. Damage to the articular disc

6. How trauma leads to TMJ ankylosis

7. Classification of TMJ ankylosis
• Kazanjian’s classification:
• Rowe classified TMJ ankylosis according to:
• Topazian’s classification:
True ankylosis False ankylosis
When there are fibrous/ osseous
adhesions between the surface of the
TMJ
When the ankylosis is due to other
pathologies not directly related to the
joint.
Location of problem Type of tissues involved Extent of fusion
Intra-articular Osseous Complete
Extra-articular Fibrous Incomplete
Both
Type I Type II Type III
Affects the condyle only Intermediate type Affects condyle. coronoid
and cranial base

8. Sawhney’s grading of TMJ ankylosis (1986)
(Sawhney CP. Bony ankylosis of the temporomandibular joint: follow-up of 70 patients treated with
arthroplasty and acrylic spacer interposition. Plastic and reconstructive surgery. 1986 Jan;77(1):29-40.)

9. History:
• Accurate history is important to differentiate between true and
pseudoankylosis
• History of trauma directly to the joint or indirectly to the chin
• History of ear infection
• History of forceps delivery
• Extracapsular causes like zygomatic arch fractures, OSMF should be
ruled out
• Clinical examination:
• Restricted mouth opening with difficulty in mastication and jaw
movements.
• Patients often have associated obstructive sleep apnoea.
• Patients are often seen with craniofacial syndromes, skeletal
deformities and psychological distress.
• Patients often come with a scar over chin.
Diagnosis of TMJ ankylosis

10. Unilateral ankylosis Bilateral ankylosis
Obvious facial asymmetry Mandible is symmetrical but micrognatic
Deviation of chin to affected side Bird-face deformity
Flattening and elongation of unaffected side Retrognathic mandible
Well defined antegonial notch Prominent antegonial notch bilaterally
Absence of condylar movements on affected
side
Inability to open mouth
Unilateral posterior cross-bite B/L Class II malocclusion, multiple carious teeth,
crowding ± anterior open bite
Reduced mouth opening Increased chin throat angle

11. Radiographic investigations
• Orthopantomograph- will show both
the joints which can be compared in
unilateral cases
• Lateral oblique view- will show
anteroposterior dimensions of the
ankylotic mass. Elongation of coronoid
process also seen
• Posteroanterior view- will show the
mediolateral extent of the ankylotic
mass and also highlights asymmetry in
unilateral cases.
• Lateral Cephalogram- Helpful to
evaluate the associated skeletal
deformities.
• CT scan- Helpful guide as it gives the
picture of the ankylotic mass in 3D and
its proximity to other anatomical
structures.

12. Management of TMJ ankylosis
Infancy Childhood
(Growing age group)
Adults
Cause:
• Agenesis of the TMJ (rare)
• Birth trauma
• Infection
Cause:
• Trauma
• Infection
Cause:
• Trauma
• Infection
Aim of treatment:
• Restore movement and
function
• Reconstruction may be
done later
Aim of treatment:
• Restore movement and
function
• Reconstruction of the TMJ
• Correction of occlusal and
cosmetic deformity:
 Early teen: Distraction
osteogenesis, myofunctional
appliance
 Late teen: Orthognathic
surgery, Distraction or both
Aim of treatment:
• Restore movement and
function
• Reconstruction of the
TMJ
• If OSA present,
distraction may be done
at first followed by
release of ankylosis and
TMJ reconstruction.

14. Bony
Components
Components of TMJ
Soft-tissue
components
• Condyle of
mandible
• Articular eminence
• Glenoid fossa
• Articular disc
• Joint capsule
• Ligaments
• Muscles

15. Unique features of TMJ
• Its articular surface
covered by fibrocartilage
instead of hyaline cartilage.
• The right and left TMJ form
a bicondylar articulation
and functions together as
one unit.
• Only joint in human body
to have a rigid endpoint of
closure that of the teeth
making occlusal contact.
• In contrast to other
diarthrodial joints TMJ is
last joint to start develop,
in about 7th week in utero.

