**5. Complications after surgery**

15

Although significant complications in the postoperative phase subsequent to surgery are not dramatic, it varies from mild pain to more serious persisting pain with restricted jaw move‐ ment and re-ankylosis. These unexpected adverse events and complications after surgery are mostly divided into two broad categories; those related to re-ankylosis and those related to the overgrowth of the cartilaginous autograft [38]. Although significant complications in the postoperative phase subsequent to surgery are not

In the literature, there are two main reasons for re-ankylosis after surgical release including inadequate resection of the ankylotic mass intraoperatively and also, absence of patient compliance regarding post-operative jaw exercises [39-40]. The higher rate of reported reankylosis in children comparing to adults may be due to poor compliance to aggressive postoperative physiotherapy [4]. Complete diagnostic assessment of the ankylotic area, based on preoperative imaging examinations, is necessary to determine the extent of bony fusion and the length of the coronoid process on both sides [38]. The extent of bony fusion in both sagittal and coronal planes should be studied carefully to prevent any serious complication of facial nerve and maxillary artery injuries. Adequate mouth opening must be checked intraopera‐ tively as a clinical indicator of successful surgery. Further ipsilateral or contralateral coronoi‐ dectomy with or without soft tissue release may need to be performed to achieve required mouth opening [38]. Growth behavior of inserted grafts including under and overgrowth may also present some complications in later stages of treatment. The role of jaw mobility exercises at home and at physiotherapy in prevention of re-ankylosis cannot be over-emphasized in children or adults. The preventive approach should be strict adhesion to surgical protocol and post-operative physiotherapy requirements, monitored by both the orthodontist and surgeon (Figure 19). dramatic, it varies from mild pain to more serious persisting pain with restricted jaw movement and re‐ankylosis. These unexpected adverse events and complications after surgery are mostly divided into two broad categories; those related to re‐ankylosis and those related to the overgrowth of the cartilaginous autograft (38). In the literature, there are two main reasons for re‐ankylosis after surgical release including inadequate resection of the ankylotic mass intraoperatively and also, absence of patient compliance regarding post‐operative jaw exercises (39‐40). The higher rate of reported re‐ankylosis in children comparing to adults may be due to poor compliance to aggressive post‐operative physiotherapy (4). Complete diagnostic assessment of the ankylotic area, based on preoperative imaging examinations, is necessary to determine the extent of bony fusion and the length of the coronoid process on both sides (38). The extent of bony fusion in both sagittal and coronal planes should be studied carefully to prevent any serious complication of facial nerve and maxillary artery injuries. Adequate mouth opening must be checked intraoperatively as a clinical indicator of successful surgery. Further ipsilateral or contralateral coronoidectomy with or without soft tissue release may need to be performed to achieve required mouth opening (38). Growth behavior of inserted grafts including under and overgrowth may also present some complications in later stages of treatment. The role of jaw mobility exercises at home and at physiotherapy in prevention of re‐ankylosis cannot be over‐ emphasized in children or adults. The preventive approach should be strict adhesion to surgical protocol and post‐operative physiotherapy requirements, monitored by both the orthodontist and surgeon (**Figure 19**).

**Figure 19. a) Panoramic radiograph of re‐ankylosis after previous costochondral grafting b) 3D CT showing complete bony ankylosis of the right condyle.** However, if the re‐ankylosis occurs, the best option for its management depends directly on the type **Figure 19.** a) Panoramic radiograph of re-ankylosis after previous costochondral grafting b) 3D CT showing complete bony ankylosis of the right condyle.

of ankylosis. Bony re‐ankylosis needs additional surgical procedures. Fibrosis re‐ankylosis may be managed by means of progressive jaw mobility exercises that can be delivered through different approaches. Some removable appliances may help clinicians overcome this problem (**Figure 20 a‐d**). If the patient cannot comply with these techniques, the surgeon should help them by initiating physiotherapy under local anesthesia. However, if the re-ankylosis occurs, the best option for its management depends directly on the type of ankylosis. Bony re-ankylosis needs additional surgical procedures. Fibrosis reankylosis may be managed by means of progressive jaw mobility exercises that can be delivered through different approaches. Some removable appliances may help clinicians overcome this problem (Figure 20 a-d). If the patient cannot comply with these techniques, the surgeon should help them by initiating physiotherapy under local anesthesia.

