The sequential management of recurrent temporomandibular joint ankylosis in a growing child: a case report

This case report introduces sequential management of the left TMJ ankylosis resulted from trauma in early childhood. TMJ reconstruction was carried out using costal cartilage graft after removing ankylosed tissues of the left TMJ. The use of costochondral graft is a common practice for condyle reconstruction in children with ankylosis. The advantages of this procedure include biologic and anatomic similarity to the mandibular condyle, growth potential in pediatric patients, ease of harvesting and adapting the graft, and low morbidity of the donor site [7, 9]. Because of the similarities of its primary and secondary cartilages to those of the mandibular condyle [9], the costochondral graft will provide growth potential and keep pace with the growth of the unaffected side, maintaining mandibular symmetry throughout growth [7]. However, long-term studies on mandibular growth in children with reconstructed TMJs using costochondral grafts show excessive growth on the treated side, occurring in 54 % of the 72 cases evaluated, and only 38 % of the cases presented equal growth with the opposite side, and ankylosis can be expected in rare instances from the recipient site [10–12]. It is recommended that early mobilization and aggressive physiotherapy should be done after releasing the intermaxillary fixation (IMF) and immediately postoperatively for patients reconstructed with the costochondral graft [5]. In this case, there were radiographic and clinical evidences confirming re-ankylosis on the recipient site after 1 year postoperatively and mainly due to the IMF with elastic over 8 weeks after surgery and non-compliance with proper physiotherapy.

Even though proper healing was expected after reconstruction of the left TMJ with costal cartilage graft, additional surgical interventions, including interpositional arthroplasty, were performed due to re-ankylosis of the affected site. There is no consensus in the literature on a standard protocol for management of TMJ ankylosis, but three modalities are commonly used: (1) gap arthroplasty, (2) interpositional arthroplasty, and (3) excision and articular reconstruction [13]. The first modality is performed without intervening grafts or materials and is based on resection of ankylosed bone. According to the literature, a minimum of 15-mm gap is recommended between the recontoured glenoid fossa and the mandible for preventing re-ankylosis [14, 15]. Gap arthroplasty offers an advantage of a simple procedure and requires a short surgical time. However, disadvantages include the following: (1) creation of a pseudoarticulation, (2) a short mandibular ramus with anterior open bite in bilateral cases and posterior open bite in unilateral cases, (3) failure of removal of pathologic bone tissue, and (4) high risk of recurrence [16, 17]. The interpositional arthroplasty is recommended after gap arthroplasty as a means to limit resection and recurrence. In this procedure, autogenous and alloplastic materials are placed in the osteotomized area. The important criteria in the choice of graft or interpositional material are cost, esthetic consequences after graft removal, long-term behavior, risk of infection, biocompatibility, tolerance, and prevention of recurrence [16]. In a comparative study, satisfactory results were observed in 92 % of cases with skin graft [18] and 83 % of cases with temporal muscle flaps [13]. Among the several alloplastic materials, gold foil, silastic sheet, acrylic, stainless steel, and silicone prostheses have been used [19–21].

Alloplastic temporomandibular joint replacement can provide a viable option for the multiple operated patients with distorted TMJ anatomy or severe anatomical discrepancies involving the TMJ with recurrent ankylosis [22, 23]. Orthopedic surgeons often prefer alloplastic prosthesis in the replacement of joint in similar situations involving other joints over the use of autogenous bone into the area where reactive or heterotropic bone is forming [24]. In this case, alloplastic prosthesis could be a good selection to prevent recurrent TMJ ankylosis in a growing child.