16. Important structures related to TMJ
 Nerves:
1. Facial nerve
2. Auriculotemporal nerve
3. Inferior alveolar nerve
 Vascular structures:
• Middle meningeal artery
• Internal maxillary artery
• Superficial temporal artery
• Masseteric artery

17. Facial Nerve
• The main trunk of the facial nerve exits
from the skull at the stylomastoid
foramen.
• Surgical landmarks for
identification of facial nerve:
• Tragal pointer - The main trunk of the
facial nerve is located 1 cm anteroinferior
and 1 cm deep to the tip of the tragal
cartilage.
• Digastric ridge- The main trunk is just
superior to the attachment of the
posterior belly of the digastric muscle to
the digastric groove. This landmark also
marks the approximate depth of the facial
nerve.
• Tympanomastoid suture line - The nerve
lies 6 to 8 mm deep to the inferior end of
the tympanomastoid suture line.

18. Facial Nerve
• Surgical landmarks for
identification of facial nerve:
• Stylomastoid foramen - The base of
the styloid process is 5 to 8 mm deep
to the tympanomastoid suture line.
The facial nerve can be identified as it
exits the stylomastoid foramen and
passes over the posterolateral aspect
of the styloid process.
• Mastoid - For revision cases, extensive
tumors or, as a last resort, a
mastoidectomy can be performed to
locate the vertical segment of the
facial nerve, which can then be
followed as it exits the mastoid.

19. Relation of VII nerve with TMJ
• Approximately 1.3 cm of the facial nerve is visible to surgeon
until it divides into temporofacial and cervicofacial branches
• According to Alkayat & Bramley’s classic article (1979)

20. Radiologic study by Miloro et al

21. Applied Aspects
• The temporal branch of the facial
nerve emerges from the parotid gland
and crosses the zygoma under the
temporoparietal fascial to innervate
the frontalis muscle
• Postsurgical palsy manifests as an
inability to raise the eyebrow, close the
eyelid and ptosis of the brow.
• Damage to the zygomatic branch
results in temporary or permanent
paralysis to the orbicularis oculi and
may require temporary patching of the
eye to prevent corneal desiccation and
abrasion.

22. Auriculotemporal Nerve
• first branch of the mandibular nerve after it
exits the foramen ovale.
• supplies sensation to the skin in the temporal
and preauricular region, the anterior external
meatus
• The auriculotemporal nerve provides most of
the innervation to the capsule of the
temporomandibular joint itself
• Branch of mandibular nerve, post division
• Radiographic assessment of the exact course
of this nerve through the mandible is
necessary if screws will be placed through the
ramus as is necessary for prosthetic joint
replacement
Inferior Alveolar Nerve

23. Vascular anatomy of TMJ
• Superficial temporal artery and vein:
are routinely ligated during preauricular
approaches.
• Internal maxillary artery: is usually not
encountered unless a condylectomy is
performed.
If a condylectomy is performed,
Dunn‐Dautrey retractors are used as
the internal maxillary artery normally
runs-approximately 3 mm medial from the
midsigmoid notch.

24. Talebzadeh N, Rosenstein TP, Pogrel MA. Anatomy of the structures medial
to the temporomandibular joint. Oral Surgery, Oral Medicine, Oral
Pathology, Oral Radiology and Endodontics. 1999 Dec 1;88(6):674-8.

25. Masseteric artery
A careful dissection of 16 intact
human cadaveric head specimens was
done. The location of the masseteric
artery was then determined in
relation to 3 points process:
1 ) the anterior-superior aspect of the
condylar neck = 10.3 mm;
2 ) the most inferior aspect of the
articular tubercle = 11.4 mm;
3 ) the inferior aspect of the sigmoid
notch = 3 mm.
Journal of Oral and Maxillofacial
Surgery. 2009;67 (2) : 369–371

26. Surgical Approaches to TMJ
1. Preauricular : Dingman’s, Blair’s, Thoma’s,
Al-kayat and Bramley’s, Popowitch’s
2. Postauricular
3. Endaural approach
4. Post ramal/ Hind’s approach
5. Submandibular/Risdon’s approach
6. Hemicoronal
7. Bicoronal