a b

**Figure 20. A 5‐year‐old with bilateral condylar ankylosis following a traumatic event. He underwent a surgical procedure to release the ankylotic condyles, which involved bilateral Figure 20.** A 5-year-old with bilateral condylar ankylosis following a traumatic event. He underwent a surgical proce‐ dure to release the ankylotic condyles, which involved bilateral coronoidectomy also, a) Restricted opening secondary to re-ankylosis, b) Intraoral appliance consisting of labial pads, and acrylic posterior bite plates that incorporate two vertical-direction screws, c) The patient was asked to open the screw once a day, d) Because of the fibrosis type of an‐ kylosis, the patient was able to open his mouth significantly more after treatment.

**coronoidectomy also, a) Restricted opening secondary to re‐ankylosis, b) Intraoral appliance**

#### **consisting of labial pads, and acrylic posterior bite plates that incorporate two vertical‐direction 5.1. Treatment**

16

**21 h‐k**).

**5. Complications after surgery**

426 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

cartilaginous autograft (38).

(Figure 19).

surgeon (**Figure 19**).

15

bony ankylosis of the right condyle.

the overgrowth of the cartilaginous autograft [38].

Although significant complications in the postoperative phase subsequent to surgery are not dramatic, it varies from mild pain to more serious persisting pain with restricted jaw move‐ ment and re-ankylosis. These unexpected adverse events and complications after surgery are mostly divided into two broad categories; those related to re-ankylosis and those related to

In the literature, there are two main reasons for re-ankylosis after surgical release including inadequate resection of the ankylotic mass intraoperatively and also, absence of patient compliance regarding post-operative jaw exercises [39-40]. The higher rate of reported reankylosis in children comparing to adults may be due to poor compliance to aggressive postoperative physiotherapy [4]. Complete diagnostic assessment of the ankylotic area, based on preoperative imaging examinations, is necessary to determine the extent of bony fusion and the length of the coronoid process on both sides [38]. The extent of bony fusion in both sagittal and coronal planes should be studied carefully to prevent any serious complication of facial nerve and maxillary artery injuries. Adequate mouth opening must be checked intraopera‐ tively as a clinical indicator of successful surgery. Further ipsilateral or contralateral coronoi‐ dectomy with or without soft tissue release may need to be performed to achieve required mouth opening [38]. Growth behavior of inserted grafts including under and overgrowth may also present some complications in later stages of treatment. The role of jaw mobility exercises at home and at physiotherapy in prevention of re-ankylosis cannot be over-emphasized in children or adults. The preventive approach should be strict adhesion to surgical protocol and post-operative physiotherapy requirements, monitored by both the orthodontist and surgeon

In the literature, there are two main reasons for re‐ankylosis after surgical release including inadequate resection of the ankylotic mass intraoperatively and also, absence of patient compliance regarding post‐operative jaw exercises (39‐40). The higher rate of reported re‐ankylosis in children comparing to adults may be due to poor compliance to aggressive post‐operative physiotherapy (4). Complete diagnostic assessment of the ankylotic area, based on preoperative imaging examinations, is necessary to determine the extent of bony fusion and the length of the coronoid process on both sides (38). The extent of bony fusion in both sagittal and coronal planes should be studied carefully to prevent any serious complication of facial nerve and maxillary artery injuries. Adequate mouth opening must be checked intraoperatively as a clinical indicator of successful surgery. Further ipsilateral or contralateral coronoidectomy with or without soft tissue release may need to be performed to achieve required mouth opening (38). Growth behavior of inserted grafts including under and overgrowth may also present some complications in later stages of treatment. The role of jaw mobility exercises at home and at physiotherapy in prevention of re‐ankylosis cannot be over‐ emphasized in children or adults. The preventive approach should be strict adhesion to surgical protocol and post‐operative physiotherapy requirements, monitored by both the orthodontist and