27. Preauricular Approach
• Basic incision was given by
Dingman (1951)
• Blair & Ivy modification–
“Inverted hockey stick “
incision. Facilitate exposure
of arch along with condylar
area.
• Thoma in 1958 Angulated
vertical incision. -carried out
across zygomatic arch infront
of ear to avoid main trunk
of facial nerve

28. Alkayat and Bramley Modified Preauricular Incision
(Al‐Kayat A, Bramley P. (1980) A modified preauricular approach to the temporomandibular joint
and malar arch. Br J Oral Surg, 17:91.)
1. Reduced haemorrhage 2. Provision of donor site for temporalis fascia
3. Better cosmetic result 4.Lesser chance of facial nerve injury

29. Facial nerve branches are not damaged

30. Post auricular approach
• Introduced by Bockenheimer
• Advantage:
1. Excellent exposure of the
entire joint and the ability
to camouflage the scar
in patients who have a
tendency to form keloids.
2. Better posterior exposure
of TMJ
• Disadvantage:
1. Auricular stenosis
2. Should not be used in the
presence of joint infection
or chronic otitis externa

31. Post-auricular approach

32. Endaural Approach
• Lempart (1938)
• Short facial skin incision
extending in to ext. auditory
meatus
• Advantage: Excellent cosmetics
and posterolateral exposure
• Disadvantage:
1. Meatal stenosis or
chondritis
2. Injury to the branches of the
facial nerve
• Care must be taken not to incise
the tragal cartilage because a
perichondritis or poor wound
healing may result.

33. Post-ramal/ Hind’s Approach
• E.C Hinds & Girotin (1967)
• Indications –
1. Condylar neck fractures
2. Condylotomy
3. Vertical ramus osteotomy
• Incision- 1cm behind ramus of
mand. and extends 1cm below the
lobe of ear.
• Advantages: Highly cosmetic,
excellent visibility and accessibility.
• Note: Injury may occur to posterior
facial vein and main trunk of facial
nerve.

34. Structures encountered during Hind’s approach

35. Combination of Retromandibular + Endaural Approach
• Indication:
For additional access to the
temporomandibular joint for open
fracture reduction, costochondral
grafting, total alloplastic joint
reconstruction, or tumor
resection.
• When combining both incisions,
the surgeon must leave an
intervening bridge of tissue that
extends inferiorly at least 3 cm
from the lowest point of the
bony external auditory canal to
protect VII nerve

36. Submandibular Risdon’s Approach
•Risdon (1934)
•Mainly used for
neck of condyle &
ramus region
•Incision: Placed
one‐finger breadth
below the angle of
the mandible
ensuring avoidance
of the marginal
mandibular nerve

38. Relations of marginal mandibular nerve
(Dingman RO, Grabb WC. Surgical anatomy of the mandibular ramus of the facial nerve based
on the dissection of 100 facial halves. Plastic and Reconstructive Surgery. 1962 Mar
1;29(3):266-72.)
• The marginal mandi-
bular(MMN) branch of the facial
nerve, posterior to the facial
artery, passed above the inferior
border of the mandible in 81%
of dissections
• It ran superficial to the facial
vein in 98% cases
• Damage to MMN:
The patient is unable to depress
the lower lip and show the
mandibular anterior teeth.

39. Surgical techniques
• Surgical goals for correction of ankylosis:
1. To free up the ankylosis
2. To return the patient to function
3. To reconstruct the joint and restore the vertical height of the ramus
4. To prevent recurrence
5. To restore normal facial growth pattern
6. To improve esthetics and rehabilitate the patient
Release of ankylosis is done by 2 methods:
Condylectomy: Only the condyle is detached and removed.
Osteoarthrotomy (Gap arthroplasty): Excision of the entire joint and/
an adequate amount of bone below the joint.

40. Anaesthesia considerations during TMJ
ankylosis surgery
• Airway often gets
compromised in TMJ ankylosis
cases
• Fiberoptic intubation/ elective
tracheostomy is preferred.
• Hypotensive anaesthesia is
preferred (Mean intraop
arterial pressure: 55-60mm of
Hg)
• Avoid long acting muscle
relaxants until access to the
mandible is gained. This will
help in identification of the
facial nerve branches.

41. Condylectomy
• Condylectomy consists of excision of
the condyle only.
Indications:
• Severe osteoarthritis
• Various other types of arthritis e.g:
Rheumatoid arthritis
• Malunited condylar fractures with
limitation
of motion and pain during mastication
• Fibrous ankylosis cases where the
articular space has not been
completely eliminated.
 Disadvantages of condylectomy:
1. Loss of vertical height of ramus
2. In bilateral condylectomy cases,
there will be anterior open bite
3. In unilateral cases: Deviation of chin
to affected side on mouth opening.

42. Osteoarthrotomy (Gap arthroplasty)
• Creates an anatomical gap in the ankylosed segment to
form an artificial joint space.
• Commonly done in complete ankylosis cases
• Key points:
1. A gap of about 1-1.5cm is created to and is not
interposed with any material.
2. Bony landmarks to be identified: Zygomatic arch first
followed by neck of the condyle and sigmoid notch/
anterior border of ascending ramus (if ankylotic
mass is large).
3. Dunn retractor may be engaged at the neck of the
condyle to protect the surrounding tissues and
maxillary artery.
4. Two horizontal bony cuts are made in the most
superior aspect of the ramus.
5. Inferior osteotomy cut should be made first followed
by the superior cut.
6. Medial portion of ankylotic mass must be
completely removed.

43.  Complications of Gap arthroplasty:
• Excessive gap may lead to anterior open bite
• Reankylosis if physiotherapy is not done postopertively

44. Interpositional arthroplasty
• Principle: An interpositional material
is placed between the bone ends after
excision of the ankylotic mass to avoid
contact and minimize chances of
reankylosis.
• Interpositional material can be:
a) Autogenous: Temporalis
muscle/fascia, costochondral graft,
dermis graft, fascia lata,
sternoclavicular grafts.
b) Alloplastic:
1. Metallic: Titanium, gold
2. Nonmetallic: Silastic, acrylic, etc.
• Complications:
1. Second surgical site morbidity
2. Foreign body reactions seen with
alloplasts

45. Kaban’s protocol
1. Aggressive excision of the fibrous/ bony ankylotic mass
2. Coronoidectomy on affected side
3. Coronoidectomy on opposite side if steps 1 and 2 do not result in
maximum interincisal opening of >35mm
4. Lining of joint with temporalis fascia/ the native disc
5. Condylar reconstruction with either transport distraction
osteogenesis/ costochondral graft with rigid fixation
6. Early mobilization; if DO used; if CCG used, early mobilization with
minimal intermaxillary fixation (not >10 days)
7. Aggressive physiotherapy
Kaban LB, Bouchard C, Troulis MJ. A protocol for management of temporomandibular joint
ankylosis in children. Journal of Oral and Maxillofacial Surgery. 2009 Sep 1;67(9):1966-78.

46. Postoperative physiotherapy
• Physiotherapy is as important as the surgery itself.
• The patient should be encouraged to start active active exercises as soon as it can be
tolerated.
• Initially: Pressure with finger/ simple finger exercises
• Later: Ice-cream sticks, tongue blade, Heister’s jaw opener for forceful mouth openin
• Medications can be given to relieve pain and enable movements.
• Heat application to the region prior to exercise permits easy movement to relieve mu
spasm.

47. Reconstruction of Acquired Temporomandibular Joint Defects
• Factors to be considered during selection of reconstruction technique:
1. Age of the patient
2. Severity of the problem
3. Surgeon’s experience
4. Socioeconomic factors
5. Ability to perform postoperative physiotherapy
TMJ reconstruction
Autogenous grafts
Nonvascularized:
Costochondral graft
Sternoclavicular joint
Iliac crest graft
Coronoid process
Vascularized:
Free fibula flap
Second
Metatarsophalangeal joint
Alloplastic
reconstruction
Types:
Stock prosthesis
Custom-made prosthesis