**a b**

**Figure 19. a) Panoramic radiograph of re‐ankylosis after previous costochondral grafting b) 3D CT**

**Figure 19.** a) Panoramic radiograph of re-ankylosis after previous costochondral grafting b) 3D CT showing complete

However, if the re‐ankylosis occurs, the best option for its management depends directly on the type of ankylosis. Bony re‐ankylosis needs additional surgical procedures. Fibrosis re‐ankylosis may be managed by means of progressive jaw mobility exercises that can be delivered through different approaches. Some removable appliances may help clinicians overcome this problem (**Figure 20 a‐d**). If the patient cannot comply with these techniques, the surgeon should help them by initiating

However, if the re-ankylosis occurs, the best option for its management depends directly on the type of ankylosis. Bony re-ankylosis needs additional surgical procedures. Fibrosis reankylosis may be managed by means of progressive jaw mobility exercises that can be delivered through different approaches. Some removable appliances may help clinicians

**showing complete bony ankylosis of the right condyle.**

physiotherapy under local anesthesia.

Although significant complications in the postoperative phase subsequent to surgery are not dramatic, it varies from mild pain to more serious persisting pain with restricted jaw movement and re‐ankylosis. These unexpected adverse events and complications after surgery are mostly divided into two broad categories; those related to re‐ankylosis and those related to the overgrowth of the

#### **screws, c) The patient was asked to open the screw once a day, d) Because of the fibrosis type of ankylosis, the patient was able to open his mouth significantly more after treatment.**  *5.1.1. Unilateral condylar overgrowth*

**Treatment Unilateral condylar overgrowth** A 29‐year‐old man was seen for treatment of severe facial asymmetry secondary to right condylar overgrowth (**Figure 21 a‐e**). There was a history of TMJ ankylosis of the right condyle at age 3. Three years later, the patient underwent an autogenous costochondral graft to reconstruct the right mandibular condyle. The condylar structure was composed of the cartilage part of rib graft. As A 29-year-old man was seen for treatment of severe facial asymmetry secondary to right condylar overgrowth (Figure 21 a-e). There was a history of TMJ ankylosis of the right condyle at age 3. Three years later, the patient underwent an autogenous costochondral graft to reconstruct the right mandibular condyle. The condylar structure was composed of the cartilage part of rib graft. As reported by the patient, the condylar overgrowth initiated approximately four years after graft surgery, when he was 10 years old, which lead to a marked facial asymmetry. On clinical examination there was chin deviation and midline divergence (mandibular dental midline shift). On functional evaluation of the patient, there was a

reported by the patient, the condylar overgrowth initiated approximately four years after graft surgery, when he was 10 years old, which lead to a marked facial asymmetry. On clinical examination there was chin deviation and midline divergence (mandibular dental midline shift). On functional evaluation of the patient, there was a significant restriction on full range of anterior and transverse jaw motion, with deviation upon opening. The treatment plan was to remove the condylar overgrowth through a preauricular incision (**Figure 21 f, g**). Postoperative facial photography and panoramic view showed significant improvement in facial symmetry at 18 month follow up (**Figure**

significant restriction on full range of anterior and transverse jaw motion, with deviation upon opening. The treatment plan was to remove the condylar overgrowth through a preauricular incision (Figure 21 f, g). Postoperative facial photography and panoramic view showed significant improvement in facial symmetry at 18 month follow up (Figure 21 h-k).

**Figure 21.** Male aged 29 years, a,b) severe facial asymmetry secondary to right condylar overgrowth is apparent, c‐e) 3D computed tomography, posteroanterior and panoramic radiographs of the patient before surgical procedure, f) intra‐operative view of the right condylar overgrowth mass, g) excess part of overgrowth of the condyle. h,i) postoperative clinical appearance of the patient after surgical removal of condylar overgrowth mass, j,k) Final posteroanterior and panoramic radiographs **Figure 21.** Male aged 29 years, a,b) severe facial asymmetry secondary to right condylar overgrowth is apparent, c-e) 3D computed tomography, posteroanterior and panoramic radiographs of the patient before surgical procedure, f) in‐ tra-operative view of the right condylar overgrowth mass, g) excess part of overgrowth of the condyle. h,i) postopera‐ tive clinical appearance of the patient after surgical removal of condylar overgrowth mass, j,k) Final posteroanterior and panoramic radiographs of the patient following 18 months follow up.

17

**Acknowledgment:**

of the patient following 18 months follow up.