48. Costochondral graft
• Most widely used autogenous graft for TMJ
reconstruction
Advantages:
1.Most widely used
2. Has a cartilage cap, mimicking both the bone
and cartilaginous components
3. Has intrinsic growth potential (Useful in
children)
4. Easy accessibility and adaptation
5. Gross anatomic similarity to the mandibular
condyle
• Limitations:
1. Unpredictable growth
2. Poor bone quality
3. Possible separation of cartilage from bone
4. Possible donor-site complications: pleural tear,
pneumothorax, pleural effusion, atelectasis,
empyema.
5. Reankylosis: 5-39% of cases

49. Procedure
• Ideal rib for harvesting: Right
sixth rib
• Reasons for preferring right
6th rib:
1. Aesthic: Incision can be
placed in the
inframammary crease
2. Least muscle attachment
present compared to other
ribs
3. Length is satisfactory
4. Postoperative pain is less
likely to be confused with
cardiogenic pain

50. Sternoclavicular joint grafts
• Advantages:
1. Better anatomic and physiologic
characteristics than CCG
2. Contains a cartilaginous cap
3. Has the potential for growth
(Useful in children)
5. Probability of regeneration at donor
site
• Limitations:
1. Unacceptable location of surgical scar
2. Donor-site complications: damage to
the great vessels, instability of the
shoulder, clavicle fracture

51. Iliac crest grafts
• Anterior iliac crest grafts are preferred as it can be harvested without
changing patient position.
• Advantages:
1. Has a cartilage cap, mimicking both the bone and cartilaginous
component
2. Has potential for growth (Useful in children)
3. More suitable for large mandibular defects
• Limitations:
1. Donor-site complications: altered gait, poor scar/bone contour,
herniation of abdominal contents, ilium fracture, peritonitis,
retroperitoneal hematoma
2. Second surgical site

52. Coronoid process
• Many times we perform removal of
the elongated coronoid process in
TMJ ankylosis.
• Advantage:
1. Avoidance of secondary surgical
site and associated donor
complications
2. Less evidence of graft resorption
• Limitations:
1. Relatively pointed architecture
2. No long-term studies are found
3. No growth center

53. Transport distraction osteogenesis
• Pre-requisite: Patient must have a large enough
residual bone to allow placement of 2 screws to
control and transport the DO segment.
• Advantage:
1. No need for interpositional material
2. No secondary donor site morbidity
3. Patient can function during distraction
osteogenesis
4. Simultaneous correction of secondary
deformities
• Limitations:
1. Lengthy procedure
2. Patient cooperation is a must
• Complications:
• Failure of hardware
• Lack of consolidation

54. Vascularized bone grafts
• Second metatarsophalangeal joint
free flap:
• Advantages:
1. Combination of articular cartilage &
bone
2. Fitting anatomy because of small
size
3. Has potential for growth
• Limitations:
a) Donor-site complications: esthetic
loss of a toe
b) Simple hinge joint does not follow
the same movements as the TMJ
(Potter JK, Dierks EJ. Vascularized options for reconstruction of the mandibular condyle. InSeminars in plastic
surgery 2008 Aug (Vol. 22, No. 03, pp. 156-160). © Thieme Medical Publishers.)

55. Vascularized bone grafts
(Potter JK, Dierks EJ. Vascularized options for reconstruction of the mandibular condyle. InSeminars in plastic
surgery 2008 Aug (Vol. 22, No. 03, pp. 156-160). © Thieme Medical Publishers.)
• Free fibula flap:
• Not reported for condyle
reconstruction in ankylosis cases
• Potter & Dierks recommend fibula
as a good option for defects of
mandibular condyle when:
1. Wound beds are compromised
2. Nonvascularized bone grafts
are contraindicated.
• Limitations:
1. Lacks articular cartilage
2. Donor-site complications:
3. ankle stiffness, instability and
weakness, numbness of the
lateral side of the leg, pedal
ischemia, foot edema

56. Vascularised options for reconstruction of Mandibular condyle
(Potter JK, Dierks EJ. Vascularized options for reconstruction of the mandibular condyle. InSeminars in plastic surgery 2008
Aug (Vol. 22, No. 03, pp. 156-160). © Thieme Medical Publishers.)
Type of defect Description Choice of vascularized graft
Class I Defect of the mandibular condyle
only. The condylar replacement
would articulate against the
undersurface of the intact articular
disk.
Contoured fibular flap
Class II Defect of the condyle & the
articular disk. A reconstruction of
the condyle would articulate
against the fibrocartilage lining of
the glenoid fossa and articular
eminence.
1. Need for simultaneous
proximal mandible
reconstruction?- Contoured
fibular flap with auricular
cartilage interposition graft
2. Reconstruction of TMJ
structures only?- Second
metatarsal transfer
Class III Defect that includes the condyle,
disk and glenoid fossa of the
temporal bone. A reconstruction of
the floor of the middle cranial fossa
as well as a condylar replacement
may be necessary to restore the
temporomandibular articulation.
• Need for simultaneous
proximal mandible recon-
struction? Nonvascularized
osseous reconstruction of
glenoid fossa: interpositional
soft tissue graft; contoured
fibular flap Second metatarsal
transfer with fibular flap -
• Reconstruction of TMJ
structures only? - Second
metatarsal transfer

57. Alloplastic reconstruction of TMJ
(Quinn PD. Alloplastic reconstruction of the temporomandibular joint.
University of Texas at Dallas, Southwestern Medical Center; 1999)
• Surgeons often use stereolithographic models for construction of
custom-fitted total joint prostheses in a two- staged surgical procedure

58. Alloplastic reconstruction of TMJ
(Quinn PD. Alloplastic reconstruction of the temporomandibular joint. University of Texas at
Dallas, Southwestern Medical Center; 1999)

59. Stock prostheses Custom-made Prostheses
Make fit Made to fit
Lower cost Higher cost
Shorter treatment time frames Longer treatment time frames
Removal of bone No or minimal removal of bone
More difficult to obtain primary stability Easier to obtain primary stability
Potential micromovement No micromovement
Placement versatility Less placement versatility
Potential for longer surgical time Potential for less surgical time
Limited use for large defects Excellent for large or difficult anatomic defects

60. Importance of fat graft in prevention of heterotopic
bone formation
• In 1992, Wolford developed
the technique of placing
autogenous fat grafts around
the TMJ prostheses to
prevent postsurgical
heterotopic bone and fibrosis
development.
• Pedicled buccal fat grafts can
also be used.
• Rationale: To obliterate the
dead space around the joint
prosthesis, thus preventing
the formation and
subsequent organization of a
blood clot/ hematoma (which
calcifies later).
(Wolford LM, Karras SC. Autologous fat transplantation around
temporomandibular joint total joint prostheses: preliminary
treatment outcomes. Journal of oral and maxillofacial surgery.
1997 Mar 1;55(3):245-51.)

61. Factors which prevent reankylosis
• Radical resection of the ankylotic mass.
• Condylar and disc reconstruction. Various studies have proved that
restoration of the vertical ramus height by condylar and disc
reconstruction with different interpositional materials significantly
reduces possibility of recurrence.
• Ipsilateral and/or contralateral coronoidectomy. These operations
are often necessary according to the passive maximal mouth opening
intraoperatively because the coronoid process may be too large to
affect the mouth opening in long-standing cases.
• Filling the remaining dead space with buccal fat pad. Hematoma
formation and ossification in the dead space of the surgical site may
contribute to the re-ankylosis (Wolford et al., 2008).
• In certain long-standing cases, extended elevation or even cutoff of
masseteric muscle is required.
• Early postoperative exercises and appropriate physiotherapy are
critical for preventing reoccurrence of ankylosis.

62. One-stage vs Multistage treatment in TMJ ankylosis
• Post-ankylotic facial deformities include:
a) Micrognathia, reduced facial height, poor jaw–neck definition, chin shift to
the affected side, and occlusal discrepancies.
b) In unilateral cases, a cant of the occlusal plane is frequently observed due
to mandibular hypoplasia on the affected side, and hence a secondary
ipsilateral vertical deficiency in the maxilla is seen.
(Mehrotra D, Vishwakarma K, Chellapa AL, Mahajan N. Pre-arthroplasty simultaneous
maxillomandibular distraction osteogenesis for the correction of post-ankylotic dentofacial deformities.
International journal of oral and maxillofacial surgery. 2016 Jul 1;45(7):820-7.)
Correction of TMJ ankylosis and facial deformities can be done in:
1. One-stage surgery provides simultaneous release of ankylosis and
correction of skeletal deformities.
2. Multi-staged treatment protocol involves, releasing of ankylosis first. This
is followed by orthodontic treatment and correction of secondary
deformities at a later stage or vice versa.

63. One-stage vs Multistage treatment in TMJ ankylosis
Treatment
protocols
Multistage
More preferred in severe skeletal and
dental deformities. e.g: Bird face
deformities, medical condition,etc.
Release of ankylosis first
followed by correction of
facial deformity
Correction of facial
deformities first by
simultaneous
maxillomandibular
distraction followed by
arthroplasty
One stage
Preferred in patients with mild to
moderate preop malocclusion and
skeletal deformities. Eg: Unilateral
ankylosis
Simultaneous release of
ankylosis and correction of
skeletal deformities.

64. One stage treatment Multi-staged treatment
Advantages:
• Provides more immediate and
complete satisfaction to the
patients.
• Psychological benefits
• Less expensive
Advantages:
 Gives the clinician ample opportunity to
monitor relapse or malocclusion
development.
 Provides a more stable postsurgical
outcome in the appropriately selected
patient population
 Facilitate early and active postoperative
exercise of mouth opening.
 Useful in obstructive sleep apnoea
Disadvantages:
• Often results in an unstable proximal
condylar segment as a remaining problem
during the distraction process
• Intermaxillary fixation is often necessary
for bone healing, which hampers mouth
opening exercises and increases the
incidence of recurrence.
• Longer operation time.
Disadvantages:
 More prolonged span of
treatment period
 More expensive
Zhu S, Wang D, Yin Q, Hu J. Treatment guidelines for temporomandibular joint
ankylosis with secondary dentofacial deformities in adults. Journal of Cranio-
Maxillofacial Surgery. 2013 Oct 1;41(7):e117-27.

65. One staged treatment

66. Multi-staged treatment

67. Management of TMJ ankylosis in patients
with Obstructive Sleep Apnoea (OSA)
• Many patients present with a triad of TMJ ankylosis, micrognathia
and OSA.
• Incidence of reankylosis due to non-compliance for active jaw
physiotherapy has been high in this group of patients with OSA.
• Reason for higher incidence of reankylosis in this group:
1. Patients generally have severe AHI (>30) and PAS <4mm
2. This leads to a choking sensation due to blockage of the airway
during jaw opening exercise which reduces patient compliance
• Thus, in these patients with reduced PAS, severe AHI and OSA, it is
better to perform distraction osteogenesis of the retrognathic
mandible at first followed by release of TMJ ankylosis.
(Andrade NN, Kalra R, Shetye SP. New protocol to prevent TMJ reankylosis and potentially
life threatening complications in triad patients. International journal of oral and maxillofacial
surgery. 2012 Dec 1;41(12):1495-500.)

68. (Andrade NN, Kalra R, Shetye SP. New protocol to prevent TMJ reankylosis and potentially
life threatening complications in triad patients. International journal of oral and maxillofacial
surgery. 2012 Dec 1;41(12):1495-500.)

69. Complications of TMJ Surgery
• During anaesthesia:
1. Difficult intubation due to
restricted mouth opening.
2. Aspiration of blood during
extubation. We must place
a throat pack immediately
after releasing the
ankylosis.
3. Danger of tongue falling
back and obstructing the
airway after extubation.
We should consider
delayed extubation or use
oropharyngeal airway.
• During postop follow up:
1. Infection
2. Open bite
3. Reankylosis
4. Facial nerve palsy
5. Prosthesis failure
6. Graft resorption

70. Complications of TMJ Surgery
• During surgery:
1. Haemorrhage due to damage to blood vessels:
Internal maxillary artery
Superficial temporal vessels
Inferior alveolar vessels
2. Damage to external auditory meatus
3. Nerve injury: Zygomatic and temporal branches of facial nerve,
auriculotemporal nerve
4. Damage to glenoid fossa and accidental entry into the middle cranial
fossa.